This week the political hot potato of surgical waitlists hit the headlines - after a new equity tool was rolled out for Tāmaki Makaurau surgeons.
Piloted in February, and now expanding further, the 'Equity Adjustor Waitlist Tool' is an algorithm used to score and prioritise patients for surgery, according to five criteria.
They are: clinical need, time on waitlists, ethnicity, location, and deprivation level.
Medical and public health experts have largely applauded the idea but some surgeons have expressed concerns, particularly around one of the five factors - ethnicity.
Te Toka Tumai Auckland (formerly Auckland DHB) has rolled the tool out to reduce surgical waitlists, in an attempt to tackle long-standing health inequities - especially for rural, low-income, Māori, and Pasifika peoples.
Opposition MPs have slammed the new tool, but health experts say it's long overdue.
Sir Collin Tukuitonga, population health expert and Associate Dean Pacific at the University of Auckland, told Newshub it's about time the equity adjuster was introduced.
"We've got a health reform process that is giving courage and opportunity to address inequities that have dogged our country for years."
Where did the equity tool come from?
The equity tool was built by a steering group at Te Toka Tumai (formerly Auckland District Health Board) last year.
The group included data and analytics specialists, Māori and Pacific health teams, and surgical services leadership.
It was then piloted in Auckland Hospital's urology surgical department, and was shown to have a positive impact on equity, warranting a further rollout.
Sir Collin said the tool is one initiative that came after the Pae Ora (Healthy Futures) Act (2022) became law last July.
Until now, he said, Aotearoa had been unwilling to put in place "serious interventions".
"Perhaps because there might be some public opposition," he said.
Te Whatu Ora told Newshub the pandemic affected equity worldwide, and the new tool would help identify patients who needed help earlier.
The most urgent patients will still be prioritised first.
Sir Collin said the health sector reform under Pae Ora that put this in motion was "a fantastic decision, in the sense it's a courageous decision".
"I don't think it's going to matter for the majority, because non-Māori and non-Pasifika will get their surgery - there's no question."
Dr Rawiri Jansen, chief medical officer at Te Aka Whai Ora, said ideas to reduce waitlists were needed after the pandemic interrupted planned care.
"We want to make sure Māori are not over-represented on that long-waiter list," he told TVNZ's Breakfast on Tuesday.
The notion that Māori are getting preferential treatment is "unfortunate and sometimes frankly offensive - and we should call it out", he said.
Dr Jansen said the goal was to slash waitlists, but in an equitable way.
Māori die on average seven years younger than non-Māori, which "is the official justification from Te Whatu Ora'' for the tool, Sir Collin said.
He doesn't know how much it will affect life expectancies, "but a lot of these surgical interventions will improve people's wellbeing, and quality of life".
Te Toka Tumai Auckland's 2021 annual report confirms even once Māori and Pasifika are in the system, "both groups wait longer for surgery and are more likely to have their surgery cancelled".
What does the medical profession think?
Dr Morgan Edwards, president of the New Zealand Society of Anaesthetists, said the society supports the new tool.
"This is an attempt to try and achieve more equity, rather than give any advantages," she said.
Dr Edwards pointed out Māori and Pasifika have a tougher time in the health system, whether that's seeing a GP, getting specialist referrals, and attending appointments.
That's before they even get on a waitlist.
By the time they're in line for surgery, Dr Edwards said Māori are likely to be at a later stage of disease.'
"They're already far behind their non-Māori counterparts. This is a small step to address that inequity," she said.
John Whaanga, deputy director-general Māori health at Te Manatū Hauora, told Waatea News the tool is evidence-based policy.
"My role is not to get involved in the politics but to draw on the evidence and the evidence is clear. We have to do fundamentally a better job for Māori."
Dawson Ward, acting director adult surgical at Te Toka Tumai Auckland, said three years ago they identified equity issues around access to care.
"We have demonstrated by the use of data that this is the right thing to do and is getting the results we want, so there is a lot of enthusiasm to roll it out further," he said.
Dr Mike Shepherd from Te Whatu Ora said health staff just want to ensure all Kiwis receive "the best healthcare possible."
"And this is part of that solution," he added.
The changes are based on evidence that shows Māori and Pasifika face more barriers in the health system, often before they even reach a surgical waitlist, Dr Shepherd argued.
"Early analysis shows the tool is effective at helping to eliminate the existing inequities," he said.
President of the Association of General Surgeons, Dr Vanessa Blair, said ethnicity is a risk factor for some health conditions.
"Bariatric surgery is an example - or gastric cancers, colon cancer, where Māori have higher risk," she said.
For emergency surgeries, she clarified ethnicity won't be a factor there.
The Association's members still had questions though, she said.
"What weighting is given to ethnicity?"
Everyone in Aotearoa would have surgery completed within four months, if there were enough fully-staffed and equipped surgical theatres, said Dr Blair.
Auckland bariatric surgeon Dr Michael Booth told 1News on Monday ethnicity had never really been taken into account for treatment.
"It has really been based around need."
"Bringing ethnicity into the debate is going to be problematic in some respects. What is a Māori for example," he questioned.
But Sir Collin said nobody disputes that clinical need must come first, however, "often need is higher in certain ethnic groups".
"We've always adjusted our interventions depending on population need - and ethnicity is an approximation of need."
He used bariatric (weight loss) surgery as an example.
Māori and Pasifika have higher obesity rates, but "surgical rates for gastric bypass is highest in Pākehā, and lowest in Māori and Pasifika", Sir Collin said.
A 2020 study looking at Counties Manukau publicly-funded weight loss surgeries shows Pākehā and 'Other European' patients are more likely to get a bariatric procedure actually done.
Sir Collin thinks that shows the total opposite of need.
"Here are two population groups with the highest need, yet they don't get what's needed."
What the politicians said.
On Monday, Prime Minister Chris Hipkins defended the policy at his post-Cabinet press conference, pointing out that the goal was to reduce waitlists "fairly and equitably."
Then on Tuesday, Hipkins told AM people shouldn't be getting less access to healthcare "because they are Māori, Pasifika, in rural communities, or on low incomes."
"What we're talking about here is people who are languishing on a waitlist for a less-urgent clinical need", not emergency surgeries, he said.
ACT leader David Seymour told AM on Monday it's "completely wrong" that ethnicity is part of the decision-making process.
"We've got a Government that is actually actively promoting racial discrimination now and it's got to stop," he said.
Also appearing on AM on Monday was Greens MP Chlöe Swarbrick, who said not to forget ethnicity was just one of five factors considered.
"I'm really loath for us to get into a debate just about that pure point of ethnicity."
Te Pāti Māori co-leader Debbie Ngarewa-Packer hit back at Seymour's comments.
"I guess that we're used to seeing them [ACT Party MPs] identify as Māori conveniently," she told Newshub on Tuesday.
Greens' health spokesperson Ricardo Menéndez March told Newshub colonisation has left lasting intergenerational effects - one of those being health inequity.
It has "created the conditions for many groups to die younger and face ill health," he said.
National's health spokesperson Dr Shane Reti spoke to AM on Tuesday, saying clinical decisions must be made on health need first.
"There are a range of factors that contribute to inequities. The way to address this is cultural competency training," he said.
Dr Reti added it's "still confusing as to what the weighting is going to be for ethnicity".
Health Minister Dr Ayesha Verrall said it was important to consider ethnicity in healthcare decisions.
"The reformed health system seeks to address inequities for Māori and Pacific people who historically have a lower life expectancy and poor health outcomes," she said.
Hipkins directed Dr Verrall on Monday to make sure the new tool isn't replacing one form of discrimination with another, before it's expanded nationwide.
But Sir Collin wasn't impressed with that.
"It's unfortunate the Prime Minister has intervened in that way. Courageous decisions need to be made if we're going to make an impact on inequity," he told Newshub.
What has the media reported?
Media reports have been variable on the topic, with the focus squarely on ethnicity in most of them, and the vast majority of stories written by non-Māori and non-Pasifika journalists.
"It's unfortunate that people have focused on ethnicity" when rural and low-income people also benefit from the new tool, Sir Collin told Newshub.
"Rural New Zealanders will tell you they have had equal disadvantage. Many of these folk are Māori too, of course."
He reiterated that the new tool is not just about Pasifika and Māori.
"This is about population groups that have not had a fair go, or their needs met."
The New Zealand Herald first reported the story on Monday, alleging that "several surgeons" were disgruntled by the move.
The anonymous "surgeons" spoke to Newstalk ZB, citing the need to prioritise patients by treatment urgency and time on the waitlist.
The consensus among medical and public health experts is the opposite - that these two criteria alone haven't ever worked well for Māori and Pasifika.
Stuff's Monday story claimed the Equity tool has had backlash "from many people", listing the lobby group Taxpayers Union and the ACT Party.
Te Ao Māori News featured three stories, one of them an opinion piece arguing in favour of the new tool.
Pacific Media Network didn't report on the Equity Tool, but instead featured a story about the Government's rheumatic fever strategy announced last week to tackle rates among Māori and Pasifika.
NZ Herald podcast The Front Page on Wednesday challenged the "ethics" of the Equity Tool, and also alleged the tool had caused "divisiveness".
Newsroom published a story angled on the fact that ethnicity has been a factor in surgical waitlist prioritisation for years, to deal with the Māori and Pasifika patients who were "disproportionately waiting for surgery compared with other population groups," particularly due to COVID-19 delays.
1News published two stories, and was the only large news company to include a report from a Māori or Pasifika journalist.
RNZ's coverage was largely based on political reaction, and had a couple of interviews with surgeons to balance it out.
Newshub's first story on the topic was angled on David Seymour's comments, after he appeared alongside Chlöe Swarbrick on AM.
The story on Newshub Live at 6pm that night noted that Te Whatu Ora had stepped in to provide comment on behalf of Te Aka Whai Ora / the Māori Health Authority.
AM host Ryan Bridge grilled the Prime Minister on Tuesday, over Māori and Pasifika "jumping the queue a bit", to which Hipkins responded "the opposite" had been the case in the past - with Dr Shane Reti also appearing on the show.
Newshub did a 6pm story Tuesday on Marama Davidson being booted out of Parliament after accusing the Opposition of racist questioning over the health issue, and had Brooke van Velden on AM Wednesday morning saying the "wheels [were] falling off the bus" for the Government.
ARE MĀORI AND PASIFIKA REALLY DISADVANTAGED IN HEALTHCARE?
Former Te Whatu Ora chair Rob Campbell said Māori and Pasifika patients must be a priority for healthcare, in an opinion piece for the NZ Herald Monday.
"Across a wide range of health outcomes - Māori and Pasifika people experience poorly relative to other populations," he said.
"I think the stirrers know that, and know that they are making an issue of something which is simply a rational and caring and equitable approach to queues which we must reduce for all."
A 2019 report in The Lancet Journal said inequity in Aotearoa has been entrenched through colonisation, which isn't "often cited as an explanation for health inequities".
The authors said due to colonisation, Māori have lower incomes, lower life expectancy, worse education, and health outcomes among other impacts.
"Furthermore, colonisation is often considered to be a historical event rather than an ongoing process that is negatively affecting the health of Indigenous people," the study said.
Sir Collin said the Equity Tool sends a signal to whānau that certain groups are being prioritised better now.
"Often Māori and Pasifika don't go to the GP. Even if they go, they're often not referred as readily as others. But what this does is GPs, patients, and their whānau can see this and say 'well if I'm concerned about my health, I'll make the effort to attend clinics'."
In 2019, the Waitangi Tribunal raised concerns about institutional and individual racism in the health system, coming after hearing evidence and consensus from witnesses.
A 2022 study by Waipapa Taumata Rau / The University of Auckland found that health inequities between Māori and non-Māori adults costs the country at least $860 million each year.
When it comes to life expectancy, the gaps between Māori, Pasifika and other ethnicities are stark.
For males, Māori live the shortest lives on average at 73.4 years, compared to Pasifika (75.4), Pākeha (81), and Asians (85.1).
For females, Māori again have the lowest life expectancy of 77.1 years, versus Pasifika (79), Pākehā (84.5), and Asians (87.9).
According to Te Aka Whai Ora, Māori die at twice the rate of non-Māori from cardiovascular disease.
Te Manatū Hauora data from 2021 showed Māori and Pasifika people were both significantly more likely to report cost as a barrier to seeing their GP than other ethnicities, often the first step before surgical referral.
So in the end, the Equity Tool will save taxpayers money in the long run, Sir Collin told Newshub.
The reason being, he said, was due to our ageing population, and inequities.
"As people get older, they need more healthcare."
He told Newshub you can't do anything about ageing, but you "can do something" about inequities, which in reduces the cost to the taxpayer.
"These decisions are good for all of us."
