Winning ugly

Written By: - Date published: 7:19 am, June 21st, 2023 - 146 comments
Categories: Christopher Luxon, health, national, racism, same old national - Tags:

Another week and another example of National using dog whistle racism to stir up hatred and try and gain political advantage.

This time it is to attack the notion that our health system should be seeking to look after those most in need.

During Covid the Auckland District Health Board’s Clinicians noticed that the list system did not favour Maori and Pasifeka and set out to address this problem.  The primary consideration was still need.  But extra points were awarded to those ethnicities in an attempt to ensure that the allocation process produced a statistically fairer result.

Jo Moir at Newsroom describes the background:

During Covid-19 medical professionals in Auckland identified that Māori and Pasifika were disproportionately waiting for surgery compared with other population groups and sought to fix it when operating theatres were back up and running after the 2020 lockdowns.

All the health data pointed to ethnicity being a significant factor, so alongside clinical need – how urgently someone requires surgery – Auckland hospitals started working its way through waitlists using those two criteria for routine surgeries.

When doctors decide who should be front of the queue, everyone is first and foremost put into a clinical priority category of urgent, semi-urgent, or routine.

Duncan Bliss, Te Toka Tumai surgical services manager, is part of the team who created the algorithm for a new equity adjustor score that was rolled out in Auckland in February.

He tells Newsroom he can’t stress enough that clinical need “always takes precedence and the equity adjustor doesn’t interfere with that”.

So the policy, created by clinicians, appears to be rational.

And Sir Colin Tukuitonga has explained why results were so bad for Maori and Pasifeka and why an adjustment is appropriate.  From the Herald:

Sir Collin Tukuitonga, a leading expert in Pasifika health, said Māori and Pasifika patients could be moved to the front of surgical lines due to the inequalities in the previous stages of the health system, such as the referral process.

“Māori and Pacific people tend to linger on the referral list… and inevitably, I think people will say that there’s also an institutional bias, possibly a racism that doesn’t put them where they need to be in order to get the surgery,” Tukuitonga said.

“The referral pathways are not that straightforward.”

Tukuitonga specifically used the example of bariatric surgery, which helps to aid those with morbid obesity, which he said was “much more” prevalent in Māori and Pacific communities than in Pākehā. He said this could be another reason why these patients are being brought forward in the waiting times.

“For most of the surgical interventions, Māori and the Pacific people don’t get to get the rates of interventions that might be warranted given their conditions,” Tukuitonga said.

He added: “In other words, it’s not acceptable to have a group in the population where obesity is a major problem and yet they’re not getting the physical intervention that they require.”

And the consequences of what Tukuitonga described are clear.

But National, egged on by the Herald and Newstalk ZB, sensed a chance to blow that dog whistle hard.  And blow it they did.  As well as blame the Government for something that Auckland’s clinicians had decided on.

And Luxon was not going to worry about reality getting in the way of a good old racist smear as this interaction with media yesterday shows:

Q – What evidence do you have to support the fact that there was a government directive?
A – Clearly the clinicians are saying there’s criteria that’s been passed down to them that they are expected to activate or to make priority and ranking decisions around patients on. In this case, what we’re saying is look, there is just no need for that.
Q – That criteria has been given to the clinicians by a multidisciplinary team who designed the algorithm. They were the same team who in COVID decided their clinical need and ethnicity should be the only two measures for waiting lists that’s now broadened out to five criteria, which is what we’re talking about today. So a multidisciplinary team of medical professionals, Maori Primary care groups, a whole bunch of medical professionals and clinicians came up with this. So what’s your evidence that the government told them to do this?
A – Very simple, very, very simple, there is no room or no need, we always look to prioritise health services and people’s medical needs and surgical needs not their ethnicity.
Q – That doesn’t answer the question. What evidence do you have that the government directed this?
A – Well, it’s clear you’ve had a reaction from from the surgeons to say that this is not something that we are comfortable with at all.
Q – I’ve just explained to you that a team of medical professionals …
A – I don’t care. There is no room.
Q – You don’t care about the facts?
A – There is no room for health services to be based on basis of ethnicity rather than the facts.

This transaction shows how disingenuous Luxon is.

Getting back to the heading of this post there is a saying in sport that winning ugly is fine as winning is the only important thing.  Clearly National believes that this applies to politics too and is willing to win this election using ugly tactics and completely indifferent to the damage that it will cause to the country.

I hope they lose.  If they gain power they will wreck the place.

146 comments on “Winning ugly ”

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  1. SPC 1
    21 June 2023 at 7:44 am

    Part of the problem is lack of home ownership – moving from rental to rental and not being able to register with a GP. One reason for the lower rate of vaccination for Maori children in recent years. Which is why alternative approaches – used in the pandemic – should be rolled out.

    The USA's average life expectancy has fallen to 76.4 in 2023. There caused by restricting health care to employment (limited welfare support related transiency high drug addiction and imprisonment rates) or otherwise to medicaid and medicare.

    https://www.hsph.harvard.edu/news/hsph-in-the-news/whats-behind-shocking-u-s-life-expectancy-decline-and-what-to-do-about-it/

  2. Thinker 2
    21 June 2023 at 7:44 am

    … Although 'ethnicity' could be a proxy for other underlying factors, so I think the medical profession shouldn't rest on that aspect. You can't really fix 'ethnicity' by itself and prevention is better than cure.

    Regarding the Luxon comments, a party that behaved such that Hager's Dirty Politics book was largely accepted will likely do dog-whistle politics.

    Unfortunately, while I don't think National will win this election, it's possible that Labour could lose it, thereby Luxon drifting to power despite many seeing him as unsuited to the role.

  3. Ad 3
    21 June 2023 at 8:15 am

    Well Mickey thank God for you and the few who defended this minor and rational adjustment to the surgery lists.

    The number of sad old Labour people on this site yesterday who just did the standard howl-with-the-dogs without a shred of investigation into the basic ethnic divide in health inequalities was frankly depressing.

    • SPC 3.1
      21 June 2023 at 8:43 am

      19th? Most of it was led by those not old Labour who flock here when there is the chance of undermining support for an incumbent Labour government (by such methods).

      But sure it is disappointing how readily some fall for the inference of unfair support for Maori – which speaks more to concern about limited/scarce health resources. In times of insecurity, those who exploit rather than those who build come to the fore.

      There are those manipulated by it and those who recognise it for what it is. The lesser and the greater society weighed in the balance.

    • miravox 3.2
      21 June 2023 at 9:42 am

      I guess we all should have known an unpaywalled NZ Herald article by Jason Walls and Barry Soper was mischief making.

      • adam 3.2.1
        22 June 2023 at 1:56 am

        The tory press being the tory press.

        Welcome to NZ, we like our papers white with black lettering thanks.

  4. roblogic 4
    21 June 2023 at 8:35 am

    Vile tactics. I had hoped that Luxon would steer away from dirty politics, but this race baiting is even worse. Scummy and immoral

  5. tc 5
    21 June 2023 at 8:41 am

    Add this to their stated abolishment of the Maori health authority if elected.

    Sad how this is playing out with their desperation to grab power and damm the consequences.

  6. tsmithfield 6
    21 June 2023 at 9:27 am

    While there may not have been an explicit government directive, it has been implimented by the government-established health body and was intended to be rolled out across the country.

    Te Whatu Ora – Health New Zealand has introduced an Equity Adjustor Score, which aims to reduce inequity in the system by using an algorithm to prioritise patients according to clinical priority, time spent on the waitlist, geographic location (isolated areas), ethnicity, and deprivation level.

    And, Hipkins has seen fit to press pause on the policy, pending further investigation.

    So, if the policy was merely clinical, then Hipkins, presumably, would have left it to the clinicians.

    But, the whole idea is completely illogical for a number of reasons:

    Firstly, the idea of ethnicity being a reason for inequity in surgery access is really conflating a number of factors such as need, location, access to primary health care etc. Given those factors are already largely covered in the criterea, it seems to me that it is highly questionable as to whether ethnicity adds anything further of value other than to have the effect it currently is on the public debate.

    Secondly, the policy makes the logical error of applying general statistical data to individual circumstances. Undoubtably, it is true that on average, Maori and PI people are disadvantaged in terms of health generally for a wide variety of reasons. But, the statistical data often may not apply on an individual level. For example, people such as Shane Reti and David Seymour who likely do not have the risk factors of people living in isolated communities for example.

    Thirdly, the policy does nothing about the factors that drive the general health disadvantage for Maori and PI people. For instance, access to doctors, smoking cessation programs, education etc.

    • Ad 6.1
      21 June 2023 at 9:37 am

      So despite all those criteria all concentrated around one ethnicity, we are so afraid that we can't even mention its name. After 200 years of living together.

      Hipkins is doing his blue-lizard-tongued usual move of killing anything that doesn't eat a sausage roll with tomato sauce. He will kill the measure of course because it's in his way, like he does everything else.

      I'm just guessing you're an epidemilolgical expert who can generate reasons other than ethnicity for measurable differences in surgical referrals, treatments, and positive outcomes for Maori.

      • tsmithfield 6.1.1
        21 June 2023 at 9:47 am

        I think that if all those problems are bundled under the construct "ethnicity", then, firstly is doesn't actually help solve the underlying problems because "ethnicity'' itself is seen as the problem.

        Secondly, a lot of people who have a similar bundle of problems but happen to not be in that ethnic group will likely miss out on help they need, simply because they are not in the target ethnic group.

        Finally, don't you think it is a bit racist in a strange sort of way? Implying to people that they are somehow disadvantaged because of their ethinicity is a bit insulting to those of that ethnicity who have made a success of themselves through their own merits. It is a bit like giving someone a five metre head start in a 100 metre race on the basis of ethnicity, even though through their own hard work they have made themselves the fastest in the field on their own merits.

        • SPC 6.1.1.1
          21 June 2023 at 9:56 am

          Do you have a problem with a points system in migration, or a move from the old decile system to another for school funding?

          You refer to historic factors that may contribute to more health problems within one sector – but resent any effort at redress. The infer its about equal accountability at the individual level, because not all Maori faced those problems equally. Guess what they are not likely to be in need of the health services, and might be on private health insurance anyhow.

          It seems reasons for obstruction/opposition are diverse and varied and inconsistent.

          • Molly 6.1.1.1.1
            21 June 2023 at 10:26 am

            I don't understand the point you are attempting to make here.

            • Shanreagh 6.1.1.1.1.1
              21 June 2023 at 10:52 am

              Yes Molly, thanks.

              It seems reasons for obstruction/opposition are diverse and varied and inconsistent.

              Clearly an example from SPC of the old 'if you don't say you are for it, right away you are threfore against it' argument. Gee whiz in my working life I got so tired of this……thrown at people who want to ask questions, tease out the rationale. And then who may be in favour, or not.

              People to the left are not a hive mind and neither should we expect them to be.

              • SPC …
                21 June 2023 at 11:01 am

                I would say you are not characterising this very well

                But, the whole idea is completely illogical for a number of reasons:

                That is not

                people who want to ask questions, tease out the rationale.

                Saying his reasoning was inconsistent is merely an observation.

                But you do the talking about others on the left.

        • Shanreagh 6.1.1.2
          21 June 2023 at 10:54 am

          Valuable points to put forward and to discuss tsmithfield. I am not always in agreement with what you say, but in many cases I am because it is commonsense and dogma free.

        • James Simpson 6.1.1.3
          21 June 2023 at 11:24 am

          Secondly, a lot of people who have a similar bundle of problems but happen to not be in that ethnic group will likely miss out on help they need, simply because they are not in the target ethnic group.

          That's how I see it.

          Bob and Peter have the same health issue. They both live in rural Northland. They are both in their mid 40s. They have both been waiting 14 months for their surgery.

          Bob has Maori ancestry. Peter is an immigrant from India.

          Should their ethnicity in this instance be taken into account when prioritising treatment?

          I don’t think it really advances the issue, by calling people racist, or dog whistling, simply because they question this system.

          • SPC 6.1.1.3.1
            21 June 2023 at 11:43 am

            But it's OK to propose

            any effort to redress inequality in access to primary care leading to higher levels of Maori in treatment categories than their relative population

            as racist?

            As it’s something determined on by Auckland’s clinicians, it would have come under front line service delivery focus on effective performance in improving health outcomes.

      • Molly 6.1.2
        21 June 2023 at 9:57 am

        Just because there is a concentration of poor outcomes for Māori, does not mean that contributing factors have been identified.

        Unless you are saying the primary contributing factor is that of Māori ancestry? If you are, what evidence do you have to base this supposition on?

        "I'm just guessing you're an epidemilolgical expert who can generate reasons other than ethnicity for measurable differences in surgical referrals, treatments, and positive outcomes for Maori."

        Do you not see the contradiction in this statement?

        Economic disparity, lack of access to primary and specialist care, reluctance to visit health practitioners and follow treatments, previous disparity in DHB treatments meaning location played a part, etc…

        These are possible factors that are not ethnicity based, but may have more impact on Māori because of their representation in these groups.

      • tWiggle 6.1.3
        21 June 2023 at 3:36 pm

        https://www.newsroom.co.nz/ethnicity-a-factor-in-surgery-waitlists-for-years

        Interestingly, the ethnicity factor could potentially be assigned to other ethnic groups over-represented in waiting lists, not only to Maori and Pasifika (which are 2 ethnicities, not one, by the way).

        'The four measures that come underneath the priority, clinical need, have all been given a weighting, but Bliss [surgical services manager] says it varies from service to service. “Take neurosurgery for instance, clinical priority and days waiting absolutely take precedence over everything else,” he says.

        But when it comes to low-end routine surgeries Bliss says if the proportion of Māori and Pasifika on the waitlist exceeds their population percentage then a higher weighting is given to ethnicity.'

        Technically, if SE Asians were over-represented in the waiting lists compared to their proportion of the population, then the ethnicity weighting could be applied to them. If it were only Treaty political pressure, Pasifika would not be on the current ethnicity list.

    • miravox 6.2
      21 June 2023 at 9:52 am

      "Firstly, the idea of ethnicity being a reason for inequity in surgery access is really conflating a number of factors such as need, location, access to primary health care etc. Given those factors are already largely covered in the criterea, it seems to me that it is highly questionable as to whether ethnicity adds anything further of value other than to have the effect it currently is on the public debate."

      No, there other factors that relate to ethnic differences are not related factors such as need, location, access to primary health care etc. How do I know this? My PhD thesis (and work i continue to do) was investigating access to a particular specialty, it looked at patient experience, as well as GP, specialist and administrative staff views and adminstrative data.

      While the factors you mention are important for everyone, they don't explain why there were fewer Māori on the waiting list, who took longer to get their first specialist appointment. Structural (and personal) racism is most definitely a thing and it affects how Māori interact with the health system.

      • tsmithfield 6.2.1
        21 June 2023 at 9:58 am

        While the factors you mention are important for everyone, they don't explain why there were fewer Māori on the waiting list, who took longer to get their first specialist appointment. Structural (and personal) racism is most definitely a thing and it affects how Māori interact with the health system.

        Fair enough. So, it seems that institutionalised racism is a problem that needs to be solved. That is why actually specifying in detail the issues, rather than bundling them under a nebulous concept such as "ethnicity". If the bundle of problems that are represented by that label can be unpacked then they can be targeted and dealt with.

        I think this leads to far more fundamental change than the model that was being implimented.

        • miravox 6.2.1.1
          21 June 2023 at 10:08 am

          " If the bundle of problems that are represented by that label can be unpacked then they can be targeted and dealt with."

          They've been unpacked for years.

          https://scholar.google.com/scholar?hl=en&as_sdt=0%2C5&q=access+to+healthcare+M%C4%81ori&btnG=

          • Molly 6.2.1.1.1
            21 June 2023 at 10:16 am

            First paper I clicked on did not define ethnicity as a factor:

            https://www.tandfonline.com/doi/abs/10.1080/10376178.2016.1195238

            ' This paper argues that socio-political factors resulting from the entrenchment of colonialism have produced significant personal and structural barriers to the utilisation of healthcare services and directly impact the health status of these two vulnerable groups. Design: Discussion Paper. Conclusions: Understanding the actual barriers preventing the utilisation of healthcare facilities, as perceived by Indigenous people, is essential in reducing the gross disparity between Indigenous and non-Indigenous morbidity and mortality in Australia and New Zealand."

            Waiting for someone to point out correlation is not causation – but apparently it does need to be said – Ethnicity is not necessarily the cause.

            • tWiggle 6.2.1.1.1.1
              21 June 2023 at 3:44 pm

              https://www.newsroom.co.nz/ethnicity-a-factor-in-surgery-waitlists-for-years

              'Bliss says the equity adjustor score is designed from a health perspective, not a political one. “We haven’t looked at it from race or whether it might be controversial, it was based on data.” Life expectancy and mortality rates paint a bleak picture for Māori and Pasifika in New Zealand with European or other males having a life expectancy of 81 years compared with 73.4 years for Māori and 75.4 years for Pacific males.

              Bliss says that is data that could potentially be used in place of ethnicity, but he hadn’t looked closely enough at it to know if it was a fair comparator. “I think we’d have to look at it but also ask why. Why would we try and do that? “Not using the word 'ethnicity' because it’s too political doesn’t feel like the right thing to be doing in health,” Bliss says. “We treat patients based on need and ensure there aren’t inequities.” '

              Semantics.

          • tsmithfield 6.2.1.1.2
            21 June 2023 at 10:17 am

            I am genuinely interested, from a research perspective, how ethnicities are specified for research purposes. Because, there are varying degrees of most ethnicities, so attempting to isolate specific ethnicities for study must be a bit difficult, as to where the line is drawn. And, if there is not a consistent definition then it must make it difficult to replicate previous studies.

            For instance, I think my son's partner is 1/16th Maori. So, would she be included in your research?

            • Molly 6.2.1.1.2.1
              21 June 2023 at 10:25 am

              "For instance, I think my son's partner is 1/16th Maori. So, would she be included in your research?"

              Interesting question. Another could be, how is the preferential treatment ethnicity identified?

              Is it dependent on how someone fills in their GP form? Which is a self-declaration requiring no supporting documentation.

              Can someone change this information perhaps attached to their NHI number?

      • Molly 6.2.2
        21 June 2023 at 10:11 am

        "While the factors you mention are important for everyone, they don't explain why there were fewer Māori on the waiting list, who took longer to get their first specialist appointment. Structural (and personal) racism is most definitely a thing and it affects how Māori interact with the health system."

        Then this factor should be weighted in terms of how much it contributes to poor outcomes, and not be assumed to be the only factor. It should also be addressed by metrics to do with training and transparency – not imposition of a ethnicity based merit system.

        Anecdotal only: My Māori and non-Māori relatives taken as separate demographics indicate a different approach to healthcare. Māori relatives are often more involved in natural therapies and will persist in that approach for longer before going to health practitioners. A Māori woman on a hospital ward with me, gave a familiar excuse for not getting treatment for bowel cancer diagnosed two years earlier – she was busy, it was not that intrusive on her feelings of well-being etc, she had other things she wanted to get done.

        I don't know how prevalent this approach is to personal healthcare among Māori, – I'm just saying perhaps these other factors need to be investigated and addressed for more effective long-term solutions.

        And it is fundamentally – and unequivocally – an institutionally racist system to give preferential treatment on the basis of ethnicity.

        • miravox 6.2.2.1
          21 June 2023 at 10:24 am

          "And it is fundamentally – and unequivocally – a institutionally racist system to give preferential treatment on the basis of ethnicity."

          Except, as the Jo Moir article explains, that's not what is happening.

          I also have relatives who are in the socially deprived end of practically any socio-economic system. My sister died younger than she should have, from lung cancer, so totally understand from on an individual basis how crucial fair access to advanced healthcare is – especially for people who don't have much faith in institutions.

          I also know, at a systemic level what that means – which is why I'm so pissed off we don't have reform of the health system that wipes out private care that effectively pits underserved demographic groups against each other while the rich pay to avoid the waiting lists.

          I have no problem at all with the Auckland solution in the public system as explained in Jo Moir's article. I certainly would, if it were as described in the NZ Herald hit-piece (which seems to have done what it intended – stir up divisions in groups who have common interests in system change).

          • Molly 6.2.2.1.1
            21 June 2023 at 10:37 am

            You seem to be mixing inequity due to access to healthcare, with poorer outcomes due to ethnicity.

            The Jo Muir article seeks to provide justification for an algorithm that does not address the underlying factors but will produce results that will improve the statistics:

            "Hipkins tells Newsroom there is clear evidence Māori, Pasifika, rural people, and those in low-income communities have had to wait longer for clinical care than others and have been discriminated against."

            It's the equivalent of "teaching to test" – ie. test results may be improved, but the knowledge of students often suffers.

            It's a lazy way of redressing outcomes.

            • miravox 6.2.2.1.1.1
              21 June 2023 at 10:54 am

              "You seem to be mixing inequity due to access to healthcare, with poorer outcomes due to ethnicity"

              No, I'm not. both these things are real. One (improved access) can help address the other (outcomes). I do agree however, that unless that there are other issues. Some reform on persons/cultural/financial barriers is happening in tandem with waiting list criteria. The success of those may mean that we don't need to have waiting list criteria at all.

              On broadly ethnic grounds, don't you think its unfair that people can avoid waiting lists altogether by paying for private care that takes nurses and doctors out of the public system? Who are the people at the top of that shorter waiting list? What about those who aren't quite so rich but can scrape up the cash for one specialist assessment in private care (again, mainly pākehā) and then jump back in the queue in public care for their free follow-up treatment – ahead of those people still waiting for assessment?

              • Molly …
                21 June 2023 at 10:57 am

                "On broadly ethnic grounds, don't you think its unfair that people can avoid waiting lists altogether by paying for private care that takes nurses and doctors out of the public system?"

                These are individual wealth grounds. You are conflating them with ethnicity,

                The failure of our public health system to acquire and retain quality staff is a separate issue.

                • miravox …
                  21 June 2023 at 11:27 am

                  "These are individual wealth grounds. You are conflating them with ethnicity"

                  It's individual and group wealth. I've said before I believe the waiting list criteria to be a blunt tool. But short of reforming the capitalist system, I don't expect Māori and Pacific people (as a demographic) to languish on the the waiting list, for longer that their Pākehā fellow citizens (the data is in – it's a fact). The criteria always puts clinical need first – and rurality and social deprivation.

                  According to the article above "if the proportion of Māori and Pasifika on the waitlist exceeds their population percentage then a higher weighting is given to ethnicity".

                  I simply don't have a problem with ensuring pākehā are seen proportionate to their population percentage (especially knowing how many of us have skipped up places on the waiting lists in ways that are not available to socially deprived people of whatever ethnicity).

                  Again, I'd be happy if we didn't need balancing criteria, but until we work through the myriad of issues involved in delivering good public healthcare for all, a blunt tool is better than no tool at all.

                  I think I'll leave it there – this is my view, based on the research I've spent a lot of time studying and I won't be changing it quickly. I suspect your view is quite settled too.

                  • tsmithfield …
                    21 June 2023 at 11:41 am

                    Again, I'd be happy if we didn't need balancing criteria, but until we work through the myriad of issues involved in delivering good public healthcare for all, a blunt tool is better than no tool at all.

                    I think it is not only a blunt tool, but also a highly ineffective in both outcomes and targeting, and just likely to cause more trouble than it is worth, as is being discovered now.

                    The reason I say that, is because the problems run much deeper than just access to operations.

                    For example, access to primary health care due to a lack of GPs in isolated areas, poor prognosis for recovery from operations due to underlying conditions such as diabeties, high smoking rates amongst Maori and Pacifica making them more vulnerable, poor education and information about health screening in various areas etc.

                    So, I think if there is a lot more attention paid to these areas, then the health outcomes as a whole for Maori and Pacifica, and other ethnicities with similar issues, will be a lot better as a whole.

                    • SPC …
                      21 June 2023 at 11:52 am

                      It's going to be hard to improve primary health care for that sector of the population if they have a higher number of people waiting for treatment than the rest of us.

                    • tWiggle …
                      21 June 2023 at 3:54 pm

                      Well, tsmithfield, looks as if you have argued yourself into supporting Labour's Maori health authority, initiated in 2022.

                      https://www.futureofhealth.govt.nz/maori-health-authority/

                    • tsmithfield …
                      21 June 2023 at 11:08 pm

                      Well, tsmithfield, looks as if you have argued yourself into supporting Labour's Maori health authority, initiated in 2022.

                      I don't have a problem with too much of that, other than I would remove the ethnicity part of it, for the reasons I have already given, and would focus the initiatives on need generally, which in turn would include vulnerable Maori communities.

            • weka 6.2.2.1.1.2
              21 June 2023 at 4:11 pm

              The Jo Muir article seeks to provide justification for an algorithm that does not address the underlying factors…

              What does that mean? Do you mean that surgeons making decisions about waiting lists shouldn't be taking into account factors in addition to clinical issues? That they should be helping patients with poverty? What?

              but will produce results that will improve the statistics:

        • SPC 6.2.2.2
          21 June 2023 at 10:37 am

          I guess we know where you would stand in the American pantheon, opposing affirmative action.

          • Molly 6.2.2.2.1
            21 June 2023 at 10:41 am

            Would "we"?

            Affirmative actions re opportunity, is a different situation to healthcare don't you think?

            Why not stick to the discussion regarding using ethnicity instead of factors addressing poverty, unequal access, transparency of care etc.?

            • SPC 6.2.2.2.1.1
              21 June 2023 at 10:52 am

              Your claim

              And it is fundamentally – and unequivocally – an institutionally racist system to give preferential treatment on the basis of ethnicity.

              And

              unequal access

              Affirmative action was about unequal access (background factors such as poverty).

              All other health factors being equal, and knowing of the historic inequality in lifetime outcomes etc, why not add ethnicity/being an indigenous people as a factor?

              • Molly …
                21 June 2023 at 10:54 am

                "All other health factors being equal, and knowing of the historic inequality in lifetime outcomes etc, why not add ethnicity/being an indigenous people as a factor?"

                Correlation is not causation.

                • SPC …
                  21 June 2023 at 11:10 am

                  Correlation is not causation.

                  So what! If we want to improve the relative health of Maori this involves both primary care and treatment access. And if we will not do this for the indigenous people what does it say about our signing UNDRIP?

                  • Molly …
                    21 June 2023 at 5:07 pm

                    "So what!"?

                    I support policy based on robust evidence, which I believe has a better likelihood of achieving long-term sustainable change.

                    I don't have the motivation of politicians to produce well-packaged, easily digestible, simplistic answers to complex issues.

                    My power lies in my electoral votes, and my ability to critique policies as they are released in the hopes that they will be improved upon.

    • Muttonbird 6.3
      21 June 2023 at 12:29 pm

      How odd. We should discard general statistical data for Māori because there are two rich Māori over there.

      • tsmithfield 6.3.1
        21 June 2023 at 2:19 pm

        No. We should apply problems highlighted by statistical data at the population level not the individual level.

        If we apply statistical data to individual cases, there will continually be instances where the shoe doesn't fit, and injustices will occur elsewhere as a result.

    • Anker 6.4
      21 June 2023 at 4:23 pm

      100% TSmithfield. All well made points.

      • weka 6.4.1
        21 June 2023 at 4:55 pm

        all your comments are going into trash until you reply to moderation. Please look at the Replies list for my comments.

  7. SPC 7
    21 June 2023 at 10:05 am

    The effort seems to be to frame any inclusion of ethnicity as a factor amongst others as a move to an ethnicity/race based system.

    Misrepresentation, the new pretty legal.

    • Molly 7.1
      21 June 2023 at 10:19 am

      "The effort seems to be to frame any inclusion of ethnicity as a factor amongst others as a move to an ethnicity/race based system."

      In terms of healthcare and giving precedence using ethnicity – rather than medical factors only – how is this not "an ethnicity/race based system"?

      • SPC 7.1.1
        21 June 2023 at 10:34 am

        If that was a fair description – how would one describe any state subsidy of the private education and health insurance system reserved for those who can afford the cost of entry – given the under-representation of Maori in that group?

        • Molly 7.1.1.1
          21 June 2023 at 10:38 am

          As one based on individual wealth – not ethnicity.

          • SPC 7.1.1.1.1
            21 June 2023 at 10:44 am

            Sure – akin to the lack of tax on CG, wealth and estate common in other OECD countries, a favoured class (of those with private wealth) notable for the relative lack of indigenous people in its make-up.

            • Molly 7.1.1.1.1.1
              21 June 2023 at 10:53 am

              Due to my ethnicity, you speak of me as a cohort apart from you.

              I personally find it insulting, and indicative of a racist perspective stemming from a (misplaced) sense of guilt and perhaps superiority.

              The pursuit of neo-liberal ideas in government and policy has affected many whose lives were based on the ability to live a well-balanced life in a one-income working class household.

              There is racism in New Zealand. But it is not necessarily the sole factor in poor outcomes.

              Improving access for ALL to high quality healthcare, education and opportunity is needed. Work-life balance and well-being should be able to be attainable on a working class wage – regardless of ethnicity.

              • SPC …
                21 June 2023 at 11:14 am

                Due to your ethnicity … you lost me there. What was your point again?

                I get the one New Zealand brand, but some aspiration to improve the lot of the indigenous people is not based on guilt or supremacism, but acceptance of Treaty redress and UNDRIP.

                And the old egalitarian dream requires tax on wealth.

                • Molly …
                  21 June 2023 at 3:24 pm

                  "Due to your ethnicity … you lost me there. "

                  You keep referring to me as indigenous – as if that is my primary identification factor. I find it absurdly racist, when I am on the receiving end of it. It assumes the actual contributing factors of poverty, housing overcrowding etc are a fundamental and unavoidable part of being Māori. There is also an implication that non-Māori are excluded from these factors – so a double hit.

                  " …get the one New Zealand brand, but some aspiration to improve the lot of the indigenous people is not based on guilt or supremacism, but acceptance of Treaty redress and UNDRIP."

                  So says you. I disagree. I believe belated reference to a two hundred year old document, can be easily manipulated to give credence to a wide range of racist and undemocratic policies – that will benefit individuals within the political class – including those who are Māori.

                  "And the old egalitarian dream requires tax on wealth."

                  So says you. Again, I disagree. For the reasons stated on my past comments you are probably referring to.

                  Which also didn't include the probable occurrence that the really well-off hold their assets in business and overseas, which as far as I know aren't affected. The more I consider "the compelled donation to the government to obscure past and current failures" that you call the wealth tax – and look policies such as this, it is a blueprint for how not to govern for health and well-being of all.

                  • SPC …
                    21 June 2023 at 3:58 pm

                    I was referring to your stressing the irrelevance of ethnicity, then mentioning your own.

                    And for someone who posts so much about being a woman with woman's identity, are you going to call it sexist if one mentions need to focus some attention to neglected women's health (certainly at the issue of well known common conditions of women that are not well diagnosed and thus lead to years of delay for operations – as happens to some Maori for other reasons).

                    I believe belated reference to a two hundred year old document, can be easily manipulated to give credence to a wide range of racist and undemocratic policies – that will benefit individuals within the political class – including those who are Māori.

                    Sure claim other Maori are racist and have an undemocratic agenda, once assimilated into private wealth class culture.

                    It's related to iwi property claim. Nothing wrong with owning stuff and claiming compensation for theft.

                    Ask those who do not own property, how they rate in terms of wealth to others, have spare resources to cope with cost of living emergencies and obtain healthy housing in which to raise a family.

                    There is a reason why the aggregate statistics do not lie.

                    As to the past nostalgia (one income earner and home ownership and the 5 day week) – it was financed with a top rate of tax at 66%, subsidised home ownership (including the mortgage payment rebate) and family benefit etc.

                    And assets held offshore are already in the tax orbit.

                    • Molly …
                      21 June 2023 at 4:46 pm

                      "I was referring to your stressing the irrelevance of ethnicity, then mentioning your own."

                      You write of indigenous in terms of "the other". It's relevant to point this out, and attempt to avoid accusations of racism towards Māori, by informing you I am one. But it appears you are not easily embarassed – so be it.

                      "And for someone who posts so much about being a woman with woman's identity,"

                      … I've never posted about having a woman's identity….

                      are you going to call it sexist if one mentions need to focus some attention to neglected women's health (certainly at the issue of well known common conditions of women that are not well diagnosed and thus lead to years of delay for operations..

                      Sex, being both binary and immutable – has clear divisions in medicine. These sex based factors have been identified. Your comparator is poor.

                      "– as happens to some Maori for other reasons)."

                      How do you define ethnicity? And it is the throwaway phrase "for other reasons" which should be the most significant.

                      “It’s related to iwi property claim. Nothing wrong with owning stuff and claiming compensation for theft.”
                      Apparently this is only true – depending on ethnicity.

                    • Shanreagh …
                      22 June 2023 at 2:00 pm

                      As to the past nostalgia (one income earner and home ownership and the 5 day week) – it was financed with a top rate of tax at 66%, subsidised home ownership (including the mortgage payment rebate) and family benefit etc.

                      You write about this, it seems to me with a hint of criticism.

                      I can actually see nothing wrong with

                      • one income earner families, if they want to be ie choice
                      • home ownership
                      • 5 day week
                      • top tax rate of 66%
                      • subsidised home ownership including mortgage interest payment tax rebate
                      • family benefit paid to the non working partner if wanted.

                      when we look at what is available now.

                      For me the price for changes to these aspects have mainly been paid by the workers while benefitting bosses

                      eg

                      • we have frantic workers working 60-80 hours a week, often with no extra pay or OT
                      • we have workers on ghastly split shifts that enable a firm to maintain 24 or 16 hour coverage but do nothing for home/family life
                      • we have families of portfolio workers ie those holding down several jobs each, every day….
                      • we have diminishing levels of home ownership
                      • we have tax rates that favour the wealthy and do not use the tax system to best advantage. The Greens tax rates proposal is part of the 'wealth' tax proposal I support but it should be unlinked from the rest of the proposal

                      I feel that we could do worse than to be aspirational for some of these aims. We should not lock in regimes where everyone in a family has to work as a matter of survival

                    • SPC …
                      22 June 2023 at 2:40 pm

                      You write about this, it seems to me with a hint of criticism.

                      It was written to note howthe that society Molly misses was afforded (I could have added tariffs and strong unions to ensure higher wages), with some cynicism as to whether she would support measures of that sort to realise it.

                      The main problem with making that work today is the upward pressure on land values and how high our infrastructure costs have got.

                      In terms of employment law – we had the 40 hour week and overtime hours/penal rates. The ECA reforms allowed employers to break up jobs into segments and make people travel between jobs in their own time and at their own cost and without penal rates (for shift and weekend work). This single reform undermined our quality of life. For mine, people should not be required to be available for shift or weekend work to get a job.

                      The other issue is support for the non working partner. It's long past time for there to be partner access to income support between jobs (no work test if children are under 5). This would help disabled people who find partners and also those on the DPB as they begin to form new partnerships.

  8. Darien Fenton 8
    21 June 2023 at 1:09 pm

    Seemed fair to me : Factors : 1. clinical priorities, 2. time spent on the waitlist, 3. geographical location, 4. deprivation level. 5. ethnicity. It's not new btw : it has been used in DHBs before but just a beat up and opportunity to have another go at dividing the country.

    • Molly 8.1
      21 June 2023 at 4:48 pm

      I understand 1. and 2., but how did 3., 4. and 5. make it into the algorithm?

      Why geographical location?

      How is both 4. and 5. ascertained? I've never been asked my socio-economic group in forms completed for the Ministry of Health.

      • Shanreagh 8.1.1
        21 June 2023 at 6:38 pm

        How is both 4. and 5. ascertained? I've never been asked my socio-economic group in forms completed for the Ministry of Health.

        Yes quite.

        If the same methodolgy is used here as was used in a much derided funding provision in my suburb to enable older villas to be be upgraded for bathroom & kitchen facilities, it was done by access to stats (from the census) down to mesh block level. This showed that those living in the western part of the suburb had lower incomes than those on the eastern part. Western part was had a higher proportion of rented accomodation while the eastern part had young families renovating with sweat equity, multiple jobs etc .

        The funds were not targetted at landlords but at those with a higher place on the deprivation index because they were renting. But renters could not access the funds. While the ones in east probably had higher gross incomes but mortgages and high costs of renovation and maintenance that they were doing the hard yards and could really have done with help, which came with low cost architectural advice.

        So mesh block or postcodes can be analysed from the census and 'conclusions' made. To say that when using this kind of data you need to be careful with assumptions and conclusions and look at all elements would be a basic thought. The allocation of funds in this case in my suburb that did not give enough weight to ownership patterns and looked at incomes only and got way off track..

        And again Molly, to do this kind of study properly we get back to the idea you have mentioned before and that is net income as others may have low cost or subsidised housing and other $$$ plans that give them more in the hand than others who are perceived to be on a higher gross income and therefore 'wealthier'.

        Having worked in the health sector we need to be looking at what happens before we get to the lists (or doesn't happen) as well as managing the lists.

        Rural people, low income people also have poorer access to basic health care. So a drive to a centre with a medical centre may be problematic because of transport issues.

        For some, including Maori there is a need to be able to access care from their own, at marae etc, having people who can work across traditional and Rongoa Maori remedies.

        In some areas great strides have been made doing this (Kokiri marae (Seaview) and Papawai marae (Greytown) are two in my area. They have clinics and focus on wellness for their populations. Wainuiomata marae holds wellness clinics and works in with local practitioners and in the area of Southland where my sister lives some of the 'heavy lifting' as far as timely access to vaccinations for Covid for all the population in the small area were handled by one of the marae there…..a tiny marae that geared up.

        Bonding or pay scales to encourage a rural presence may be good.

        But it is not only Maori but often women too who have to accept a lesser service in rural areas. One car, don't drive, no public transport, single sex (male) practices, no ethnic diversity, no money……

        All parts of the algorithm need to be looked at. This week we have seen inadvertent double counting in the roading/speed limits proposal in Wellington. So each element in the algorithm needs to be interrogated to make sure that it does not include elements of the others, to avoid double counting.

        So from Darien's post

        1. clinical priorities, 2. time spent on the waitlist, 3. geographical location, 4. deprivation level. 5. ethnicity

        Is time spent on the waiting list linked to geographical location? In some areas it will be because all residents in a location eg say Wairoa in Nthn HB would need to travel for specialist advice, All Whanganui residents access some specialists at mid Central (Palmerston North). Clinics by bringing specialists to the centre are a way but people in Wairoa rural and Whanganui rural areas will still need to travel.

        I can see that there could be some fuzziness in thinking here between 2 & 3.

  9. Gosman 9
    21 June 2023 at 1:54 pm

    ACT managed this brilliantly in the house yesterday as they put forward all their MP's who have Maori whakapapa to ask questions over why should they get preferential treatment over others due to their ethnicity. It led to Marama Davidson being ejected for allegations of racism which looks foolish when the people she is accusing of this can claim to be Maori as well.

    • weka 9.1
      21 June 2023 at 2:06 pm

      Māori people can ask racist questions too Gosman.

    • SPC 9.2
      21 June 2023 at 2:24 pm

      So people who can afford health insurance and represent class interest are not supportive of provision based on greater need, including an ethnic group suffering health disadvantage …

      And use the excuse that the targeting in this case is based on ancestry/ethnicity being one of the indigenous people. Do they recall ACT offering confidence and supply to the government that signed UNDRIP?

      • Shanreagh 9.2.1
        21 June 2023 at 6:50 pm

        This is a generalisation.

        So people who can afford health insurance and represent class interest are not supportive of provision based on greater need, including an ethnic group suffering health disadvantage …

        One of the reasons that some take out privately paid health insurance is that they see it as a way to ease pressure on the public health system by doing their bit and paying for themselves.

        I have health insurance and have had it for over 40 years…..it was available through our union when I started in the PS. The sentence above was one of the points made in favour of taking it out.

        I would venture to say that if the health needs are catered for by interventions paid for by individuals this still takes pressure off the public hospitals. Any pressure taken off surely helps others access health care.

        This comment about class, health insurance is very similar to some of the arguments advanced to tax the so-called 'wealthy' A little kneejerk in my view perhaps not in the class of the politics of envy but somewhere along that line……

    • adam 9.3
      22 June 2023 at 2:05 am

      The best thing about Quentin Tarantino is he puts on screen some of the ugly aspects of the human condition for all to see. What I don't understand from the act members in the house is, why they felt they each had to give us their impression of Stephen Warren.

  10. pat 10
    21 June 2023 at 2:20 pm

    Its an upside down world when those opposing race based assumptions are labelled racist.

    • weka 10.1
      21 June 2023 at 2:30 pm

      it's not opposing race based assumptions. It's opposing redressing systemic racism that means that Māori and Pasifika people are badly served by the health system. Why anyone would oppose that is not yet clear, other than that they don't understand the policy and what it is based on.

      • Molly 10.1.1
        21 June 2023 at 3:27 pm

        Because it is not evidenced that the outcomes are due to ethnicity alone.

        And it should be addressed by identifying those contributing factors and implementing effective means to address them.

        What is being provided is a way to manipulate the outcome figures, without addressing the why.

        • weka 10.1.1.1
          21 June 2023 at 4:02 pm

          Because it is not evidenced that the outcomes are due to ethnicity alone.

          there are no single causes. Clinical issues don't sit in isolation either. Why do you expect ethnicity to?

          And it should be addressed by identifying those contributing factors and implementing effective means to address them.

          We already do this, or know but don't do it. Meanwhile, one of the drivers of poor health outcomes is poverty, and neither Labour nor National are willing to seriously address that. Why should Māori, who are disproportionately affected, put up with shitty health care in the meantime. And, poverty as a driver doesn't sit alone either.

          What is being provided is a way to manipulate the outcome figures, without addressing the why.

          That could be said about a very large chunk of the health system. Why do so many people need surgery in the first place? Shouldn't we be addressing poverty, diet, lifestyle, stress before giving people surgery? Yes, but the person needing surgery this year won't be helped by that.

        • Craig H 10.1.1.2
          21 June 2023 at 4:20 pm

          https://journal.nzma.org.nz/journal-articles/disparities-in-post-operative-mortality-between-maori-and-non-indigenous-ethnic-groups-in-new-zealand-open-access

          Results

          From nearly 3.9 million surgical procedures (876,976 acute, 2,990,726 elective/waiting list), we observed ethnic disparities in post-operative mortality across procedures, with the largest disparities occurring between Māori and Europeans. Māori had higher rates of 30- and 90-day post-operative mortality across most broad procedure categories, with the disparity between Māori and Europeans strongest for elective/waiting list procedures (eg, elective/waiting list musculoskeletal procedures, 30-day mortality: adj. HR 1.93, 95% CI 1.56–2.39).

          Seems to be a problem even after adjusting for other factors like age.

          • Molly 10.1.1.2.1
            21 June 2023 at 4:31 pm

            So, identify and address those identified factors.

            See if it is related to:

            Income: eg. returning to work earlier, not able to get support people, returning to an unheated overcrowded house,

            Work: Is work more physical in nature, shift-work etc.

            Access: Is access to aftercare not suitable for those on shift-work, unaffordable etc.

            Information: Are patients well-informed about aftercare and how to access help and support?

            It is the identification of contributing factors that will provide for everyone.

      • pat 10.1.2
        21 June 2023 at 5:05 pm

        The reality is everyone is being failed by a failing health system….you dont remedy that by prioritising on any basis other than need….that is what triage is.

        • Molly 10.1.2.1
          21 June 2023 at 5:08 pm

          Agree, pat.

        • weka 10.1.2.2
          21 June 2023 at 6:15 pm

          The reality is everyone is being failed by a failing health system….you dont remedy that by prioritising on any basis other than need

          They are prioritising on need.

        • weka 10.1.2.3
          21 June 2023 at 6:33 pm

          If two people of the same age with the same medical condition, the same general health, and having been on the waiting list for the same time present to a surgeon, how should the surgeon decide who goes first?

          • pat 10.1.2.3.1
            21 June 2023 at 6:58 pm

            if everything else is equal, toss a coin.

            • Incognito 10.1.2.3.1.1
              21 June 2023 at 7:03 pm

              Nope, you select the one who took longest to get on the waiting list.

              • weka …
                21 June 2023 at 7:18 pm

                it's like people haven't even thought about the rationales.

                • Incognito …
                  21 June 2023 at 10:20 pm

                  But it is more than just “rationales’; it’s based on real clinical experience in hospitals in Auckland and Northland accrued over some time (since 2020).

                  The cognitive dissonance here is strong today coupled with poor reading comprehension and not being familiar with the topic & facts. Plus a few other factors that I won’t mention because it will trigger the usual kneejerk responses from some.

              • pat …
                21 June 2023 at 7:20 pm

                "if everything else is equal"…im sure you can read.

              • Shanreagh …
                21 June 2023 at 7:36 pm

                Yes this is my point as well Incognito…..what happens prior to getting on the list?

                Remembering that all sorts of 'Micky Mouse' tricks have been done to 'manage' waiting lists over the years and people have been 'on' or 'off' or sent back to their GPs to manage.

                In some parts of NZ it is a postcode generated lottery, people who access healthcare ie on boundaries can work across the postcodes and get access to a couple of places (public hospitals in a couple of cities) with surgical facilities. They may have specialists who work in two public hospitals.

                Others have to rely on tertiary facilities half an island away (Gisborne/East Coast/Northern HB, rural Whanganui) getting an appt at a clinic is the first and often very difficult part. This is after your GP has felt you need more attention that they can give, and even bfore getting on the list.

                But before that is the provision of primary healthcare……Marae can provide wellness checks and a venue for specialists.

                All these points have been known for ages and ages. Health is the usual political football.

                Are we getting any better at all?

                Judging by Corey's views not much. Yet there has been a power of work done over the years by dedicated people wanting to solve the problems.

                Quite frankly, and you will scold as I've gone away from the topic, my belief is that the neo-lib crock has a lot to answer for. I feel sad that this current govt with its eye watering election result in 2020 and mandate has not explicitly unwrapped some of the stuff that was done then. Buying back the family farm/silver is always more $$$$-wise than you got from selling it in the first place……

        • Shanreagh 10.1.2.4
          21 June 2023 at 6:57 pm

          Agree with that wholeheartedly. The point being is that we are a poor-ish country and our people need early health interventions and we need to find a way to do that across cultural etc factors.

          If we generate more $$$ by bringing more new $$$$ in by selling goods that others want then we can lift up the income of the country. At the moment we seem to cutting a cake that is getting smaller and smaller while the numbers of people needing a piece gets larger and larger.

          NB easier said than done.wink

          • weka 10.1.2.4.1
            21 June 2023 at 7:21 pm

            NZ is not a poor-ish country though. And perpetual growth will block our ability to both mitigate and adapt to the climate/eco crises.

            early health interventions happen before someone needs even a GP. Eliminating poverty reduces the negative health impacts of poverty and takes the pressure off the health system and budget because less people get ill in the first place.

            • pat 10.1.2.4.1.1
              21 June 2023 at 7:44 pm

              If NZ is not a 'poorish country' why is our health system failing at the most basic level?

              Is it a lack of political will?

              A lack of expertise?

              A lack of funds?

              • Shanreagh …
                21 June 2023 at 7:51 pm

                Yes indeed.

                Our 'lucky country' neighbours with access to natural resources have untold advantages over NZ.

                • weka …
                  21 June 2023 at 8:26 pm

                  Australia is going to have a very hard time as the climate crisis deepens. Minerals are less important than rivers and the ability to grow food.

              • weka …
                21 June 2023 at 8:25 pm

                Decades of neoliberalism has put the wealth in the hands of people who don't hold values around things like public health good or raising all people out of poverty or stablising/lowering housing costs.

                We can try and increase wealth via traditional economic theory, but the transfer of that wealth will continue (look at what happened in the pandemic). The system needs an underclass to function, and it needs power and money to be in the hands of the few. These are features not bugs.

                Lack of political will? I guess. I think it's also lack of imagination expertise. It's not like we don't have alternatives, but few will take something like Doughnut Economics seriously, because they can't see how to get there from here (and tbf, we're not well socialised to be able to imagine such things and politicians are no exception).

          • miravox 10.1.2.4.2
            21 June 2023 at 9:24 pm

            The cake is getting smaller?

            https://www.macrotrends.net/countries/NZL/new-zealand/gdp-per-capita

            I don't think so, it's just bigger slices of the larger cake are going into fewer hands, not more hands, destroying the environment and egalitarianism in the process.

  11. tWiggle 11
    21 June 2023 at 4:11 pm

    Ask an engineer – a working model that fits 80% of cases is a pretty good one for most applications. I learnt the difference between the ideal research world and real-life applications when retraining into an engineering field. It doesn’t need to be perfect to work well.

    It appears you want a perfect surgical prioritisation algorithm, Molly, to address your ideal of perfect justice. And you seem to demand perfect definitions for grab-bag words like ethnicity used to evaluate surgical schedules.

    As commentators at TS are neither professional philosophers nor surgical staff or clinicians, I predict that you will not find the answers you seek here. An 80% approximation is good enough for most.

  12. Corey 12
    21 June 2023 at 4:24 pm

    I think they should add age to these criteria. Below 40 should get priority.

    The life expectancy for gen z and gen y has got to be low 70s if not mid 60s.

    Generation debt, with no assets, no hope of getting assets, lower buying power compared to previous generations due to decades of wages falling and not keeping up with growth, most of our incomes go to paying obscene amounts in rent for cold damp houses that make us sick, power and heating is disgustingly expensive, and healthy food or food in general in NZ is full on daylight robbery.

    Forget race. My generation is absolutely fucked. Period. Most of us will not make it to a pension if we do, pensions will not exist.

    Add to that climate change and paying of older generations debt.

    We are fucked beyond belief.

    And with obesity only getting worse and worse (some experts think 50% of the world will be obese by 2035) we probably won't even have a health system in 2050 because obesity at those levels will be unaffordable.

    If we're going to have no assets our entire lives swimming to work and working constantly, just so most of our wages can go to renting a damp box, and the rest of our money goes on luxuries like groceries, power and if the rich get our way , water! Working hard to make sure the state gives well housed older people pensions that we will never get, I think….

    People under 40 should get priority too.

    • Molly 12.1
      21 June 2023 at 4:53 pm

      "People under 40 should get priority too."

      Problem with such an approach, is that it is another value judgement. And if you prioritise location, deprivation, ethnicity and then youth, you will also be asked to prioritise carers – whose ill-health impacts on others, business owners – whose health may be a priority for ensuring workplaces continue supporting workers, people involved in health care – self explanatory, etc….

      Eventually, everyone is included and the priority becomes those with the most pressing clinical diagnosis or need.

      • Patricia Bremner 12.1.1
        21 June 2023 at 6:12 pm

        Well that went round the mulberry bush. crying I suppose I should just accept that family and friends got diabetes from sugar and flour, and or died early from smoking or drinking with related cancers, as their ancestors had not developed what was needed over generations to fight off the effects due to their ethnicity.

        Remember how we killed Indian children with the gift of milk biscuits. They lacked an enzyme needed, having been weened early. It was as if they were eating bricks. Their gut needed rice milk biscuits. Now they were disadvantaged through their ethnic diet. Why could we not accept the same could be happening here?

        Dead is dead, Your use of "causation". The surgeons and clinicians are looking for what is equitable… and sometimes they suggest ethnicity may play a part.. just as my red hair makes me prone to certain disorders or disadvantages.angry

        Why such a list stirs such hyperbole and loaded comments brings many of us to despair.

        • Molly 12.1.1.1
          21 June 2023 at 8:01 pm

          "as their ancestors had not developed what was needed over generations to fight off the effects due to their ethnicity"

          When this is directly evidenced – it should play a part in diagnostics.

          Like Sickle Cell Beta Thalassemia Disease – http://www.idph.state.il.us/HealthWellness/fs/sickle_beta_thalassemia.htm#:~:text=Sickle%20cell%20beta%20thalassemia%20(Hb,in%20people%20of%20Mediterranean%20descent.

          or Huntington's disease etc.

          Where is the clinical (not assumptive) evidence?

          • miravox 12.1.1.1.1
            22 June 2023 at 8:47 am

            I know I said I'd leave it, but just to understand how far you'd accept genetic differences by ethnicity…

            "When this is directly evidenced – it should play a part in diagnostics."

            And treatment that improves the lives of whole communities – not just the diagnosed person? Just one example – would you mind Māori and Pacific people's being at the head of the queue for one of our most common chronic and disabling diseases, i.e. gout?*

            https://bpac.org.nz/bpj/2008/may/docs/bpj13_gout_pages_29-31.pdf

            …Until recently very little information about the genetic basis of hyperuricaemia and gout in any population has been available. … A genetic variant within the GLUT9 gene which encodes for a glucose transporter has been associated with susceptibility to hyperuricaemia and gout… The initial results indicate a higher level of the GLUT9 variant in Māori, which may partly explain why Māori have inherently higher uric acid levels [and Gout]."

            And would you mind more resources, that could prevent gout and associated cardio-vascular disease and T2 Diabetes (and disability and death), being used to prevent gout attacks and disability in Maōri and Pacific communities (currently Māori and Pacific peoples are less likely to receive preventative treatment consistently). Thereby reducing waiting lists for everyone who have these serious health issues e.g. waiting for surgery for heart disease and diabetes-related amputations?

            Because that's the type of ethnicity-related waiting lists/differences in health resources we've been talking about for years and the complications of gout are particularly relevant to the Auckland waiting lists decisions.

            As the Jo Moir article states (and I paraphrase because waiting lists are for all medical conditions – not just the surgery that headlines to stir up public outrage)

            "… if the proportion of Māori and Pasifika on the waitlist exceeds their population percentage then a higher weighting is given to ethnicity… Clinical need is still the first consideration, however."

            *For people aged 20–44 years, the prevalence of identified gout for Māori and Pacific peoples is three and seven times that of non-Māori, non-Pacific populations. (HQSC Gout Atlas)

            • Incognito 12.1.1.1.1.1
              22 June 2023 at 9:12 am

              Thank you.

              There are other examples of genetic differences underlying increased prevalence and poorer prognosis in Māori and Pacifica peoples – more will come to light, as this is an active area of study & research. However, I fear your efforts will be in vain.

            • Molly 12.1.1.1.1.2
              22 June 2023 at 3:26 pm

              This is an attempt to isolate a preponderance of a particular disease amongst Maōri and Pacific communities – and use it to justify an argument for preferential consideration across all diagnoses.

              It is a fundamental flaw, not offset by what you have provided.

              " The initial results indicate a higher level of the GLUT9 variant in Māori, which may partly explain why Māori have inherently higher uric acid levels [and Gout]."

              The gout experienced by non-Maōri and Pacific people, is just as painful, just as debilitating, and just as detrimental to well-being.

              The information you have provided, indicates an option to test everyone who is diagnosed, to see if they have the GLUT9 variant, then their families can be informed. Much as women with the BRCA variant can inform those in their families of their higher risk for breast and ovarian cancer.

              "And would you mind more resources, that could prevent gout and associated cardio-vascular disease and T2 Diabetes (and disability and death), being used to prevent gout attacks and disability in Maōri and Pacific communities" …

              Health resources allocated for prevention should be spent with these outcomes for patients in mind, whether used by Te Whatu Ora, or any other government funded organisation. Access to healthcare providers who receive government funding, should not be limited to patients of certain ethnicities. Or is that what you are suggesting?

              "(currently Māori and Pacific peoples are less likely to receive preventative treatment consistently)."

              And the hard part is figuring out exactly why. Then determining which factors play the biggest part, and also what resources are required to change those factors to produce better outcomes.

              I understand completely that this logical pathway to long term improvement is not one you support.

              You (and others here) prefer to artificially improve the statistical outcomes for Māori and Pacific identified patients – and discount identifying and addressing all the contributors to current outcomes, or the negative impact on other patients with the same clinical profiles.

              So far, so unpersuasive.

              • miravox …
                22 June 2023 at 4:57 pm

                "And the hard part is figuring out exactly why. Then determining which factors play the biggest part, and also what resources are required to change those factors to produce better outcomes.

                I understand completely that this logical pathway to long term improvement is not one you support."

                Ha! that's funny. I have a PhD in doing exactly this. Here's a paper from it. Just so you know I’m not kidding. This is the the administrative data bit – from there, I asked people why they what prevented them early treatment, and what made making appointments difficult. I could see who got a second chance at an appointment if they missed one, and who didn't, I could see primary care providers consider what they termed 'poor behaviours' when they made decisions about who they would refer – because they felt the need to ration referrals. You can take a wild guess on who got the second chance appointments and early referrals.

                TLDR To achieve equitable access and outcomes, I found that health services needed to invest in communities in all sorts of ways, including considering ethnic differences in barriers to care.

                Again, until we can change our economic system, remove institutional racism and change priortising based on the ability to pay (private health care facilities) then the changes Auckland have made in their waiting list prioritisation (noting clinical need comes first) seem eminently practical and ethical to me. Fighting for the scraps is not the way forward, but nor is having another generation of Māori wait at the end of the queue until that happens.

                • Molly …
                  22 June 2023 at 10:34 pm

                  "Conclusion: Non-attendance is associated with ethnicity, age and waiting times. It is likely that high deprivation influences ethnic variations in attendance but reasons for young people's non-attendance were difficult to identify. Patients domiciled further from the main rheumatology clinic were also less likely to attend. The influence of ethnicity and deprivation may be underestimated in this study as high Maori and Pacific ethnic populations live closer to well-resourced clinics. Focusing administrative resources on at-risk groups and restructuring the clinical service to improve uneven waiting times would be expected to improve attendance rates across the region."

                  Your own conclusion has not managed to identify the contributing factors.

                  "Again, until we can change our economic system, remove institutional racism and change priortising based on the ability to pay (private health care facilities)…

                  Eliminate opportunities for institutional racism. Once again, you conflate private care access with equal access to public health.

                  then the changes Auckland have made in their waiting list prioritisation (noting clinical need comes first) seem eminently practical and ethical to me. "

                  Seems eminently political and unethical to me. Clinical needs should be the sole criteria.

                  "Fighting for the scraps is not the way forward, but nor is having another generation of Māori wait at the end of the queue until that happens."

                  You are supporting a fundamentally flawed solution by redirecting in a variety of ways.

                  Despite your research and PhD – I find them all unconvincing.

                  • Incognito …
                    22 June 2023 at 10:52 pm

                    Clinical needs should be the sole criteria.

                    Nope, clinical/health outcomes should be the sole criteria used to guide and justify decision-making. Therefore, ethnicity must be included as a confounding factor. NB this has already shown to improve health inequities in hospitals in Auckland and Northland, which is why it is now rolled out elsewhere too.

                    Your denial and wilful ignorance are inexcusable.

                    • Molly …
                      23 June 2023 at 11:03 am

                      "Your denial and wilful ignorance are inexcusable."

                      I guess I'll have to live with your condemnation.

                    • Incognito []
                      23 June 2023 at 9:44 pm

                      Nope, you’ll have to live with an inexplainable closed-off mind.

                    • miravox …
                      23 June 2023 at 9:53 pm

                      Nope, you’ll have to live with an inexplainable closed-off mind.

                      ^ This.

                    • Molly …
                      24 June 2023 at 9:31 am

                      Having failed to persuade via non-conclusive evidence supporting incoherent reasoning, it all boils down to: "^ This.".

                      laugh

                  • miravox …
                    23 June 2023 at 9:10 am

                    "Your own conclusion has not managed to identify the contributing factors."

                    The conclusion to a paper on administrative data wouldn't do that – it just gives broad categories – like ethnicity and age and location etc. You don't have to agree with me. Just do a google scholar search – I'd suggest "why maori dont get healthcare early"

                    The issue of of ethnic differences in healthcare access is long, but maybe it's getting a bit boring with researchers finding the same things over and over again – you could go back to the 1999 'closing the gaps' to see it was known back then that ethnicity is an important factor in delays to care – over and above socio-economic deprivation. That being Māori and living in socio-econimic deprivation was effectively a double banger for delayed care.

                    Reserchers have focussed on reasons for this situation and how to make equitable adjustments to improve access for people least likely to get early treatment since at least this time. Waiting list adjustments are by no means the only tool being used to do this.

                    "Clinical needs should be the sole criteria."

                    I don't know why you would think that is ever the case in a health system that has to ration it's resources and is staffed by real people with real biases. In an ideal world that might happen – people can turn up with identical problems and the staff, beds and other resources are available for the patients at the same time for surgery or consultation and these are completed for both patients. And the outcomes are the same (meaning their next lot of healthcare is the equally the same).

                    In our world none of that happens. Clinicians make judgements about who gets what when every consultation they have. Who gets referred, who gets surgery first? Is it the mum with no family support? The sole earner who might lose their job? or maybe the patient that needs a tweak to correct the outcome of the first problem.? Of course they make decisions that take into account social and other health circumstances.

                    And because they have to make judgements, clinicians can also (unwittingly maybe) let their biases show. Research has found (see google scholar search list, if you did one) that Māori are disproprtionately affected by this – whether they have a genetic predisposition or not.

                    "You are supporting a fundamentally flawed solution by redirecting in a variety of ways"

                    I take issue with your view I'm redirecting. I've been quite clear I believe we have a fundamentally flawed health system and that waiting lists and choices about where people are on them, is a blunt tool to compensate.

                    And until the system is perfected, my view is that equity is the best we have at compensating.

                    /ENDS.

                    • pat …
                      23 June 2023 at 10:05 am

                      A better use of (increasingly limited) resources for everyone would be to address the causes of the FSA DNA rate…not to reduce the effective throughput of the system by prioritising the non attendant cohort.

                    • Molly …
                      23 June 2023 at 10:59 am

                      "/ENDS."

                      /REBOOTS

                      "The conclusion to a paper on administrative data wouldn't do that – it just gives broad categories – like ethnicity and age and location etc. You don't have to agree with me. Just do a google scholar search – I'd suggest "why maori dont get healthcare early""

                      Sure. First paper is here:

                      https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1470538/

                      "EXPLANATIONS FOR HEALTH DISPARITY

                      A number of different explanations have been suggested for the inequalities in health between Maoris and non-Maoris. One common suggestion is that these differences are due to genetic factors.19 However, about 85% of genetic variation occurs randomly and is not related to race or ethnicity. The striking time trends in Maori mortality and morbidity during the 20th century demonstrate that environmental factors played the major role.20 Thus, although genetic factors may contribute to differences in health status between Maoris and non-Maoris in the case of certain specific conditions, they do not play a major role in population and public health terms.

                      Nongenetic explanations for differences in health between Maoris and non-Maoris can be grouped into 4 major areas focusing on socioeconomic factors, lifestyle factors, access to health care, and discrimination. These explanations are not mutually exclusive, but it is useful to consider them separately while bearing in mind that they are inextricably linked."

                      Now the disccrimination factor is the one that probably is the crux of the current policy. Let's see how that is determined and addressed;

                      The conclusions of this 2006 paper are interesting, especially given that some of concerns about Māori proiders have now been redressed. Funding is stabilised and patient bases should be as established as regular GP appointments

                      So, it seems instead of investigating further – and understanding why these changes have not had marked differences, the assumption of institutional racism takes precedence.

                      What other solutions could be proposed, implemented and measured? A proposal that comes to mind fairly easily, if we are talking prevention rather than ill-conceived "cure".:

                      1. Free yearly checkup for all NZer's to allow early identification of disease or areas of concern, Many people get this through workplaces, but not all and not typically those in lower-income employment and definitely those not employed. This would be a full bloodworks, and any other regular screening process. Train phlebotemists and other personnel to the level required to do this annual check – recording of blood pressure, weight, etc. People will only be called in if there are anomalies, and they should also be able to access the results themselves,
                      2. Make such checkups – and other services such as after-care – more accessible to shift-workers by having evening or weekend clinics.

                      We need a better health service for all.

                      ""Clinical needs should be the sole criteria.""

                      Fair enough that you point out this is not the sole criteria, i should have said the priority criteria, and pointed out that the standard resourcing constraints apply.

                      But it is interesting that your focus is on unconscious bias, and so your conclusion is to offset that with "conscious bias" for treatment.

                      "And until the system is perfected, my view is that equity is the best we have at compensating."

                      Your equity is based on assumption that ethnicity is THE reason that Māori can't see over the fence. I don't think your assumption is necessarily true. None of the recommendations you have made or provided actually isolate ethnicity or bias as the main contributing factors.

                      The solution is a poor attempt to redress an unknown and unevidenced factor – and call it racism when this is pointed out.

                    • miravox …
                      23 June 2023 at 11:51 am

                      A better use of (increasingly limited) resources for everyone would be to address the causes of the FSA DNA rate…not to reduce the effective throughput of the system by prioritising the non attendant cohort.

                      Hi Pat,

                      From administrative data, the standout reason for Māori FSA non-attendance in my field is long waiting times. Māori are likely to have been waiting longer to even get on the waiting list. Go figure.

                      Of course there are other reasons, and there are various ways these are being addressed, and yes, some of these are tailored to ethniticy, and also to other factors like age, rurality and gender.

                      Meanwhile – what to do about Māori (and Pacific peoples) who are over-represented, popoulation-wise on waiting lists, and have probably taken longer to get on the list in the first place. I support an equity approach that Auckland has taken to address this.

                    • pat …
                      23 June 2023 at 1:48 pm

                      Hi Miravox

                      From a public health user perspective getting a FSA (and subsequently joining a waiting list) is an unmeasured.

                      Referrals for basic investigation, nevermind specialist appraisal are regularly declined due to a lack of capacity….the circumstance of those declined is not known .

                      This is (again) not a policy designed to address the health issues of the community but a political statement.

                    • miravox …
                      23 June 2023 at 2:17 pm

                      Hi Pat

                      You might be better discussing your view with Duncan Bliss, Director Adult Surgery – ORLHN, OMS, ARHSD, Neurosurgery, Orthopaedics, Ophthalmology.. His data-driven view is: [my bold]

                      When Moir spoke to one of the people behind the algorithm, Te Toka Tumai surgical services manager Duncan Bliss, he told her that there was no arguing that what ethnicity you are has an impact on what sort of healthcare you get in New Zealand.

                      In every piece of data from the health system, Māori and Pasifika people were falling behind, he said.

                      "I said to him, 'Did you take into consideration how [the algorithm] would be received? Have you been surprised by the backlash that's come from this?'

                      "And his response to me was, 'Well, we haven't looked at it from race … it was based on data. We come at these things from a health perspective, we don't come at it from a political one',"

                      Maybe he can tell you whether he got his data from administrative systems of political actors.

                      DHBs might not be able to afford to do the research into such things who has who has been waiting longest, where they come from, and why, but doctors are often academics too, and use those resources, using a variety of methods, to investigate disparities in healthcare.

                    • pat …
                      23 June 2023 at 2:41 pm

                      Claiming political indifference dosnt make it so….if the policy is solely data driven then it should have been rejected as the data clearly shows it will make the system less efficient.

                    • miravox …
                      23 June 2023 at 2:54 pm

                      Claiming political indifference dosnt make it so….if the policy is solely data driven then it should have been rejected as the data clearly shows it will make the system less efficient

                      1. I think you're mixing up the fact that some people will use data as a political statement and some people will use data to improve systems despite others using it to sow dissent rather than understanding.

                      2. Can you give me a link that in your considered view will tell me how and why "the data clearly shows it will make the the system less efficient"?

                    • pat …
                      23 June 2023 at 4:02 pm

                      You provided the link yourself Miravox.

                      If you have a limited capacity to screen (as we do) and you increase the proportion of screenees who have a greater propensity to not attend you must decrease your throughput…and reduced screening throughput flows through to a reduced successful (treatment) outcome….do the math.

                      Data.

                    • miravox …
                      23 June 2023 at 4:19 pm

                      Really? That's a callous way of looking at things.

                      That data shows we need to do more to reduce barriers and improve access, not to leave a whole bunch of people on the healthcare scrap heap! – for people with long waiting times, one of those things was as simple as sending reminders (which is pretty routine now) before the appointments, given how far away the appointments are.

                      For others its to ensure the timing of the appointment fits within their employment commitments, to ask if the patient has transport/childcare and ensure they understand there importance of the appointment (i.e. improving health literacy).

                      A win-win for patients and EDs (which would have to deal with very sick patients who end up there because they were struck of the list).

                    • pat …
                      23 June 2023 at 5:13 pm

                      It is not callous…it is data driven (as the good doctor claimed)

                      What the data suggests is we need to address the causes of DNAs to FSAs and that will lead to an improved effective use of limited resources AND better outcomes for Maori and Pacifica (and young people, rural people and all those with a greater than average propensity to attend FSAs)

                    • miravox …
                      23 June 2023 at 5:21 pm

                      What the data suggests is we need to address the causes of DNAs to FSAs and that will lead to an improved effective use of limited resources AND better outcomes for Maori and Pacifica (and young people, rural people and all those with a greater than average propensity to attend FSAs)

                      That doesn't mean whe knock people off the waiting list. That means we address the causes of non-attendance so they (especially Māori and Pasifika and others with problems attending) can attend! Jeez.

                    • pat …
                      23 June 2023 at 5:35 pm

                      That means we dont try and solve a problem of non attendance by increasing the proportion of non attendees to pre treatment assessment …jeeez.

                      Talk about trying to solve a problem by ignoring the cause.

                    • miravox …
                      23 June 2023 at 9:19 pm

                      I'm sorry but we're miles apart in our interpretation of this subject that there is no point at all in continuing the conversation.

                    • pat …
                      23 June 2023 at 10:18 pm

                      It would appear so

                      I support changes that improve the effectiveness of a limited resource and you appear more concerned with making political statements.

      • Shanreagh 12.1.2
        21 June 2023 at 7:04 pm

        They used to look at families and earners before in an ad hoc manner ……another reason why for me as a mostly single person earning my priority was to keep myself earning. Having a health insurance was a way of doing this as well as keeping out of the public health system so others could access it.

    • weka 12.2
      21 June 2023 at 5:02 pm

      except there are people in all generations that live under those conditions.

    • SPC 12.3
      21 June 2023 at 11:16 pm

      Life expectancy is still on the upward trend. And there are no forecasts saying otherwise.

      Housing standards are not in decline (legislative requirements). And despite aggregate health supply demand factors being a concern, there are constant advances in medicine.

      Debt levels to GDP are not high by historic standards, but low. And not even with the cost of super to boomers will that change (there is $60B in the Cullen Fund)

      Whether Generation X and Y support the continuation of tax paid super is a decision that they will make – atm no one is proposing a move to contribution based super and means tested pensions which is the alternative.

      There will be a local capacity shortage of care to old boomers – lack of carers 9But hat is resolved by willingness to use migrants). But that is because of a demographic bulge – this does not apply to those of the younger generations (and is resolved by use of migrants as we do with medical staff).

      And while the impact of rising sea levels and more extreme weather events during the 21st C might well become greater than one of coastal erosion and inability to insure housing in flood prone areas, it's unlikely to impact on the working life period (more one of waiting for the retirement village to become a coastal resort).

      The real problem might be coping with the stress of being unable to save to own property and lack of rental security (one answer is long term housing supply by Investment Funds). There are political solutions, make sure the next Labour government has progressive tax and incomes policies.

  13. pat 13
    21 June 2023 at 6:00 pm

    I note the title of this post …Winning Ugly.

    It is the opposite…we are 'losing ugly' and its time to recognise the fact

    • Patricia Bremner 13.1
      21 June 2023 at 7:12 pm

      Winning ugly refers to Dirty Politics and Hollow Men, good descriptions of characters who fight ugly/dirty.sad

      • pat 13.1.1
        21 June 2023 at 7:25 pm

        Winning ugly in this post refers to abandoning the fundamental principle of treating everyone the same regardless of wealth, intellect, race or culture etc so as to atempt to retain the levers of power for a further 3 years so as to acheive SFA as has been demonstrated for the past 6.

        You can dress it up any way you like but that is the guts of it.

        • Shanreagh 13.1.1.1
          21 June 2023 at 7:47 pm

          Wow Pat yours and Corey's posts (at 4.24pm) are the most heartfelt and sad I have read for a while…….

          Thank you both.

          Yes holding on the levers of power, and what for, so we can throw out or abandon policies that will/may frighten the horses and hold on to the levers of power for another 3 years after this?

          • pat 13.1.1.1.1
            21 June 2023 at 7:54 pm

            "attempt"

            • adam 13.1.1.1.1.1
              22 June 2023 at 2:13 am

              Come on pat get real, the Tories are a leaderless mess at best, self interested to a fault and so far up their masters back passage it's xmas.

              Not saying labour much better, but I'm voting the maori party just to give all those corporate dogs the shits.

              • Shanreagh …
                22 June 2023 at 2:08 pm

                Good onya Adam.

              • pat …
                22 June 2023 at 2:41 pm

                "Come on pat get real, the Tories are a leaderless mess at best, self interested to a fault and so far up their masters back passage it's xmas."

                The 'real' that should concern you greatest is the fact that over 70% of those who intend to vote are willing to do so for organisations that consistently demonstrate a complete lack of ability to address the issues which afflict us.

            • Shanreagh 13.1.1.1.1.2
              22 June 2023 at 2:11 pm

              Yes Pat 'attempt' is much better and so having been circumspect, non threatening and therefore non adventurous for another three years where does that get us?

  14. Shanreagh 14
    23 June 2023 at 12:54 pm

    @ Molly

    The conclusions of this 2006 paper are interesting, especially given that some of concerns about Māori proiders have now been redressed. Funding is stabilised and patient bases should be as established as regular GP appointments

    So, it seems instead of investigating further – and understanding why these changes have not had marked differences, the assumption of institutional racism takes precedence.

    Yes this seems to be the case. Identify the problem, do nothing to follow up the findings and if called upon blame it on racism.

    Though in some cases there have been successes with strong marae based access. This goes only so far. Clinics and visiting specialists are great. But still for treatment many need to travel to access something that may alleviate symptoms. This happens for all rural dwellers and in areas where Maori are the majority in rural dwellers. Have they done studies on rural dwellers taking the next steps?

    Two interesting papers/thoughts in Stuff today 23/6/23

    Prof Dr Peter Davis who has been a researcher in health related population based issues for many years

    https://www.stuff.co.nz/opinion/132396631/using-ethnicity-to-decide-hospital-waitlists-doesnt-solve-the-real-issues

    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.

    …

    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.

    …

    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 to medical treatment.

    And yet, one of the most striking items of information I witnessed on the ADHB was the very high proportion of Maori and Pacific children who ended up in hospital despite suffering from conditions that were treatable in primary care.

    …

    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.

    When I worked in health in the 1990s (RHA) we looked at setting up GP clinics at hospitals to siphon off the common presenting GP-type issues, we encouraged clinics on marae, after hours clinics, Rongoa Maori.

    Since then work has been done to lessen payment, which had been identified as an issue. I have seen reports of a number of studies saying there are issues accessing primary health care but not very many seem to drill down and look at why? Are any of these initiatives still going? What were the conclusions?

    I do know that at the time there was a quiet/unstated resistance (primary & hospital care levels) to looking at population based funding/demographics and working to what that told us, particularly in areas where there was a high Maori population.

    Crudely, at that time, it seemed every hospital wanted the latest whizz bang technology, very few were interested in working as a centre of excellence or even just meeting the need for interventions, in Maori child health needs, or adolescent psychiatric conditions, family health. In the parlance of the time these were just not 'sexy'. We had a clinical leader at the time who said that depsite the need to fix our whole society really, that scope existed within the health sector for innovative work to ensure health needs were met especially in community and primary health care as Prof Davis is saying.

    Also in Stuff is this article

    https://www.stuff.co.nz/opinion/132392765/fairness-and-the-lack-of-transparency-about-elective-surgery

    Professor John McMillan is chair of the National Ethics Advisory Committee (NEAC) and editor in chief of The Journal of Medical Ethics (JME).

    I am grateful to see input on the ethical side of this.

    While he thinks that equity adjusters may work well he states

    But how can anyone reach an informed view about whether the equity adjusters are fair when they are not made publicly available? The lack of transparency about what they are and how they operate within algorithms creates an opening for those who want to discuss them in a negative way.

    …

    This problem is not confined to the equity adjusters; the elective treatment algorithms themselves are not as transparent as they once were.

    …

    We led the world in developing Clinical Priority Assessment Criteria (CPACs), and scoring systems were created for a range of elective treatments.

    CPACs drew upon the views of specialists about how patient need should be assessed. Then there was a national process where specialists within fields such as orthopaedics, cardiology and ophthalmology agreed the clinical criteria and how they should be weighted.

    …

    Prioritisation decisions involve deciding which patient should be treated first out of a set of patients who need treatment. While these are “clinical” judgments, they’re also fundamentally ethical judgments and, given the likelihood of reasonable disagreement about who should be treated first and for which reason, fairness requires that decisions are made in a consistent way using transparent criteria.

    The centrality of transparency for the fairness of publicly funded health care systems has been described in the British Medical Journal as accountability for reasonableness.

    Linking (my links) to the article about reasonableness highlights that

    To hold decision makers accountable for the reasonableness of their decisions, we have argued that the process must be public (fully transparent) about the grounds for its decisions; the decision must rest on reasons that stakeholders can agree are relevant; decisions should be revisable in light of new evidence and arguments; and there should be assurance through enforcement that these conditions (publicity, relevance, and revisability) are met.

    https://www.bmj.com/content/337/bmj.a1850

    Prof McMillan concludes

    This current heated discussion of equity adjusters has been fuelled by our losing sight of the importance of accountability and transparency when prioritising elective health care.

    I think the concern about the way the algorithms may be used has arisen because we do not know how they were developed, how they will be used etc. So their use falls over at a very early stage as there seemingly is not widespread knowledge about them,

    Just looking in from away it seems to me that this crude index may be a culmination of stalled, uncompleted, unacknowledged work across the health sectors on barriers to primary health care. Also we do not have any indication, that I have seen, whether access, including ethnicity being dealt with by special clinics, would have meant the ability to treat earlier in the ilness ie before they got to a hospital waiting list stage.

    Waiting lists and the people and conditions that have their lives tied up on them used to be intensively managed, it is hugely administrative and a mix of clercial and clinical expertise. With the clerical expertise needed it does fall into thos areas of not being 'sexy' and 'bureaucrats' and 'midddle management' and 'we need nurses' arguments.

    Actually you need both. Some work that was done a million years ago indicated that each surgeon. specialist operated, in the widest sense of the word, effectively with an average of 7 support people throughout the system. Clearly they'd share a part of the waiting list managers & their staff.

    This is this is the article about the CPACs.

    https://www.bmj.com/content/suppl/1999/02/04/314.7074.131.DC1

    Developed under the auspices of the Regional Health Authorities back in the day, as were the demographics and most of the studies I have mentioned here. Hopefully, finally, Te Whatu Ora will be able to build on the start made by this group.

    • Molly 14.1
      24 June 2023 at 9:07 am

      @Shanreagh

      Thanks for that. Very interesting reading, and salient points to the topic at hand.

      Your work in the health sector seems to be recorded in the 2006 paper I looked at above after miravox's recommendation:

      https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1470538/

      I had a couple of friends work in marae based primary care, and it seemed chaotic – whether due to funding issues, the expected disruption of new organisations before systems are established, or something other – I don't know.

      What did attract patients to register, was the fees free service.

      I come from a family with Maori ancestry on both maternal and paternal sides. However, there is a closer connection to marae etc from my mother's side.

      There is also a noticeable difference in personal motivation to see access healthcare between the two groups of relatives – which includes follow up when something is identified.

      .y family is large – over 70 first cousins on the maternal side, and around 27 on the other. So while not conclusive, it may indicate possible places to concentrate research to identify the reasons for such reticence.

      I'm basically a solutions person. I also want there to be no disparity in health outcomes – I just believe this is not only the wrong way to achieve it, but also yet another policy that feeds division.

      I'm warming towards the idea of a free, full annual workup – that would reduce some of the more expensive costs of treating advanced stages of disease if identified earlier, regular monitoring of our children's health, and making this yearly occurrence as accepted as possible.

      Specifically trained personnel – not fully trained nurses, could do most – if not all – of the assessment processes.

      All NZers would have a personal reference for their own health indicators.

      • Shanreagh 14.1.1
        24 June 2023 at 6:13 pm

        I'm warming towards the idea of a free, full annual workup – that would reduce some of the more expensive costs of treating advanced stages of disease if identified earlier, regular monitoring of our children's health, and making this yearly occurrence as accepted as possible.

        I think this is a great idea too.

        How do we deliver it? Have multiple ways and non threatening ways I am picking

        I also want there to be no disparity in health outcomes – I just believe this is not only the wrong way to achieve it, but also yet another policy that feeds division.

        I agree with this. Apparently the CPAC concept did stirling work, was publicly available and the able to be tested. Why is something like this not being updated? To me the Auckland scenario seems a bit (lot) kneejerk especially when well known 'elders' in the public health and medical ethics world have some concerns.

        I rank Prof Peter Davis highly.

  15. Drowsy M. Kram 15
    24 June 2023 at 11:20 am

    Imho, an adequate explanation for some of the opposition to positive discrimination / affirmative action programmes that aim to improve health outcomes for Māori and Pasifika communities in Aotearoa NZ can be found in this NZMJ article.

    Pākehā/Palangi positionality: disentangling power and paralysis
    [2 Sept 2022; PDF]
    Until Pākehā/Palangi recognise our power is strengthened by racist systems we will continue to look outside of ourselves for solutions rather than within.
    …
    “Proactive, mutually supportive, and innovative relationships between Tangata Whenua and Tangata Tiriti are our future. We should embrace the change and reflect it within our new outcome-focused and equitable health system.” [ – Sharon Shea]

    Individual and systemic (institutional/national) racial bias can be mutually-reinforcing. If observations of bias and iniquitous outcomes seem too close to home, it may be helpful to consider relevant health systems research and perspectives from other countries.

    Equity, Diversity & Inclusion: Race, Ethnicity & Culture [Toronto Uni]
    This Libguide is about equality, diversity, and inclusion in healthcare.

    Researching unconscious bias in health care – Michelle van Ryn, Ph.D. [2:34 mins]

    Affirmative action and equity in Aboriginal and Torres Strait Islander health [Sept 2005]
    The most obvious difficulty faced by Indigenous people who are beneficiaries of affirmative action is the self-doubt stemming from accusations that we do not merit such support. Unfortunately, it appears that many Australians still think Indigenous people get “too many benefits”. In one survey, almost a third of participants believed that car loans are paid for us by the government, and almost two-thirds thought that we receive more social security benefits than non-Indigenous people. In another survey, more than half of respondents believed Indigenous people were “treated over generously by the government”. The hostility to affirmative action programs, which is compounded by these misconceptions, can only be reduced through education that explains the benefits of diversity and the need to remedy historical injustice.

    Partnership for Justice in Health:
    Scoping Paper on Race, Racism and the Australian Health System         [May 2021; PDF]
    However, what is not considered here is the extent to which those very same organisations subscribing to the notion of a ‘representative organisation’ remain institutionally racist. High attrition rates such as seen in the teaching profession and examples of racial discrimination, as documented by Aboriginal police officer Veronica Gorrie in her memoir ‘Black and Blue’, suggest that unless institutions take steps to address racism within their own ranks, the ‘representative organisation’ approach will remain largely a ‘tick box’ exercise that effects no substantive change.

    I'm lumbered with several unreasonable personal biases that are so deeply ingrained they cannot be purged – all I can do is counteract them as best I can when they arise.
    If only I could counteract the biases that I'm unaware of – best of luck there.

  16. Shanreagh 16
    24 June 2023 at 6:31 pm

    I'm lumbered with several unreasonable personal biases that are so deeply ingrained they cannot be purged – all I can do is counteract them as best I can when they arise.
    If only I could counteract the biases that I'm unaware of – best of luck there.

    Thank you Drowsy. Very interesting links.

    I actually don't believe that the critiques by the people here and the ones I have linked to are personal biases. Certainly I know the work by Davis/McMillan is scholarly and Peter Davis is achieving doyen status as far as being a voice for funding being allocated from population or epidemiological work.

    Molly/me have a difference with the Auckland model on its benefits/ability to deliver while Miravox comes from the other way. I don't think any of us are expressing bias in a pejorative sense.

    As far as your last sentence is concerned, with a HR hat on, you would be the expressing the view that there is knowledge that you don't know..i.e 'knows what they don't know'. It will sing out a cautionary note as you have found, you know there are 'unaware biases'. This trait is a most desirable one for an employee to have…..And for a colleague poster here on TS to have. smiley

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