I I I pauIAMA WHIRINAKI I Interwoven Paths I I o I I I I I I I I I The Report of the Central RHA Wanganui Need'S Assessment I
MOH Library IIII I 95503M I I I I I I POUTAMA WHIRINAKI I INTERWOVEN PATHS
The title ofthis report was given by Te Roopu Awhina - the Advisory Group I ofTe Ihonga Hauora, the Central Regional Health Authority.
The name literally means "Interwoven Pathways" and its translation is intend~d to I portray the interwoven paths ofTe Ihonga Hauora and the people ofthe Whanganui communities. I It is also likened to the untamed surging rapids and the tranquility ofthe Whanganui river. I "From the mountains to the sea I flow, I am the river and the river is me. "
"Ko au te awa, ko Ie awa ko au, I e rere marika ana ki te moana. " I I I I I
Published by the Central Regional Health Authority I Wellington. New Zealand March 1996 I ISBN 0-47~~20208~3 I WJ{ 'I I CONTENTS I
I EXECUTIVE SUMMARY 7
I CONSULTATION 9
CHAPTER 1: INTRODUCTION 11 I Needs Assessment Studies in the Central Region 12 Criteria for selection oflocalities 12 I Definition of the study area 12
I CHAPTER 2: SOCIO-DEMOGRAPHIC PROFILE OF WANGANUI 15 Highlights 16 I Source and Presentation of Data 17 Demographic Profile 17 I Total population 17 Population trends 17 Ethnic group populations 18 I Age/sex profile 20 Social Profile 22 I Family type 22 Household income 22 I Income support 23 Unemployment 24 I Accommodation 24 Educational qualifications 24 Access to private transport 25 I Summary 25
I CHAPTER 3: THE HEALTH STATUS OF W ANGANUI 27 Highlights 28 I Introduction 29 Hospitalisation 30 I Causes of death 31 Important health issues 32 Information Centre Ministry of Health Age-specific causes ofhospitalisation and death 44 Wellington 1 Summary 50
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CHAPTER 4: WANGANUI HEALTH SERVICES - WHAT THEY ARE AND HOW THEY ARE USED 53 I Highlights 54 Primary Care Services 55 I Secondary Health Services 64 Mental Health Services 66 I Alcohol and Drug Services 67
CHAPTER 5: CONSUMER VIEWS 69 I Highlights 70 Introduction 71 I Themes 72 Cost ofservices 72 I Choice 75 Continuity ofcare 76 I Other barriers to health services 76 Transport 77 I Weekend help 78 Horne visiting 78 Waiting times 78 I Quality issues 80 Early childhood services 82 I Information 82 Pharmacies 83 I Dental care 83 Provider attitudes 83 I Cultural 84 Carer relief 84 Characteristics ofsatisfactory services 84 I Priorities for change 85 I CHAPTER SIX: NGA IWI MAORI 0 ROTO 0 WHANGANUI - MAORI IN WHANGANUI 87 I Highlights 88 Introduction 89 I What Maori had to say 91 Issues raised at the consultation hui 92 Current services and their responsiveness to Maori health needs 99 I I
Poutama Whirinaki -Interwoven Paths 2 I I
CHAPTER 7: THE VIEWS OF COMMUNITY GROUPS 103 I Highlights 104 Introduction 105 I Overview 106 Who the groups represent 106 I Services used 106 The Most Important Health Issues for Wanganui 107 Major themes 107 I Social and political issues 107 Access 108 I Positive Aspects of Services Used 110 Access 110 I Information and communication III Customer satisfaction III I Aspects ofHealth Services That Are Not Meeting People's Needs 112 Access 112 Information and communication 114 I Consumer satisfaction 115 Suggested Improvements 116 I Access 116 Information and communication 118 I Increased resources 118 Priorities for Improvement 119 I Access 119 Information and communication 120 I Increased resources 120
CHAPTER EIGHT: HEALTH PROVIDERS' VIEWS 123 I Highlights 124 Introduction 125 ,I Our approach 125 Health Issues in Wanganui 126 I Children and adolescents 126 Elderly people 129 I Women's health issues 130 Maori 132 People who cannot pay for services 133 I People with mental health problems 133 Rural communities 135 I Other vulnerable groups 135
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Barriers to health care 136 Strengths of health care services available 138 I Problems in the provision of services 139 I CHAPTER 9: CONCLUSION AND RECOMMENDATIONS i41 Conclusion 142 I Key facts about Wanganui and its people - and what that means for health services 142 I Key health issues 144 Sexual health issues 148 Dental services 149 I Children and family health services 149 Services for older people 150 I Specialist services 151 Summary 155 I Strategic Framework 156 Macro issues 156 I Health service strategies 159 Timetable and estimated cost 170 Three year implementation plan 170 I
BIBLIOGRAPHY 173 I ACKNOWLEDGEMENTS 175 I APPENDICES 177 Appendix A: Advisory/Liaison Group 178 I Appendix B: Socio-Demographic Tables 179 Appendix C: Health Status Tables 182 Appendix D: Maori Groups 188 I Appendix E: Responses Received From Community Organisations 189 Appendix F: Wanganui Providers Interviewed 190 I I I I I
Poutama Whirinaki -Interwoven Paths 4 I. I I LIST OF FIGURES I Map ofWanganui and core area 13 I 2 Population proportion by ethnic group, for sub-areas ofWanganui District, 1991 19 3 Population proportion by life cycle age group, Wanganui District sub-areas, 1991 21
I 4 Population proportion by life cycle age group, by ethnic group, Wanganui District, 1991 21 'I 5 Household income distribution, by sub-area ofWanganui District, 1991 23 6 Dwelling tenure type, sub-areas ofWanganui District, 1991 24 I 7a All causes of hospital isation by gender and area, 1989-1994 30 7b All causes of hospitalisation by ethnicity and area, 1989-1994 30
I 8 Major causes ofhospitalisation for infants under one by area, 1989-1994 45 'I 9 Major causes of hospitalisation for children 1-4 years by area, 1989-1994 45 10 Major causes ofhospitalisation for children aged 5-14 years by area, 1989-1994 46 I 11 Major causes ofhospitalisation for males aged 15-24 years by area, 1989-1994 46 12 Major causes ofhospitalisation for females aged 15-24 years by area, 1989-1994 47
I 13 Major causes ofhospitalisation for males aged 25-44 years by area, 1989-1994 47 I 14 Major causes of hospitalisation for females aged 25-44 years by area, 1989-1994 48 15 Major causes ofhospitalisation for males aged 45-64 years by area, 1989-1994 48 I 16 Major causes of hospitalisation for females aged 45-64 years by area, 1989-1994 49 17 Major causes ofhospitalisation for adults aged 65-74 years by area, 1989-1994 49
'II 18 Major causes of hospitalisation for adults aged 75 years and over by area, 1989-1994 50 I 19 GMS claim rate per head of population 1993/94 56 :1 20 Dental benefit claims per adolescents 58 I :1 'I
:1 5 Poutama Whirinaki -Interwoven Paths LIST OF TABLES I I
Projected usually resident population by age group, Wanganui District, 1991, 2006 (medium variant) 18 I 2 Iwi affiliation, Wanganui District Council, 1991 20 I 3 All causes ofdeath by gender, ethnicity and area, 1988-1992 31 4 Asthma hospitalisations by ethnicity, area and age, 1989-1994 33 I 5 Diabetes hospitalisations by ethnic group and area, 1989-1994 34
6 Coronary heart disease hospitalisations by gender, ethnicity and area 1989-1994 34 I 7 Other heart disease hospitalisations by gender and area 1989-1994 35 I 8 Cerebrovascular disease hospitalisations by gender, ethnicity, and area, 1989-1994 35
9 All cancer hospitalisations by gender, ethnicity and area, 1989-1994 36 I 10 Leading causes ofcancer hospitalisations, 1989-1994 36 I 11 Grommets surgery hospitalisations by age, gender and ethnicity, 1989-1994 37
12 Fracture hospitalisations by gender, ethnicity, and age, Wanganui 1989-1994 39 I
13 Motor vehicle crashes hospitalisations by gender, ethnicity and age, Wanganui 1989-1994 40 I
14 Intentional self-harm hospitalisations by age, gender and ethnicity, Wanganui 1989-1994 41 I 15 Head injuries hospitalisations by age, gender and ethnicity, Wanganui 1989-1994 42 I 16 Psychoses and paranoid states by admission type and gender, Wanganui 1987-1991 43 17 Schizophrenic disorders - readmissions by age, gender and ethnicity, I: Wanganui 1987-1991 43
18 Neuroses and depressive disorders hospitalisation by age, gender and ethnicity, I,' Wanganui 1987-1991 44
19 Hospital-based services provided at Good Health Wanganui 64 ,I I
Poutama Whirinaki - Interwoven Paths 6 I I EXECUTIVE SUMMARY I This report presents the findings of a health needs assessment project carried out in Wanganui in 1995 and I makes recommendations on the basis ofthose findings. Wanganui was selected as one of the priority areas for the conduct of a comprehensive needs assessment I project, on the basis ofkey socio-economic factors associated with low health status and high health need. Locality studies which focus on particular high need areas have been used by Central RHA to target different I resources and/or improved services to the people in those areas to achieve health gains. The project focused on those suburbs adjacent to the west side of the Wanganui river, and two eastern suburbs. These suburbs, which in the report are collectively called the core area, were in turn selected, I because socio-economic indicators and previous studies suggested these were areas of higher health need relative to other parts of Wanganui. While people from a wide range of socio-economic groups and backgrounds live in both the core area and the rest ofWanganui, important population differences exist. The I core area has a higher proportion of younger people and Maori. Average household income and formal educational levels are low, unemployment and income support levels are high and children in the core area are more likely to be brought up in a single parent family. A higher proportion offamilies rent their homes I and greater mobility is reported.
There was evidence that people in Wanganui, in particular in the core area had poorer health status than I elsewhere. While the majority of people surveyed in Wanganui rated their health status as good or very good, the proportion who did so was lower than that estimated from the New Zealand Health Survey for the Central region as a whole. Mortality and hospitalisation data also suggest that people living in Wanganui, in I particular the core area ofWanganui, have worse health status relative to the region as a whole for a range of conditions. Wanganui had a higher age-standardised death rate than elsewhere and this was even higher in the core area. Ofparticular concern were the high rates of infant deaths in the core area, twice that ofthe I regional average. Hospitalisation rates for asthma, acute respiratory infections, heart disease, stroke, complications of pregnancy and birth, injuries, and mental illness were all higher in the core area. These I rates were even higher for Maori. Risk taking behaviour such as smoking, and motor vehicle crashes, many of which are likely to be linked to alcohol consumption, were higher in the core area.
The socio-economic and demographic characteristics ofa community, the availability oftransport, and the location and acceptability of health services provided, all influence the extent to which people will use them. A similar range of services are available in Wanganui as would be found in similar size cities in the Central region. However there is some evidence to suggest that people use some health services less frequently in Wanganui, than elsewhere in the region. Benefit claims, though a crude measure ofutilisation, tended to be lower in Wanganui relative to the region as a whole. Expenditure levels on general medical services (GPs), adolescent dental benefits and pharmaceuticals, were all lower than the regional average. There are a growing number of services provided by Maori for Maori in Wanganui, through the Te Oranganui Trust. However, the proportion ofMaori health providers remains small.
Unemployment, particularly among young people and Maori was seen as one ofthe major factors impacting on the health ofpeople in Wanganui. Being young and unemployed tends to be linked with negative factors I such as low levels of education, low self-esteem and limited life skills. This makes for more limited information-seeking skills, less confidence and ability to make use of existing health services. Cost of health services was a problem for many people, particularly those from the core area. People from low I income households, regardless of the source of income, found cost a major barrier to the use of health services, in particular GP fees and prescription part-charges.
7 Poutama Whirinaki -Interwoven Paths I While most people surveyed were generally satisfied with the level ofhealth services available in Wanganui, there was general concern that it was becoming more difficult to get help when it was needed. While cost I was the major issue for primary health services, waiting for an outpatient appointment or admission for non-urgent surgery was the major issue for secondary services. Such issues were also frequently raised in interviews with providers and in responses from community organisations. Consumers and community I organisations were more likely to raise issues to do with access to services, such as transport, length oftime waiting at GP or hospital outpatient appointments, and acceptability or appropriateness ofthe services. I Providers were more likely to focus on specific conditions ofconcern such as asthma, diabetes, risk taking behaviour such as smoking, alcohol and drug abuse, unprotected sexual activity, particularly in teenagers and the short, medium and long term implications of families at risk. While cost and waiting times were I commonly noted, the more limited information-seeking skills among some people, particularly the young and Maori were also seen as a barrier to ready access of health services. I While providers expressed general and specific concerns about Maori health and identified a number of factors associated with this (including health attitudes and behaviour and socio-economic factors), few suggested that part of the problem may lie with the services themselves. In contrast, a number of Maori I expressed strong opinions on a perceived failure ofmany health service providers, in the community and in hospitals, to recognise and accept the four cornerstones ofMaori understandings ofhealth. I The report concludes that the key issues identified largely reflect the Government's health gain priority areas of Maori health, child health and mental health, as well as issues related to youth and older people. Recommendations include measures designed to achieve health gains in these and other areas by: I
• working with other agencies to address those underlying issues which influence and shape health status and utilisation such as employment status, income and education and issues associated with user part I charges • supporting the development of a local health and information strategy in Wanganui I • providing greater support for families, particularly families at risk
• increasing health promotion and education services for youth, including Maori and rurally-based youth I
• purchasing additional early intervention mental health services for young people
• purchasing an alcohol and drug service from a Maori provider for Maori youth in Wanganui I • supporting older people in their wish to remain living in the community I • encouraging a more integrated, systematic and cost effective response by general practitioners and other health providers to the management ofconditions such as asthma, diabetes and glue ear and the reduction ofrisk taking behaviour such as smoking
• improving the availability of family planning services in Wanganui, particularly for women from low income households
• addressing issues for people with visual impairment
• improving the availability ofdental services for people on low incomes and health promotion and education programmes targeted to children and young people • initiating discussions nationally on anomalies in the subsidisation ofdisability support equipment. .:1 I
Poutama Whirinaki Interwoven Paths 8 I I CONSULTATION
I Central RHA welcomes your comments on Poutama Whirinaki - Interwoven Paths. I Please address written comments to: FREEPOST I Submission (Wanganui Needs Assessment Project) Central Regional Health Authority POBox 424 'I WELLINGTON Fax: (04) 472 7639.
'I You are also able to make an oral submission to us ifyou wish, during the week 13-17 May .lnfonnation on how to do this will be publicised closer to the date.
I Ifyou would like further copies or you want to make brief comments on this document please phone your local community coordinator: Barbara Robson I Phone/Fax: (06) 323 3034 Freephone: 0800404848.
I The closing date for submissions is 24 May 1996.
All submissions received will be independently analysed and an executive summary of the report will be I provided to you if a name and address is supplied. I I I I I I I I
I 9 Poutama Whirinaki Interwoven Paths I I I I I I I I I I I I I I I I I I I
Poutama Whirinaki - Interwoven Paths 10 I I I I I I I I I I Chapter 1 INTRODUCTION I .:. I I I I I I I I I I 11 Poutama Whirinaki -Interwoven Paths I NEEDS ASSESSMENT STUDIES IN THE CENTRAL REGION I
A number ofneeds assessment studies have been conducted by Central RHA to gain a comprehensive view I of the health status and health service needs of people in particular parts of our region. Similar studies to that undertaken in Wanganui have been carried out in Wairoa, Porirua, Hastings and Napier. I It is our responsibility, as the purchaser ofhealth services for the Central region, to work with communities to identify their unmet needs. We then work with them to develop strategies which will best address those I needs and improve their health. Needs assessment studies are one of the sources of information which Central RHA draws on in planning and purchasing health and disability support services for the people in the Central region. Our region is diverse, both in geography and people. It extends from Hawke's Bay in the I East to Wanganui in the West to NelsonfMarlborough in the South.
While Central RHA has developed a number of overarching strategies to guide our service purchasing, we I also recognise that communities have different needs which may require different solutions. Within a city, for example, areas with a higher proportion of people on low incomes, children, older people, Maori or Pacific Islands people are also likely to have higher and/or different health needs from other areas. By I focusing on particular high need areas through locality studies, Central RHA can target services to these areas to achieve health gains. I Criteria for selection of localities I Localities in our region were prioritised for study on the basis ofsocio-demographic factors associated with low health status and high health service needs. "Health and equity" (HEQ) scores developed by the Ministry I of Health using Census data (including variables such as ethnicity, age, income level and source, marital status, education, home and car ownership, and household status) were used to rank each Census Area Unit in the region. I
Wanganui was one of the localities which had a significant number of Census Area Units, with scores indicating higher "socio-economic deprivation". Earlier studies also suggested that some areas in W anganui I had higher health needs than others. I The poor health status of Maori in Wanganui and surrounding areas has also been confirmed in other studies.2 I
Definition of the study area I
The Wanganui Needs Assessment Project is focused on Wanganui urban area (which we call simply Wanganui), but also takes into account the surrounding district. Because the focus ofthe study was those I parts of Wanganui which might have the highest health needs, a "core area" made up of Census Area Units with the lowest socio-economic status was defined. The core area has been defined as a "likely best fit", to help focus analysis. Itdoes not imply any absolute division from the rest ofWanganui. Chapter 2 provides I further information on socio-economic differences within Wanganui. The "core area" included 12 of Wanganui urban area's 27 Census Area Units: CastlecliffNorth, Castlecliff South, Mosston, Balgownie, I Gonville West, Laird Park, Wanganui Central, Cooks Gardens, Lower Aramoho, Upper Aramoho, Wembley
1 O'Connor P 1989. Health Facts 1989: Health statisticsjor the Wanganui area, Wanganui: Public Health Unit. I 2 Thompson L 1993. Politics ojHealth. Responding Personally: Developments in Maori Health. Wellington: Public Health Association Annual Conference.
Poutama Whirinaki -Interwoven Paths 12 I I Park and Putiki. (See Figure 1) With the exception ofWembley Park and Putiki on the east ofthe river, the I areas selected form a fairly coherent physical community. I Figure 1: Map ofWanganui and the core area I I
I Wanganui I • Core area Rest ofWanganui I f-LLL4--'--'---Y 2 km I Castleci iff Putiki I Balgownie Methods used in carrying out the needs assessment
I Developing local networks I From the outset the Central RHA project team sought to establish and build relationships with key people and organisations in the Wanganui community. A project such as this needs not only the co-operation of those who live and work in the community but also their involvement and commitment to identifying, I enabling and ultimately monitoring any changes that result.
The Wanganui Community Health Group was consulted early in the process. A number ofmembers ofthe I group also made valuable direct contributions to the project. The project team also met with members ofthe local iwi at a hui at Te Ao Hou Marae and information about the project was sent to key health professional I organisations. We held meetings with officials ofthe Wanganui District Council, the Whanganui River Maori Trust Board, Te Puni Kokiri, Good Health Wanganui and Progressive Health Inc. A series of key informant interviews I were carried out with persons considered to be well versed on health and related issues in Wanganui. I Advisory group An advisory group was established with the support and co-operation ofthe Wanganui District Council and the Mayoral Task Force. The purpose of the advisory group was to provide a forum for liaison and I communication between the Central RHA project team and the Wanganui community. Members included key health provider groups, the local authority, other relevant organisations and community representatives. An independent chairperson was appointed. Meetings were held with the group throughout the project. I Initially the aim was to seek advice on the appropriateness of methods being proposed, and the conduct of
I 13 Poutama Whirinaki -Interwoven Paths I the research. Later the group was asked to comment on the conclusions and provide advice on priorities. The terms of reference and membership ofthe advisory group can be found in Appendix A. I
Carrying out the research I
In order to obtain as comprehensive a picture as possible, a number of different research methods were used. This included: I • a review ofprevious health and related studies and reports carried out in Wanganui
• an analysis ofthe socio-demographic characteristics ofWanganui (chapter 2) I
• an analysis ofthe health status ofpeople in Wanganui as measured by recent hospitalisation and mortality data and other sources (chapter 3) I • a description ofheaIth services available and how they are used in Wanganui (chapter 4) • interviews with consumers, in small groups and through survey techniques, about health and disability I issues, their use ofand views about specific types of services (chapter 5) • interviews with Maori consumers and discussions with representatives of Maori organisations at hui, to I ensure Maori experiences and views were obtained (chapter 6) • a postal survey ofa wide range of community organisations (chapter 7) I • interviews with the main service providers in Wanganui (chapter 8).
The conclusions and recommendations for different and additional services (chapter 9) were shaped by the I findings of the project, within the context ofGovemment and Central RHA policies. I I I I I I I I I
Poutama Whirinaki - Interwoven Paths 14 I Poutama Whirinaki - Interwoven Paths I HIGHLIGHTS I I • At the time ofthe 1991 Census, Wanganui had a usually resident population of40,899. This comprised 92 percent ofWanganui District's total population. I • Maori, numbering 6768, accountedfor 17percent ofWanganui's total population. • Major Iwi represented in Wanganui District are Te Ati Hau Nui -A-Paparangi (19 percent ofall people I with Maori ancestry), and Tuwharetoa (11 percent).
While the total population of Wanganui city grew by 4 percent between 1981 and 1991, the Maori population in this area increased by 23 percent. I
• The population ofWanganui District is projected to increase by around 7percent over the period 1991 2006. Much ofthis increase will occur in the older age group. I • The population ofthe core area is 18,678, and makes up 46percent ofWanganui 's total population. I • The rest ofWanganui has a population of22,221. Outside the urban area, 3591 people live in the rural areas ofWanganui District, including settlements up the Whanganui River. I • The core area has a relatively high proportion of young and older people, who tend to have particular health service needs. Twenty-seven percent ofthis area's total population is under fifteen years ofage, compared to 22 percentfor the rest ofWanganui. I
• The core area has a smaller proportion ofits population in the 65 plus age group than the rest of Wanganui (J2 percent as compared with 17percent), but this is still slightly above the regional average. I
• Two-thirds ofWanganui District's Maori population live in the core area; one-quarter in the rest of Wanganui; and 8 percent in rural Wanganui. I
• Twenty-seven percent ofthe core area's population are Maori, compared to 8 percentfor the rest of Wanganui, and 17percentfor rural Wanganui. I
• The core area is relatively poor in socio-economic terms. Sixty-two percent ofhouseholds in the core area received total income of less than $30,001 in 1991, as compared to 47 percent in the rest of I Wanganui.
• In the core area, 39percent offamilies received two or more types ofincome support in 1991, compared I to 22 percent in the rest ofWanganui.
• Forty-five percent offamilies with dependent children in the core area are single parent families, I compared to 23 percent in the rest ofWanganui.
• A significant proportion offamilies in the core area live in dwellings rentedfrom HOUSing New Zealand. I
• In the core area, 44 percent ofresidents aged 15 or over had no educational qualifications, compared to 30 percent in the rest ofWanganui. I
In the core area, 22 percent ofdwellings did not have private motor vehicles, compared to 12 percent for the rest ofWanganui. I I Poutama Whirinaki Interwoven Paths 16 I I SOURCE AND PRESENTATION OF DATA
I Infonnation has been drawn mainly from 1991 Census data (using Supennap 2, Statistics New Zealand's Census database), with additional material from Statistics New Zealand's 1993/94 Demographic Profile for I Wanganui District. Detailed data are presented in statistical appendices. 3 Besides the core area, data are presented, where appropriate, for "the rest ofWanganui" urban area, W anganui I (which is the total ofthe urban area), rural Wanganui (those parts ofWanganui District not included in the urban area), Wanganui District, and for comparative purposes, the Central region as a whole. I
I DEMOGRAPHIC PROFILE I _____Total population I The total num ber ofpeople who usually lived in Wanganui, at the time ofthe 1991 Census, was 40,899. This I comprised 92 percent ofWanganui District's total population of44,604. The population ofthe defined core area ofWanganui was 18,678, which was 46 percent ofthe total population I ofWanganui urban area. Outside the urban area, 3,591 people lived in the rural areas ofWanganui District, including settlements up the Whanganui River.4 The population ofCensus Area Units and defined sub-areas ofWanganui District are I detailed in Appendix B 1. I _____ Population trends
I Changes from 1981 to 1991
Over the decade 1981 to 1991, the population ofWanganui urban area increased by 4 percent-a growth rate I typical ofthe Central region as a whole. Most ofthis growth occurred in the early to mid 1980s. I Over this decade, the core area's population grew by only 1 percent, with a net population gain of 243 people. Area units with the greatest absolute population growth in the core area were Laird Park (147), Wanganui Central (90), and Gonville West (69).The only area unit with a marked population decline was I Cooks Gardens (down 24 percent, a net population loss of 141).
The rest ofWanganui experienced a higher growth rate: 7 percent (net population gain of 1,467). Within this I area, Springvale East experienced the greatest population growth (up 73 percent, a net gain of768).
J Because of random rounding ofCensus data (to the nearest multiple of3), figures in the tables will not necessarily sum exactly to the given totals. Compounding of these rounding errors may also lead to figures not being exactly consistent between tables, depending on the level of I aggregation. 4 Census data are not readily available for these small settlements, which are included in the Fordell-Kakatahi Census Area Unit.
I 17 Poutama Whirinaki Interwoven Paths I
The population of rural Wanganui grew by 8 percent over the decade 1981 to 1991. Most of this growth occurred in Maxwell area (up 25 percent, net population gain of258). I
The pattern of growth across each of Wanganui District's Census Area Units, and defined sub-areas, is detailed in Appendix B 1. I
Projected population I
There is no, information on the likely future population for different parts of Wanganui District. For that reason, the following information relates only to the District as a whole.S I
Over the fifteen years 1991 to 2006, the population ofWanganui District is likely to increase by around 7%. Using medium projections this would be a net population gain of2,894. I
Over this period, children aged under 15 years are projected to decline slightly as a proportion ofthe total population, from 24.6 percent to 23.1 percent. On the other hand, older people (aged sixty years and over) I will increase from 18.9 percent ofthe total population, to 20.1 percent. I Table 1: Projected usually resident population by age group, Wanganui District, 1991,2006 (medium variant) I
Age group (years) March 31 0-14 15-59 60+ Total I
1991 (base) 24.6 56.5 18.9 100 I 1996 24.8 56.1 19.1 100 2001 24.6 55.9 19.5 100 2006 23.1 56.8 20.1 100 I
Looking at this another way, the number ofchildren under 15 years ofage is projected to increase by only 1 percent over the fifteen years 1991- 2006 (an absolute increase of 153). In contrast, the number of older I people is projected to increase by 13 percent (an absolute increase of 1,123). I
-----Ethnic group populations 6 I
As at the 1991 population Census, there were 33,021 European, and 6768 Maori residents in Wanganui. These two ethnic groups together comprised 98 percent ofthe Wanganui population (81 percent European, I and 17 percent Maori). There were also 486 Pacific Islands people, and 420 people from other ethnic groups living in this area. I
5 Source: Statistics New. Zealand. Wanganui District Council Demographic Profi Ie, 1993/94 Series. Ethnic group - specific population projections I are not available at this geographic level. G Ethnic group definitions used in this analysis are as follows (except where otherwise specified): Maori: people who identified themselves as belonging to the Maori Ethnic Group, as either their sole ethnic group, or one ofthe ethnic groups to which they belonged. I Pacific Islands: people who identified as belonging to specific Pacific Island groups, including in combination with any other ethnic group, but excluding those who specified Maori as one of their ethnic groups. European: people who identified themselves as belonging solely to European ethnic group(s).
Poutama Whirinaki Interwoven Paths 18 I I Within the core area, Maori make up 27 percent ofthe total population, and European people 70 percent. In I rural Wanganui, Maori make up 17 percent ofthe total population, and European people 80 percent.
I Figure 2: Population proportion by ethnic group,for sub-areas ofWanganui District, 1991
1'1:1 ~ I 1'1:1 100% II) > 90% ..(.) II) c. 80% I I/) ...II) .5 70% c I 0 60% ..1'1:1 :i 50% c. 0 c. 40% I cu 0 30% -.... -0 20% I c 0 1: 10% 0 c. 0% ...0 I D.. Core area Rest of Wanganui Rural Wanganui I Sixty-seven percent of Wanganui District's Maori population (4,992) live in the core area, 24 percent I (l,773) in the rest of Wanganui, and 8 percent (603) in rural Wanganui. By comparison, 36 percent of Europeans (13,065) live in the core area, 55 percent (19,953) in the rest ofWanganui, and 8 percent (2,886) in rural Wanganui. Within Wanganui, the largest number ofMaori reside in Castlecliff, Gonville, Wembley I Park, and Aramoho. Area Units with the highest proportion ofMaori are Putiki and Balgownie (50 percent).
The number ofpeople in each ethnic group, for each ofWanganui District's Census areas and defined sub I areas, is detailed in Appendix B2.
I Iwi composition
Te Ati Hau Nui-A-Paparangi is the largest Iwi in Wanganui District, with 1,569 members. This iwi comprises I 19 percent ofall people in Wanganui District with Maori ancestry.7
Tuwharetoa is the next largest iwi in Wanganui District, with 912 members (11 percent). Seven other iwi I have 300 or more members in Wanganui District, as detailed in the Table below. One third ofthis area's people with any Maori ancestry are reported not to know which iwi they belong to, or not to belong to any I iwi. I
1 Total iwi figures are not necessarily identical to figures in other tables relating to the Maori population, as iwi data relate to people with any Maori ancestry a larger number than those who identified themselves in the 1991 Census as belonging to the Maori ethnic group. Numbers I for iwi given in the table do not necessarily add to the total given in the bottom row, as there will be some double counting of people stating affiliation to more than one iwi. There are also a large number ofseparate iwi, each with few members, not specified in the table.
I 19 Poutama Whirinaki - Interwoven Paths I Table 2: [wi affiliation, Wanganui District Council, 1991 I Population Percent
Te Ati Hau Nui-A-Paparangi 1,569 19 I Tuwharetoa 912 II Ngapuhi 483 6 I Ngati Kahungunu 453 6 Ngati Apa 420 5 Ngarauru 411 5 I Tainui (excl Ngati Haua, 348 4 Hauraki and Ngati Raukawa) Ngati Raukawa 345 4 I Ngati Porou 336 4 Don't knowlbelong 2,685 33 to any iwi I Total 8,202 100 I
Ethnic group population trend I
In Wanganui District as a whole, the Maori population increased by 21 percent over the ten years from 1981 to 1991, as compared to an increase of 2 percent for Europeans. The Maori population increased by I 24 percent in the core area over this period, while it declined by 4 percent in rural Wanganui. By contrast, the European population decreased by 5 percent in the core area from 1981 to 1991, while increasing by 12 percent in rural Wanganui. I I -----Age/sex profile
Twenty five percent ofWanganui District's usually resident population was under 15 years old at the time I of the 1991 Census. This compares to 23 percent for the Central region as a whole.
People aged 65 years and over comprised 14 percent ofWanganui District's total population. This proportion I is higher than the average (11 percent) for the Central region.
In the core area, the population is relatively young; with 27 percent in the under 15 years age group, and I 12 percent aged 65 years and over, as shown in Figure 3. By contrast, the rest ofWanganui has an older popUlation, 17 percent being aged 65 years or over. Rural Wanganui has relatively high proportions of I under 15 year olds, and 25 to 44 year olds.
As elsewhere, females out-number males at older ages, particularly over the age of65 years. The number of I people in each age-sex group is given in Appendix B3, for each ofWanganui District's defined sub-areas. I I
Poutama Whirinaki -Interwoven Paths 20 I I Figure 3: Population proportion by life cycle age group, Wanganui District sub-areas, 1991 35 I Beore area I 30 IiRest of Wanganui I I I 5
I o Under 15 15to24 25 to 44 45 to 64 65 & over I Age group (years) Ethnic group age profiles
I The age profiles ofMaori and European ethnic groups in Wanganui District are quite different, as can be seen in the Figure below. Fifty percent ofthe Maori population is under 20 years ofage, as compared to 28 I percent ofthe European population. Whereas 17 percent of Wanganui District's European population is aged 65 years or over, this is the case I for only 3 percent ofthe Maori population. This pattern ofdifference between ethnic group age profiles also holds for the core area. The profile ofthe small Pacific Islands population is similar to that for Maori. Numbers in each age group, for Wanganui I District's main ethnic groups are given in Appendix B4. I Figure 4: Population proportion by life cycle age group, by ethnic group, Wanganui District, 1991 40% I IiiiIEuropean 35% c::JOther I = 30% g= ;-25% ~ e I ~ ~20% 0 Q.=.r::: ~ '0 15%. I o '0- 10% -=(l) I ~ 5% (l) c. 0% I Under 15 15 to 24 25 to 44 45 to 64 65 & over Age group (years)
I 21 Poutama Whirinaki Interwoven Paths I SOCIAL PROFILE I
The following sections describe socio-demographic features of the population which tend to indicate high I community health needs.8 A range of indicators suggest that these needs are likely to be higher in the core area than for other parts ofWanganui. However, variations also exist within suburbs, as has been found in other places. Suburbs which appear to be financially better offmay also have residents who are less well off, I Or who for some reason or other have high health needs. On the other hand, suburbs which appear to be poorer may also have some residents who are better off, in terms ofboth socia-economic and health status. These local variations need to be taken into account when health and disability support services are being I targeted. I Family type I
In Wanganui District as a whole, 33 percent of all families with dependent children were single parent families, at the time of the 1991 Census. This is considerably higher than for the Central region as a whole I (24 percent).
In the core area, 45 percent ofall families with dependent children were single parent families with dependent I children, compared to 23 percent in the rest ofWanganui, and 17 percent in rural Wanganui.
Maori had the highest proportion ofsingle parent families with dependant children in Wanganui District as I a whole: 47 percent; compared to 25 percent for European families. I -----Household income I Household income levels in Wanganui are, on average, considerably lower than for the Central region as a whole. Fifty-four percent ofhouseholds in Wanganui District received total income 9 ofless than $30,00] in I 1991, as compared to 41 percent for the Central region. A marked difference is found between income levels in the core area-where 62 percent ofhouseholds received less than $30,001 -and the rest ofWanganui, as shown in Figure 5. I I I I I Barwick H 1991. The Impact ofEconomic and Social Factors on Health. Report prepared for the Department of Health by the Public Health Association ofNew Zealand.
Total income, including income support, before tax, received by persons aged 15 years or over in respective households, from all sources, for I the year ended 31 March 1991.
Poutama Whirinaki -Interwoven Paths 22 I I Figure 5: Household income distribution, by sub-area ofWanganui District, 1991 20 I fEl Core area 18 Ii Rest of Wanganui
CI) I :E 16 0 J: 14 Cl) CI) ::: 12 0 I J: 10 -0 c 8 I :r0 0 6 Q. 0 a..~ 4 I 2
° $ 5,000 $10,001 $20,001 $30,001 $50,001 I or less (%) $15.000 $25,000 $40,000 $70,000 (%) (%) (%) (%) I Total household income
However, there is considerable variation ofhousehold income within both the core area, and other parts of I Wanganui. In the core area, median household income ranges from $16,659 in Gonville West, to $30,372 in Putiki. In the rest ofWanganui, the median ranges from $20,730 in Kowhai Park, to $41,409 in Bastia Hill. Some ofthis variation may be accounted for by different size (and hence earning potential) ofhouseholds in I different areas. Similarly differing age composition ( the proportion ofpeople in retirement age), influences I the average earning potential in respective areas. I -----Income support
In the Wanganui District, 77 percent of families received some kind of income support in the year ended I March 1991, as compared to 70 percent for the Central region as a whole.
Main types of benefit received were National SuperannuationiGRI (19 percent of families) and Family I Benefit, alone or in combination with other benefits (24 percent). Two or more benefit types were received by 29 percent of families in Wanganui District, compared to 21 percent for the Central region as a whole. Within Wanganui, 39 percent offamilies living in the core area received two or more benefits, compared to I 29 percent in rural Wanganui, and 22 percent in the rest ofWanganui.
Eighty-five percent ofMaori families lO in Wanganui District received some kind ofincome support, compared I to 76 percent of non-Maori families. Two or more benefit types were received by 47 percent of Maori I families, compared to 26 percent ofnon-Maori families. I I 10 Families in which at least one parent identified as of Maori ethnic group.
I 23 Poulama Whirinaki Interwoven Paths I -----Unemployment I In Wanganui District, 7 percent of the population aged 15 years or over were unemployed, as at the 1991 Census, compared to 6 percent for the Central region as a whole. Within Wanganui, the core area had a higher rate of unemployment, at 10 percent, than rural Wanganui (7 percent), and the rest of Wanganui I (5 percent).11 I _____Accommodation I Thirty-nine percent of homes in Wanganui were owned without mortgage at the time of the 1991 census. This is a higher proportion than for the Central region as a whole (34 percent). Mortgage-free ownership is highest (45 percent) in the "rest ofWanganui", and is related to the comparatively high proportion ofolder I people in this area. While mortgaged home ownership is found in similar proportion across the three sub areas of Wanganui District, the core area has a significant proportion ofdwellings which are rented, many from Housing New Zealand (I I percent). In rural Wanganui, a substantial proportion of dwellings I (I9 percent) are tenanted rent free (eg farm cottages). I Figure 6: Dwelling tenure type, sub-areas ofWanganui District, 1991 I I I I I I Ownecwitha Owned w;;''1OUl Rented RenteC, other Other/n.s. Mortgage a Mortgage From:Hous:r::; Corpo:ation (%) I _____Educational quali'fications I Thirty-six percent of Wanganui District's residents aged 15 or over reported in the 1991 Census that they had no educational qualifications a higher proportion than for the Central region as a whole (29 percent). I The proportion with no qualifications is considerably higher in the core area, at 44 percent. Of the Maori population in Wanganui District, 50 percent had no qualifications, as compared to 32 percent for non Maori. I
11 Data for 1994, derived from the Household Labour Force Survey, are not available below the level ofWanganui District, due to large sampling I error implicit in small number-based estimates.
Poutama Whirinaki -Interwoven Paths 24 I I I _____Access to private transport Sixteen percent ofWanganui's dwellings did not have motor vehicles available for private use, at the time of the 1991 Census - a higher proportion than for the Central region as a whole (13 percent). In the core I area, over one in five dwellings (22 percent) did not have any motor vehicles. This was considerably higher than for the rest of Wanganui (12 percent). In rural Wanganui, only 3 percent of dwellings had no motor I vehicle.
I Summary
A general pattern ofsocio-economic deprivation is found in the core area ofWanganui. Other sections of I this report look at how this is reflected in the health of people living in the core area and at specific service implications.
I I I I I I 'I I I I I I
I 25 Poutama Whirinaki - Interwoven Paths I I I I I I I I I I, I' II I I I I I :1 I I Poutama Whirinaki -Interwoven Paths 26 I I I I I I I I I' Chapter 3 THE HEALTH STATUS I OFWANGANUI .:. I I I I I I I I I
I 27 Poutama Whirinaki - Interwoven Paths I , HIGHLIGHTS . I I • Wanganui people living in the core area tended to have a higher early death rate, once differences in age groups were taken into account, than the rest of Wanganui. Male death rates in Wanganui were 61 I percent higher than female rates. The largest gender differences in death rates were found in the core area. • Circulatory and respiratory diseases accountedfor most ofthe differences in death rates between males I andfemales. Heart disease showed the biggest difference ofall, with men in the core area having twice as high a rate ofheart disease as women. I • Females went to hospital more overall, due to conditions linked to birth and reproduction. However, males tend to have higher rates for almost all causes ofhospitalisation. I • Although the total hospitalisation rates for Maori were higher than for non-Maori, the difference was greatest in the rest ofthe Wanganui area.
• During infancy, perinatal conditions (complications ofbirth which impact on the baby), acute respiratory I infections and birth defects were the leading causes ofhospitalisation.
• Among preschoolers, acute respiratory and ear diseases were the major causes ofhospitalisation.
• Respiratory diseases were the most common cause ofhospitalisation among school children (5-14), followed by upper and lower limb fractures. I
• In the 15-24 and25-45 age groups, the major causes ofhospitalisation differed between young men and women. For both age groups, conditions related to child bearing continued to dominate as major causes I ofhospitalisation amongfemales, while irifury-related conditions were the major causes ofhospitalisation among males. I • In the 45-64 age group, coronary heart diseases and cancer were the main causes ofhospitalisationfor males, while cancer andfemale genital disorders were the leading causes for females. I • Among the elderly population, cancers and heart disease continued to dominate as major causes of hospitalisation for both sexes. I • Both mortality and hospitalisation rates for chronic diseases except for asthma were higher for middle aged and elderly people. Hospitalisation due to asthma was highest in the core area. I • Hospitalisation rates were higher for coronary heart disease, cancer, and stroke in Wanganui than the Central region's average, and were also higher within the core area. Lung cancers among males and breast cancer among females were the leading causes ofhospitalisation in the Wanganui urban area. I • Vehicle accidents andinjuries were the leading causes ofhospitalisation among young adults, particularly young males. I • Psychoses andparanoid states, schizophrenic disorders, and alcohol/drug dependence were the main causes ofmental illness in the Wanganui urban area. I • Females were more likely to be admitted to mental health institutions due to psychoses and paranoid states, while males were more likely to be hospitalised due to schizophrenic disorders, or alcohol/drug dependence. I
Poutama Whirinaki Interwoven Paths 28 I I I INTRODUCTION . I This chapter describes the health status of people living in Wanganui. 12
I The best infonnation we have to describe people's health status is that on the causes of people going into hospital or dying. HoweVer, such infonnation provides only part of the picture of health, and has some important limitations. It does not tell us, for example, ofsickness which people treated themselves, or where I they sought help from their family, general practitioners or other primary health care services. While death rates give us infonnation about very serious conditions, differences in patterns of hospitalisation can also reflect the different ways medical staff may manage particular conditions, or different hospitals' admission I policies.
In order to overcome some ofthese limitations, a survey ofhealth service users was carried out in Wanganui I in May/June 1995. Results are included in this chapter, and complement our findings from secondary data sources and interviews with health service providers.
I Comparisons ofhealth status based on age (using eight life cycle groups), gender, ethnicity (Maori and non Maori) and geographical area are made throughout the chapter. Eight life cycle groups were identified. I Where possible, death and hospitalisation rates in the core area are compared to the rest ofWanganui.I3 In those cases where numbers are too few, the whole Wanganui urban area (called simply Wanganui) is compared I with the Central region. Particular attention is given to the core area, which was described in the Introduction. I4
I We also report findings on deaths, public hospital separations (discharges, transfers and deaths in hospital) and admissions to psychiatric hospitals. Is Data were analysed over a five year period as follows: I • 1988-1992 for mortality 1 July 1989- 30 June 1994 for public hospital separations I • 1987 -1991 for psychiatric admissions.
One way of finding out about health status is to ask people how they would rate their own health. When I people who took part in the health survey in Wanganui were asked this question, the vast majority (82 percent) felt their health was good or very good. A further 18 percent described their health as fair or poor. This group contained a higher proportion ofwomen and older people. Those people who said their I health was poor also made more frequent visits to health services.
The New Zealand Health Survey 1992 found that 90 percent of those aged 15 and over considered their I health to be excellent, very good or good. That means that a greater proportion of people in the Wanganui survey reported poorer health status than the national average. However this may reflect the survey population I used (users ofGP services), than a real difference between Wanganui and the New Zealand population. IZ Our analysis ofhealth status in Wanganui draws primarily on New Zealand Health Information Service national database collections and other studies in Wanganui.
I D Rates are only reported where the number ofannual average observations in the cell is equal to five or more.
14 Analysis ofthe health status ofpeople resident in the communities ofthe Wanganui river was not undertaken because the popUlations were too small.
I 15 For each ofthe data collections (public hospital separations, mortality and psychiatric admissions) five years of data were aggregated and an average per year calculated. I 29 Poutama Whirinaki ~ Interwoven Paths I -----Hospitalisation I During 1989-94 there was an average of 7,594 hospitalisations per year in Wanganui. The overall hospitalisation rate was slightly higher ( 1.3 times) than that for the Central region. Overall rates were even higher in the core area than in rest ofWanganui. I
Maori rates ofhospitalisation for all causes were higher than non-Maori in both the core area and the rest of Wanganui. I
Figure 7a: All causes o/hospitalisation by gender and area, 1989-1994 I
Area I Central region I Wanganui urban area I Rest of Wanganui I Core area
o 500 1000 1500 2000 2500 I Rate per 10,000 age-standardised to New Zealand total population 1991 • Female 0 Male I
Figure 7B: All causes o/hospitalisation by ethnicity and area, 1989-1994 I
Area I Central region I Wanganui urban area I Rest of Wanganui I Core area
o 500 1000 1500 2000 2500 Rate per 10,000 age-standardised to New Zealand total population 1991 I • Maori 0 Non-Maori I I
Poutama Whirinaki -Interwoven Paths 30 I I I Major causes of hospitalisation The major causes ofhospitalisation (based on average number ofpublic hospital separations) were similar for both the core area and the rest of Wanganui. The exception was perinatal conditions, which featured in I the top ten for the core area but not the rest, and arthropathies (such as rheumatoid and osteo arthritis) for which the reverse applies.
I There was some variation in the major causes of hospitalisation between Maori and non-Maori males, reflecting the different age structures of the two populations. 16 Cancers, coronary heart disease, chronic obstructive respiratory disease (CORD) and other heart disease were the most common causes of I hospitalisation for non-Maori males. CORD, perinatal conditions, acute respiratory infections and head injuries were the most common causes for Maori males.
I Normal delivery, pregnancy and labour complications, and reproductive disorders were the leading causes of hospitalisation for both Maori and non-Maori women in Wanganui. I I -----Causes of death There was an average of 462 deaths per year in Wanganui between 1988 and 1992. The overall death rate I for Wanganui was slightly higher than the average for the Central region. Mortality in the core area was 29 percent higher than in the rest of Wanganui.
I While males and females largely die from similar causes, they do so at different rates. As elsewhere, male death rates in both the core area and the rest of Wanganui were higher than female death rates for all age I groupsY The difference was more marked in the core area. While Maori health status in Wanganui as measured by mortality rates would appear to be better than the average for Maori for the region, caution should be applied in interpreting this finding due to the small I number ofdeaths involved. I Table 3: All causes ojdeath by gender, ethnicity and area, 1988-1992 Core Area Rest of Wanganui Wanganui Central Region I No* Rate** No.* Rate** No.* Rate** No.* Rate** Male 108 1,344 123 1,007 231 1,140 3,643 1,028 I Female 94 806 137 634 231 706 3,325 650 Maori 8 476 2 - 10 393 249 787 Non-Maori 193 1,109 258 807 452 926 6,719 808 I Total 202 1,028 260 796 462 891 6,967 811
* Average number of deaths per year 1988-1992 I ** Rate per 100,000 age-standardised to New Zealand total popUlation 1991
Death rates are highest in the first year of life and in the older age groups. Deaths in the over 75 year age I group accounted for about 54 percent oftotal deaths in Wanganui.
16 Central RHA 1995. Mortality and Morbidity Profile ofthe Central Region. Wellington: Central RHA. I 11 Central RHA 1995. Mortality and Morbidity Profile ofthe Central Region. Wellington: Central RHA. Ibid.
I 31 Poutama Whirinaki - Interwoven Paths I Major causes of death I The most common causes ofdeath in Wanganui during the period were, coronary heart disease, cancer, and strokes. Coronary heart disease accounted for 26 percent, cancer 23 percent, and strokes 11 percent of all deaths. As elsewhere, strokes accounted for a much higher proportion offemale (13 percent) than male (8 I percent) deaths. IS
The male rate for these major causes of death was higher than that for females. In particular, males were I nearly twice as likely as females to die from coronary heart disease and cancer.
The core area had slightly higher rates than the rest of Wanganui for the three most common causes of I death. I _____ Important health issues I In this section, we discuss patterns of death and hospitalisation for selected conditions. The conditions examined are: asthma, diabetes, circulatory conditions, cancers, injuries and mental health. These conditions have been selected as all are major and/or preventable causes ofhospitalisation and/or death in New Zealand. I
Asthma
Asthma is a major health problem for young people in Wanganui, as elsewhere in New Zealand. A survey I of children in Wanganui and surrounding areas found that asthma prevalence among children appeared to be slightly higher than that found in other areas. 19 Nearly a third ofpeople surveyed in Wanganui in 1995, or a member of their household, reported experiencing an attack ofasthma in the previous 12 months, and/or I currently taking medication for asthma. This is a similar proportion to that found in Porirua in 1994.20 A similar proportion ofchildren and adults reported having asthma in the Wanganui survey. A higher proportion ofpeople living in the core area reported having had an asthma attack (37 percent) than those people living I in the rest ofWanganui (27 percent). Passive smoking, allergens and viral respiratory infections are factors in asthma. Fifty-seven percent of survey respondents in Wanganui who reported that they or a member of their household had experienced an asthma attack in the last 12 months, lived in a household where someone I· smoked. This reflected the findings ofthe Porirua survey.21
Most people in the Wanganui survey who had asthma (89 percent) sought treatment from their GP, although I a small proportion sought help from the hospital outpatients' clinic. The vast majority of respondents (95 percent) had no problems getting help or advice for their asthma. I The overall rates of hospitalisation for asthma in Wanganui during 1989-1994 were one and a halftimes higher than those in the Central region. Rates in the core area were even higher. . I As elsewhere, hospitalisation for asthma is highest among children. Previous studies in Wanganui have shown that there is no difference in the prevalence of asthma between different socio-economic areas in I Wanganui. Despite that, children from the core area have higher rates ofEmergency Department attendances
18 Mortality and Morbidity Profile ofthe Central Region. Op cit. I 19 0 'Connor P 1991. Asthma Prevalence Survey Among Form One and Two Students in the WanganuilRangitikeilWaimarino Areas. Pub Iic Health Unit Wanganui. <" Central RHA 1994. Strong Links: Building better services to meet the health and disability support service needs ofpeople in Porirua Wellington: Central Regional Health Authority. p41. I 21 op cit p42
Poutama Whirinaki Interwoven Paths 32 I I and hospital admissions. 22 Between 1989 and 1994 the rate ofhospitalisation from the core area was double I that ofthe rest ofWanganui.
Table 4: Asthma hospitalisations byethnicity, area and age, 1989-1994
Ethnic group Age of life Core area Rest of Wanganui Wanganui Central region
No'" Rate'"'" No* Rate'"* No'" Rate"'''' No" Rate* * Total 1-4 52 340 30 240 82 295 1,066 192 I 5-14 31 99 19 57 50 77 567 44 15-24 16 52 10 33 25 43 352 25 total*** 134 65 82 40 216 52 2,944 34 I Maori 1-4 26 4]7 9 484 35 431 345 444 5-14 10 84 3 - 13 80 138 83 15-24 4 - 1 - 5 39 91 53 I total * * * 55 87 17 72 72 83 802 87 Non-Maori 1-4 26 287 21 197 47 238 720 151 5-14 21 109 ]6 55 37 76 430 39 I 15-24 ]2 57 8 32 20 43 261 21 total*** 79 59 65 36 144 46 2,142 28 I * Average number of public hospital separations per year July 1989-June 1994 ** Age-specific rate per 10,000 population I *** Rate per 10,000 age-standardised to New Zealand total population 1991 Although Maori hospitalisation rates for asthma were lower than for Maori elsewhere within the region, I they were nevertheless still higher than for non-Maori in Wanganui.23 I There was an average ofonly one death a year from asthma in Wanganui. I Diabetes It is estimated that around 3-4 percent ofpeople in New Zealand have diabetes, for about half ofwhom it is undiagnosed.24 The prevalence among Maori is estimated to be four to six times higher than among Europeans. I Surveys conducted in Auckland and Tokoroa have shown diagnosed diabetes among Maori to range from 6 9 percent. Among those who participated in the 1995 consumer survey in Wanganui, 10 percent ofhouseholds reported having a diabetic. This was a higher proportion than the 6 percent reported in the 1994 Porirua I survey.
The death rate for diabetes was 36 percent higher than the region as a whole, though because of small I numbers this difference should be interpreted cautiously. It was not possible to compare Maori and non Maori rates ofdeath, because numbers were too small (an average ofeight a year). However, other studies have shown that Maori death rates are higher in the Central region and that Maori die at a younger age from I diabetes.25 This finding is likely to also apply to Maori in Wanganui. I 22 O'Connor P ibid. O'Connor P, Miller A 1992. Review of Wanganui Hospital Emergency Department Attendancesfor Asthma in 1992. Wanganui. 23 Central RHA 1994. Morbidity and Mortality Profile ofthe Central Region. Wellington: Central Regional Health Authority. I 24 Statistics New ZeaJandlMinistry ofHealth 1993. Profile ofHealth. Wellington: Statistics New ZealandIMinistry of Health. 25 Ibid
I 33 Poutama Whirinaki -Interwoven Paths I Table 5 Diabetes hospitalisations by ethnic group and area, 1989-1994 I Ethnic group Core area Rest ofWanganui Wanganui Central region No'" Rate*"' No* Rate*'" No'" Rate** No'" Rate** Maori 4 21 2 17 6 20 162 41 ,I Non-Maori 11 7 15 6 26 6 641 8 Total 15 8 17 6 32 7 803 9 I * Average number of public hospital separations per year July 1989- June 1994 ** Rate per 10,000 age-standardised to New Zealand total population 1991 I The higher death rate in Wanganui compared to the region was not matched by higher rates ofhospitalisation for the disease. In fact, both Maori and non-Maori went into hospital with diabetes less than the regional average. I I Diseases of the circulatory system
This includes three diseases: coronary heart disease, cerebrovascular disease (stroke), and other heart diseases. I
Coronary heart disease I
The overall death rates for coronary heart disease were similar between Wanganui and the Central region, and between the core area and the rest ofWanganui. As in the Central region, male death rates in Wanganui I were almost double those offemales. The male death rate for coronary heart disease was higher in the core area. The number of Maori deaths was too small to allow for ethnic comparisons. I Table 6: Coronary heart disease hospitalisations by gender, ethnicity, and area 1989-1994
Gender and Core Area Rest of Wanganui Wanganui Central Region I causes No'" Rate"'''' No'" Rate"'''' No" Rate** No* Rate** I Total 101 53 126 42 228 47 4,149 48 Gender I Male 57 69 79 63 136 66 2,660 68 Female 44 40 47 25 91 31 1,489 31 Ethnicity I Maori 12 63 4 85 16 63 165 48 Non-Maori 89 52 122 41 211 45 3,984 48 I * Average number of hospitalisations per year July 1989-June 1994 I ** Rate per 10,000 age-standardised to New Zealand total population, 1991
People tend to go into hospital with coronary heart disease more as they get older. More Maori went into I· hospital with coronary heart disease in Wanganui than the Central regional average. I I
Poutama Whirinaki - Interwoven Paths 34 I I I Other heart disease There was no difference in the death rate from other heart disease between Wanganui and the Central region. However, the death rate in the core area was 32 percent higher than the rest ofWanganui.
Overall hospitalisation rates in Wanganui for other heart diseases were similar to the Central region. Male hospitalisation rates were nearly twice that offemales in the core area. The Maori rate ofhospitalisation in Wanganui was twice that of non-Maori. I Table 7 Other heart disease hospitalisations by gender and area 1989-1994 Gender and Core area Rest of Wanganui Wanganui Central region I Ethnicity No* Rate** No" Rate** No" Rate** No'" Rate**
Total 74 39 92 30 166 34 2,859 33 I Gender Male 41 52 46 37 87 43 1,549 42 Female 33 29 46 24 79 26 1,310 26 I Ethnicity Maori 14 70 5 78 19 71 29~ 95 I Non-Maori 60 34 87 29 147 31 2,562 31 Average number of hospitalisations per year July 1989-June 1994 I ** Rate per 10,000 age-standardised to New Zealand total population 1991. I' Cerebrovascular diseases (stroke) Death rates due to cerebrovascular diseases were highest among older age groups (75 and over) for both I males and females. The rate at which people in Wanganui went into hospital because ofstroke was similar to the Central region. However, Maori rates of hospitalisation for stroke were higher in Wanganui than the Maori rate for the I region. Male rates were 33 percent higher than female rates in all areas. I Table 8: Cerebrovascular disease hospitalisations by gender, ethnicity, and area 1989-1994 Gender and Core Area Rest of Wanganui Wanganui Central region I I Ethnicity No* Rate No* Rate*'" No" Rate"* No* Rate** I Total 54 28 68 21 122 24 2,014 24 Gender Male 27 33 31 24 57 28 983 27 I Female 27 25 37 18 64 21 1,031 21 Ethnicity Maori 12 63 4 85 16 63 165 48 I Non-Maori 47 26 65 20 112 22 1,891 23
Average number of hospitalisations per year July J989-June 1994 I ** Rate per 10,000 age-standardised to New Zealand total population 1991. .~
I 35 Poutama Whirinaki Interwoven Paths I Cancer I Cancer is more common in middle aged and elderly people. There was an annual average of33 deaths from cancer in Wanganui over the study period and a slightly higher death rate from cancer than in the region, mostly among people under 75 years old. The death rate in the core area was slightly higher than in the rest ofWanganui.
Overall hospitalisation rates for cancer were also higher (by 40 percent) in Wanganui than regionally. Lung, breast, and leukemia were the most common types of cancer for which people were hospitalised. As regionally, rates of male hospitalisation for cancer in Wanganui were higher than those for females and Maori rates were higher than non-Maori. I Table 9: All cancer hospitalisations by gender, ethnicity and area, 1989-1994 I Gender and Core Area Rest of Wanganui Wanganui Central region Ethnicity I No* Rate** No* Rate** No* Rate* No* Rate** Gender I Male 118 142 173 139 291 140 3,633 96 Female 131 129 136 84 267 103 3,412 75 Ethnicity I. Maori 28 120 11 l32 39 122 408 101 Non-Maori 221 132 298 105 1,518 115 6,637 81
* Average number of public hospital separations per year July 1989-June 1994 ** Rate per 10,000 age-standardised to New Zealand total population 1991 I Table 10: Leading causes ofcancer hospitalisations 1989-1994
Types of Core Area Rest of Wanganui Wanganui Central region I cancer
No* Rate** No* Rate** No* Rate** No* Rate** I
All causes 249 l31 309 105 558 115 7,045 82 Lung 30 16 35 12 66 14 665 8. I Breast 16 9 20 7 36 8 452 5 Leukemia l3 6 16 7 29 6 343 4 Cervix*** 4 - 2 - 6 1 114 1 I Bowel 7 4 12 4 19 4 393 5 Melanoma 5 3 7 3 l3 3 200 2 Prostate* * * 9 5 13 4 22 4 359 4 I
* Average number of public hospital separations July 1989-June 1994 ** Rate per 10,000 age-standardised to New Zealand total population 1991 I *** Gender specific cancers I I
Poutama Whirinaki - Interwoven Paths 36 I I I Ear disorders Acute ear infections which are often associated with upper respiratory infections are a common cause of sickness in children, and a reason for a visit to the doctor. Sixty percent of survey respondents in Wanganui I with children under five years (a quarter ofthe sample), reported one oftheir children having an ear infection in the last year. Almost all ofthese infections resulted in a visit to the doctor.
I Disorders of the ear (due to acute and chronic infections) were the major cause of hospitalisation among children aged 5-14 years. It should be noted that hospital data significantly underestimate the prevalence of acute infections as well as repeated episodes of acute otitis media with effusion (glue ear). Wanganui I children aged 5-14 had it 1.7 times higher rate of hospitalisation for disorders of the ear than the regional average. There was a similar difference for children resident in the core area in comparison to children in the rest ofWanganui. Regionally Maori children's rates ofhospital isation for ear disorders are twice that of I non-Maori. While Maori rates were still higher in Wanganui, the difference was less marked.
Glue ear if untreated may cause hearing loss and result in impaired speech and language understanding. I This can compromise a child's ability to learn at school. The insertion ofgrommets is one means oftreating glue ear. Grommet surgery rates were 1.8 times higher in Wanganui urban area than in the Central region over the period. In contrast to the regional pattern, Maori rates for grommet surgery were lower than those I of non-Maori in Wanganui. This is despite the fact that Maori children have almost double the failure rate for hearing tests on preschool and school entry ofnon-Maori children. The Public Health Unit report that I' the referral rate for hearing function in Wanganui in 1991, was twice as high for Maori as for non-Maori children.
I, Table 11: Grommets surgery hospitalisations by age, gender and ethnicity, 1989-1994
Wanganui Central region
I 1 to 4 5 to 14 1 to 4 5 to 14 I Gender Ethnic Group No* Rate** No· Rate** No· Rate** No* Rate** Female Maori 5 121 8 91 37 95 50 61 Non-Maori 13 135 19 79 142 61 186 34 I Total 18 131 26 83 179 66 236 38 Male Maori 4 - 8 98 55 140 65 77 Non-Maori 12 127 20 81 205 84 260 45 I Total 17 121 28 86 261 92 325 50 Total Maori 9 113 16 95 92 ll8 115 69 Non-Maori 26 131 39 80 348 73 446 40 I Total 35 126 55 84 440 79 561 44
* Average number of public hospital separations per year July 1989- June 1994 I ** Age-specific rate per 10,000 population I I I
I 37 Poutama Whirinaki -Interwoven Paths I Pregnancy and birth I Having a baby is a major reason why women in the 15-44 year age group go into hospital. In 1993, 1206 babies were born in the Wanganui sub-region. The younger age structure ofthe Maori population is reflected in the fact that 34 percent of 15-24 year old women having babies were Maori. I
On average Maori women start having babies at an earlier age than non-Maori, reflected in the fact that among 15-24 year olds, the rate was twice that of non-Maori. These higher Maori rates applied to both the I core and the rest ofWanganui. I Complications of pregnancy
While a normal pregancy and birth is the experience of most women, this is not the case for all.
Hospitalisations for complications of pregnancy were more common among both Maori and non-Maori women between 15 and 24 in Wanganui where rates were 1.7 times higher than for Central region. This was a particular problem for women living in the core area, who were more than twice as likely as women living in the rest ofWanganui to be hospitalised for pregnancy complications.
Complications of pregnancy were much higher among younger Maori women, twice that of non-Maori. The difference was less marked in women aged 25-44. This is in part likely to reflect the different age structure and age at birth of the populations. It also reflects the association found elsewhere, that women living in poorer households are more likely to have complications of pregnancy. I Complications of birth I Complications ofbirth, as regionally, were also highest among younger women aged 15-24 years in Wanganui. The rates for women in this age group were twice that of the average for the Central region. I Maori women aged 15-24 were twice as likely as non-Maori women to have a birth complication. Again the younger average age ofMaori mothers giving birth is relevant. The highest rates were found among Maori women in the 15-24 age group in the core area. This may reflect the poorer socio-economic conditions I (reflected in life style, lower use ofantenatal services because ofaccess issues or lack ofculturally appropriate forms of health care) of women living in the core area. I I I I I I
Poutama Whirinaki -Interwoven Paths 38 I I I Injuries Fractures I An annual average of 79 people per 10,000 went to hospital with fractures in Wanganui during the period from 1989 to 1994, a slightly higher rate than for Central region (60 per 10,000). Wanganui's rate of I hospitalisation for fractures did not vary much from area to area, but did vary by age, gender, and ethnicity. A similar rate of people in the older age groups went to hospital with fractures in Wanganui as in Central region, but there was a marked difference among the 15 to 24 year old age group, for whom the rate of I hospitalisation (116 per 10,000) was 1.6 times higher in Wanganui than in Central region as a whole.
There is a distinct gender difference in the pattern ofhospitalisation with fractures, especially among young I people. The male rate among the 15 to 24 year old age group in Wanganui was almost four times higher than the female rate for the same age group. Among the 5 to 14 and 25 to 44 age groups, males were twice as likely as females to be hospitalised with fractures. Older females in Wanganui were twice as likely (303 I per 10,000) as males (132 per 10,000) to be hospitalised with a fracture.
There was little difference in overall hospitalisation rates for fractures between Wanganui's Maori (83 per 10,000) and non-Maori populations (78 per 10,000 ), but some differences with particular age and gender groups.
Hospitalisation rates among males age 15-24 were slightly higher for non-Maori. In contrast, for children aged 1-4, the Maori hospitalisation rates were twice as high as thatfor non-Maori. This pattern was strongest I among boys, as can be seen in the overall male rate. Among the 25-44 age group, the Maori hospitalisation rate was 1.5 times higher than for non-Maori. I Table 12: Fracture hospitalisations by gender, ethnicity, and age, Wanganui, 1989-1994
I Maori Other Total Gender Number* Rate** Number* Rate** Number* Rate**
I Female 20 58 130 56 149 58 Males 35 1I0 152 98 188 98 I Total 55 83 282 78 337 79 * Average number of public hospital separations per year July 1989 - June 1994 I ** Rate per 10,000 age-standardised to New Zealand total population 1991 I I I I
I 39 Poutama Whirinaki - Interwoven Paths I Motor vehicle crashes I Thirty-six people per 10,000 were hospitalised per year in Wanganui from motor vehicle crashes between 1989 and 1994. This rate was similar in both the core and the rest of Wanganui, but was 1.4 times higher than in the Central region during the same period. I
As elsewhere in New Zealand, motor vehicle crashes are most common in the 15 to 24 age group in Wanganui. However, rates for this age group (90 per 10,000) were 1.5 times higher than for Central region (62 per I 10,000) during 1989-94. The difference was even greater for adults aged 25-44 who were twice as likely to be hospitalised from crashes as adults in other parts of Central region. For all other age groups, the rates were comparable. I
There are a number of possible reasons for the higher rates of hospitalisation as a result of motor vehicle crashes. Wanganui has been shown to have a higher drink driving rate than a number ofother areas in the I Central region.26 Speeding and alcohol have been shown to be key contributors to motor vehicle crashes. Higher rates may also reflect the rural environment surrounding Wanganui, with more open roads. Drivers and passengers involved in motor vehicle crashes in rural areas are more likely to be killed or to have more I serious injuries requring hospitalisation than crashes in urban areas. In smaller hospitals such as Wanganui accident and emergency departments are more likely to be staffed by junior medical staffwho may be more likely to admit a person until further assessment can be made by specialist staff. I
Males in Wanganui as in other parts ofthe Central region, were more likely than females to be hospitalised I due to motor vehicle crashes, particularly those aged 15 to 24.
TableJ 3: Motor vehicle crashes hospitalisations by gender, ethnicity, and age, Wanganui, 1989-1994 I Age 15 to 24 .25 to 44 45 to 64 Total*** I Gender Ethnicity No* Rate** No* Rate- No* Rate** No· Rate**
Male Maori 8 117 4 51 2 55 19 55 Non-Maori 28 118 25 55 7 21 71 47 I Total*** . 36 118 29 54 9 24 91 49 Female Maori 5 69 5 48 1 37 14 38 ,I Non-Maori 13 59 9 18 4 10 35 21 Total*** 18 62 13 23 5 13 49 24 Total*** Maori 13 92 9 49 3 45 33 46 Non-Maori 41 89 33 35 11 16 106 34 I Total 54 90 42 38 14 18 139 36
* Average number of public hospital separations per year July 1989-June 1994 I ** Age-specific rate per 10,000 population ***Rate per 10,000 age-standardised to New Zealand total population 1991. I Maori were 36 percent more likely overall to go to hospital as a result of a motor vehicle crash than non Maori. I Death rates were 22 per 100,000 in Wanganui, slightly higher than the Central regional rate. Death rates were highest in the core area (28 per 100,000). This was more pronounced for non-Maori (39 per 100,000) in the core area. The highest rate ofmortality was found among those aged 15-24, which is the same pattern I as for the whole ofNew Zealand.
26 Bailey 1P 1991. An Evaluation a/Community and Regional Programmes/or the Control 0/Drink-Driving Accidents in New Zealand. I Wellington: DSIR.
Poutama Whirinaki - Interwoven Paths 40 I I I Intentional self-harm and suicide The rate ofhospitalisation for intentional self-hann for all age groups was 11 people per 10,000 per year during 1989-1994, slightly higher than Central region's average. The highest hospitalisation rates were I among people aged 15 to 24 and 25 to 44.
Females had a higher rate of hospitalisation than males, particularly in the younger age groups. While the I overall female rate (14 per 10,000) was 75 percent higher than the male rate (8 per 10,000), in the 15-24 year old group, it was twice as high for females.
I Table 14: Intentional self-harm hospitalisations by age, gender, and ethnicity, Wanganui, 1989-1994
I 15 to 24 25 to 44 Total"'''''''
Gender Ethnicity No'" Rate"'''' No* Rate"'''' No* Rate"''''
I Male Maori 1 - 1 - 2 - Other 3 - 6 12 12 8 I Total*** 5 15 7 13 14 8 Female Maori 1 - 3 - 6 15 Other 9 42 9 18 21 14 I' Total*** 11 36 12 20 27 14 Total Maori 3 - 5 25 8 11 Other 13 28 14 15 33 11 I Total*** 15 26 19 17 41 11
'" Average number of public hospital separations per year July 1989-1994 ** Age-specific rate per 10,000 population I *** Rate per 10,000 age-standardised to New Zealand total population 1991.
Although the overall Maori and non-Maori rates of hospitalisation were similar in Wanganui, a marked I difference was noted among people aged 25-44. Maori had a rate 1.7 times higher than non-Maori in this age group.
I Death from suicide was 14 per 100,000 in Wanganui, similar to the regional average. Eighty-two percent of I these were male deaths. I I I I I
41 Poutama Whirinaki -Interwoven Paths I Head injuries I
The average rate ofhospitalisation due to head injuries in Wanganui urban area was 40 percent higher than the Central region. There was very little variation in rates within Wanganui. I
The incidence ofhead injuries was more common among those under twenty-five and consistently higher among males. Males aged 15-24 were more than twice as likely to be hospitalised with head injuries than I young females ofthe same age (102 compared to 52 per 10,000). Table 15: Head injuries hospitalisations by age, gender, and ethnicity, Wanganui, 1989-1994 I 5 to 14 15 to 24 25 to 44 I Total*""* Gender Ethnicity No" Rate** No" Rate"''' No" Rate"" No" Rate"" I Male Maori 4 - 9 139 4 - 21 54 Non-Maori 14 55 21 91 15 34 66 43 Total*** 18 53 30 102 19 37 87 45 I Female Maori 3 - 3 - 3 - 12 28 Non-Maori 8 32 12 55 4 - 38 24 I Total*** 11 33 16 52 8 13 50 Total*** Maori 7 41 12 89 7 41 33 40 Non-Maori 21 44 34 73 20 21 104 34 I Total*** 28 44 46 73 27 21 137 35
* Average number ofpublic hospital separations per year July 1989-June 1994 I ** Age-specific rate per 10,000 population *** Rate per 10,000 age-standardised to New Zealand total population 1991. I Mental health I The top five causes ofmental health hospitalisations in Wanganui during 1987-1991 were affective psychoses, paranoid states, schizophrenic disorders, and neurosis and other depressive disorders. Chronic psychotic disorders which included psychoses and paranoid states, schizophrenic disorder, and alcohol/drug dependence I were the most common causes of readmission. I Psychoses and paranoid states
Readmissions accounted for 76 percent of all hospitalisations for affective psychoses, paranoid states and I other psychoses in 1987-1991. The chronic nature of these conditions is reflected in the high rates of readmission, which in Wanganui were twice as high as the average for Central region. I Similar rates of first admission were found for males and females in Wanganui. As regionally, females were more likely to be readmitted to hospital than were males. 27 The highest rates for all hospitalisations for these disorders in Wanganui were in the 25-44 and 45-64 age groups. In contrast to the average for the I region, Maori hospitalisation rates in Wanganui were lower than non-Maori. However, as the numbers of Maori hospitalisations are small, differences should be interpreted with caution. I
27 Central RHA 1994. Morbidity and Mortality Profile ofthe Central Region. Wellington: Central Regional Health Authority. I I Poutama Whirinaki - Interwoven Paths 42 I I Table16: Psychoses andparanoid states by admission type and gender, Wanganui, 1987-1991 First admissions Readmissions Total admissions I Gender and Ethnicity No.* Rate** No.* Rate** No.* Rate** Female 9 4 33 16 42 20 I Male 5 3 20 II 28 16 Maori 2 - 6 9 9 14 Non-Maori 11 3 47 14 61 18 I Total 14 3 53 14 70 18
* Average number of public hospital separation per year 1987-1991 I ** Rate per 10,000 age-standardised to New Zealand total population 1991
I Schizophrenic disorders
Again the chronic nature ofthese conditions is reflected in the high rate of readmissions, which accounted I for 62 percent ofall hospitalisations in Wanganui. Rates were highest among 25-44 year olds, in particular among Maori. This may reflect poorer access for Maori to appropriate and effective community mental health support services. I, Table 17: Schizophrenic disorders-readmissions by age, gender and ethnicity, Wanganui 1987-1991 25-44 45-64 All Ages Gender Ethnicity No.* Rate** No.* Rate** No.* Rate***
I Female Maori 5 48 0 - 5 19 Non-Maori 10 21 3 - 15 9 Total 15 26 3 - 20 10 I Male Maori 2 - 0 - 4 Non-Maori 4 - 2 - 10 7 Total 6 12 2 - 14 8 I Total Maori 7 36 0 - 9 16 Non-Maori 15 16 5 7 25 8 I Total 21 19 5 7 34 9 * Average number of public hospital separations per year 1987-1991 ** Age-specific rate per 10,000 population I *** Rate per 10,000 age-standardised to New Zealand total population 1991 I I I I
I 43 Poutama Whirinaki - Interwoven Paths I Neuroses and other depressive disorders I Fewer people were hospitalised with neuroses and other depressive disorders. A greater proportion (64 percent) ofpeople hospitalised in Wanganui, were being admitted for the first time for these conditions. As elsewhere, these conditions were twice as common among females. Rates among females were highest I among 25 to 44 year olds. I Table 18: Neuroses and depressive disorders hospitalisations by age, gender and ethnicity, Wanganui 1987-1991 I Gender and 25 to 44 45 to 64 All Ages Ethnicity No'" Rate** No'" Rate"'* No· Rate·.... I
Female 7 12 4 17 8 "" 8 4 I Male 3 -' Maori 0 0 2 2 Non-Maori 9 10 7 9 23 7 Total 10 9 7 9 25 6 I
* Average number of public hospital separations per year 1987-1991 ** Age-specific rate per 10,000 population I *'" * Rate per I 0,000 age-standardised to New Zealand total population 1991 I Alcohol and drug abuse
An average of 19 Wanganui residents a year were hospitalised for alcohol or drug abuse problems during I 1987-91. The rate was slightly lower (5 per 10,000) than for Central region (7 per 10,000). Hospitalisation for treatment ofalcohol and drug abuse problems as regionally is more prevalent among males in Wanganui. There was little difference in the hospitalisation rates for Maori and non-Maori in Wanganui. I ,I _____Age-specific causes of hospitalisation and death I The pattern ofsickness and death in Wanganui becomes clearer when the causes ofhospitalisation and death at different stages ofthe life cycle are examined. People die and are hospitalised for different causes and at different rates depending on their age. The key factors are noted here. I
Infants (under one) I
Though the numbers are small (eight) and therefore caution should be used in interpreting them, the infant mortality rate in the core area was twice that ofthe Central regional average. Major causes ofdeath reflect I the regional pattern. Sudden infant death syndrome (cot death) comprised 36 percent ofall deaths in this age group. While numbers are very small and differences may be due to chance, there was a gradual decline in the number ofnon-Maori cot deaths, but less change in Maori numbers over the five year period 1988-1992. I
As elsewhere perinatal conditions, acute respiratory infections and birth defects were the main causes of I hospitalisation for both Maori and non-Maori infants.28 28 Central RHA 1994. Mortality and Morbidity Profile ofthe Central Region. Wellington: Central RHA. I Poutama Whirinaki ~ Interwoven Paths 44 I Maori infants in Wanganui as in other parts of the region, were more than twice as likely as non-Maori I infants to be admitted with an acute respiratory infection.29 I Figure 8: Major causes ofhospitalisation for infants under one by area, J989-J994 Causes of hospitalisation I Perinatal conditions Acute respiratory infections
Chronic obstructive I respiratory disease Congenital anomalies _!II I Symptoms .II1II1 Infectious diseases , Abdominal hemia o 500 1000 1500 2000 2500 Rate per 10,000 population I • Wanganui urban area I'J Central region I Preschool children (1-4) Causes of death in this age group (average of four a year) included cancer and birth defects.
I Respiratory diseases such as CORD (mostly asthma) and acute respiratory infections were the major causes ofhospitalisation. Children living in Wanganui were nearly twice as likely to be hospitalised with CORD as I the regional average. Rates in the core area were even higher. While these conditions were common to all children in Wanganui, the rates for Maori children were twice I that ofnon-Maori. While this may mean that such conditions are more common among Maori in Wanganui, it may also be that for a number of reasons; Maori may not seek help from the health services until the I condition is more serious. Figure 9: Major causes ofhospitalisation for children J-4 years by area, J989-J994
I Causes of hospitalisation Chronic obstructive respiratory disease I Acute respiratory infections Disorders of the ear I Infectious diseases Symptoms I Congenital anomalies Intracranial injury I Pneumonia and influenza o 50 100 150 200 250 300 350 400 Rate per 10,000 population I • Wanganui urban area IE! Central region
29 Central RHA 1994. Mortality and Morbidity Profile o/The Central Region, 1994, Central Regional Health Authority, Wellington. Ibid.
I 45 Poutama Whirinaki -Interwoven Paths I School children (5-14) I Causes of death (an average oftwo a year) included cancer and injury from bums.
The major causes of hospitalisation among school children in Wanganui were disorders of the ear, other I upper respiratory diseases, CORD, and fractures ofthe upper arm.
Figure 10: Major causes ofhospitalisation for children aged 5-14 years by area, 1989-1994 I Causes of hospitalisation Congenital anomalies I Oral diseases Symptoms I Head injury Upper limb fractures I Chronic obstructive respiratory disease Other upper respiratory diseases I
Disorders of the ear
o 20 40 60 80 100 120 I Rate per 10,000 population
• Wanganui urban area EJ Central region Young adults (15-24) I There was an average ofeight deaths per year ofyoung adults in Wanganui. Three quarters ofthese deaths I were ofyoung men. The major cause was motor vehicle crashes.
Head injury, upper and lower limb fractures accounted for 22 percent ofall male hospitalisations. I Normal delivery, pregnancy, and labour complications accounted for half ofall female hospitalisations. I Figure 11: Major causes ofhospitalisationfor males aged 15-24 years by area, 1989-1994
Causes of hospitalisations I
Neuroses
Psychoses I Late effect injuryl poisoning Fracture of skull I
Symptoms Lower limb fracture I Upper limb fracture Head injury I All causes o 200 400 600 800 1000 1200 I Rate per 10,000 population • Wanganui urban area Ell Central region
Poutama Whirinaki - Interwoven Paths 46 I I Figure 12: Major causes ofhospitalisationfor females aged 15-24 years by area, 1989-1994 I Cause of hospitalisations Head injury
Chronic obstructive I respiratory disease Symptoms
Pregnancy with I abortive outcome Female genital disorders
Normal delivery
I Labour complications
Pregnancy complications
I All causes 2500 o 500 1000 1500 2000 Rate per 10.000 population I El Central region • Wanganui urban area I Adults (25-44) Adults in the core area had a higher death rate (more than one and a half times) than the rest of Wanganui. I Cancer (five) and motor vehicle crashes (three) and suicide (two) were the major causes ofdeath.30 Hospitalisation rates for men in Wanganui were higher than the regional average and higher in the core area I than in the rest of Wanganui. While injuries continue to be the major cause ofhospitalisation among 25-44 year old males, other conditions I such as neuroses, psychoses, and cancer also begin to feature. Females aged 25-44 were more than twice as likely to be hospitalised as males. Among females, reproductive I conditions (normal delivery, pregnancy and labour complications) continued to be the most common cause ofhospitalisation.
I Figure 13: Major causes ofhospitalisation for males aged 25-44 years by area, 1989-1994 Cause of hospitalisations I Arthropathies Dorsopathies
Oral diseases
I Head injury
Cancer Late effects! I poisoning
Psychoses I Neuroses Symptoms I All causes 0 200 400 600 800 1000 1200 Rate per 10.000 population I • Wanganui urban area El Central region 30 Previous studies ofWanganui District have found higher rates of death for motor vehicle crashes than ~omparable areas. Public Health Unit, 1992: O'Connor P 1989. Health Facts. Health Statistics for the Wanganui Area. I 47 Poutama Whirinaki Interwoven Paths I Figure 14: Major causes ofhospitalisation for females aged 25-44 years by area, 1989-1994 Causes of hospitalisations I Psychoses Benign neoplasms I Cancer
Symptoms Pregnancy with I abortive outcome Health services, reproductive Female genital disorders I Normal delivery
Labour complications Pregnancy complications I o 50 100 150 200 250 300 350 400 450 Rate per 10,000 population • Wanganui urban area 0 Central region I Middle aged adults (45-64) I The death rates for middle aged people in Wanganui were slightly higher than the rates for the Central region and higher (one and a half times) in the core area than the rest of Wanganui. The most common I causes of death were cancers, coronary heart disease, strokes and CORD (excluding asthma). People in Wanganui were hospitalised at higher rates than the average for the region and rates were higher I in the core area than in the rest ofWanganui.
Among males, cancer and coronary heart diseases were the two most common causes of hospitalisation. I Cancer and female genital disorders were the leading reasons for middle aged women to go into hospital. I Maori hospitalisation rates were higher. Rates for CORD were particularly high, nearly five times that of non-Maori. I Figure 15: Major causes ofhospitalisationfor males aged 45-64 years by area, 1989-1994
Cause of hospitalisations I Renal and urinary diseases
Diseases of oesophagus, stomach, etc I
Other diseases of digestive system I Arthropathies Other heart diseases I Symptoms Ischaemic heart disease I Cancer
o 20 40 60 80 100 120 140 160 180 200 Rate per 10,000 population I • Wanganui urban area D Central region
Poutama Whirinaki -Interwoven Paths 48 I I Figure 16: Major causes ofhospitalisationfor females aged 45-64 years by area, 1989-1994
I Cause of hospitalisalions
Arthropathies
I Other heart disease Other diseases of digestive system I Other diseases of intestine/peritoneum Diseases of oesophagus, stomach, etc
I Ischaemic heart disease
Chronic obstructive respiratory disease
I Symptoms
Cancer I Female genital disorders ~;;;;;;;;;:::=~~
o 20 40 60 80 100 120 140 160 180 200 I Rate per 10,000 population • Wanganui urban area Il[J Central region
I Older adults (65-74)
Death rates in Wanganui for this particular age group were comparable to the Central region. However, I rates in the core area were 1.5 times higher than in the restofWanganui.
Cancer and coronary heart disease were the major causes ofdeath and hospitalisation in Wanganui for both I males and females.
I Figure 17: Major causes ofhospitalisationfor adults aged 65-74 years by area, 1989-1994
I Cause of hospitalisations Female genital disorders
Disorders of the eye I Renal and urinary diseases Cerebrovascular disease Diseases of oesophagus, I stomaCh, etc Other heart disease I Ischaemic heart disease
Symptoms Arthropathies I Cancer lii=ii;~!!iil!l!!!!!!!!!!!!!!!!!!!!!!!!!!~__-, o 100 200 300 400 500 600 Rate per 10,000 population I • Wanganui urban area [] Central region I
I 49 Poutama Whirinaki -Interwoven Paths I Elderly people (75+) I There was little difference in death rates for elderly people in comparison to the region as a whole. Overall death rates were also similar between the core area and the rest ofWanganui. The most common cause of death for both males and females was coronary heart disease, followed by cancer and stroke. I Cancer remained the leading reason for both males and females to go into hospital. I Figure J8: Major causes ofhospitalisationfor adults aged 75 years and over by area, J989-J994 Causes of hospitalisations I
DiseasesDisorders of oesophagus,,"'''1 of the eye !;==;~~::ii' I stomach, etc
Cerebrovascular disease "'.';.".'." Chronic obstructive I respiratory disease I
Cancer I o 100 200 300 400 500 600 Rate per 10,000 population • Wanganui urban area EI Central region I I
_____Summary I
The core area had higher death rates for all age groups than the rest ofWanganui. I
As found in the rest ofthe region, the main causes ofmortality among middle-aged and elderly people were chronic conditions such as coronary heart disease and cancers. Injuries were the most common cause of I death among young people.
Motor vehicle crashes accounted for 60 percent ofall deaths among tho~e aged 15 - 24, and were the second I major cause of death among people aged 25 - 44. Perinatal conditions, SIDS, and birth defects were the three major causes of death for infants. I Overall male death rates were considerably higher than female rates.
Compared to the Central region, Wanganui had higher rates ofhospitalisation. The core area had consistently I higher rates than the rest ofWanganui for all major causes of hospitalisation.
Perinatal conditions and birth defects were the main causes ofhospitalisation among infants, while CORD, I asthma, acute respiratory infections, and disorders of the ea~ were common among school-aged children. I
Poutama Whirinaki - Interwoven Paths 50 I I Among middle and older age groups, chronic conditions dominate as a major cause of hospitalisation. I Injuries accounted for 22 percent ofall hospitalisations for young men, while pregnancy and birth were the leading causes of hospitalisation among young women. CORD was a major cause of hospitalisation for females aged 45-64, while cancers and coronary heart disease were the main causes among males. I Overall Maori rates of hospitalisation were higher than those for non-Maori. While only a small variation (15 percent) was noted in the core area between Maori and non-Maori hospitalisation rates, this difference was greater (35 percent) in the rest ofWanganui. As elsewhere this suggests that ethnicity by itself is not a I sufficient indicator ofhealth status, but needs to be considered in combination with socio-economic factors such as employment status, income level, housing character, size ofhousehold and levels of education.
I Respiratory diseases were dominant among causes ofhospitaiisation for Maori. Maori infants were more likely to be hospitalised with acute respiratory infections. While this may be the result of failure to seek medical help earlier it may also be a greater readiness on the part of hospital staff to admit such babies. I Interviews with providers in Wanganui suggested that Maori babies were more likely to be admitted to hospital, because it was felt that in some cases the social circumstances ofthe family was not conducive to a rapid recovery from the illness. Maori rates for CORD were about five times higher than for non-Maori. I These rates are directly associated with the high rate of smoking among Maori in Wanganui.
With regard to mental health, chronic psychotic disorders were common causes for people to be readmitted I to hospital in Wanganui during 1987-1991. As in previous findings, both first and readmission rates were higher in the 25-44 age group.
I Generally, middle-aged people had higher admission rates for major causes ofmental illness (schizophrenic disorders, psychoses and paranoid states, neuroses and other depressive disorders). Readmission rates in I Wanganui were highest for psychoses and paranoid states (76 percent), followed by schizophrenic disorders (62 percent).
I Males had higher rates of admission due to schizophrenic disorders and alcohol and drug abuse, while for females it was psychoses and paranoid states which lead to them being admitted to hospital.
I Among Maori, readmission rates due to schizophrenic disorders were twice those ofthe non-Maori population. Both first and readmissions due to neuroses and other depressive disorders were higher among non-Maori I in Wanganui. The higher rates of death and illness found in the core area relative to the rest of Wanganui confirm the findings ofother studies, that socio-economic factors are key determinants of health status. Being able to I access health and allied services which may prevent or provide early intervention in the case of illness or injury also influences health outcomes. In the core area of Wanganui, as has been shown in other areas characterised by low socio-economic status, there are fewer services available locally; people have greater I difficulties in getting to services when needed and the up front cost ofusing the service is often too great for people to afford. For Maori these socio-economic barriers have been compounded in the past by the failure ofthe health services to recognise and take into account cultural difference in the way health is understood I and services should be provided. It is hoped that the increasing acceptance by providers that health services must be culturally acceptable to Maori and the growth in services by Maori for Maori will be reflected in I improved health status. I I
I 51 Poutama Whirinaki Interwoven Paths I I I I I I I I I I I I I I I I I I I
Poutama Whirinaki - Interwoven Paths 52 I I I I I I I I I I Chapter 4 WANGANUI HEALTH SERVICES: I WHAT THEY ARE AND I HOW THEY ARE USED I I I I I I I I
I 53 Poutama Whirinaki - Interwoven Paths I HIGHLIGHTS I
• A wide range ofhealth and disability services are provided in Wanganui, similar to those found in other I provincial cities. However, some indicators ofutilisation suggest that people in the core area ofWanganui have lower levels ofaccess to services than people elsewhere. I • There are 30 general practitioners practicing in Wanganui.
• There is one general practitioner for every 1,487 people in Wanganui District, slightly less than the I regional average ofone to every 1,524people. I • The ratio ofpractice nurse:GP is slightly lower in Wanganui District (0.53) compared to the regional average (0.66). I • GMS expenditure per head ($36. 77) was slightly lower in Wanganui sub-region than in the region as a whole ($38.16). I • Wanganui has a 20 percent higher birth rate than the region as a whole and a higher rate ofbirths to younger women. I • Plunket is the main provider ofwell child services for children under five. Less than halfofthefamities with preschool children surveyed in Wanganui reported having used Plunket services in the past twelve months. I
• Uptake ofdental care by adolescents in Wanganui sub-region may be less than some other parts ofthe Central region. Dental benefit claims per head ($44.80) were 11 percent lower than the regional average I ($50.28).
• Maori and Community Services Card holders visited a dentist less frequently than other survey I respondents.
• Pharmacists arefrequently used as afirst source ofhealth advice bypeople in Wanganui. I
• Per capita spending on pharmaceutical subsidies in Wanganui sub-region, was 8percent lower than the region as a whole. I
• Te Oranganui, an iwi authority established to represent the tangata whenua ofWanganui has contracts I with Central RHA, to provide a range ofprimary health care services for Maori in Wanganui.
• Public health nurses in Wanganui have given particular emphasis to providing care for children over I five, particularly children "at risk".
Variation in theformat in which data is available, egfor Wanganui Urban Area, Wanganui District and I Wanganui sub-region makes for confusion.
• Utilisation data is not available or not reliable for some services, suggesting an opportunity to improve I data capture. I
Poutama Whirinaki Interwoven Paths 54 I • I _____Primary health care services
I Primary health care services are those to which users have direct access without having to be referred. Access to secondary and specialist services is usually by way of referral from primary health providers. I General practitioners
I General practitioners (GPs) provide assessment, diagnosis and treatment, including well child and maternity services, referral services and on-going management for their patients. Where practice nurses are employed in a practice, they provide nursing back up, organise recall systems such as those for immunisation and I cervical screening, and educate patients. I There are 30 GPs in Wanganui, and 28 of these belong to Progressive Health Incorporated (PHI), an Independent Practitioner Association. At the time ofthe study, there was one GP to every 1,487 people in the Wanganui District (which includes Wanganui urban area and the surrounding rural areas.) This is slightly I less than the regional average of 1,524 to every GP.
PHI have fifteen practices located in Wanganui City, four in each of Springvale and Aramoho areas, and I another three single practices located in Castlecliff, Wanganui East and Gonville. The other two independent practices can be found in Wanganui City and Castlecliff.
I Ninety-three percent ofthe respondents in the consumer survey conducted in Wanganui reported having consulted their GP in the past twelve months. The majority ofthe Wanganui respondents (82 percent) had seen their GP several times over this period. This was substantially higher than that reported for the Central I Region as a whole.31 This may reflect the different sample frameworks used in each study.
Sixty-five percent ofsurvey respondents saw a doctor's nurse in the previous twelve months. Over half of I these (56 percent) saw the practice nurse several times. There were sixteen practice nurses (or full-time equivalents to them) in Wanganui District. The practice nurse:GP ratio was lower in Wanganui District I (0.53) in comparison to the regional average (0.66).
General Medical Services (GMS) claims per head of population in Wanganui sub-region for the period I from June 1993 to July 94 were $36.77 That is 96 percent ofthe Central region's average GMS claim rate of$38.16. Compared to other sub-regions, Wanganui had the fourth lowest GMS claim rate.32 I I I I
1I Ministry of Health 1994. Summary ofdata from the New Zealand Health Survey 1992-93. A report prepared for the Central RHA by New Zealand Health Information Service. I J2 A term used by the Central RHA to denote the eight geographic areas that it uses for analytical and planning purposes. In Wanganui this includes: Wanganui District, Rangitikei District, and Waimarino and Waiouru wards of Ruapehu District.
I 55 Poutama Whirinaki interwoven Paths I Figure 19: GMS claim rate per head ofpopulation 1993/94 I 60.00
50.00 I 40.00 I 30.00 I 20.00
10.00 I
0.00 > ~ "5 <: I - "0 "a. '"c.. :::: ::r:: a:l'" - E ~ - c:: (J) '"~ § 5 '" Cl Q;> (3 ::.;:'" ~ '" U :::: 'Q :::: ~ '" Q;'" ..a Q; -;: '"2 '" "'"~ 2'" z .§ ~ ~ ~ ::r::'" :2'" a.. I Pregnancy and childbirth services I Maternity services are provided by medical practitioners, independent midwives, and staff of Wanganui hospital. Services purchased by the RHA include home visits, antenatal education, information to clients, I pregnancy care, labour, birth and in-patient postnatal services, and follow-up visits after the birth. Women giving birth average three to four days' stay at the hospital. I Women can decide which primary maternity service provider they will use, including Good Health Wanganui's Maternity Unit. Primary care providers may refer pregnant women to the hospital specialist team or private specialist team as required. I
There are 51 providers claiming maternity benefits in Wanganui district including nine midwives, thirty general practitioners and twelve specialists. This provides for good choice for pregnant women in Wanganui. I
Te Waipuna Health Centre offers a maternity service focused on meeting the needs of Maori women. In 1994/95, there were 55 births attended by the centre's midwives. There is also an active home birth midwifery I group in the town.
In 1994/95 1069 babies were born at Wanganui hospital's Maternity Unit, ofwhich 15 percent were delivered I by caesarean section. This is higher than the regional average. Factors contributing to this are currently being reviewed by Central RHA. I Wanganui's birth rate is 7411 000 women aged 15-49 years, which compares to the region's birth rate of 63/ 1000. There were 1,206 babies born in Wanganui District in 1993, ofwhich 24 percent were Maori. Wanganui has a higher rate ofbirths to younger women, with 12 percent ofbirths being to women under the age of20. I This compares with a regional average of7 percent. Regionally Maori women give birth at a younger mean age than non-Maori. I I
Poutama Whirinaki - Interwoven Paths 56 I I Well child services
I Well child services aim to promote healthy children and prevent disease. They include screening of new born babies, early child development, checkups and screening throughout childhood, immunisation, parent I education, hearing and vision testing, health promotion and support for children with special needs. Well child services are shared between Plunket, practice nurses, nurses and doctors working in iwi-based I health programmes, public health nurses employed by the CHE and general practitioners. Plunket is the main provider for children under five years old. Well child care for children over five is provided by public I health nurses. Plunket services are purchased by Central RHA through a block contract. The Royal New Zealand Plunket Society provides population-based well child health services for children from 0 to five years old. This I involves working closely with the public health services, and alongside iwi-based services. Plunket's work covers: I • surveillance and support of the welfare of mothers and children • monitoring child growth and development I • nutrition and breastfeeding • prevention of sudden infant death syndrome (SIDS)
I • parenting advice and health promotion
• immunisation monitoring and advice
I • child safety and abuse prevention I • liaison and referral to other health professionals • vision, hearing and ear checks I • Karitane services. The initial Plunket visit with mothers and their new babies is usually at home until the baby is approximately eight weeks old. After that, contacts are carried out in clinics until the child reaches five years. Some of I these checks are provided at preschools. I Plunket clinics are located in Gonville, Aramoho, Castlecliff, Wanganui East, Central Springvale, St lohn's Hill, and Durie Hill. The Plunket Family Centre in Gonville provides assistance for families and parent education for the whole ofWanganui area. The Family Centre and the Central Springvale office are open I Monday to Friday, Castlecliffe, Aramoho and Wanganui East clinics are open one day a week and a monthly service is provided at Durie Hill and St lohn's Hill.
I All weekly clinics can be reached by telephone. Unstaffed clinics are diverted to the central Springvale office. Parents are able to use the national 24 hour Plunket line for after hours advice.
I The Wanganui consumer survey showed that 45 percent ofthe respondents with children aged under five in the household had used the services ofa Plunket nurse. However, Central RHA contracts Plunket to provide I 100 percent coverage in Wanganui. 'I
I 57 Poutama Whirinaki -Interwoven Paths I Dental services I The School Dental Service is provided and managed by the child health services ofGood Health Wanganui. Dental nurses provide educative, preventive and oral health care to students in school dental clinics. They also refer children to other services where there are problems beyond their scope. I There are 16 school dental clinics in Wanganui located at: I Durie Hill School Westmere School Aranui School Wanganui Intermediate School Castlecliff School Aramoho School I Kokohuia School Churton School Gonville School Keith Street School Tawhero School Wanganui East School I Rutherford Intermediate School Kiwi Street School Carlton School Upokongaro School St John's Hill School Fordell School I Schools without school dental clinics are served by a mobile dental van. I Twenty eight percent ofthe respondents in the consumer survey reported that someone in the household had visited the school dental nurse over the last year. Nearly a third (31 percent) of those who visited saw the dental nurse once, 37 percent saw her twice and 32 percent saw her several times. I
From Form 3 up to age 18, dental care for adolescents is provided by contracting private dental practitioners, through the General Dental Benefits scheme. The free treatment includes a dental examination every year, I x-rays and simple fillings. Uptake of dental care by adolescents in Wanganui District may be a little lower than some other parts of the Central region. I The average dental payment in Wanganui sub-region per teenager was $44.80, 11 percent lower than for the Central region as a whole ($50.28). A similar difference was reported in Porirua in 1992/93.33 I
Figure 20: Dental benefit claims per adolescent 80.00 I
70.00 -
60.00 r- I
50.00 r-- r- r- - r- 40,00 I
30.00 r- I 20.00 10.00 I 0.00 >- ..,... ::l .r:: ''::; til til C) '5 c a: Q) til (5 ~ C :§ U ->!. C '" cO 'iii I 'iii $: ttl z :g 2 '" 'iii ttl 2 til .§ 3 3 3 :c 2 a... I 33Central RHA 1994. Strong Links. Wellington: Central Regional Health Authority.
Poutama Whirinaki Interwoven Paths 58 I I Hospital Dental Services are provided through GHW. Hospital dental services are free only for patients I admitted to the hospital for reasons other than oral disease. Dental outpatient charges are based on general dental fees and the client's ability to pay. Dental outpatients are treated if:
• they are former long-stay clients of institutions or people with an intellectual, physical or age-related I disability who live in the community
• they have a medical condition such as haemophilia or AIDSIHIV, and therefore can not be treated in a I private practice • they cannot afford to pay their dental care if they use private dentists. These are usually Community I Services Card holders referred by practitioners. However, not everyone in this category can be treated in this way because of insufficient resources.
I Dentists had been visited by 59 percent of the respondents in the consumer survey over the last year. Over half of the Maori respondents who visited the dentist did so only once (52 percent), but non-Maori saw the dentist more than once. Maori and Pacific Islands teenagers in other parts of Central region have been I shown to have lower rates of enrolment than European teenagers.34 It is likely a similar pattern exists in Wanganui. Community Services Card holders in the Wanganui survey were less likely than others to make I several visits to the dentist.
I Sexual health and family planning services
Family Planning Services cover sexual and reproductive health including contraception, pregnancy tests, I cervical smears, STD services, advice on menopause, advice and counselling.
Family planning advice is available from GPs, Wanganui hospital, a Well Women's Clinic and the Youth I Advice Centre (YAC). There are no Family Planning Association Clinics in Wanganui. I I Well women's services A Well Women's Clinic was set up in Wanganui in 1989 to provide cervical smears. The clinic now also carries out pregnancy tests, educates women on breast self-examination and provides contraceptive advice. I Contraceptive advice is also provided by GHW's Maternity Services.
The Well Women's Clinic was set up to provide a choice for women who wanted to have cervical smears I done by a woman provider in Wanganui. There are now other female providers giving smears, such as some practice nurses and a number of female GPs. Cervical smears are available at no charge from the clinic, and approximately 50 percent of women who attend the clinic for smears said that they could not I afford to pay a GP. I I I 34 Ibid
I 59 Poutama Whirinaki - Interwoven Paths I Youth Advice Centre (YAC) I The Youth Advice Centre is a drop-in centre for young people from IOta 25 years old, and is a base for different services targeted at young persons. All services are free for young people who cannot afford to go to their general practitioner. GP services are purchased by Central RHA. Services at the Centre include: I • STO advice
• alcohol and drug counselling, intervention and education I • GP services I • family planning • Plunket services for young mothers I • violence control and prevention (Men Against Violence) • asthma education I • legal advice • budget advice. I
The Centre is situated in the Wanganui Polytechnic grounds. It serves as a permanent base for a full-time adolescent health nurse and STO educator (public health nurse) whose salaries are funded by Good Health I Wanganui. The coordinator is funded from a government community organisations grant, and other grants such as one from Trustbank. I Family planning services are provided by the adolescent health nurse, occupational health nurse and STO educator. Other providers who visit the Centre are a social worker for pregnancy counselling, a GP, a volunteer counsellor and a lawyer. Asthma education is also provided by GHW. I
YAC is open from 8am to Spm, however an 0800 free telephone service is available for youth advice, and individual staff can be contacted outside normal hours. I I Community pharmacies
Community pharmacists are available for general health advice and information in addition to dispensing I prescribed medicines and selling "over the counter" and pharmacy-only medicines. A community pharmacist may often be the first source ofadvice for people contemplating whether they need to go to a doctor. I There are eleven phannacies in the Wanganui area. Eight are located in the city, and one each at Gonville, Springvale and Aramoho areas. I Restricted medicines and special authority medicines are dispensed by Wanganui Hospital Pharmacy. I Pharmacies are open during normal business hours. Wicksteed pharmacy offers an after hours service, while Gonville pharmacy provides a home delivery service. Other pharmacies can be-called when needed~ I Pharmacies were rated the most used service by the consumer survey. Ninety-five percent ofthe respondents had seen the chemist for advice and prescriptions over the last year, with 85 percent visiting the chemist several times over this period. The use ofchemists was similar for both Maori and non-Maori respondents. I I Poutama Whirinaki - Interwoven Paths 60 I The cost of prescription medicines, other than the user part charges and premiums on some items, is met I through the pharmaceutical benefit scheme. The level of user charges depends on Community Services Card status, and whether or not the individual has a High Use Health Card. In addition, part charges apply to some prescription items where less expensive alternatives are available. Stop loss provisions also apply, I in other words people pay for a maximum 0[20 prescription items per year. I Pharmacy claims
I Wanganui sub-region has 19 pharmacies. Eleven of these are in Wanganui District. In the 1993/94 year, chemists in Wanganui claimed an average of$127 per person for prescriptions. This is 8 percent less than I the regional average of$13 7 per person.
I Diagnostic imaging and laboratory services
Diagnostic imaging services provide medical practitioners with information they need to make diagnoses I and manage people's conditions. The types of diagnostic imaging include x-rays (radiology), ultrasound, I and CAT scanning. Central RHA purchases diagnostic imaging services for patients referred from the Wanganui community. Patients without Community Services Cards need to pay fees for some of the diagnostic imaging services I provided.
Progressive Medical Imaging and Wanganui Radiology are the two private providers ofdiagnostic imaging I services. A small number of procedures attract a patient subsidy when they are provided privately. ACC payments also apply to accident-related cases. Other fees are met by patients or private insurance schemes. I I Laboratories Diagnostic laboratories collect and analyse specimens such as blood or urine, and report results to the I requesting GP. Community laboratory services are purchased by Central RHA on a fee for service basis. Most services are I provided through Wanganui Diagnostic. Schedule tests do not attract USer part charges. Laboratories services are the fourth most commonly used in Wanganui. Sixty-one percent ofthe respondents I in the consumer survey reported using a laboratory service over the past twelve months. This was substantially higher than that reported by respondents in a survey in Porirua, where only 20 percent reported using a medical laboratory in the previous two years.35 This may reflect an under representation ofyounger people I and an over representation of middle aged and older people in the Wanganui survey compared to the total Wanganui population. I I 35 Ibid
I 61 Poutama Whirinaki Interwoven Paths I Ambulance services I Ambulance services respond to accidents, medical emergencies and major incidents. They provide an emergency response, treatment and transport service. I Central RHA purchases emergency ambulance services for medical emergencies for the Wanganui and Manawatu subregions from the Order of St John, which is responsible for arranging and paying for air ambulance services as well as providing road ambulance services. Accident cases remain the responsibility I ofACe. Both road and air ambulance services are reached by dialing Ill.
An estimated 76 percent of all calls are for cardiac and respiratory problems. For the year ending 31 I December 1994, the Wanganui ambulance service dealt with 1,906 emergency calls. I Primary health services for Maori I Te Oranganui is an iwi authority which has been contracted to provide services for Maori in the Wanganui area. The services include: I • health education and promotion among whanau, hapu, iwi and other Maori groups in the community • support to families of patients in hospital by providing a safe and caring environment I • screening, assessment and counselling sessions • liaison, advocacy and follow-up support services for Maori patients and relatives under the care of I Wanganui CHE.
Te Oranganui has two sub-committees: Te Korimako which covers Taihape, Waiouru and surrounds and Te I Waipuna 0 Te Awa covering areas on the upper part ofthe Whanganui river, Ohakune and Pipiriki.
Details ofthese services are discussed in Chapter Six. I I Public health services
Public health services include health promotion and education, environmental health, control ofcommunicable I diseases and health protection. Regional public health services are provided by Mid Central Health's Public Health Unit, based in Palmerston North. Health promotion and education services are provided by Good I Health Wanganui. The health promotion services GHW provides are:
• healthy schools • hearing loss in children I • healthy cities and communites • reducing tobacco smoking • food and nutrition • prevention of unintentional injuries .. communicable disease control • child abuse I • Maori health • health ofyoung people • well child health • HIV/AIDS • parenting • road safety I • immunisation • prevention of alcohol-related harm • SIDS prevention • melanoma prevention. I
Poutama Whirinaki -Interwoven Paths 62 I I The Public Health Unit in Wanganui, based at 39-41 Drews Avenue, is the main provider. The unit contains I health promoters, child health nurses, adolescent health nurses and vision hearing testers. Public health nurses (PHNs) provide both personal and public health services. Personal health services I include immunisation checks and administration, five year old referrals, vision and hearing tests for fourth formers, referrals for health problems, physical and sexual abuse, and running clinics at intermediate and I high schools. In Wanganui the public health nurses have given particular emphasis to providing care to children, particularly children at risk. Every five year old is screened and children "at risk" identified. Groups have been set up to I deal with common problems such as bed wetting. The nurses spend as much time as possible in schools identified as "at risk" by Department ofEducation school profiles. They have become known and trusted in the schools, so that children refer themselves to the nurses as well as teachers making referrals. The nurses I also visit children's homes to do assessments before referring the children to the appropriate agency. It may take several visits to the home before the family feel comfortable with the idea of referral.
I The nurses have also formed groups at schools for parents who do not want to attend Family Centre programmes. Topics covered have included breast self-examination, self-defence, motherhood and stress, parenting skills and basic first aid. The schools are good venues as they are seen as "safe". Street meetings I have also been held at homes in the Castlecliff area. I I I I I I I I I I I
I 63 Poutama Whirinaki -Interwoven Paths I -----Secondary health services I
These are specialist medical and surgical services which an individual usually needs to be referred to via a GP. People who suddenly become seriously ill or have a serious accident can go directly to the hospital's I Acident and Emergency department for urgent surgical or medical treatment.
Specialist services may be provided on an inpatient, outpatient or daypatient basis, and publicly-provided I services tend to be grouped near to the hospital. Other support services are provided on the same site, such as laboratory services and diagnostic imaging, domiciliary services such as home or district nursing, meals on wheels and home help. I Table 19: Hospital-based services provided at Good Health Wanganui I In* Out I Alcohol and Drug ./ Cardiology ./ Dental, hospital outpatient ./ I Dental, hospital inpatient ./ Emergency Dept, 24 hour ./ ./ I Family Planning, CHE clinic ./ General Medical ./ I Haematology ./ Medical Diabetes Clinics ./ Neurology ./ I Oncology / Radiotherapy ./ Pregnancy and childbirth ./ ./ I STD, sexual health clinics ./ cardio thoracic ./ I Surgery, general outpatient ./ Surgery, general inpatient ./ Surgery, gynaecology ./ ./ I Surgery, opthamology ./ ./ Surgery, neurosurgery ./ I Surgery, orthopaedics ./ ./ Surgery, general day ./ Surgery, paediatric ./ I Surgery, urology** orolaryngology I Mental health ./ Forensic services regional Neonatal medicine ./ ./ I Paediatric medicine ./ ./ I * In-patient services include day patients. ** Urology services provided by general surgeon with special interest in urology.
Poutama Whirinaki -Interwoven Paths 64 I I I Hospital outpatient services These were used by 54 percent of the respondents in the Wanganui consumer survey over the past year, while over 40 percent ofthese respondents reported making three or more visits. Maori were more likely to I use these services (60 percent) than non-Maori (51 percent). This reported level ofutilisation was substantially higher than that found in Porirua and may reflect the different sample frameworks used in each survey.36
I The provider of medical and surgical services is responsible for also arranging for appropriate support services for patients once they are discharged from hospitaL I I Community-based services There is a range ofcommunity health and domiciliary services to support people living in their own homes, and provide health education and other non-hospital-based services. Services provided by Good Health I Wanganui are: I • general and specialist district nursing • occupational therapy, physiotherapy and speech therapy I • social work • health promotion and education I • home support (meals on wheels, laundry services for families with disabled children). Just over a quarter (26 percent) ofrespondents in the Wanganui consumer survey consulted a physiotherapist I during the previous year, and most of these (80 percent) saw one several times. This is higher than that found in other surveys.37 I I I I I I I I 36 Ibid
17 Statistics New ZealandIMinistry of Health 1993. A Picture ofHealth. Wellington: Statistics New ZealandIMinistry of Health.
I 65 Poutama Whirinaki - Interwoven Paths I Mental health services I Mental health services consist offour main groups of services: I Adult mental health and psychiatric disability services
This includes: I • primary health services I • health promotion and education • community-based assessment I • treatment, rehabilitation and follow-up services • crisis intervention and after hours services I • day hospital treatment services • inpatient hospital care for acute, medium-term, and long-stay patients I • respite care • supported accommodation (provided both by Pathways and Whanganui Community Housing Trusts) I • day services I • carer support • self-help groups. I Child, adolescent and family mental health services I These include:
• education and consultation services with community and statutory agencies I • home-based or clinic-based assessment, treatment and therapeutic services. I Child, adolescent and family services and GHW's community mental health teams are based at the hospital. Maori mental health services are provided both by Te Oranganui and Ratana Orakeinui Trusts. I Forensic psychiatric services I These include: • liaison, consultation and assessment with referrals from Courts, prisons and related organisations I • preparation of assessment reports for the Courts • community assessment and follow-up services I • inpatient assessment, treatment and rehabilitation in facilities with varying degrees of secure care. I The National Secure Unit at Lake Alice hospital provides maximum security forensic mental health services.
Poutama Whirinaki Interwoven Paths 66 I I I _____Alcohol and drug services These include: I • health education and promotion programmes • screening, referral and early intervention services I • outpatient assessment, treatment and counselling services • specific day treatment programmes, residential assessment and treatment programmes, rehabilitation I and continuing care services, and special treatment such as methadone programmes. I Detoxification services are provided in Palmerston North. Other alcohol and drug services based at Wanganui hospital are:
• outpatient referral and counselling services for substance abuse problems provided by the drug and I alcohol unit
• regional forensic mental health services are provided from Stanford House for the area from Taranaki I through to Hawke's Bay I • acute inpatient and day psychiatric care, provided by Te Awhina. I I I I I I I I I I
I 67 Poutama Whirinaki Interwoven Paths I I I I I I I I I I I I I I I I I I I
Poutama Whirinaki Interwoven Paths 68 I I I I I I I I I I Chapter 5 CONSUMER VIEWS I .; I I I I I I I I I
I 69 Poutama Whirinaki Interwoven Paths I HIGHLIGHTS I
• The major barrier to access ofhealth services reported was not being able to afford the cost ofa visit to I the GP and/or getting prescription drugs.
• Cost was more ofan issue for people living in the core area ofWanganui. I • For some people cost was a reasonfor delaying treatment or 'saving up reasons 'for a visit to the GP. I • Most peoplefelt they hadgood access to health services in Wanganui, including after hours care. I • Fewer people living in the core area hadtheir own transport and were more reliant on other people or public transport to get to health services. I • Participants in the survey and in focus groups, identified waiting times as a major issue to be addressed in Wanganui. This included waiting to get an appointment as well as long waits at the GP or hospital outpatients. The majority found such waits unacceptable. I
• There was a general beliefthat recent health service reorganisation was increasing the pressure on medical and nursing staff, particularly in hospital and affecting quality ofcare. I
o Access to clear, accurate information was rated as important in enabling the making ofinformed choices. Such information was not always available. I
• Greater coordination between service providers, particularly between primary and secondary care providers was calledfor. I
• People want health services which are caringandjriendly, cater for their needs, are well organised and affordable. I I I I I I I I
Poutama Whirinaki Interwoven Paths 70 I I I INTRODUCTION
I This chapter summarises the views of people in Wanganui about their health services. Speaking with the people who use health services was an integral part of the needs assessment project. In order to obtain an accurate account ofconsumer views, it was crucial for a wide range ofpeople to be consulted. The methods I we used included 12 focus group interviews (123 people in total) and a telephone survey, where 248 people were interviewed. We were careful to seek out the views ofMaori, and feedback on these can be found in I the chapter which concentrates specifically on Maori issues. We asked people taking part in focus groups to outline all the health services they used, the positive and I negative aspects of these health services, and their suggestions for improving them. Consumers who participated in the meetings included: I • women • older people I • parents with children at primary and intermediate school • young people I • older people with disabilities • men I • parents with preschoolers I • secondary school pupils. The telephone survey was carried out with the cooperation ofWanganui general practitioners, from whose registers patients were randomly selected. We asked those people questions about their health, and whether I existing health services were adequately meeting their needs. The method meant that people not on a GP register were not included in the survey, so we do not claim that it represents the views ofthe entire population I ofWanganui. I I I I I I
I 71 Poutama Whirinaki - Interwoven Paths I THEMES I
_____Cost of services I
The level of cost and ability to pay were important factors. Forty percent of people surveyed felt that cost I influenced their decision on whether to use a health service. "Ifthey went up too much we couldn 'j afford it. " I Nearly half of the Wanganui survey respondents living in the core areas found services too expensive, in comparison to 38 percent ofthose living in non-core areas. Maori respondents were particularly affected by the costs ofhealth services, with over two-thirds finding them too expensive. I
The cost ofhealth services particularly affected those who had just missed out on receiving a Community Services Card. Many ofthe people in this group felt that the criteria for receiving a Community Services I Card were too rigid. Those with young children reported this experience more than groups with older children or those without children. H]find cost quite a factor when you go to the doctor and end up with a bill of$85. " I
Survey results showed that people whose household income was between $20,000 and $30,000 found cost more ofa barrier than people whose household income was less than $20,000. This reinforced what we were I told by the focus groups. That is, those who just missed out on receiving a Community Services Card found cost more ofa barrier than those who earned less but had a Community Services Card. I When we analysed focus group information to find out people's attitudes to the cost of health services, certain themes became clear. Although people were concerned at the expense ofsome health services (such as the GP or dentist), they were still willing in principle to pay for primary services. I "You can't expect to get a service for nothing. "
People had different points ofview on the affordability ofhealth services depending on the stage oflife that I they were at, their circumstances and their expectations ofthe health system. I Delaying treatment or self-treatment I It was common for people to try to treat themselves or to seek advice from their local chemist before they went to anyone else for treatment. They did this to make sure their problem was worth the financial outlay ofa visit to a doctor. Parents with children ofall ages and women reported doing this, whereas young people I and men tended not to. "You look athomefirst to see ifyou 've gotsomething to help yourselfwith before yougo out elsewhere. " I Parents were more inclined to diagnose and treat themselves. Some older people and men also reported doing this, but to a lesser extent. Forty-three percent (1 OS) ofsurvey respondents felt they really needed to use health services more often, but found it too expensive for them or their families to do so. The Porirua I study found that over half (57 percent) of respondents expressed this view. Of those Wanganui survey respondents who said they could not afford the cost ofservices, 26 percent simply went without and did not use any health services. A further 31 percent went regardless ofthe cost, even ifit meant borrowing money I or getting into debt. I
Poutama Whirinaki Interwoven Paths 72 I I I GP services The cost ofvisiting a GP in particular was seen as expensive, causing a variety ofpeople to delay treatment or 'save up' reasons to go. Fifty-five percent ofpeople who took part in the survey felt that cost was a factor I which kept them from seeing a doctor more often. One younger woman reported saving up a number of complaints before making an appointment with her GP. I "/save mine up so that I've got five reasons to go. " Young people wondered if their GPs took their employment status into account when charging. (Those I young people with Community Services Cards still considered it expensive.) Being charged according to the time spent with the GP caused many women and parents irritation. This made them feel very conscious ofthe time when visiting their GP. Equally, the cost ofthe visit could be I cheaper if you hurried. "Ifyou're fast you can get in really cheap. "
I Parents with young children were very appreciative of the cheap rates for babies. Some parents of older children also praised GPs for their leniency when it came to charging for repeat visits. "Quite often you have to visit the doctor quite a lot about the same thing. He'll not charge for a I particular visit with the same child. "
Parents reported being allowed to pay the bill offas they could afford to. I "If/haven't been able to pay my account at the time, he's always been willing and understanding to I let it go until you can pay. " Some older people were concerned about families with their own homes, particularly young families. They felt that the costs related to health care on top ofessential living costs must make things very difficult. I "Ifeel sorryfor the ones who are out there in the community with their own homes, having to pay rates, insurance and the upkeep oftheir homes. They are the ones who must really struggle to get to· I see any doctors. " I After hours costs The cost ofafter hours treatment was a particular issue for parents and older women. Many parents with young children found the cost ofhouse calls and visiting a doctor after hours unaffordable. I "You have to make sure your kids are sick between office hours. "
Older women also commented on the expense ofweekend visits, concluding that they only went ifthey had I an urgent problem. "/think costs ofweekend visits are exorbitant. " I Pharmaceutical costs
I Pharmaceutical costs seemed to affect older people more than others as they were more likely to be on regular medication. Those in this situation found the combined cost of phoning the GP and having the prescription filled by the chemist costly. I "I thinkjust to ring up the doctor to get your tablets that you get every month. .. it's a bit on the nose. " I Some women with children reported frustration, especially when they had to pay for two separate prescriptions. "It's frustrating, you want to boil. "
I 73 Poutama Whirinaki Interwoven Paths I
Parents told stories of leaving prescriptions for themselves unfilled until they could afford to pay for them. Parents also noted that prescriptions seemed to get more expensive as children got older. Nearly a quarter I ofthose survey respondents who found health services expensive would have liked to have seen a chemist more often (though it was unclear if this was for advice or to purchase medication). I Other services I Some younger women found the cost of laboratory services an extra burden to an already expensive process of seeking medical help. "You go to the doctor andpay him, then go to the Lab andpay them, and back to the doctor andpay I him again."
The costs of some services that were perceived as 'extras', such as counselling, meant that many women I were unable to use them. The women who talked about this did not consider such services to be priorities and were therefore unwilling to pay for them. One had been receiving counselling but decided to stop because she could no longer afford the sessions. However, the group noted that not being able to afford I professional support adds to the stress one is already feeling. Similar feelings were expressed about the cost ofa gynaecologist. Although this is an important service for women, many felt that it was beyond their reach because ofthe cost. I "It's big money. " I Cost did not appear to be as much ofan issue ifpeople felt that the service they received was good. However, if the quality of service was not good enough, many people objected to paying for it. One older man felt very strongly about the expense of visiting his dentist, because he felt the level of service was poor. I "You pay a lot ofmoney to go to the dentist and the service that you get is appalling. "
Other older people mentioned the expense ofdental care, as did a lot of young people. Our survey showed I that of the 43 percent of people who found health services too expensive, 25 percent said they would have liked to have seen a dentist more often. I Parents with children at primary school were concerned at the cost ofvisiting an orthodontist. The on-going costs for parents whose children need glasses was discussed by parents with children of intermediate age. "Ifyou want plastic lenses, they're lighter and safer but more expensive. " I
Costs related to ageing I
Many older people discussed costs such as dentures, spectacles and hearing aids. There was concern that many elderly people did not have enough resources to lead a full life. They believed the health system I needed to take a more preventative approach, with emphasis on education and information on healthy living habits. I One group ofolder women was very concerned about the costs ofrest homes. They found the possibility of paying such amounts daunting. I "Those people are paying a colossal amount ofmoneyfor the week."
However most older people wanted more assistance with safe home assessments, so that they could afford I to make their homes safe and so stay in them longer. By this they meant financial help, not only with the assessment, but with the actual changes that the assessment recommended. I
Poutama Whirinaki -Interwoven Paths 74 I • I Secondary care There was a perception particularly among many older people that publicly funded hospital care might not be available when needed. They were frustrated by their inability to pay for operations, which meant they I had to join lengthy waiting lists. Older people felt that a lack ofresources in the health system was seriouslyI' impacting on their ability to lead a full life. I "Jfyou had the money you could payfor it. " Older people with disabilities who could not afford private treatment found the wait frustrating and stressful, affecting many other facets oftheir lives. I "The frustration causes bad temper, trouble at home, you can't go out and friends drop off People don't ring you because all you do is complain. "
I There was also a feeling among many older people that they had paid taxes all their lives and now when they wanted to use the health system they had to wait. "It's a dollar-oriented health service and that is what is upsetting most people - civilians, patients I and staff"
The men's focus group also discussed cost issues related to secondary care. They felt limited access to I public health care forced many people to 'go private' to avoid delays. They acknowledged that this was not an option for everybody. I "There is now a system whereby ifpeople pay they get priority. It's a matter ofwho 's going to pay. People once had the choice to pay and get surgery done private, now it seems to apply to the public I system. Access to surgery in the public sector is difficult andfrustrating. " I _____Choice
Most people wanted to be able to choose their health care providers, particularly their GP. Most people said I they could make that choice. Most focus groups discussed choice at a primary level, with choice at a secondary level briefly mentioned by one group. The men's group discussed the issue ofchoice vigorously._They said I that patients tend to keep going to the same doctor unless something major happens to make them change. I Changing GP People did not want to be made to feel uncomfortable, so not having to justify changing doctor was seen as a major benefit. In general, choice was discussed by the younger women's group, parents and men. Older I people and very young people were less likely to report issues related to choice. In those groups that discussed choice, many members had made the decision to change. Some had found the change beneficial while others were still not satisfied. I "There didn't used to be the choice in terms ofchanging your GP. The GPs used to close ranks. "
Women in particular felt there should be more information available to the general public on how to go I about changing one's doctor if required. "My other doctor, he was a male. I used to go in there feeling like a neurotic housewife. I didn't know I I had the choice to change. " One group of parents were concerned that if they went to change their GP they might not be able to find I another who was willing to take them on. Some group members were aware ofdoctors who were not taking on new patients. The group went on to identify certain criteria some doctors were using when deciding
I 75 Poutama Whirinaki -Interwoven Paths I
whether to accept a patient. Location, permanency of residence, family status and home ownership were important to some doctors. I "He was very strict about who he would take. "
The group felt that although they had the option to change their GP, they might have to try several doctors I before being accepted, thus the change is not always for the better. I Cultural and gender issues
A school-age group approached.choice from a different angle; that is access to Maori and female doctors. I They felt that the amount ofchoice in this area was still inadequate. They suggested more services like Te Waipuna. I In one ofthe women's groups, two members had decided to change their GP, and one had chosen a female doctor. The group said they preferred female doctors as they were more understanding and easier to relate to. I
"It's easier to relate to a female, it's not like there is a barrier there n.
"Like friends talking, rather than a professional talking to a lay person. " I I ----- Continuity of care I Continuity ofcare was an issue raised in the survey. More than 20 percent ofpeople surveyed had dealt with a different health practitioner for every appointment. This was more common among females (23 percent) compared to males (12 percent) and people holding Community Services Cards (25 percent compared to 14 I percent ofpeople without a card). This may reflect the fact that women are higher users ofhealth services.
Dealing with a different doctor was often experienced when people were using hospital services (66 percent). ·1 About half ofthose who responded said they did not mind seeing another doctor. They saw this as part of the hospital rostering system. Those who did not find it acceptable noted that it made it harder to build a relationship with the health practitioner, and said they felt dissatisfied with having to explain their condition I all over again. "You build up a rapport with that person andyoufeel very secure and very trusting. " I
_____ Other barriers to health services I Many of the groups surveyed had strikingly similar experiences and views about other barriers to health I services. Issues like lack of information, long waiting times, waiting lists and difficulties with transport were commonly discussed. Other themes were raised by particular groups only. For example, young people complained about the hours the SID Clinic is open. Young people also believed there was a lack of help in I the area ofalcohol and drug abuse.
Some older women in particular found the practice nurse to be a barrier to seeing their GP. They wanted to I visit their GP, but the practice nurse would act as a screening device. "That was a thing with our first GP, it was the practice nurse, getting past her. " I
Poutama Whirinaki -Interwoven Paths 76 I I I Information People reported a lack ofinformation in many areas, which acted as a major barrier to health care for them. Many groups expressed concern over entitlements. They believed some people did not use available services I because they were unaware ofthem.
The actual focus group meetings acted as a source of information sharing, with many people becoming I aware ofservices that they had not known about before, some ofwhich are free. This was particularly so for parents who found out about services such as the public health nurse, and for women wanting counselling. Older people with disabilities were concerned about a lack ofinformation possibly preventing some people I from receiving services they are entitled to. They discussed Disability Support Services in particular. One older woman had suffered two strokes but was not aware that home support was available to her.
I Older women were concerned about the lack of information given to a person on discharge from hospital. "People come out ofhospital and they are entitled to a follow up service. They don '[ realise it's I there." Parents ofintermediate age children made similar comments about accident and emergency services. They felt unclear about follow-up treatment because of a lack of information. Some would have liked a written I document from A&E about their treatment, so they could pass it on to their GP. "They didn't do any check up afterwards. "
I Other parents reported long waits at A&E, and believed information on why there was a delay would be helpful, especially when there was hardly anyone else waiting for treatment. I "You can be the only one out there andyou're sittingfor hours. " I "You often hear them laughing or joking, andyou're sitting there waiting to be seen. " Approximately half of the people who took part in the survey reported seeking information about health services over the previous 12 months. Most ofthis related to specific medical conditions, tests or treatments I as opposed to entitlements. Eighty percent of those needing information about health services reported receiving it.
I The men's group discussed the need for more education and information for parents on the immunisation of children. They felt this was behind many parents not accepting the freely available immunisation programme for their children. I "The rising body ofopinion is ifyou immunise you '1/ get sick. "
The group also felt that many young people lacked information and education on life skills, and as a I consequence were living unhealthy lifestyles. I -----Transport
I Transport tended to be more ofan issue for women than men, either with getting to and from the doctor or having to go outside of Wanganui for treatment or tests. I "Sometimes you have to go to Palmerston North andyou haven't got a car to get there. " This created problems for those women without their own transport who had to 'fit in' with family or I friends.
I 77 Poutama Whirinaki - Interwoven Paths I
Over 75 percent of survey respondents said they would use their own car to go to hospital or a doctor's appointment on a weekday. The remainder would go with family or friends, walk or go by taxi. Few people I mentioned public transport.
The way people went to either hospital or their GP varied by area. Only 64 percent of people living in the I 'core area' used their own transport, in contrast to 92 percent for the rest ofWanganui. The survey also showed a similar proportion ofCommunity Services Card holders in the 'core area', who are less likely to travel to hospital or the doctor in their own car. I Most people (85 percent) used the same means of travel for week days and weekends. I
-----Weekend help I
Fourteen percent of survey respondents had experienced a situation where they felt it was hard to get help when they needed it in the weekend. This was a much smaller problem than was identified in a similar study I in Porirua.
Of those who found it difficult to get help at the weekends, 36 percent said there were no hospital beds I available when needed, 30 percent had difficulties getting help from a practice nurse and 24 percent had problems getting a doctor at the weekend. I
_____ Home visiting I
A small proportion of survey respondents (15 percent), said they had experienced times when they really I preferred health practitioners to visit them at home, but found it hard to get that to happen. This was more common among Maori respondents than non-Maori. Almost half (49 percent) related their comments to getting help from a GP, while 22 percent linked their comments to outpatient services. I
The main reasons for wanting home visits were divided into three which were approximately equal: difficulties because oftheir illness; transport problems and costs; and difficulties in getting to health services because I of a disability, child care responsibilities or the length of waiting at the hospital. I -----Waiting times I Most people thought that there were problems in getting good hospital treatment when needed. Some people said they had had operations scheduled then postponed indefinitely. They said that it was often difficult to get an appointment with a specialist, in order to get an operation scheduled. Delays to specialist I treatment and service are often very lengthy, causing stress for the patient. "Concerningprostate cancer.... the hospital toldhim that it would be one to two years before he could I get a surgeon's examination before an operation. " The time it took to get a specialist appointment caused a lot ofstress for people as they knew that something I was wrong. The effects of such stress spilled into other areas oftheir lives. "Waiting to get an appointment at the hospital can cause worry and anxiety. " I
Poulama Whirinaki -Interwoven Paths 78 I I One person linked the wait with a need for psychiatric help. I "I ended up at a psychiatrist last year. " Nearly 40 percent of survey respondents recalled one or more occasions over the last year when they felt I they had to wait too long for an appointment with a health service. Fifty-four percent ofthose waited for a hospital outpatients' appointment, 16 percent for a doctor's appointment, and 10 percent waited to see a I private specialist. Seventy-seven percent of survey respondents found their long wait unacceptable. Some said they suffered unnecessary pain or anxiety, and several felt their problem was serious but not recognised as such by the I health provider. "I could drop dead before the appointment. "
I Older people were particularly affected by waiting lists. They were considered a huge barrier to secondary health services. Many older people waiting for hip, eye or knee surgery felt the quality of their life was compromised. For one older woman this meant losing her driver's licence for up to a year, as she had to I wait to have her cataracts operated on before being cleared for her licence. Another older woman had been on a waiting list for six years and may now be too old to have the operation. This lead to concern about the kind ofold age they were going to have. Those affected by waiting lists acknowledged that the same problems I did not occur for those who could afford to be treated privately. "Waiting lists are certainly a lot shorter ifyou go private. "
I Parents also experienced difficulties getting access to secondary health care for their children. Waiting to get help for children was frustrating for parents. One woman's daughter had a two and a half year wait I before the eye specialist could treat her. This delay was detrimental to the child's eyesight. "It is too late for my daughter, but for other wee children coming up, they need to work harder and I fiaster. " Another woman was feeling despondent at the time it was taking to get help for her child's behavioural problems. These problems were not only affecting the child's family, but also other areas such as school. I "It becomes a burden hearing about the behaviour ofmy child in school but not knowing how to change it."
I Parents with children at intermediate school felt that waiting lists, especially for ear nose and throat (ENT) surgery were too long. They felt that delays in treatment could have serious implications for the child's social development and progress at school, especially when hearing is affected. I "I don't think there's enough awareness ofthe long-reaching effects ofjust having to wait a year to get things seen to ...the kind ofeffect it can have on the kids. They will present at school with behavioural I problems. " While access to secondary care was problematic for those who did not have medical insurance, access to primary health services in Wanganui was considered to be very good. The men's group felt that this presented I a conflicting message to the public, whereby one's GP is concerned about one's health, but secondary care is not available.
I The men's group believed the health reforms were responsible for access problems in secondary care. They commented that the standard of care being offered is brilliant, but difficult to obtain. I "The service is good, it's just that you can't get at it. " I
I 79 Poutama Whirinaki - Interwoven Paths I
Limited access to secondary care has led growing numbers of Wanganui people to travel outside ofWanganui to get the service they need. The men's group acknowledged the stress this can cause to a patient and their I family. "I don't want to go to Palmerston North or wherever to get an operation done. It means stress it will put on in terms ofthe family. " I
Waiting times after arriving for an appointment I
Waiting times in a doctor's surgery was still an issue for many people, particularly parents, who mentioned waits of up to an hour and a half before being seen. After a long wait, some felt their appointment was I rushed, with the doctor not really listening to them. "You get in andfeel so rushed, he wants you to get out and the next one in. " I "I don't think anybody minds waiting some times, but not all the time. "
Other groups mentioned similar experiences, especially young people. I
Over half ofthe survey respondents reported waiting once they had arrived for an appointment (similar to the Porirua study). Sixty-two percent mentioned waiting at the hospital and approximately 40 percent I mentioned waiting at the doctor's surgery or health clinic they attended. I Long waits were unacceptable to 63 percent ofthose survey patients who had this experience. They felt the long waits were caused by the provider's poor organisation and they sometimes created unacceptable costs to the client, such as the need to take time offwork. Long waits were particularly unacceptable ifthe person I waiting was an older person or a young person.
For one couple who had needed treatment for their child, it was the long waits at outpatients that acted as a I barrier. After the lengthy wait they always had a rushed visit. "Ifeel quite pressurised, you couldn'tjust sit down there for halfan hour andhave a goodchat about everything. You do what you have to do and say what you have to say. " I
Many older people also discussed their long waits at outpatients and the booking system that often gave a few people the same appointment time. I I -----Quality issues
Many ofthe issues regarding quality were seen by the groups as being directly related to a lack offunding. I Quality issues were therefore closely related to cost. I Confidence in Good Health Wanganui I The misdiagnosed biopsies which were widely reported in 1994 had raised a lot ofdoubt in the community about the competence of staffat Good Health Wanganui (GHW). Nearly every group made some mention of the misdiagnosed biopsies. The incident highlighted the lack of quality control within GHW, showing I the importance of having such systems in place. However, one man felt that this unfortunate incident had led to vast improvements in methods for monitoring and quality control. "I have more confidence now than I've had before because the efficiency level has been cranked up I and it should be working effectively. "
Poutarna Whirinaki - Interwoven Paths 80 I I There were others who were not as convinced. One older woman described how she did not want to go to I GHW. Finally her doctor took her to hospital, reassuring her that it was all right. Some ofthe young people's groups perceived GHWas particularly bad when it came to making mistakes. I However, many people concluded that GHW's public image was unfortunate because there is a great deal of experience and care available there.
I One group of women suggested the need for structural stability within GHW, which they believe would help restore confidence. "We needquality ata reasonable cost. Reduce the waiting list, do something consistent. The structure I changes, keep the structure consistent. "
I Health service organisation
There was an awareness by those who had had contact with GHW, ofthe pressure medical and nursing staff I were under. They felt this was reducing the quality ofcare patients received. Comments referred to the level of nursing staff in particular. There was also concern about the hours young doctors worked. Older people with disabilities had encountered times when patients were left alone for several hours. I "The saddest thing 1 saw was an elderly woman made to sit up for four hours. "
Thirty-nine percent ofsurvey respondents felt the health service had too few staff to cope with the number I of people needing the service. (This was similar to what was found in the Porirua study). The majority (82 percent) ofthese respondents who felt that GHW had too few staffto cope cited hospital services, with I 72 percent specifically citing A&E or outpatient services. Older people especially believed that money is spent in the wrong areas, with too much money going into I management and not enough into medical staff. "There seem to be too many chiefs. "
I Many groups felt the current health system places too much emphasis on money rather than people. Again older people were more likely to make this observation, comparing the current situation.to the past. I "The mere word client instead ofpatient is bad" The men's group felt that the health reforms had created a situation where not enough money existed to do the job properly. The use of 'high tech' equipment and advanced procedures are very costly. The group I suggested that this is not being taken into account by the cost/price formula ofCentral RHA. As a consequence access to services is limited, priority is given to those who can pay.
I Older people noted that Wanganui had a high proportion ofelderly. They believed this would result in there being a high demand for secondary health services, but they doubted the availability ofsuch services. "Wanganui has a high population ofelderly people, so we are going to needthings like eyes, prostates I and hips."
Some women commented on the lack of toilet facilities at doctors' surgeries and the inconvenience this I caused, especially ifthey had small children with them. It was something that, when combined with other stresses, became problematic. However older people with disabilities commented positively on the frequency I of toilet facilities and ramps at doctors' surgeries. I
I 8i Poutama Whirinaki -interwoven Paths I ----- Early childhood services I Plunket funding concerned those with young babies. Other groups ofparents and women with grandchildren also discussed what they saw as a lack ofresources. All these groups felt that Plunket offered a valuable service, but because ofthe pressure Plunket staff are under, they felt some parents may not be getting the I support and information they require (especially young mothers).
Parents with young babies felt that the longer gaps between visits meant problems were discovered later. I Fewer visits resulted in pressure on other services such as the public health nurse and the Karitane Family Centre. "There are not so many nurses now and they are pressured with time. " I
Parents commented positively on the Karitane Family Centre, but raised issues about resources. Those who attended the Centre described how the service lacked room and privacy. I I -----Information
Information on discharge was an area which was widely felt to be inadequate. The men's group felt that I many people are being discharged from hospital without support and no clear cut guidelines as to who was responsible. I "All the agencies seem to be duckingfor cover saying it's not my problem, it's somebody else's. "
One ofthe women's groups believed that some patients were released too early, and therefore quality care I was severely compromised. "They are trying to get the waiting list down at our expense. " I Many older people were also concerned about the lack ofinformation regarding support services available to people leaving hospital. Some said they knew ofpeople who had missed out on support services because ofthis. I
Quality ofcare at the Day Clinic was brought into question, with one women's group finding the service to have little customer focus, poor follow up procedures and little information supplied. Some women were I distressed when they were given no information about what to do or who to contact ifany further problems arose after having day surgery. I Some women were unhappy with the treatment they had received while in the Maternity Unit at GHW. They were often given conflicting information by different nurses. "As each nurse came in it was a different story with each nurse and a young mother doesn '( know I whether she is coming or going. " I Women in this situation felt that poor information at a time when one is already under significant stress can have compounding effects. I Many ofthe women felt that the nurses would benefit from some sort ofawareness training, as they found some of the attitudes 'old fashioned' and inflexible. I When survey respondents were asked ifthere was anything further the health services should do to remind people when to come in for checks or treatment, 75 percent were satisfied with the level and form of information they currently received. I
Poutama Whirinaki - Interwoven Paths 82 I I _____Pharmacies I An older woman was wary about consulting the chemist on medical conditions after the chemist gave her husband incorrect advice. I HI was wary about going to the chemist after he told my husband he had indigestion and the doctor told him he had heart trouble. "
I However this was the only negative comment related to information given out by chemists. Others commented on the excellent service and information provided by chemists. Some people even reported having their I prescriptions delivered to their houses. The lack of privacy in a pharmacy shop setting was an issue mentioned by one woman upset at having I private information yelled across a shop full of people.
I _____Oental care
One group of parents with primary school age children voiced concern about the standard of preventative I dental care. They felt quality would be compromised because of cutbacks. Dental nurses were having to cover greater areas and therefore some children with special dental needs were not seen as often as they should be. I "There are not enough dental nurses in the school to cope with the workload" I _____Provider attitudes I Two lots of parents had encountered intimidating attitudes from health care professionals, over possible abuse of children. Although these parents recognised that abusive parents exist, they felt that staff were I excessively suspicious. "I don't like that attitude. That's something that makes me feel uneasy ahout A&E. "
I Some women found the attitudes of health professionals a barrier to receiving quality care. These women felt they were not treated with an open mind and friendly manner. I "It would he nice to he treated like a person. " Another parent encountered inappropriate attitudes from staff at A&E, not regarding abuse, but rather the trivialisation ofher child's complaint. She said a staff member laughed at her when she took in her daughter, I who had choked on a coin. aI really felt insulted, to be going there for what I thought was an emergency and to be sort of I laughed at and shuffled away to wait. " A couple of young people felt they were not treated very well by their GPs. One mentioned their GP's I inability to get straight to the point and the other felt misled and ignored. Some elderly people in rented accommodation felt they had encountered hostility or discrimination from specialists because they did not have medical insurance. They believed this affected the quality ofcare they I received from specialists. "I was disgusted 'Have you got medical insurance?' When I said no, they weren't interested in me. "
I "The specialist did not want to have anything to do with me because I did not have any medical insurance.
I 83 Poutama Whirinaki - Interwoven Paths I -----Cultural I The vast majority ofsurvey respondents (91 percent) did not consider they would have been more comfortable if the health professional they saw had been from the same ethnic or cultural group as themselves. This finding differs from that in Porirua, where 20 percent of respondents reported experiencing language or I cultural difficulties when visiting health services.
A higher proportion ofMaori respondents (17 percent) said they would have felt more comfortable dealing I with someone ofthe same ethnic group or culture than did non-Maori (7 percent). I _____Carer relief I Most older people with disabilities were using carers to some degree to help them with their day to day activities. In order for the arrangement to be successful, they felt that the carers needed relief from them. "The carers are needing time out. " I
The group also expressed the need for more good listeners, someone apart from the family to talk to, so that the same people were not hearing about their problems continually. I I -----Characteristics of satisfactory services I When people were asked what characteristics made a service successful, most groups mentioned: • caring and friendly service I • efficiency • GPs who listened and were prepared to do home visits I • continuity in maternity care • affordable services with quality control mechanisms in place. I
Some older people mentioned the caring and friendly service they received from their GPs. They felt they had good relationships with their GPs, who took a genuine interest in their welfare. I "They're caring for you, they want to know everything. "
Some young women commented positively on the sensitive manner in which the Medical Centre approached I cervical screening. "Cervical screening which the nurses there do, the male doctors don't have to do it. She explained what she was doing and even asked ifI wanted to see my cervix. " I
Significant emphasis was put on efficiency in a variety ofcontexts. Many older people and parents discussed their appreciation for GPs who were able to give them an appointment on the same day as they phoned. A I group ofyounger women mentioned efficiency in the context oflaboratory results.
The time one was able to spend with a health professional was also seen as important. Most groups appreciated I a health professional who listened to them and didn't rush them out. I
Poutama Whirinaki -Interwoven Paths 84 I I One ofthe groups of parents with children at primary school mentioned that the time given to parents and I children by the public health nurse was invaluable. "We covered everything withoutfeelingpressured. "
I Older people in particular also made reference to GPs who listened. It was very important, especially for those with disabilities.
I Home visits were also more ofan issue for older people, but one group ofparents with children at primary school also mentioned them as preferable.
I Continuity of maternity care was mentioned by a group of younger women and by parents with young babies. In both cases independent midwifery services were mentioned positively.
I The men's group felt strongly about quality control mechanisms, they believed that such techniques are integral to a satisfactory service.
I Young people and some groups of parents in particular mentioned cost as an important feature of any service. Young people appreciated GPs who took unemployment into account, whereas parents of intermediate-age children appreciated flexibility when paying for consultation, so that they could pay their I account in installments. Young people also rated privacy very.highly, especially in regard to sexual health. I _____ Priorities for change I When survey respondents were asked what changes they would most like to see happen in the way health services are provided in Wanganui, 224 had some comment to make. Ofthese, 80 percent had suggestions I for improvement. I Most people wanted: • reduced waiting times and lists I • reduced medical costs and prescription charges • maintenance ofpresent services and an increase in funding I • less management, and more clinical staff I • less focus on money. I Some people wanted: • equality of service regardless of income I • more alternative healing services • better and cheaper transport to health services I • better education and information about health services • more sensitivity, privacy and communication. I
I 85 Poutama Whirinaki - Interwoven Paths I I I I I I I I I I I I I I I I I I I
Poutama Whirinaki -Interwoven Paths 86 I I I I I I I I I I Chapter 6 NGA IWI MAORI 0 ROTO I OWHANGANUI I MAORI IN WHANGANUI .:. I I I I I I I I
I 87 Poutama Whirinaki -Interwoven Paths • HIGHLIGHTS . I
• Some ofthe health issues identifiedfor Maori in Whanganui are also issues for Maori elsewhere. I
• Maori understanding of health is based on four cornerstones - the spiritual, the mental, the physical and the family. All need to be taken into account in the diagnosis and treatment ofillness. I • A number ofsocial and economic factors including higher unemployment and lower household income I contribute to the lower health status ofMaori in Whanganui.
• Cost is a major barrier to using health services when they are needed. As elsewhere, cost challenges I include GP and dentist fees andprescription charges.
• Maori tend to delay using health services until emergencies arise for family members. I
• Maori want to find ways to decrease episodes of ill health, but feel inadequately informed about appropriate preventative measures. Local health services are challenged by Maori, to provide timely, I readily accessible, understandable health information andto reduce the negative impact ofmisinformation.
• Culturally insensitive attitudes ofsome health providers act as barriers to future health service use. I
• Rural Maori are particularly affected by costs, isolation, travel time andproblems in accessing health providers. I • Maori seek health services which are suitable and sensitive, including home help services. I • Complaints procedures, evaluation andaccountability systems andpatient advocacy services are needed across the health services to ensure the provision ofequitable, suitable and and sensitive services for Maori. I I I I I I I I
Poutama Whirinaki -Interwoven Paths 88 I I I INTRODUCTION
I The urban community of Whanganui and its surrounding land, (commonly called Wanganui with no 'h' sound) is situated on land which is under the guardianship ofthe iwi ofTe Atihaunui-A-Paparangi, Ngati I Apa, Nga Rauru-ki-tahi and Tamaupoko. Maori regard themselves as the guardians ofPapatuanuku, the earth mother, not as the owners. Individual ownership of land is a concept that came with the European settlers. Maori within their tribal areas have I associations with the whenua (land) that distinguish them from Maori who are not from that tribal area. This close connection to the land is often shown through the returning of the whenua (placenta) of a new born baby back to the tribal area ofthe parents. I HI think that health in terms ofthe demise ofour own health being disconnected and relocated from I our whenua and our marae and basically those things that were goodfor us, that made us strong. "38 In Whanganui as is in many other parts of Aotearoa, grievances stemming from the loss of land to the settlers last century await resolution. Local tribes are demanding their right to exercise'Whanganuitanga', I which has been described as: "... the supreme authority ofTe Ati Haunui-A-Paparangi in its own district to be the guardian ofthe land andriver andall its resources, and to legislate according to Maori customary law how the land I andpeople are to be protected."39
In February 1995, the tangata whenua of Whanganui exercised 'Whanganuitanga', through reclaiming an I old pa site, Pakaitore, currently known as Moutua Gardens. Those involved in the occupation ofPakaitore argue that the practice of"Whanganuitanga" is essential in order for gains to be made in the health, education I and wellbeing oftangat a whenua in Whanganui. Statistics show that approximately 6,768 Maori live in the urban area ofWhanganui (17 percent ofthe total population of40,899) and 27 percent ofthat population is based in the 'core area' which has been defined by I this report as an area of high health need.
Many threads make up a community. For Maori, it is common to be involved in a number ofinitiatives on I different levels: as health providers, agents of the Government, support people, treaty negotiators, tribal negotiators and many more. It is the tribal connection that is first and foremost when dealing with "iwi I business". I Social factors which innuence the health of Maori How people work to keep themselves well and what causes sickness differs somewhat with each individual I and culture. The failure ofsome health services providers to acknowledge and understand those differences contributes to the poor health status of Maori. I I
I )R Focus Group report 1995.Central Regional Health Authority. )?Niko Tangaroa 1995 in Cate Brett Beyond the Comfort Zone North and South, June 1995.
I 89 Poutama Whirinaki - Interwoven Paths I When Maori talk about health, they take into account either consciously or sub-consciously the four cornerstones ofhealth: I • taha wairua - the spiritual • taha hinengaro - the mental I • taha tinana - the physical • taha whanau the family. I When someone is ill, Maori take these four aspects of that person into account to find what is wrong and where the problem stems from in order to treat it. I
The four cornerstones I
"It is also about what are the things that keep youphysically healthy as well, so you must have to think about your mental health, your psychological health and all that and using those things to keep you I sarfi e. "
"Basically who you are and who we come from. All those very basic things that we as Maori have lost, I because ofthe advent ofthe fifties and sixties assimilation and getting Maori to come to the urban areas. I "But ifyou did need health care, for me in my own situation, what I would do and why... I actually looked at alternatives that we had and who I could go to. I am talking about whanau particularly because I know who they are...... so that has been an option for me. " I
Socio-economic status is also linked to health status. Indicators ofsocio-economic status identified in Hauora Maori Standards ofHealth 111 40 are: I • income • employment I • housing • education I • family structure. I Many of these issues were referred to in the focus groups because of the perceived impact on the health status ofthe person, their whanau and the wider community. I The Maori population of Whanganui I Twenty-nine percent ofthe Maori popUlation in Whanganui identify themselves as belonging to the iwi of that area (Te Atihaunui-A-Paparangi, Ngati Apa, and Ngarauru). However, there is still a large portion of Maori living in Whanganui that do not identify themselves with any iwi. I
The majority of Whanganui Maori live in the core area, but still remain connected to their tribal whenua boundaries. Eight percent of Maori still live in the rural areas of Whanganui District, including the river I area. I 40 Pomare E, Keefe-Onnsby V, Onnsby C, et al 1995. Hauora- Maori Health Standards III. Kilgour R, Keefe V 1992. Kia Piki Te Ora.
Poutama Whirinaki - Interwoven Paths 90 I I Te Ati-Haunui-A-Paparangi represent 19 percent ofthe total Maori population living in the core area, with I Ngati Tuwharetoa making up another 11 percent ofMaori.
Ofthe total population in the core area, 27 percent are Maori. Also, 50 percent ofthe Maori population is I under the age of twenty years of age. Whanganui has a large proportion of young Maori (15 years and under) and a small proportion of elderly Maori (who make up just 3 percent ofthe total Maori population). Health services have special issues to focus on in relation to each of these groups. They must provide I quality care for the increasing number ofteenagers, while providing care which will provide the opportunity for older people to remain in the community for longer. They also need to address the issues affecting men I and women in the intervening age groups. Sixty-two percent ofthe households in the core area receive a total income of less than $30,001, according to 199] figures. Forty-three percent ofthe people living in the core area aged between 15 and 65 have no I formal qualifications.
Most Maori are at the lower end of the income scale, and the majority ofthose lack formal qualifications. I This group receives most of its financial support from Income Support services. I -----What Maori had to say I Previous hui I Central RHA regularly consults with Whanganui Maori, and held several special hui to involve Maori in this needs assessment project. Before those, Whiitiki Taura Here Tangata met on Kaiwhaiki, Paraweka, Maungarongo and Ratana Marae with Maori of Whanganui to hear the concerns of individuals, whanau, I hapu and iwi regarding Maori health and health status in the Whanganui area.
As a result ofthose consultative hui, Whiitiki Taura Here Tangata had the responsibility ofcontracting with I Maori to become providers ofhealth services particularly designed to meet the needs ofthe Maori popUlation in Whanganui.
I A range of issues and questions were raised relating to the provision of health services to Maori. Areas identified as needing marked improvement included child health services, rural health services, and home I based services for the elderly.41 With the assistance ofTe Puni Kokiri hui, were called in November 1994 for Maori groups and organisations to meet with Central RHA, to discuss their concerns and issues relating to Maori health in the Whanganui I area. A list ofthe organisations who participated is attached as Appendix D.
I Small group interviews
As well as the series of hui, which were held over three days, specific focus groups and interviews with I provider groups and consumers were carried out. The focus group interviews with Maori were carried out I through a contract with Te Oranganui. The main issues identified by the focus groups were common to Maori throughout the Central region, I although the order of priority they gave them varies in different communities. 41 Report on Maori Consultation Hui at Maungarongo Marae, Ohakune August 4 1993,
I 91 Poutarna Whirinaki -lnterwoven Paths I
The health status of Maori has pushed these issues to the forefront. The Government has identified Maori health as a priority. I I _____Issues raised at the consultation hui
Access I
Problems ofaccess to services reported, ranged from hospital waiting lists to travelling to services. Lack of access due to major road blockages or wash outs has a particular impact on those Maori living in the rural I areas. "This is as far as the road goes. Further north are more ofour people but they are reached by boat. Everyone is entitled to services no matter where they live. This is semi-civilisationfor us I paradise. "42
Another concern expressed by rural Maori was the tourist industry and the increase in population caused by I an influx oftourists. Not having health services to even cater for the Maori population who live up the river raised concerns, but it is also an issue when what resources they do have up the river, are used to cater for tourists who have not taken into consideration the terrain and have come unprepared for the environment I they are visiting. Inadequate equipment and lack of local knowledge often lead to the need for expensive emergency services, rescue and medical support. I Problems with access to services was highlighted by all the focus groups. The barriers which prevented access were wide ranging and impacted on people at different levels, whether or not they are Maori. Barriers I such as cost, lack oftransport, lack ofinformation and how to gain access to services are issues which face the general population. I Some providers make an effort to eliminate as many ofthe barriers as possible through taking the services to the people, rather than the people having to come to the services. Some services are more able than others to be delivered in this way. I "Midwifery service is seen to be well received by the women because ofthe fact that I am a woman and I go to their homes. They don't have to come to the centre for their care. I access them, I come to them. " I This type ofapproach in the maternity area eliminates the transport and cost barriers. I Many Maori do not go to health services until they are in need of emergency care. It is important to ask why. What is it that is hindering Maori from getting access to services earlier? I Even though Maori within Whanganui are closer to service providers than those based up the river, access to those services is still an issue. Travel time may not be a problem, but cost often is. The lower their socio I economic status, the more problems Maori have with access issues, regardless of geographic boundaries. "There has been a whole lot ofmoney wasted in terms oftrying to get Maori to actually access the services. I don't think accessibility is an issue ... it's always affordability. " I I I 42 Report from Hui Held At Paraweka Marae Pipiriki 13 September 1994.
Poutama Whirinaki -Interwoven Paths 92 I I Cost Cost is a major barrier to Maori getting appropriate and necessary health services. This issue was ofparticular concern to the Kaumatua Kaunihera, as many ofthem wanted to be cared for by their whanau members, but I there was no financial support for whanau members. "I won't ask my whanaufor their help because I know they don't receive any money for helping me and they would have to use their money to come to me. I can't see why a total stranger who doesn '( I know me or may not understandmyneeds, can get paidfor looking after me when my own family who know me and know what I want and need have to use their resources . ..
I For others, paying for health care is not high on the priority list. "The priorities in my life go food, clothes, house and then ifany is left over, the doctor. "
I Returning people back to the community in order for the community to become more responsible for their own isn't always the best for Maori. They often lack the resources to care for themselves, and cannot easily provide the care for a mentally disabled child, no matter how much they want to. For some it is a difficult I choice to make. ':/want my boy out ofKimberley because I know that he is not happy there. But I can't bring my boy I home, because there is no money to support him in the community. My boy's sickness is mysickness. " Paying for specialist services but not getting any results is very disheartening for some. "It was $40 thefirst visit andI went backfor three visits after that and it was $25 each visit. That was I seven years ago. I haven't heard nothing and I still won', go back. I just think that they should I attempt to get in touch with me ifthey had thought ofsomething. " Using services because they are the cheapest does not necessarily guarantee that the services are going to be quality services. I "I was lookingfor the most economical, cheapest dentist I couldfind and obviouslyyou are going to get someone who is not as reputable .... Those better places you have got to pay a lot...... but I just I can '( afford it. GPs, pharmacies, diagnostic and dental services were all identified as carrying large costs. This is a major issue for many people due to their employment status. I "They could never find my problem, so I flatly refused to go back just to pay $25 to hear 'we still don't know what it is '. So I never found out what it is. "
I "Idon '{ like the fact that we pay double on public holidays, like Waitangi Day. After hours is dearer as well. So you really have to be sick within a certain time, its cheaper. Be sick between nine to five I on Monday to Friday. " For elderly people who have to visit the doctor on a regular basis for such things as kidney problems, the monthly costs ofthese visits far outweighs the financial support available to help cover costs. I HI have to visit the doctor each month for afull medical. Travel into town and then my regular dose ofmedication costs $40 as well as what it costs me to see the doctor. I don 'f think I need to see him I every time, but I have to get my medication. " Some Maori need regular checks to monitor things such as blood pressure, but ifthese fall at a time where I finances are low, they will not go. "Ihave heart problems and I need to get my blood pressure checked every month. IfI can't afford to I get to town or go to the doctor's, I won't go. I will miss the checks because they are too expensive. " This can put Maori at high risk, because iftheir blood pressure is up and they do not do anything about it, the likelihood is that they will eventually end up in hospital requiring more than just a blood check.
I 93 Poutama Whirinaki - Interwoven Paths I Terminally ill care I People who require regular and consistent visits to doctors or specialists experience some ofthe cost which affects people who are terminally ill. Throughout our consultation, people said that those who are terminally ill or who must frequently visit their GP and require medication could be charged less or get cheaper rates. I "... She had to pay $35 when it came to her medication. Her and Dad were finding it hard because there was only one income ... So the terminally ill should have cheaper rates. It's not really their fault that they are dying. " I
Culturally appropriate services I
Finding services that are suitable and sensitive to the needs of different people is difficult to deal with, as there is usually a lim ited number of service providers. There is not always much choice of who to go to. I
Concern about the attitudes of non-Maori service providers were expressed. Some of these attitudes are negative and possibly stem from wrong assumptions and misinterpretations. Tension has been high within I the community of Whanganui over the last year, following the reclamation of Pakaitore. Misguided and misinformed attitudes hinder constructive communication. Stereotypical attitudes towards Maori can influence the way some service providers react to Maori clients. I "My Dad went to him, he hadan ulcer andhe (the doctor) didn't even look at him. He just said 'you'd better give up smoking then '. He said, 'I've never smoked a cigarette in my life, why would I give up I smoking when I don't even touch it', and he didn't even look at him (Dad). "
Whether it is described as cultural sensitivity, cultural appropriateness or cultural safety, it is a responsibility I ofall service providers to take into consideration the cultural aspects which surround assessment, treatment and care procedures when dealing with Maori. "Their meals and all that, I remember one time when Nanny went to hospital, she gets really chesty I and everything... we were wondering why she wouldn't eat... Someone went up and asked 'why aren't you eating' and it was because there was a commode in the room... They just didn't think or even ask, 'why haven't you eaten your meal? ' They just thought she wasn't hungry andput it away. I Because there was a toilet in the room. She hadn't eaten for ages. "
How service providers become more aware of issues which concern Maori and how they should deal with I those issues and concerns needs to be worked out in consultation with local Maori and Maori providers. This was identified as a major concern when treating the terminally ill and nga tupapaku, the deceased. Service providers need to be aware that there is protocol surrounding nga tupapaku and they should ask I what needs to be done and how. Providers don't necessarily have to know all the protocol, but should either have someone who does employed specifically, or at least signal how they intend to deal with those issues. "Just in terms ofhow our mother was treated when she passed away, -she was left open, her chest very I open, blood over herface and when she was declared dead, the doctors andnurses walked out. They didn't think ofcleaning her up a little bit, making her look presentable because there was all the family coming in to give their respects ... " I Handling of the tupapaku and transportation ofthe tupapaku are major issues for Maori. Many Maori are I lost in terms of what to do and who to tum to for some guidance and support. Some whanau are lucky to have members who know what needs to be done, particularly when a body is returned after autopsies have been performed. I I
Poutama Whirinaki -Interwoven Paths 94 I I I Complaints procedures and advocacy roles Complaint procedures and advocacy roles can be difficult for Maori when they deal with large mainstream providers. Ifpeople are not happy with the services they receive, what can they do about it? Who do they I ask for help? Are health professionals likely to assist them in bringing a colleague into line? Some Maori believe not. "Another incident was they used trainee nurses at the time ofthe first procedure when they put the I cast on and they hadput it on wrong because they hadput too much weight on the broken bones. I had to take her back... She looked at the cast and then she goes, 'oh it has been put on wrong', so we were another six hours in hospital... I asked the question why was it put on wrong in the first place. I .. .Isaid in future that they should not use trainee nurses ifthey do not know what they are doing. "
However, the major concern is what happens if life-threatening mistakes are made. Not only may it cost I someone's life but a good nurse may be lost because ofthe personal effect it may have on her or him. "My grandmother had a heart attack last week. She was in hospital and she can't understand what they are saying. It's the way they say it. When they go away we have to explain to her what they are I saying. .. and they are going 'between 1 to 10 how sore is it?' She just says 'ae', because she can't understand "
I The role ofan advocate is usually left to whanau, especially when dealing with kuia and kaumatua. However, ifwhanau are not there to advocate. on. behalf of their kuia and/or kuroua, the concern is who will provide I that service. "My brother was an undertaker in Christchurch so what he did so everybody knew what was going on, he went with the undertaker andtold him that he was one too ... everybody was happy with the way I things went. "
I Waiting time
Long waiting times for making or keeping appointments were also identified as barriers. Because of the I costs involved, the seeking of services was the last resort for many people. They would only seek services if their children's health was at risk or when helping someone else (like a kuia or kaumatua), rarely for oneself. Appointments are difficult to keep due to the long time spent in the waiting room. I "I went in there because I had to have stitches and my knee it was just goingfor it, because I went through the shower door, and I was bleeding all over the place and I ended up waitingfor two hours I before someone came along.... " "You have to scream before they take you ".
I Long waiting times were associated mainly with GPs and secondary service providers. Anxiety and frustration are usually the reasons why people then opt out of seeking services from these providers again. "My appointment was for two 0 'clock. I didn't get in there untiI3.45pm, that's a hassle in having to I hang around and wait for one particular person. " I However, some of the clients have taken into consideration the limited amount of resources some health providers have to work with, and what strain it places on those delivering the services. "You have to waitfor a long time before you get in and when you get your baby checked you have to I wait because there is only one weight (machine) so you have to wait for that doctor to finish in the room with their patient.... So there's another 15 minutes there too. " I
I 95 Poutama Whirinaki -Interwoven Paths I
Some service providers attempt to reduce waiting times by providing the service at convenient times for the client and in the client's home. I "Ifthe mother has been up all night with baby and I go and baby is due to be weighed then I won 'I weigh baby I will leave baby sleeping... So I work with the women andfit in with them as much as I can. I
Information I Maori people said the information they received was often: I • untimely and out of date • irrelevant and lacking explanation I • not meaningful to their current health needs and conditions.
Poor advice and poor information ultimately leads to frustration and a desire to seek services from somewhere I else. However, this is not a viable solution as there is no other provider within the area of secondary and tertiary services. I Misinformation and bad experiences often lead to negative attitudes and feelings about services from certain providers - namely the hospital. "When I came home all Ifoundwas that a lot ofmy whanau who were going into hospital were either I dying or whatever so I got the impression that I wasn '[ going to the hospital ifI was sick here, go up there and die. " I "For some reason in Whanganui you don'tfeel like it is safe to go to hospital andyet that should be the place to go ifyou are sick. " I
These misconceptions need to be rectified especially ifthey are having such an effect on patients, and the hospital is the only service accessible within the area. I "Ihate hospitals. I got turned offwhen my brother died, about 17, 18 years ago... I use an excuse to get out ofgoing to hospital. I will have to be on my death bed before I go. " I Maori usually only accept going to hospital under duress. This is caused by factors suchas the insensitivity ofstaff, the lack ofwhanau contact, and being dependent on a stranger. Improved information is needed for Maori within local GP services, maternity services and secondary care services. I
Whanau voluntary work I
Because for some hospital can be a threatening environment, whanau members want to stay with their family member to make sure that the care that is given is explained to the patient, that they are comfortable I and happy. However, many hospitals do not have facilities for this to take place and regard this type of support as an inconvenience. There was criticism ofthe attitudes of some hospital staff. Some had had to have confrontations with staffconcerned. "Ijust said 'Well you're going to have to move me '. The nurses' treatment to my mother was very impersonal, so the family took over the nursing. .. and she didn't feel comfortable with the nursing staffthere. "
Poutama Whirinaki Interwoven Paths 96 I Other cases where whanau support is not recognised or considered is when caring for the elderly and the I disabled. "My grandfather is a paraplegic. We askedfor help to massage him, to keep his body going... We weren't allowed to do it because we werefamily.. .!t 's not that we wanted the pay, it'sjust that Koro I wanted us to look after him. "
This issue also affects those people who need Home Support. Elderly people are often not happy about I strangers coming into their houses and bathing or feeding them. Our kaumatua and kuia want those who they know around so that they can say what they want and they are not whakama (shy) about who is in their I house and washing their clothes, preparing their kai and providing intimate care!" I Service use Problems of access to primary health care services is thought to contribute to Maori being high users of secondary care services. As has already been discussed, many Maori are not seeking access to services I unless it is an emergency.
While there is growth in the numbers of Maori providing primary health care services, hospital specialist I services are in the main run by non-Maori providers. Many Maori feel that if they are going to die, they would rather die at home with their whanau. I "He (Doctor) couldn't understand thefact that she had carried her son, her brother, her immediate family out ofthat hospital, it really broke her spirit to think that she had to go there herself" .'
I "She would rather die than go there, so she said take me back to Jerusalem. So I took her back, her spirit had lifted because she was home, but her illness deteriorated" I Maternity services
I Maternity services currently provided by one ofthe service providers in the Whanganui area tries hard to take the service to the people who need it. This has been received positively by clients. However, providers find they do not just provide maternity services, but also have to incorporate other services such as being a I social worker and facilitator (to access other services).
Because ofthe high proportion ofMaori rangatahi in the Whanganui area, teenage pregnancy is high. There I is concern that maternity services be focused on providing support for mothers not only while they are preparing for the birth oftheir child, but also for at least the first six months ofthe baby's life. In this way the parenting skills ofthese young women have settled and given the baby's health a strong base to grow from. I "Ifyou can get themfollowed through to six months then they should have a good grounding, their support should be a good basis on which to build andthe first six months is vitalfor the health ofthe I baby. " Follow-up care is an area that has been identified as a priority for all Maori women, with a focus on young I Maori mothers. I I I - 97 Poutama Whirinaki -Interwoven Paths I Alcohol and drug services for adolescents I Services for adolescents in all health areas have been highlighted as an area which needs planned and detailed development. Some Maori said that drug-related problems stem from peer pressure, unemployment, lack of positive role models orjust outright boredom and isolation from larger cities where there are things I that could possibly keep their minds occupied in other ways. "Through my experience I believe that it is caused by peer pressure and stand over tactics, and I know that that is going down, I've seen it too. " I
However, for some service providers, the problem is not lack of services, but lack of appropriate people to deliver those services to Maori. There are not enough Maori in the area who are qualified to deliver some I ofthe counselling that is needed for young Maori, and to train takes several years. For some, working within a mainstream service provider is also difficult, as there are times when conflict arises over the style and delivery ofservices. I HI had a prison programme going once, but because there were clear differences in the delivery of the services and the way I wanted to do things was not within the Justice system, I was not asked to go back again. It was a shame, because there are a lot ofour young Maori men who are in need of I support when they are in that type ofenvironment, and to be able to get that support from a Maori is not exactly common. " I Sometimes it is not the system and the structure that Maori providers have trouble fitting into, but some of the people in power in it. I "I was willing to go into Lake Alice andprovide some 'cultural' trainingfor patients as well as staff, but the staffdid not think they needed training and I wasn't prepared to just work with the patients. To make a difference I neededthe staffto be on board as well. " I Staffoften suffer stress due to a lack of service providers in this area. I There are Maori providers who are trying to establish a national network for support. However, because these organisations operate nationally, funding is not guaranteed. In this type ofhigh stress work the turn over of staff is high, especially when funding is only on an annual basis, and comes from a variety of I sources. "They tried to introduce a bonding system when we trained, to retain the workers, but with no guarantee offunding because we got bitsfrom here and bits from there, there was no security, no guarantee for I workers, therefore they move into more secure jobs. "
This has also raised the issue of people getting access to different types of support from other funding I agencies. Some people have not succeeded in getting the support that they have been entitled to because of all the 'red tape' they have to go through to get it. "There's too much paperwork for some support - I can', be bothered. All the papers do is let them I see whether we are double dipping orfor their stats. Not to help me get the necessary support that I needany quicker. " I Accountability of providers I Concerns about who monitors the service providers and what aspects oftheir services are being monitored have been raised not only in the focus group meetings, but through the initial consultation hui held in 19931 I 94 in the Whanganui area. People asked what happens to services which are culturally insensitive towards the needs of Maori, and how these services can be made culturally safe. I
Poutama Whirinaki -Interwoven Paths 98 I I Many feel that there should be services within the hospitals that people can go to access some support or to I complain to ifthey are not happy with the services they have been given. Services need to be accountable to their consumers, and generally services that are not can be affected by consumers going elsewhere to I other services. However, if the service provider is the only one within the area, choice is not a reality. For many Maori, not going to health services leads to major health problems and sometimes death, because I they have left it too long to seek the services they need.
I ----_Current services and their responsiveness to Maori health needs
Te Oranganui is an iwi authority which was established to represent tangata whenua ofthe Whanganui area. I It is made up ofthe four iwi ~ithin the Whanganui region. Their joining together was important to ensure that there was no isolation and alienation of individual iwi organisations and groups in negotiations with I Government. Te Oranganui Trust was established to represent the Maori ofWhanganui in the health arena. Any health I initiatives for Maori have been dealt with through this Trust. Te Oranganui currently have contracts to provide the following services: I • primary care services and GP services through Te Waipuna Health Centre for those within the urban boundaries ofWhanganui and the outskirts ofthe town I • eight community workers through Te Korimako who service the areas around Ohakune, Raetihi, Taihape, Marton and Whanganui urban area
• a 'suitcase' service which is to provide primary care services to the rural areas ofthe Whanganui river I and rural communities along the river; I • a mental health contract to provide day activities for turoro and emergency beds for respite care • a Maori Liaison Service for the elderly.
I The latter service provides support, information and guidance to elderly who need home support and are being assessed by non-Maori within the CHEs. The liaison person is there to provide support and to make sure that the needs of the patient are identified correctly and appropriate people are there to meet those I needs.
Issues identified in this needs assessment reinforce earlier findings and expand on the scope ofthe problem. I A consistent theme ofthe hui and other meetings with Maori was a wish for a wider range ofservices to be provided for Maori by Maori, as well as more services.
I Although new services for Maori have already been contracted for, prior to the completion ofthis needs assessment, these issues and concerns have been raised on a number ofoccasions by Maori in the Whanganui area. There will no doubt still be some gaps in services, but this may not necessarily mean that we purchase I a new service. A new component may be negotiated as part ofexisting services.
I Provider concerns
The majority of concerns that were raised by consumers, were also raised by Maori providers ofservices. I However, it was from a different perspective that these issues were raised.
I 99 Poutama Whirinaki Interwoven Paths I Transport and community health workers I Transport was a concern for the providers as not only were they aware of the difficulty that some people faced in finding transport for themselves and their whanau to access health services, but for the community health workers, they were the main source oftransport support for many of their consumers. This poses I problems for some ofthe providers as they are not funded to provide transport specifically, but to facilitate access, provide support and refer onto other providers for the provision ofservices. I Contracts are becoming more and more volume based and this places providers in a difficult position where they are continuously put in a situation oftrying to meet the needs and demands oftheir client group as well as trying to meet their monthly outputs. One consultation/visit could take up to one day, ifit involves taking I one person to a specialist appointment which is in Palmerston North; when they arrive they have to wait for a couple of hours, then have their appointment, then tum around and drive back and drop the client off (sometimes out in the rural areas) and then return to work. I
Education and health promotion I
To try and prevent the need for health services is one ofthe main aims ofone provider group. The focus has been to work within the kohanga reo as that is one ofthe main environments that providers can access the I majority oftheir clients young parents. "Educating, the parents need educating badly as far as children's health needs go. They have a I better understanding ofglue ear, asthma, asthma prevention. Those two are major, nutrition is another thing, it is parents that need educating within the kohanga reo. " I Providers are working hard to provide as much support to their clients as reasonably possible within the resources they have. However, it is also the wish of those providers that each individual take some responsibility for their personal health and the health of their whanau members. However, health as a I priority for most ofthese whanau does not rate highly when measured up against food and clothing and a roof over their heads. I Alternative care I Costs ofseeking health services can be very high - not necessarily for treatment, but to access the services, to take time out from work to seek services, transport and also time-wise. Many Maori are openly seeking and using Rongoa Maori (traditional Maori healing). Maori providers are supportive ofthis in such a way I that they do not pass judgement on whether or not people should be using Rongoa. Rongoa can range from taking herbal remedies to mirimiri (massage). "/ think we are sympathetic to alternative practices. / notice how some GPs are very suspicious I ofanything alternative but we feel that alternative things work and ifpeople like them then we have no problem with that. " I Work hours I Although providers have set hours ofwork, Maori providers stressed through their interviews that working with Maori in the health sector, does not remain within the hours of 8am-Spm Even though they are not I required to provide 24 hour care, some providers do. This can be because they are the only point ofcall that their community know where they will get a response ifcalled upon, or they are the only contact within 30 minutes ofsome oftheir population and mainly because their services are free. Iwi commitments also take I
Poutama Whirinaki Interwoven Paths 100 I I up a lot oftime when the providers are not working. These are usually very important to maintain networks I and keep up with the issues and concerns of their local community. "The hui are not only for local people, but for outside people as well, out ofthe area and that of I course broadens your networks. Often they come here and have training with us. So far as opening hours, although you get paidfor 40 hours a week, you are on call all the time. Ifthere is a hui, you are expected to go and you go! Ifsomeone rings you at 100 'clock at night you don't say 'sorry I I don't start till 8 0 ' clock - you go and see what the problem is! "
I Other factors
Providers acknowledge that there are factors outside the health sector that have an influence on the health I status of individuals within the Whanganui area, especially unemployment. Many Maori are unemployed as mentioned, and it is through that unemployment that whanau are placed under a lot ofunnecessary stress. For providers to deal with this issue (although it is not part of their contract nor their job descriptions) I usually sees them either pulling from their own pockets and/or going to the food banks and collecting parcels for some of their whanau they service. Many whanau will not access the food banks because they are whakama, but the providers will do that for them and no orie loses face because it is all done just between I one member of the whanau and that person.
"A lot ofthem are proud or whakama to seek help, but ifyou persuade them to think along the lines I that it is a service that we can try to help with. We can't always help but we do try to help, they will I come forward in the end. Not always at the time that you make it known, but later. " Providers also provide support in terms ofaccessing other services such as Income Support, Department of Justice and other government agencies who ultimately have a role to play in providing support to these I unemployed whanau. Being up-to-date with the types of support that are available from each department and what the processes are to access that support is one of the key roles identified by one of the provider I groups. The providers identified a number ofgroups who they view as a priority when looking at the needs for more health services. The two main groups however, were adolescents and kaumatua and kuia. For the elderly, I the concern is that they are possibly viewed as not so urgent when it comes to waiting lists for surgery. Some providers are concerned how the priority lists for operations are made up - and are those lists linked to the age of the patients that are requiring treatment? Do the younger people get to go first on the list I because they may have a longer lifespan than the elderly? This is the message that one provider feels is being promulgated covertly by the hospitals, as no explanation is given as to how these waiting lists are I prioritised. Young mothers and their whanau were the priority among the young ones. There is only so much that the current providers can do. What has been identified as a service gap for Maori, is the provision ofalcohol and I drug services for Maori adolescents. This gap was highlighted by Maori at hui and in focus groups and I reinforced by providers within the Whanganui area. I Future development of current Maori providers Maori providers are often challenged about their level ofmainstream qualifications from some mainstream health professionals. Maori providers, especially the community health workers are viewed as unqualified I and react when so challenged. They see the current status ofMaori health in their community that has been in the hands of 'qualified non-Maori' for a number of years and know that there has been little if any, gain
I 101 Poutama Whirinaki - Interwoven Paths I
for Maori. Maori providers view their biggest strength as being Maori. That fact alone enables some relationship to develop between the provider and their clients. I "Jthink our biggest strengths are the fact that we are Maori, we are with them andnot from that level (mainstream providers). We work with them to a stage where they need to be referred on. " I However, that does not mean that Maori providers are not willing to upskill and develop within their work. Much ofthe constraint around self-development and upskilling stems from the lack of resources to do so, and also the lack of appropriate training providers and training courses. There are two aspects for Central I RHA to consider in the future development of Maori providers - the provision of resources to allow for upskilling to take place, and the development/purchase ofappropriate training packages for Maori providers. I I I I I I I I I I I I I I I
Poutama Whirinaki Interwoven Paths 102 I I I I I I I I I I Chapter 7 THE VIEWS OF I COMMUNITY GROUPS I I I I I I I I I
I 103 Poutama Whirinaki -Interwoven Paths I HIGHLIGHTS I
• The health needs ofchildren, particularly those from low income households, were among the most I important health issues identified Other key issues identified related to women, older people, and people with psychiatric and other disabilities. I • While there was general support for the way health and disability support services were provided in Wanganui, there was also considered to be roomfor improvements. I • The main barriers perceived to people accessing health services included cost, lack oftransport and availability ofsome services and an unacceptable length ofwaiting times for some non-urgent surgery. I
Cheaper or free GP visits for preschool children, reduction or removal ofprescription part charges and a lower threshold ofeligibilityfor a Community Services Card were called for. I
• Bringing health services to the people in rural areas and in those parts ofWanganui such as Castlecliff, where fewer people have access to private transport and/or improving availability ofpublic transport I was advocated
• Increased resources were called for to reduce waiting times at hospital and for non-urgent surgery, to I increase the reach ofwell child services, including dental health, and to improve health and disability support services for people with disabilities. I • There was a general call for improved access for consumers to information about health and disability support services in Wanganui. I • Better communication by health professionals to their patients, within the different parts ofthe health services and between health and other agencies was urged I I I I I I I I I Poutama Whirinaki - Interwoven Paths 104 I I INTRODUCTION
I In order to establish the views ofcommunity groups in Wanganui, a postal survey was undertaken ofgroups representing a wide range of interests. Representatives ofMaori organisations were invited to take part in a number ofhui held in Wanganui. Their views expressed at the hui and in written submissions are reported I in Chapter 6. I The project and its objectives were outlined and groups were asked for feedback on: • who they represent I • the most important health and disability support issues they face • the main services used by clients and members I • positive features of their services • suggestions on ways in which these services could be improved
I • the priority areas for improvement.
A total of83 responses were received from the 182 groups surveyed, a rate ofreturn of46 percent. A list of I groups who responded is contained in Appendix E. Responses were categorised into the following' groups:
• general groups, representing social service agencies, churches, and some groups which concentrate on I one problem only • health service interest and support groups
I • disability support groups, including mental health support groups I • groups concerned with older people • education sector, including preschools, primary and secondary schools and one special needs school.
I The content ofthe responses was consistent through all categories. I I 'I I I I
II 105 Poutama Whirinaki - Interwoven Paths I OVERVIEW I
_____ Who the groups represent I
There was wide interpretation ofthe question about who the groups represent. Responses ranged from 'all I segments of the population' and 'Wanganui City', to specific populations such as 'bereaved parents' and 'cancer patients'. Four groups mentioned 'lower income' clients. Only three groups (primary schools) mentioned areas which related to core areas ofthe project, and then only indirectly. I
The largest proportion of responses were from health interest and disability support groups. There were very few responses from general/recreation or sporting groups. I
The groups represented children and their families, young people, and older people (50-plus), as well as disability groups. That few support groups focused on people in the 30 - 50 year old age group reflects the I fact that this age group tends to have fewer health and disability problems relative to other age groups.
There was only one reference to Maori, though it must be assumed there will be a significant number of I Maori included in client and member groups.
The total number ofmembers or clients ofthe groups who responded appear to make up a significant part of I the population ofWanganui (up to 30 percent). However, it is highly likely that some double-counting has occurred where, for example, people have multiple disabilities, or where clients use several agencies for I different services. I _____ Services used I All health services in Wanganui - whether in the public, private, alternative or voluntary sector - got at least a mention. The services specified most, were those provided by Good Health Wanganui (GHW). Ofthese, child health, maternity, mental health, medical and surgical services got the most attention. However, GP I services were the single most frequently mentioned, closely followed by public health nurses.
References to specialist treatment such as ophthalmology, orthopaedics and audiology were as common in relation to older as younger people. The same is true of the use of support services such as physiotherapy and occupational therapy.
Mental health services are used by members ofall ofthe groups which responded, not just the mental health support groups. Alcohol and drug services as well as child and adolescent services are used by schools. Child and adolescent services are also used by disability support groups.
A wide range of voluntary services are used by numbers of groups, showing that the range of community health services is broad, though no one service appeared to be more popular than others. There was little I mention of home help services, or support provided by women's groups. Some other important non-health groups were also not mentioned: church-based social services, counselling groups such as Relationship Services and Men Against Violence, and the Disabled Persons Assembly. I"
Poutama Whirinaki - Interwoven Paths 106 I I THE MOST IMPORTANT HEALTH ISSUES FOR WANGANUI
I _____ Major themes
The strong loyalty and ownership felt by the Wanganui community for its hospital and health services was I clearly expressed. I The main themes in the responses were: • access; including cost, travel time, and waiting times for surgery, appointments, and clinics I • lack of information about services and how to get access to them • positive appreciation of professional care and attention, for both inpatient treatment and domiciliary I services, and for primary care services (such as GPs and public health nurses) • negative comments on cost, including charges for prescriptions I • lack ofcommunication and liaison between health professionals and consumers or support agencies • criticism of health politics, including the cost of management and administration, the Jack of central I government funding, and a lack ofconfidence inGHW.
I _____ Social and political issues
I The changes to health services in recent years have created uncertainty for many groups and for some a lack ofconfidence in the system. Groups representing older people were the most critical.
I Mental health problems, including depression, suicide, grief, fear ofviolence, emotional and physical abuse, loneliness, poor self esteem and addictions are ofmajor concern. Mental health issues drew comment from seven out of the 20 groups in the general category. Stress, such as caused by juggling the demands of I partner, children, home and work, and the need for practical assistance when under stress, was also discussed. How to stay well and safe was an issue for at least one group.
I Poverty as a health issue was raised by Plunket. Three schools also said that children's poor health condition was related to lack of money and lack ofjobs. I "Lack ofmoney means less is spent on health care. " Five responses in the general group referred to the problems ofageing. Becoming frail and unable to care for oneself as a result ofdegenerative conditions were matters ofconcern to this group. The availability of I adequate community support services were the dominant concern for groups representing older people. "They're valuable because they enable the elderly to live in and make a worthwhile contribution to I the community". Maternity and gynaecological services were mostly a concern for general and health interest groups, but I women's health was also mentioned by a secondary school. People from the education sector were especially concerned with physical, mental and social wellbeing, and I with primary care services. Poor nutrition and diet were mentioned by five primary schools and one preschool. "Children often don't have food, enoughfood, or enoughfood ofthe proper type".
I 107 Poutama Whirinaki - Interwoven Paths I
Management of infectious illness, common childhood complaints and behaviour problems also worried many people. I Disability support groups raised the need for ongoing support services for people with disability. I _____ Access I
Access to health services drew extensive comments from all groups of respondents. Statements about affordability, local availability, waiting lists and waiting times were the main concerns. I
Cost I
It was pointed out that financial stress often contributes to health problems. The cost of health services means that people do not have access to health care, or delay seeking treatment because they are unable to I afford it. Women in particular said they tend to delay medical care for themselves until their children need help. I The cost ofhealth services particularly affects those who just miss out on a Community Services Card. The cost of prescriptions was a problem noted by seven groups. The fear of being unable to meet the cost of I long-term care and the inability to afford health insurance were also mentioned. Two respondents commented on the lack ofaffordable dental care. I Waiting lists and waiting times I Groups in all sectors expressed their concern about waiting lists and waiting times, but older people were particularly concerned. I The lengthy delay in waiting for cataract operations, joint replacements, eye treatment and general orthopaedic cases were cited most frequently. Waiting time for non-urgent attention was also an issue, but there was no indication of whether this was for surgery or another type of medical attention. I
One mental health group was concerned that surgical waiting lists and the uncertainty of when someone would go into hospital meant caregivers were unable to plan in advance for respite care. I
Availability I Women's groups were unhappy about the fact that most providers (including specialists) were male. I Many groups thought it important that hospital care should be provided by suitably qualified health professionals in a centre as close as possible to home. If treatment was not available close to home, there I needed to be easily obtainable information on eligibility for transport and accommodation support.
A mental health group recorded a need to access services at an early stage, instead ofwaiting till a client is I in crisis. I I Poutama Whirinaki -Interwoven Paths 108 I I Transport Problems with getting to support services for people without their own transport was noted by a number of I groups and was of particular concern to mental health support groups. I Information and communication With the exception of groups representing older people, groups in all sectors thought there is too little information about health services and how to get access to them. People were also concerned about a lack I of accurate information about treatment, such as being informed about the side-effects of prescribed medication.
I Communication between health professionals, consumers and other services was seen as an important issue, particularly by health interest groups and disability support groups.
I Health education, particularly about common childhood illnesses, was a significant concern for schools.
I Customer satisfaction
Customer satisfaction was not mentioned as a significant issue in itself, but recurred in responses to more I specific questions. I I I
I I I I I I
I J09 Poutama Whirinaki - Interwoven Paths I POSITIVE ASPECTS OF SERVICES USED I
-----Access I
General groups commented in particular on the even spread ofhealth services throughout Wanganui. Health interest groups appreciated the access to health professionals, and an improved access to specialists "who I are generally very helpful and willing to listen and keep the consumer informed". Secondary schools noted the availability of services and that they were mainly free. "It is site-based, ie at school. It is free. Action is taken very quickly. " I Mental health support groups praised the community-based services for people with psychiatric disability. I Simple referral procedures, consumer-friendly services, professional standards and on-going support were valued. Other disability support groups appreciated their access to specialist services for those with neurological disorders, and their collaboration with hospital services. I
There was good support for the work of general practitioners in Wanganui. All of the groups reported favourably on the amount ofchoice, easy access and prompt attention they received. More practice nurses I and female doctors were also appreciated.
School health services in Wanganui should be very encouraged by the responses to this question. There is I overwhelming support for the work ofpublic health nurses, particularly for their liaison with other services and the follow-up they do with families. There were frequent positive comments on how the availability and accessibility of public health nurses enabled prompt action to be taken. I "The school health nurse is accessible and approachable to all, is easy to contact, visits school weekly, is known andavailable to parents andchildren, andis a trustedperson because confidentiality is assured. She is willing and able to follow up problems with parents!caregivers; is able to refer on I to appropriate authorities; and runs parenting courses in school. "
"The PHN often defuses a situation before it becomes a major health concern. " I
"The majority ofour learning problems, truancy etc are health-related. The school health nurse is able to access these families where we can'/. Home visits by teachers, principals, SES staffand I visiting teachers tend to be regarded as hostile or threatening. The school health nurse is able to open channels ofcommunication between home and school as well as being able to offer the support I ofother health services. Our health nurse facilitates referral to all other health services. She is vital to the health needs ofour school and community. " I One respondent defended Wanganui's health services, pointing out that people's expectations have greatly increased over the years. "We can never go back to the 'good'days ofthe 1930s to 1940s, because people are living longer, I they therefore need more health care. Families do not or cannot take responsibility for... elderly or sick members. There are more cars on the road and more accidents, there are many more kinds ofoperations now done and demanded I hip and organ replacements, cataract operations and heart by-passes, etc etc. So there will always be waiting lists; injustices andinequalities for those who cannot afford specialist services in private hospitals, or who cannot fight for themselves or their dependents. " I I
Poutama Whirinaki Interwoven Paths no I I Another person from a disability support group agreed. I "As we live in the real world we can never please all the people all the time and there is always people that however much is provided will always be negative. Personally ffeel that everyone does I a very goodjob. " Free services, such as immunisation, dental care for children, maternity, and prescription exemptions were I valued by preschools. I ----- Information and communication Education sector groups praised the liaison and support they received from both primary and secondary services. I "[Health services} create a rapport with a range ofproviders which educates the parent, gives reassurance to the child, creating harmony for all, andpreventive treatment to maintain the overall health ofthe child This knowledge gives confidence and moral support to the parents that reinforces I a healthy well-balanced child"
A health interest group commented that good information and advice gives confidence to a new mother at I home. Other health interest groups commented that good information for decision-making was available, and that GPs have become more helpful and willing to listen.
I One disability support group found that there was generally good liaison between agencies and government I departments. I _____Customer satisfaction Comments from groups representing older people show a high level of satisfaction with existing services, and an appreciation for the way services are provided at Good Health Wanganui. Particular mention was I made of medical and nursing staff.
Disability support groups expressed their satisfaction for the understanding and caring ofhealth professionals, I and for being able to refer themselves directly to services. Particular mention was made of seminars the assessment and rehabilitation service have introduced for patients and carers.
I "It provides a beneficial network, facilitating support required after discharge - enhances return to
normality n.
I Secondary schools expressed satisfaction with all services, particularly hospital departments. The adolescent health nurse's services are much appreciated, and both the Drugs and Rehabilitation Unit and the Child I Adolescent and Family Health Unit are also seen as very helpful. Primary schools particularly appreciate paediatric and orthotic services. They are "professional, courteous I [and} efficient". The school health services provided by public health nurses, vision-hearing testers and dental therapists I were also praised as "routine and reliable n. "The hearing and vis ion problems found at school are usually followed up qUickly andresolved, thus I helping the child to make normal educational progress. " Local doctors have useful background knowledge of students through their relationships with families.
I III Poutama Whirinaki - Interwoven Paths I ASPECTS OF HEALTH SERVICES THAT ARE NOT MEETING PEOPLE'S NEEDS I I -----Access Cost I
The cost ofaccessing health services is a concern for groups in all sectors. One general group thought more flexibility for individuals for Community Services Card entitlement is needed. I "The financial component hurts many ofthe families who have the greatest needs even though there is a subsidylcard for them. " I Two general groups and a mental health support group said dental services were too expensive. Travel costs for treatment in another centre are not always available for both parents when taking a child for treatment. I "[The} reimbursement process means you have to pay out first, and many families do not have the cash to get there in the first place. " I The disability allowance was criticised as too little. "[The} disability allowance is not adequate to cover additional costs incurred through disability thus causing severe financial hardship for some. " I
A mental health support group was critical of the lack of assistance for prescription glasses. Another said prescription costs were too high. For most people however, it was just the general cost of health care which I they felt was threatening health. "Costs costs costs - there is no extra money for children to be taken to the doctor in some families; the cost ofall medical services puts most ofus offseeking help early. " I
Availability I
One of the general groups was critical of the lack of family planning services. The local service is not affiliated with the national organisation and does not provide a full range of services, such as cervical I smears. This group wanted more choice in who they see. Another group said it was unsatisfactory to have to go out ofthe area for an abortion, and not be able to consult a female specialist. I People with disabilities were dissatisfied about several things. Twenty-eight days of alternative care was seen as not adequate for some. I "They may be prematurely forced into institutional care against their will (and at huge cost), causing strain andfrustration for families. " I This point was echoed by a mental health support group. "More flexibility is required so that only hours used are deductedfrom the allocation, eg three hours rather than halfday minimum. " I
Some children require more hands-on therapy on a daily basis, as is available in other areas. Equipment was seen as an area needing improvement by disability groups. More choice, design, trialing, maintenance, and I knowledge of what equipment is available is needed.
A shortage of speech therapists means that people who would benefit from this therapy miss out. Groups I said they are needed on a regular basis both in hospital and after discharge. This does not always occur.
Poutama Whirinaki - Interwoven Paths J12 I I I There is no low vision clinic in Wanganui, and no domiciliary physiotherapist. Older people were concerned about services not being available when they are needed, or having to travel out ofWanganui to use them. Having to 'go private' for urgent tests was another issue for this sector. Older I people also thought they needed a social worker in the community to visit carers more regularly. "Carers need immense support and someone to talk to at every stage ofthe disease ".
I A secondary school thought there should be a government subsidy for practice nurses working in the school environment. Primary schools said that dental therapists are no longer available for curriculum support in health and nutrition, and they have trouble completing treatment of all pupils in the allocated time. (A I preschool also mentioned this). Primary schools also felt that a counsellor would help with disturbed and troubled children.
I More staff available for physiotherapy was something primary schools wanted, and they also worried that some students are neglected in other ways too. They commented, for example, that there is now no provision of head lice shampoo. I "The school health nurse is only scratching the surface ofmany ofour community health problems."
Preschool groups were particularly concerned about: accident and emergency services being very slow; I Plunket not having enough funding to meet their service requirements; there being no resident neurologist, which means families have to go out of town or privately; and the fact that the Family Planning Clinic is I only open on Mondays and Fridays. I Transport One primary school said Wanganui can be a hard place to get around with young children. I "The geography ofWanganui makes it difficult for parents (particularly solo mothers) to get their children to doctors ifthey have other children. "
I The cost ofgetting to treatment was also mentioned. "Often money runs short quite quickly when travelling out oftown for treatment. Mostfamiliesfind I this a strain, especially those on a benefit or low incomes. " People also criticised the system for paying people back for travel costs. "Reimbursement is quite slow and often the instruction to keep receipts does not come until some I weeks have passed It is important to have funding more readily available. "
One disability support group found that when people have to travel for outside treatment or assessment, it is I unsettling and di.sruptive. On the other hand, another was critical of the reluctance on the part of some professionals at GHW to refer patients to other areas where there is more expertise in different disabilities. I Waiting lists and waiting times
I All ofthe groups had comments about long waiting lists. Several references were made to a perceived delay of up to three years for an appointment at the eye clinic, or for a hip replacement. Groups also felt there were unacceptable delays in diagnostic testing. A disability support group was frustrated by the way I appointment times get changed, causing undue concern to elderly people. A group for older people believed waiting lists caused stress and a deterioration in health. I "Ifone needs hospital or specialist help, one needs to persist, keep ringing, try to get a cancellation. Those who don't realise this or who feel unequal to doing it, go to the end ofthe queue. "
~I 113 Poutama Whirinaki -Interwoven Paths I
Another group thought there were not enough social workers. A primary school group expressed concern that "wheelchair equipment is dreadfully slow in coming". I
Two mental health support groups referred to long gaps between sessions with the alcohol and drug unit. The waiting list for Child Adolescent and Family Services was also seen as too long. I
For one disability support group, the procedure for getting referred to a visiting specialist was considered slow and inadequate. The delays in diagnosis and in getting help with the early stages ofthe disorder slows I the adjustment to the disability. It is also costly to have to be referred by a GP to a specialist physician first. I _____ Information and communication I Clear, accurate and accessible information about health services is an issue for a number ofgroups, particularly disability support groups. "The criteria for accessing mental health services is often unclear and information about what kind I ofwork mental health services undertake is not readily available. "
Several groups referred to health professionals who lacked knowledge and understanding ofthe conditions I ofa particular disability. I One group thought that the restructuring of the health system has created an information gap so that the public no longer knows what is where, leading to a fragmentation of health services. I For mental health support groups there is a lack of understanding of mental disorders.
Health interest groups referred to a lack of information on services following discharge from hospital. A I secondary school was concerned that with the numbers of Asian students entering New Zealand schools, more information was needed about what public health services they could access. A preschool group felt more information on infectious diseases was needed. I
There was extensive comment on the lack of follow-up, co-ordination ofservices and communication between services. I "Mental health services do not liaise with community groups as well as they could There is an uncoordinated approach and a lack offeedback between services. " I Mental health support groups felt health professionals should be more informed about community support services. Health interest groups highlighted issues arising from treatment received outside the Wanganui area. I "Often a child andfamily are back home before the next treatment begins, but the local health I professionals have hadno notification oftheir return, their medical status, or iffollow up contact is required Parents do not feel comfortable to contact the local authority when there is a problem, especially when it is quite obvious the local professionals do not know. Parents can be put in the I position ofbringing health professionals up-to-date with the state ofplay and the protocols. Many feel uncomfortable in doing this. " I A primary school thought there should be better liaison between doctors prescribing ritoulin and schools, because the school sees some side effects. I A health interest group believed that pregnancy counselling is inadequate. I. Poutama Whirinaki -Interwoven Paths 114 I Parents were also seen as being often treated in a patronising way, and told "you wouldn't understand (the I medical details ofchild's condition). " I ----- Consumer satisfaction I A number of issues affecting customer confidence and satisfaction were recorded.
Although general practitioners received praise, they were also criticised. I "Doctors don '( have time with each client; there is a lack ofpractice nurses at some GPs - only a receptionist, and there is also over-prescribing oftranquillisers, sleeping pills, etc. "
I Two groups indicated that early discharge from hospital can affect patient confidence, especially if it is made without prior assessment ofthe home situation and the patient's ability to cope.
I Cultural insensitivity from health workers, including reception staff was an issue for a general group. Another commented that personal patient information is often not available for specialist appointments because it I has been lost or misplaced between departments - so another appointment becomes necessary. Professional practice in the Child Adolescent and Family Service drew one criticism. There was a perceived tendency to blame someone in the family, and also a lack ofconfidentiality evident. A secondary school I also commented on the need for access to confidential health guidance/counselling. I One group said their organisation and clients have real lack ofconfidence in GHW. Another wanted more accountability for the medical profession. Itwas believed that present disciplinary procedures are indadequate, I leading to a lengthy response time, and to 'cover-ups'. I I I I I I I I
I 115 Poutama Whirinaki - Interwoven Paths I SUGGESTED IMPROVEMENTS I
In this section specific suggestions were made by some respondents in relation to those services which were I seen as not adequately meeting community needs. I _____ Access I Cost A general group thought that the current criteria for the use ofCommunity Services Cards was too rigid, and I should be more flexible.
Reducing the number of managers and putting money into patient care was a priority for a number of I groups. Several groups believed that management is greatly overpaid, and money is not directed to staffing and services where it is most needed. "Cut out top-heavy administration. " I "Have less managers and more general staffto see patients."
One group for older people thought hospitals should be run by medical personnel and not business managers. I
A mental health support group indicated that people on low incomes cannot afford to take up opportunities such as sport or leisure activities which would increase their wellbeing. I
Several preschool groups wanted reduced fees for preschool and young children, and felt that follow up appointments for conditions like ear ache should be free. I
Availability I Location of services received two comments from general groups: I • the sexual health services clinic should be in the community not at the hospital, and should be linked with broadly available Family Planning services I • health centres should be better located. The Talbot St. Centre, for example, which has now closed down, should have been at Wanganui East Shopping Centre. I A preschool group wanted an ECG machine in Wanganui so residents wouldn't have to travel out oftown. Another group thought there was a need for more social work staff. I A women's group identified a need for women- and children-friendly doctors, subsidised dental care for adult women and more women GPs and specialists. I The Hospice believed there should be an extension of specialist services to ensure that the terminally ill, their families and carers have access to appropriate care when required. They believe this would mean some re-organisation ofthe way current services are delivered, but would result in overall improvements in I efficiency, cost effectiveness and above all, quality ofcare. I I Poutama Whirinaki - Interwoven Paths 116 I I A mental health support group suggested self referral to mental health facilities should be available. DisabiJ ity support groups wanted a range of improvements: I • access to speech therapy and physiotherapy by self referral • a Low Vision clinic in Wanganui (including rental equipment) I • payment to family members and more flexibility in alternative care • domiciliary physiotherapist, occupational therapist and speech therapist services I • increased coverage by a neurologist • a Wanganui-based rehabilitation and assessment service. Several groups felt that clients with chronic I progressive disease deserve to be assessed on an on-going basis by experts in their fields, such as neurologists, urologists and physiotherapists I • extended swimming therapy • more theatre time and finance allocated to eye services.
I Primary school groups want: • new entrant checks and twice yearly visits to the dental nurse reinstated
I • more physiotherapy services, especially for older students
• mobile clinics
I • free medication available for dealing with head lice
• the continuation of public health nurses (this was a strong plea) I "Just ensure that services are not cut or curtailed, especially our health nurse as she is the only person we can rely on to attend to health matters in the school on a regular weekly basis - parents rely on her!"
I H Do not cut the nurse's hours in fact we could do with more. " I A preschool was interested in readily available and accessible dental services at affordable cost. I Waiting lists and waiting times Again there was widespread support for shortening waiting lists, especially for cataract surgery and hip I replacements. One group wanted to shorten the intervals between sessions at the alcohol and drug unit. A preschool group thought the excessive delays at hospital appointments should be reduced. I "Small children are very hard to keep amused" I Transport A disability support group suggested transport to and from hospital for treatment should be provided because I it was exhausting and often difficult for carers. I
I 117 Poutama Whirinaki -Interwoven Paths I ----- Information and communication I All groups said they wanted more simple, clear and easily understood information. This was particularly important for parents and caregivers who had to take children for treatment out oftown and needed to know the travel policy. I
All groups thought there should be an improvement in liaison and co-ordination at all levels of health services: between doctors and the hospital, between different departments in the hospital, and also between I the hospital and outside agencies. One suggestion to achieve this was to educate nurses and GPs about support services in the community. Several groups noted that their expertise and abilities were not recognised. I People also wanted better liaison between treatment centres outside Wanganui and local health professionals. It was suggested that this could be done either through a local contact, or an appointed coordinator in the treatment centre. I
A disability support group thought there should be greater acknowledgment ofparents as valuable resources who should be listened to. I "Some parents comment that GPs are only pill-pushers and don't have good listening skills. "
Another group said parents feel there should be more cooperation between education and health to ensure a I holistic approach to their child's management. I Groups for older people shared similar views. Rest horne workers should be given education and guidance in the specific requirements ofAlzheimers. There should be consultation with consumers, taking on board their concerns and observations. I "When hospitalised, little or no notice is taken ofthe elderly person's knowledge oftheir condition and its associated ramifications. " I Some preschool groups suggested there should be better health promotion and education on glue ear screening and eye testing, especially for parents. I A health interest group thought there was a need for more openness from management about decisions made, and a willingness to admit mistakes. A general sector group made the point that health is not a commodity nor a profit making enterprise. I I _____ Increased resources
Many groups believed improvements could only come through increased resources, especially in medical I and nursing staff, so that waiting lists could be reduced. There was also a call to increase community-based services such as Plunket nurses and dental therapists. I Other suggestions were for mobile clinics or drop-in centres, a larger centralised Family Centre with specific group facilities, including overnight accommodation, and a day care facility, especially for dementia. A I secondary school wanted a dedicated health resource person in schools full-time, - rather than the person having to 'tag' this on to other duties. I One group representing the elderly claimed the total abolition of all RHAs in favour of a single national authority to purchase services would solve all problems. I I Poutama Whirinaki -Interwoven Paths 118 I I PRIORITIES FOR IMPROVEMENT
I _____Access I Cost Cheaper dental care, prescriptions and GP visits featured as priorities for improvement across all sectors, I particularly for beneficiaries and children. One group for older people expressed grave concern about elderly not being able to afford rest home care. I Availability
I The general sector groups highlighted counselling services as a priority. They wanted easy access, more time spent with children and families under stress, and counselling for victims of health professionals' I mistakes, as in GHW's diagnosis crisis. In terms of current health providers, some people also thought Progressive Health Incorporated (PHI) at present have a monopoly, and wanted a more balanced provider group, including nurses and other health I professionals. It was felt that the sexual health service should be community-based and more user friendly. One group suggested a woman gynaecologist and otherwomen specialists were priorities.
I Other specific priorities included the need for safe accommodation for children and young people in crisis, and a disability support group sought accommodation to meet the needs ofthe young disabled. They suggested community and home support services available on the same basis as ACe. A mental health support group I identified the need for an adolescent offenders programme.
I Waiting lists and waiting times I Shorter waiting lists and waiting times were identified as priorities by general sector groups, disability support groups, older people and preschools, especially for hip replacements, cataract surgery, grommet I insertions and tonsillectomies. Keeping to appointment times at hospital clinics, especially when volunteers have provided transport, was important for one general group and a disability support group. Long waits at audiology clinics was also I mentioned.
I Travel and transport
Financial assistance for travel was a priority identified by one general sector group and two health interest I groups. I Mental health services need to be more mobile. Transport is a real problem in rural areas, said one mental health support group.
119 Poutama Whirinaki - Interwoven Paths I -----Informa'tion and communication I Simpler, clearer and easily accessible information about health services was a priority identified by only one group, but it appeared to underpin many ofthe other suggestions. One disability support group believed consumers were confused about which agency deals with what. A health interest group gave priority to I written information for parents and caregivers on travel policies.
Improved communication and liaison between health professionals, health services and other agencies was I a priority for one group, in order to avoid duplication and ensure client safety. Mental health support groups wanted an improvement in coordination between health services and community groups. One preschool group suggested public relations between the hospital and community could be improved, referring to bad I publicity over pathology misdiagnoses in 1994.
Education was a priority in several areas: I • for new mothers and 'at risk' parents I • for children about drugs and alcohol and sexual issues • to "smash the barriers of ignorance regarding disability" I • for the elderly on diet, general living conditions and assistance available • for parents on the signs and symptoms ofcommon infectious diseases, so that sick children are kept at I home. I ------Increased resources I The need for 'more' was a priority on several fronts. People want more: • social work staff I • home nursing services
o theatre time for eye operations I
o specialists
• coverage by a neurologist I
• speech therapy
• alternative care provisions I • hospital beds allocated to Alzheimers' patients I • staff and waiting areas in A & E • more staff and attention in maternity I • more visits by Plunket nurses • visits by vision and hearing testers. I I
Poutama Whirinaki -Interwoven Paths 120 I I Specific services identified as priorities included:
I • home support services, where practical help and advice on equipment is wanted I intermittent care for patients to give carers more time out • appropriate accommodation for people under 65 with disabilities I • the prompt establishment of a low vision clinic • domiciliary physiotherapy I • a rehabilitation unit, like the one at Palmerston North Hospital • day care I • services for the elderly (because the need will become critical in the near future because of growing numbers) I • a nurse/counsellors, at least part-time in large schools. I Wanganui people's highest priorities for improving their health system can be summarised as: I reduced costs for health care • more education and information on health services I • better communication between all health services • reduced waiting times, both for surgical treatment and outpatient clinics. I I I I I I I I I
I I2I Poutama Whirinaki - Interwoven Paths I I I I I I I I I I I I I I I I I I I
Poutama Whirinaki Interwoven Paths 122 I I I I I I I I I I Chapter 8 HEALTH PROVIDERS' I VIEWS I .:. I I I I I I I I
I 123 Poutama Whirinaki - Interwoven Paths I, HIGHLIGHTS I I • Health providers felt that while many of the health issues facing Maori, elderly and people on low incomes were similar to other places, there were relatively more people "at risk" in Wanganui. I • Major barriers to health service use were seen as costs ofhealth services and low income ofmany users. Such barriers meant some people delayed getting treatment longer than desirable, resulting in avoidable hospitalisations. I
• Other barriers were failure ofparents to recognise early symptoms ofillness in their children and seek appropriate treatment. I
• Sexual health needs, smoking andsubstance abuse andpoor dental health were highlighted as issues for adolescents. I
• Castlecliff was clearly identified by providers as an area where there are too few health care services. Poor public transport makes it difficult for many people living in Castlecliff to get to services in other I places.
• Most providers felt either that there were no major cultural barriers to health care, or that cultural I barriers were less important than financial barriers. I • The main problem areas providers saw in terms ofaccess were the waiting lists for cataract surgery and joint replacements. I • All ofthe providers interviewed felt they offered a strong and appropriate service. They did, however, suggest some improvements: clear future development ofservices I more community education better co-ordination with other services. I' I I I I I I
Poutama Whirinaki -Interwoven Paths 124 I I I INTRODUCTION
I We talked with a wide range of people who provide health care and services in Wanganui as part of our consultation. The people interviewed represented primary and secondary health care providers, private and publicly funded, and including some other community groups and organisations which provide health care. I This chapter summarises their views.
I -----Ourapproach
I The provider groups contacted included: • service managers I • CRE medical and nursing staff • managers of private hospitals I • Children's and Young Persons Service (CYPS) • general practitioners (GPs) and practice nurses I • private psychologists .• Plunket nurses I • domiciliary midwives • Home Birth Association I • St. John Ambulance • representatives from the Youth Advice Centre (Y AC) I • pharmacists • dentists I • optometrists. I A fuHlist of providers interviewed appears in Appendix F. The majority were interviewed face-to-face or in groups, and the remainder by telephone. Topics covered included: I • a description ofthe service provided • local health and disability issues I • barriers they saw to people having access to services, and which groups were at risk of not receiving adequate services I • how well the health services were provided, including strengths, gaps and service extensions • general comments and recommendations.
I Summaries ofeach interview were sent back to the relevant person or group for comment and ifthey wished distribution for further comment to any other relevant people. A summary ofthe interviews with the sample I ofGPs was distributed to all the other GPs in Wanganui for comment.
I 125 Poutama Whirinaki - Interwoven Paths I HEALTH ISSUES IN WANGANUI I
The providers interviewed were generally of the opinion that low income, unemployment and economic I depression in Wanganui had had a negative effect on health, and increased the need for health services. Poor nutrition and parenting, substance abuse, stress, and conditions bordering on clinical depression also lead to a greater need for services, they believed. The closure ofthe Railway Workshop in the late 1980s had had a I noticeable effect on the town. "A lack ofoptimism is related to income and a high rate ofunemployment. " I For its size, Wanganui has a high number ofpeople with specific health care needs, including people on low incomes, young Maori and Maori in general, and elderly people. Both clients and families from the prison I and forensic units also have special needs, providers felt, because they tend to stay in town after rehabilitation and treatment, and the families of prisoners often move around a great deal. I Below we discuss the health issues for each of the most potentially vulnerable groups separately: children and adolescents, elderly people, women, Maori, people who cannot pay for services and people with mental health problems. Health care in Wanganui and the barriers to access have been summarised for the community I as a whole. I -----Children and adolescents I Several health and disability issues affecting children in Wanganui were strongly identified by providers. A number offamilies were considered to be "at risk" due to stress, low income, unemployment and a lack of parenting skills. The Child Health Nurses, the Child, Adolescent and Family Mental Health Service I (CAFMHS), GPs and other providers thought some children were "at risk" due to a combination of poor nutrition, child neglect, scabies and unfilled prescriptions. These children were more likely to require health care. Abuse ofchildren in one form or another (including emotional and physical abuse) was thought to be common, and under-recognised by health professionals. The CAFMHS reported that I "Abuse within the home (physical, emotional, sexual and domestic violence) is often afeature ofthe families ofthe children using this service. " I Some children are not taken to the health services either because the parents cannot afford to, or do not recognise the need for them. Children may be taken to Accident and Emergency (A&E) services because parents can not afford to take them to the GP. Junior medical staff at A&E may not be adequately trained to I provide the best care for children.
Asthma is a big problem, particularly in Maori children. Ear infections and glue ear are also common I problems, although recently the situation has improved as increased ENT surgery has reduced the waiting lists for grommets and tonsillectomies. I Optometrists interviewed were concerned about seeing too few children with visual problems. They felt that the vision testing ofpreschoolers may not be adequate or frequent enough to detect all the children who need treatment. CHE services reported under referrals of children with both hearing and visual problems. I Providers felt that early treatment of these problems was vital, as children who missed out on learning because they had vision or hearing difficulties had problems catching up, and may develop behavioural problems. I
Poutama Whirinaki -Interwoven Paths 126 I I "A common symptom ofhearing loss is paranoia, which means children are more likely to be aggressive I to protect themselves. "
The cost ofspectacles is a particular problem for children with visual impairment. There can be considerable I delays between recognising that the child needs glasses and the child getting them, because a number of parents can not afford the necessary $200 to $300. All the providers working with children considered it an I anomaly that hearing devices and other disability aids were subsidised, yet glasses were not. Preschool children can be enrolled in a dental programme so that they get professional dental care, but the I numbers ofchildren who are part ofthis programme are lower than providers would like. I Children at risk In Wanganui the public health nurses have redefined their role to emphasise care of children, particularly those at risk. For this reason, they have renamed themselves child health nurses. Every five year old is I screened, and at risk children identified. Groups have been set up to deal with common problems such as bed wetting. The child health nurses spend as much time as possible, in schools identified by Ministry of I Education school profiles as likely to have a higher proportion ofchildren with high health needs. The child health nurses have also formed groups in the schools for parents who do not want to attend Family I Centre programmes. The parents themselves are asked which topics they would like to discuss. Topics covered have included breast self-examination, self-defence, motherhood and stress, parenting skills and basic first aid. The nurses report that these groups have been a success in increasing parents' self-esteem I and reducing their sense of isolation, and they aim to form more. The schools are good venues for these courses as they are seen as "safe". Street meetings have also been held at homes in the Castlecliff area. I Adolescent health issues
I Sexually transmitted diseases (STDs) are a major problem for Wanganui teenagers. GPs interviewed thought that adolescents knew little about sexually transmitted diseases and there was a lack of public education I about STDs. Child health nurses and social workers work together to keep track ofstreet kids and adolescents who may I move around a great deal. Adolescent pregnancy rates are perceived to be increasing in Wanganui, and several of the providers interviewed felt that some ofthe adolescent pregnancies were planned. Young mothers are more likely to be I at risk ofnot getting enough maternity care, and need a lot ofsupport after the baby is born. Abortion is not available in Wanganui, and until recently women had to travel to a private clinic in Auckland to terminate a pregnancy. However since mid-1995, Central RHA has also purchased abortion services for women from I Wanganui from Capital Coast Health in Wellington. .
Smoking is a problem among young women, especially during pregnancy. Substance abuse (both alcohol I and other drugs) is also widespread. I "Many young clients are into marijuana and other drugs as they have nothing else to do. " There are limited recreational and work opportunities for young people in Wanganui, especially the young unemployed. I "Some young people do not see much future for themselves and no chance of getting a job. "
I 127 Poutama Whirinaki - Interwoven Paths I
Poor dental health is also an issue for adolescents, especially those who have left school and now have to pay to go to a dentist. I
Medical professionals felt the whole area of adolescent health needed more professional expertise. At particular risk are young people who have left home but are not entitled to any benefits, and therefore have I no money to pay for health services. I Health care for young people
GPs generally felt that young people tend not to come to them for health care, largely because they feared a I lack of confidentiality and could not afford it. Many young people do not have the skills or knowledge necessary to get access to other services. "Adolescents do not lend to come to GPs. Ifthey need to come for a sexual health issue some are I worried that their family will find out. "
Wanganui's STD clinic, family planning clinic and alcohol and drug clinic are all located at the hospital. I Young people are perceived as tending not to go to them, because of transport difficulties and the lack of anonymity involved in attending hospital clinics. For these reasons the Youth Advice Centre (YAC) was set I up in Central Wanganui.
Some providers identified a need for increased parenting education for adolescents. Plunket are running I education classes in schools to promote the idea that children require a lot ofwork and are not just good fun. I Gaps in health care for children and young people
A number of gaps in heath care for young people were identified by providers. I
Primary and secondary providers and the CYPS identified a need for residential care for children and adolescents on a short- or long-term basis. This is not currently available in Wanganui. Providers felt there I was a need for both therapeutic residential care and residential care for an estimated 40 children annually with conduct disorders. The Child Adolescent and Family Mental Health Service (CAFMHS) cannot currently treat child sexual offenders for example, without residential care. There is also no local psychiatric day I treatment or inpatient treatment available for children or adolescents. Providers also identified a shortage of appropriate foster home care. I Alcohol and drug programmes are only available from the hospital alcohol and drug treatment centre. Both the programmes and the location of the clinic are thought to be unsuitable for young people. There are neither residential programmes for people with alcohol and drug problems nor an inpatient detoxification I facility in Wanganui. I Anger management was also identified as a problem. Health camps are closing to children with anger management problems. There are no special schools available for difficult children, who tend to be passed around from school to schooL Some providers worried that there is poor coordination between the health, I welfare and education sectors over the needs ofchildren and adolescents.
Specific problems which providers identified included a shortage ofspeech therapists, and a physical access I problem for children with disability who need to attend the CAFMHS, as the service is located in a building with stairs. I I Poutama Whirinaki - Interwoven Paths 128 I _____Elderly people I Health issues
I There were a number ofspecific health issues affecting Wanganui's ageing population, identified by CHE senior service and rest home providers, GPs and optometrists: I Demand for surgery
I There is a current shortage of, and increasing need for, cataract surgery and joint replacement surgery. Several providers reported long waiting lists at Good Health Wanganui, delaying access for people who did not have insurance and the ability to access private care. Delays in surgery for both conditions limited the I independence and mobility of elderly people. An optometrist interviewed noted that elderly people with cataracts may not be able to pass the eye test required for renewal oftheir driver's license. I "The lack ofa license means greatly reduced independence. "
I Lack of housing for the elderly
There is little supported pensioner housing in Wanganui and limited availability of transitional housing. I This results in people going into rest homes early, or staying in the community longer than they should. A rest home provider felt that because more elderly people are staying in the community for longer than previously, they need more high level care when they finally enter rest homes and hospitals. There are a I number ofelderly in the community who were "onlyjust coping". Ambulance officers reported that many ofthe houses the elderly lived in were quite unsuitable in terms of design, with a cluttered environment and access problems. Support systems for the elderly are not always good. Young house surgeons may not I understand the home environment into which the elderly were being discharged.
I Financial problems
Elderly people may have financial problems in accessing services. The CHE senior service reported that I elderly people not entitled to funding may ..."refuse to payfor services which they required and then have repeated hospital admissions because they do not have the help that was neededfor them to remain safely in I their own homes. " I Health care for elderly people A fear of change and a lack of information about subsidies and asset testing may be preventing the elderly I from receiving appropriate care. "They may be reluctant to seek care as they are frightened by change. "
I Providers felt the support services for the elderly in the community are quite good but said some elderly people may not be aware of them or know how to make contact. Transport was not identified as a major problem, as Age Concern operates a service to transport the elderly to health care in Wanganui and to I specialist services in Palmerston North. However, parking in the central city area, particularly near the laboratory, could be a problem for elderly people who drive themselves to appointments.
I The pharmacies in Wanganui are community ones and all operate home delivery services, which are well used. Some of the pharmacists provide advice to the elderly in their own homes on their medication and
I 129 Poutama Whirinaki -Interwoven Paths I how to use it. Several ofthe phannacists interviewed recommended extending this domiciliary service. I Three funding anomalies which may prevent elderly people from getting appropriate care were identified by providers. I • The intennittent care or alternative care subsidy available to give the caregiver a break is not available to elderly people who live alone but who need this care at times, such as for short-tenn illness. The only option in these cases has been to admit the elderly person to hospital even though they do not need I hospital care. • Elderly people must be income and asset tested to receive home care. The cash assets allowed are less I than those for rest home admission. A CHE provider reported that it was difficult to persuade people to spend their cash assets on home support, whereas ifthe income and asset test levels were the same as for rest home and home support, it would be easier to keep people in their own homes. I • Families who care for a parent are disadvantaged. If families need home support to care for an elderly parent while they are at work, their own income and assets are tested. If the elderly person wishes to I enter a rest home, only the income and assets ofthe elderly person are taken into account. I _____ Women's health issues I Maternity care I In Wanganui this is provided equally by independent midwives, GPs and the hospital maternity team. Domiciliary midwives said that the demand for their care was greater than their availability. There is little private specialist care in Wanganui. The CHE provider reported that socially disadvantaged and very young I women are referred to the hospital for care ... "when no-one else wants them".
Maternity care providers said that the issues in Wanganui are probably similar to those elsewhere, but there I are a higher proportion of "at risk" women in Wanganui. Smoking during pregnancy was identified as a particular problem by several groups. I Post-natal care I Plunket reported that new mothers feel pressure to leave hospital too soon after childbirth, and do not have adequate support if they encounter problems in, for example, breastfeeding. However, the CHE provider I felt that the reasons for and benefits of being discharged earlier from hospital ought to be better promoted. Plunket felt they were not able to see mothers as often as needed, so some children were missing out on basic care. Because Plunket nurses find they are involved in a lot ofsocial work with families, they would I like to extend the Plunket service to include intervention with "at risk" families. Providing Plunket cafe to the poorer suburbs is made more difficult by the absence ofPlunket committees in those areas. Domiciliary follow-up care could also be difficult for women living in rural communities. I
Family planning services I
Family planning in Wanganui is available from GPs, from the hospital clinic and from the Well Women's Clinic. There is no Family Planning Association Clinic in Wanganui. Young women can get contraceptive I I Poutama Whirinaki Interwoven Paths 130 I advice from the YAC. The CHE feels that family planning is under-resourced in Wanganui. The financial cost of getting contraceptives was identified as a problem by GPs and other providers working with I adolescents. Practice nurses and CHE providers reported that hospital STD and family planning clinic I services may be difficult for women to reach because of poor public transport and limited opening hours.
I Well Women's Clinic
The Well Women's Clinic in Wanganui was set up in 1989 to provide cervical smears, and give women I access to female smear takers. It is now seeing fewer women, as other providers have responded to women's wishes. Smears are available from some practice nurses and there are now a number offemale GPs. Smear tests are available at no charge from the clinic, and approximately 50 percent of women who attend the I clinic for smears could not afford to pay a GP. The Clinic reports that Maori women are now adequately catered for, but Pacific Islands women may not be. The clinic specifically targets women over 45 and I women who have not had a cervical smear for five years.
I Gaps in health care for women
I Providers identified a number ofgaps in health care available for women in Wanganui. • There is no mammography available in Wanganui, and travel to mammography services in Palmerston I North could be difficult for elderly women. • There is a high demand for colposcopy. A CHE provider reported long waiting lists for the service, I although another provider felt the service was adequate. • Termination ofpregnancy is not done at Wanganui hospital. At the time ofthe consultation with providers, termination of pregnancy services for Wanganui women were provided through a private clinic in I Auckland. Travel and counselling costs were publicly funded, but women paid $410 to cover the cost of the procedure. Publicly funded services for Wanganui women are now also purchased through Capital I Coast Health. • There were no female obstetricians and gynaecologists in Wanganui at the time. A provider reported I that some women travelled outside Wanganui to go to a female specialist. I I I I I
I 131 Poutama Whirinaki -Interwoven Paths I _____Maori I The following section reports the views ofnon-Maori health care providers. Maori health status is seen as low, and providers identified a number ofproblem areas:
• high level ofteenage pregnancy I • smoking during pregnancy I • the need for more and better sexual health services and safer sex education • high incidence of glue ear I • many child admissions to hospital and a lower threshold for admission. Maori children were more likely to need hospital admission because of social reasons. "To get goodfood, free antibiotics and because ofa lack ofsocial support at home. " I • poor access to GPs, although this has improved since the opening ofTe Waipuna Health Centre
• need for more information and counselling about prescribed medication I
• more education and availability of dental care. Maori are: " ...at risk ofnot receiving adequate dental care because they can't afford it and they are not aware ofthe I serious effects it can have on general health. " • sleep apnoea was identified by adult health services at GHW as a problem for both Maori and Pacific I Islands people. I Health care for Maori
It was noticeable that few providers spontaneously mentioned race or culture as a barrier to receiving I appropriate health care. After they were prompted, these were still not usually considered an issue. Providers felt that family income and education levels were more significant barriers than ethnic background. Some, such as a psychologist, pharmacists and the child health nurses felt that cultural sensitivity and awareness I by health care providers had overcome any cultural problems. Several providers felt that Maori people may find it easier to talk to non-Maori in some cases, for example about abuse and terminations of pregnancy. I However, providers in the mental health field had a different view. They felt that Maori health professionals were essential to provide appropriate mental health care for Maori. Appropriate domiciliary care, for example for Maori with terminal diseases or who are elderly, was seen as another area of cultural difficulty. There I were no elderly Maori or Pacific Islands people in or receiving community care from Kowhinui Hospital (a Presbyterian hospital for the elderly). Maori either preferred to provide the care themselves, could not afford private care or saw such care as culturally inappropriate. Whanau providing care to the elderly were I particularly affected by the funding anomaly which requires means testing ofthe caregiver ifhome support is applied for. I Providers thought that the existence ofTe'Waipuna has improved access to primary health care for Maori. The child health nurses saw Te Waipuna as more user-friendly, accessible and community-based than most I services. Concerns were expressed by some CHE services about the standard of care delivered by Maori health workers, and the need for on-going education and monitoring. I I
Poutama Whirinaki - Interwoven Paths 132 I I I Gaps in Maori health care Fewer Maori use the community health services than might be expected from the number of Maori admissions I to hospital. There are no Maori community health nurses. The cost of services is obviously a major barrier to many Maori using them. I Where services are provided affects how easily and readily Maori make use ofthem. There is a shortage ofmental health programmes for Maori, especially young Maori.
I Providers felt that specific education for Maori is needed on sexual health, parenting, smoking and pregnancy. I _____ People who cannot pay for services
I All the providers interviewed thought the people most at risk ofnot receiving adequate access to health care were those who could not afford to pay for services. This was a problem identified by all providers for people who were unemployed or on a low income. The groups seen as having most difficulty in paying were I Community Services Card (CSC) holders and people who were just above the cut offpoint for being eligible foraCSC. I "The lower socio-economic groups can't pay and need the health care the most. "
Health issues for lower socio-economic groups include:
I • stress and problems relating to unemployment I • smoking, especially during pregnancy • no regular dental health checks or treatment with private dentists because ofthe costs
• long waiting times for hospital dental treatment for people who cannot pay privately. There is strong I demand for treatment ofcavities and dental infections. Pharmacists reported supplying pain killers for "rotten teeth" I • high incidence of infectious diseases such as scabies and nits I • fewer health care services in some lower socio-economic areas. I _____ People with mental health problems
The amount ofmedia coverage ofmental health issues had led us to expect that this issue would be frequently I raised in provider interviews However, mental health issues were only raised by providers working directly in the mental health area and by GPs.
I Providers of mental health care were particularly concerned about three groups:
• Maori. Concerns include dual diagnosis ofalcohol and drug problems, alcohol abuse, schizophrenia and I bipolar affective disorder. • young males, especially those who are from a low socio-economic group and are poorly educated. I Concerns include substance abuse, depression, paras~icide or suicide, conduct disorders and child abuse. • elderly. Concerns include depression and Alzheimers disease.
I 133 Poutama Whirinaki Interwoven Paths I Health care issues for people with mental health problems I Differentiating between mental health and psychiatric problems was a problem for many providers. The adult mental health service works primarily with people with psychiatric problems rather than people with broader mental health problems, and they felt there was a gap in services for counselling and support. Two I private psychologists reported that unless clients are receiving ACC subsidies, and are referred by the Family Court or the Children's and Young Person's Service (CYPS), they cannot afford to pay for private psychological services, and there is no publicly funded care for some areas of mental health. I "Care is available but people requiring care cannot afford to payfor it unless they are receiving a subsidy ofsome sort. " I Counselling is available from community groups, church groups and alternative health care providers such as naturopaths. However, people with psychiatric disabilities were seen by providers as less able to get access to these services. I
Providers felt that reductions in the number ofhospital inpatient beds had meant a greater need for community based care, which is not necessarily available. An increased level ofprofessional intervention in the mental I health area is required, and community-based psychiatric services need to be adequately resourced. Community-based services are not equipped to deal with acute problems, but they often have to. CYPS I reported that it sometimes provides care for people for whom there is no adequate mental health care available. Providers gave examples of children who mental health services could no longer cope with, and children from homes where the parents were not receiving adequate care for mental health problems. I
A private psychologist identified two particular problem areas in mental health care - people with moderate disabilities and children with behavioural disorders. People with moderate physical and intellectual disabilities I need assistance from a range of services, not just medical ones. There was a lot of discontent perceived among the families of people with disabilities, because families felt their needs were not being adequately met. I
Providers felt that people with major disabilities tend to be well provided for, ("as they should be") but consumed a disproportionate amount of the limited resources. For example, children with more severe I disabilities use most of the teacher aide time allocated. The result is that people with moderate disabilities tend to miss out on services, and are forced to just 'make do'.. I Several providers also thought that children with behavioural problems or conduct disorders which were socially or physically induced were not getting the services they needed. These children fall between the gaps of health, education and social welfare, with none of these agencies taking responsibility for them. I Providers saw a huge need for the families of these children to get some support. Voluntary agencies do their best but are over-stretched, and many of the children they deal with need professional help. Many people could not afford to go to a private professional, and the free services like the Child, Adolescent and I Family (CAF) Service tend to be inundated with clients and therefore have long waiting lists. I
Gaps in health care for people with mental health problems I
• An absence of residential treatment programmes.
• A need for therapeutic programmes, intensive group therapy, programmes for borderline clients, clients I with more than one mental health problem and clients with phobic disorders.
• More family support, as currently the CAF service see the child but do not treat the families. I
• Better screening by GPs for alcoholism, depression, paranoid illness and physical abuse.
Poutama Whirinaki - Interwoven Paths 134 I I I __---Rural communities Rural communities were not included as the main focus ofthis project, but the following issues were raised by providers about the difficulties faced by people living out of the town ofWanganui.
I • Difficulties in transport to health care services in Wanganui.
• Difficulties in providing health care to rural communities. For example, the number ofcars available for I travel limits some CHE services. While visits can be provided on a scheduled basis, this does not cover crisis situations, such as those in the adult mental health area. I • Elderly people in rural communities may not have home care services available to enable them to stay in their own homes. I I -----Other vulnerable goups A separate group at risk of not receiving adequate health care was identified by some providers as those people without access to primary health care, in particular people without a GP. The number of people in I this category is unknown.
CHE providers identified the following groups who were not covered by existing services or who were in I danger ofnot fitting the definitions of care for either service and "falling between services":
• people with chronic obstructive respiratory disease (CORD). A need for regular visits to patien,ts was
I identified <
• disabled people, especially the young disabled; people with chronic psychiatric disabilities; people with I long-term head injuries, especially young people; and those under 65 with long-term chronic disabilities (Huntingtons and Parkinson's diseases). The district nurses reported that Wanganui may be chosen as a place to live by disabled people because of its easy access to the city and inexpensive housing
I • oncology patients. This is a big issue because of Wanganui's elderly population. Services currently provided are considered by providers to be understaffed
I • intellectually handicapped children and adults with mental health problems
• chronically ill teenagers, who can fall between the paediatric and adult services
I • clients with more than one mental health problem (dual diagnosis), especially young Maori I • Social Welfare clients may be in danger ofnot receiving adequate antenatal care. I Specific service gaps Providers raised the issue ofspecialist services which are not available in Wanganui. They saw a need for support for people who had to travel to such services, and a need to educate and inform people ofthe support I available to them. I Some ofthe service gaps have been discussed previously. However other specific examples were given. • Babies requiring specialist neonatal care. It was considered appropriate that this care be provided outside I ofWanganui, but it was importantthat parents were adequately supported and informed.
I 135 Poutama Whirinaki Interwoven Paths I
• There are no genetic services available in Wanganui and people had to travel to Wellington to have access to them (there are only three locations in New Zealand). In the past a system ofvisiting specialist I care had worked well. • There is no private dermatologist in Wanganui. I • There had been no vascular surgeon for two months. I _____Barriers to health care I Every provider consulted considered that the cost of health services was the greatest barrier to people's health care. I "Cost cuts across race. "
To a lesser extent, other barriers were also raised. These have been discussed above. I
Financial barriers to health care I
It was clear from observations made by GPs and CHE providers that money is a major financial barrier for many Wanganui people. People are going for health care at a much later stage than they would have five to I ten years ago. Prescription charges and GP fees were considered by all providers as too much for many people to pay. Delays in treatment and inappropriate use ofservices are the result. Ambulance officers are more likely to be called out to children who are seriously ill, for example children who are running high I temperatures and are having convulsions, particularly in the Castlecliff area. Frequently, the children's parents had delayed going to the GP, and the ambulance may be the first health care provider contacted. That delay in getting primary health care often means that more secondary services are necessary because I the condition has become worse and now requires hospitalisation. District nurses and pharmacists reported that they are more often asked for health advice since GP and prescription charges were increased. I As well as causing delays in treatment, financial barriers to care may result in the inappropriate use ofsome health care providers. An example given by GPs and the CHE was the use of Accident and Emergency (A&E) at Good Health Wanganui for quite minor problems, which could have been more appropriately I dealt with by a GP. "People will sit and wait... for quite minor treatment because they cannot afford GP care. " I The higher cost ofafter-hours GP care also increased the use ofA&E. I Cost was a major barrier to people's access to private health care services. Services such as private hospitals, private physiotherapy and private counselling are all only available to people with subsidies (such as from ACC or the family court) or to those who could afford to pay. I
Ambulance services cost $45.00 for each caB, although the charge is covered by ACC in the case ofaccidents. Charging for the service was very hard to accept for ambulance officers who feel the charge discouraged I people from using the ambulances. In some cases, taxis are being used as transportation to hospital as the cost is less. "Ambulance fees are a problem, especially for the chronically ill. " I I
Poutama Whirinaki Interwoven Paths 136 I I I Information barriers Poor awareness of services or knowledge of the need for care may be a barrier to access. People may be unsure when to go to the GP, and what to do if they have difficulties in the system. Several providers I commented that people may not know about services which are available for them.
I Cultural barriers
Ethnicity was not spontaneously raised by providers as a barrier to accessing health care. Generally, most I non-Maori providers interviewed felt there were no cultural barriers to health care in Wanganui for Maori. The exceptions given were mental health care and care for the terminally ill and elderly. I Transport .
I Transport to services was a problem in Wanganui as the public transport system from some localities was poor, in particular to the hospital from Castlecliff, Waverley and Aramoho. One provider reported difficulties in public transport to the Emergency GP Centre. I "There is no budget to assist with travel costs across the city (to the hospital). Taxi vouchers are not available and there is no goodpublic transport system. The cost is very significant as people do not I have budgeting skills. " I Waiting times for services General practitioners felt that all hospital waiting times are too long, especially for semi-urgent outpatient I surgery. It was felt that people are suffering and conditions deteriorating unacceptably because of delays before surgery. In particular, waiting times for cataract operations and joint replacements were seen to be too long. This wasa major issue for elderly people. There was a demand for services to be increased. GHW I could provide the service but the number ofoperations contracted for is considered not to meet the demand. Providers felt that long waiting times for secondary care could result in additional costly use of primary I care. The Southern Cross private hospital provides an option for people who can afford private care but there was I concern about whether patients could still have access to district nursing on their return home. Assessment services are seen to provide a barrier to care for people with mental health problems and for the elderly. Waiting times for semi urgent mental health cases are also thought to be too long. Providers felt that I assessment services for the elderly are inadequate, with too few provided to meet clients' needs. The shortfall has created a bottleneck in assessment services, they believed. I Providers' attempts to overcome barriers to care
I Efforts to overcome financial barriers to health care are made by several providers. Some GPs provide free consultations or work with patients to establish an affordable way for them to pay medical fees. Several providers thought that people earning a little too much to be eligible for the Community SerVices Card may I have the most financial problems, as they are often not willing to ask for help with doctors' fees. Pride may I prevent some people from taking advantage of reduced fees.
137 Poutama Whirinaki - Interwoven Paths I
Pharmacists reported providing clients with prescriptions in affordable doses, or allowing payments to be deferred. The child health nurses often manage to obtain medical care and pharmaceuticals for children in I need through their personal contacts.
Specific at risk groups have been targeted by health care providers. GHW maternity services target at risk I mothers and midwives visit young mothers at home where the need is identified. The child health nurses target at risk children in schools. I
-----Strengths of health care services available I Knowledge of the local community I Many ofthe providers interviewed, including the Health Promotions Unit, GPs and CHE services, expressed the view that Wanganui was a city where providers and the community knew each other and could work together. I "Wanganui is a city where people know each other surprisingly well. People are remarkably adaptive and supportive. " I GPs in Wanganui felt they were a cohesive group that worked well together. Health professionals at GHW felt that one of the strengths oftheir service was the smaller size ofthe hospital, which meant that people I knew each other and the community. There was a strong nursing service and good support for staff who tended to stay for long periods. I Community involvement I Many of the providers interviewed thought one of the strengths of the service they offered was that it is community-based. Pharmacies in the Wanganui area regard themselves as "community pharmacies". They all provide home delivery services to elderly customers, and this service is well used. Advice and counselling I are frequently provided by pharmacists, some of whom visit elderly people in their homes to show them how to use medications. Some CRE services felt a strength ofthe service they provided was the development ofcommunity services. I
Coordination between services I
A particular strength ofthe Wanganui area, according to community health nurses and some CRE providers, is the degree of networking and coordination within and around the CRE. The child health nurses reported I good coordination between different provider groups and little inter-group conflict. Monthly community liaison meetings are held. There is also good professional liaison. "It is easy to get a community focus in Wanganui". I Areas where coordination between services could be improved were identified by the Health Promotions I Unit who felt coordination with public health nurses could be improved. Community health nurses felt there was a need for better integration between their service and others, such as the senior service and private providers, to prevent patients falling through the gaps. Some private providers felt there was a need for I greater coordination oftheir services with CHE services. The child health nurses commented that services for children with disabilities are poorly integrated. I Some providers thought that coordination had been affected by privacy legislation, which has made it more difficult for professionals to share information on particular clients.
Poutama Whirinaki -Interwoven Paths 138 I I I _____Problems in the provision of services • Funding. This was cited as a problem by many groups of providers. GPs felt they were inadequately I funded for operating recall systems and for coordinating with other providers. • . Time-consuming paper work was also an issue. CHE providers and other providers felt that reporting of statistics on client contacts did not adequately reflect the time it was necessary to spend liaising I between providers, schools, and other agencies.
• Unpaid services. Clients' inability to pay for services has meant providers have had to try to accommodate I those who could not pay. GPs, pharmacists and private providers such as physiothempists and psychologists are providing some unpaid services to clients.
I • Transport. A specific problem reported by CHE services was transport to provide domiciliary care, both in rural and urban areas.
I • Extending services. Most providers consulted would like increased funding or a greater security of existing funding to enable them to extend their services. Some GPs, for example, would like to extend into providing counselling, but current funding does not allow for this. Pharmacists identified a need for I a health professional to give elderly people advice on the use of medications in their own homes. CHE Outpatients services would like to introduce evening and weekend surgery to minimise disruption for people. The oncology nurse saw a role for formal preventative care and screening for families with a I history ofcancer. Education was identified as an area where more could be done, especially by pharmacists. This would include more education on the preventative aspects of health, such as diet and lifestyle. I Increased promotion and education of people in the community about services available from health care providers, in particular practice nurses and pharmacies, was also seen as important. Education is I also required about how to get access to existing services and the support available, providers thought. • Relationships between providers. GPs interviewed expressed concerns about the fragmentation of primary care. Clients are attending specific services such as the Women's Centre and Youth Advice I Centre (YAC) which are less expensive than GPs, but may not provide the holistic care provided by GPs. GPs felt that although specific health needs were provided for, no one was monitoring general health. They suggested that primary health care should be provided through (but not necessarily by) GPs, to I ensure a coordinated approach.
• Coordination. Links between service providers could be difficult. An example given was immunisation, I where a number ofdifferent providers - such as Te Waipuna clinic, public health nurses and GPs - may all be involved in immunisation, with no one provider having overall responsibility for a case. GPs are not funded for time spent in coordinating with other providers to check on whether immunisations have I been received. A similar problem may be encountered with regard to smears, breast checks and Well Women's' checks.
I Other providers expressed the view that GPs had responded to the existence ofother primary services by improving the services they were offering. One provider commented that "Te Waipuna hadkept GPs on I their toes ". Some providers, including practice nurses, identified the need to reduce the barriers between primary I and secondary care, and improve coordination between primary health care workers. The GHW senior service felt that links with GPs in Wanganui could be improved. There was a perception by some CHE providers that GPs did not refer patients to secondary care often enough, or necessarily to the appropriate I specialist.
I 139 Poutama Whirinaki - Interwoven Paths I Contracting arrangements for services, particularly as the GPs become stronger, was seen by two providers as having the effect of "diminishing goodwill between services andproducing an undercurrent which is I not adding to the spirit ofcooperation ".
• Local services. In general, itwas clear that providers wanted to protect Wanganui's right to provide its I own services, rather than to receive them from Palmerston North. Many providers felt that Wanganui should be able to provide its own health services. I I I I I I I I I I I I I I I I
Poutama Whirinaki -Interwoven Paths 140 I I I I I I I I I I Chapter 9 CONCLUSION I AND I RECOMMENDATIONS I I I I I I I I
I 141 Poutama Whirinaki -Interwoven Paths I CONCLUSION I
_____ Key facts about Wanganui and its people I - and what that means for health services I Wanganui is a provincial city with its own unique characteristics. Nowhere in Wanganui are people far from either the river, the sea or the land. The city has a long history ofMaori settlement. There has been a long and at times turbulent relationship between tangata whenua and the European settlers, and those who I followed after them. People from a wide range ofsocio-economic groups and backgrounds live in Wanganui. Some are members oflocal iwi or descendants ofearly Europeans, others are more recent arrivals. Closure of the railway workshops in Wanganui in the mid 1980s probably had the most significant impact on the I local economy of any event in the post war period.
The core area which needed particular focus because of possible unmet health needs, comprised those I western suburbs adjacent to the river from Castlecliff at the river mouth up to Aramoho. The area included two suburbs on the east of the river. Analysis of socio-demographic data shows that the 'core area' is relatively deprived in socio-economic terms. This study has shown that this is reflected in worse overall I health status in the core area as measured by higher mortality and morbidity (largely hospitalisation) rates for a number ofconditions, and greater barriers to accessing health services when these are needed. Castlecliff was clearly identified by providers as a suburb where health care services were under provided. People I living in the area also had more difficulty than those in other areas in getting access to health care services because of poor public transport. I While the focus ofthis study has been primarily to identify significant unmet needs ofresidents ofthe core area, it is recognised that some residents in the rest of Wanganui, particularly older residents, and rural I Maori may have needs which are not currently being met.
It is important to note that variations exist between and within suburbs both in the core and elsewhere in I Wanganui. I Ethnic and age patterns
Maori and Pakeha/European are the two main ethnic groups in Wanganui. The proportion of Maori in the I population (17 percent) is higher than the average for the Central region (13percent). The suburbs which made up the core area in general had higher proportions ofMaori than the rest ofWanganui. This ranged from a low of 13 percent in Wanganui Central, to a high of 50 percent in Balgownie and Putiki. However I the health needs ofMaori in these two suburbs are likely to be different, in that Putiki has a higher proportion ofolder Maori than Balgownie and the highest median household income in the core area. I At present a higher proportion ofthe Maori population (39 percent) are under the age of15 compared to the non-Maori population (22 percent). This difference should be reflected in child health services which cater for the particular needs of Maori. The proportion of the Maori popUlation at present over 65 is currently I very small, some 3 percent. Population ageing will lead to an increase in the proportion ofMaori over the age of65 in the next decade. However, if current patterns of poorer health status for Maori continue, this I increase may be smaller because ofhigher Maori mortality in the under 65 year olds. Demands on the health services from an ageing population in Wanganui are exacerbated by higher rates ofchronic diseases among older Maori. I I Poutama Whirinaki Interwoven Paths 142 I The tangata whenua ofthe area are Te Atihaunui-A-Paparangi, Ngati Apa and Ngarauru iwi. Members of I these iwi represent 29 percent of all Maori in Wanganui. A further 35 percent of Maori are affiliated to other iwi, while around a third ofMaori reported in the 1991 Census that they were not affiliated to any iwi.
I Maori in Wanganui have been strong advocates, over a number ofyears, for the delivery ofhealth services for Maori by Maori. This culminated in the establishment of the Te Oranganui Iwi Health Authority, to represent the tangata whenua. Central RHA has contracted with Te Oranganui, to provide a range ofprimary I health care services for all Maori in Wanganui.
The very young and the very old are likely to be higher users of health services, though this use may take I different forms. Older people are more likely to need treatment for chronic conditions. Such conditions may require the older person to visit their GP on a regular basis, take medication, be admitted to hospital for medical or surgical treatment or have home support services. Children and young people are more likely to I require treatment for acute infections, injuries which may require short term stay in hospital and have greater need for programmes to encourage healthy lifestyles and the adoption of life skills.
I Wanganui District has slightly higher proportions of younger and older people than the average for the Central region. Differences exist between the age structures of the core and the rest ofWanganui, with the I former having a higher proportion of younger people and the latter a higher proportion of older people. As we move towards the year 2000, purchase of services which reflect the needs ofthe older age group will be increasingly required. Current projections for Wanganui suggest that the largest growth will occur in the I group over the age of 60, ( a 13 percent increase by the year 2006) as a result ofthe ageing ofthe current I population and smaller family sizes. Planning for this eventuality needs to be already underway. I Socio-economic features Wanganui has a higher proportion than the region as a whole of single parent families with dependent children, lower average levels of household income, higher levels of income support, unemployment, I persons aged 15-64 with no educational qualifications and carless families.
Children in the core area are more likely to be brought up in single parent families and in families where I there is less disposable income to spend on purchasing health or other support services.
Unemployment particularly among young people and Maori, was consistently identified as a health issue in I Wanganui. This was demonstrated in high levels of stress, family violence, alcohol-related problems, impoverished families, (financially, educationally and spiritually), malnourished children and the continuation ofa cycle of 'families with problems'. The impact ofa lack ofmoney and jobs on the physical, mental and I social wellbeing ofchildren was of particular concern to those in the education sector and those providing child health services. Ofparticular concern to a number of schools was the poor nutrition and diet of many I ofthe children. Low levels of educational qualifications among adults in the core area, (43 percent left school without attaining any qualifications - a higher proportion ofwhom are likely to be Maori) reduce opportunities for I employment. This can also be a barrier to reducing unhealthy behaviour and these people having access to appropriate health services. Education has been shown to be closely associated with changing risky health I behaviour such as smoking, excessive alcohol consumption and high fat diets. People with higher levels of education tend to have better information-seeking skills, greater confidence, and are better able to make use of health services. In part, this is also likely to reflect the greater income earning capacity which usually I accompanies higher levels of education.
I 143 Poutama Whirinaki Interwoven Paths I For many people in the core area as well as the rest ofWanganui, the ability to purchase health care services is constrained by the need to purchase other essential services. I • Parents with young families who are likely to use health services more frequently and potentially incur higher costs, also have other costs such as outgoings on home mortgage or rental accommodation, food, transport and education. I
• Older people, while more likely to own mortgage-free homes, are more likely to be on a fixed income and also have limited disposable income. While a similar proportion of home owners in the core area I and the rest ofWanganui had mortgage outgoings, a higher proportion ofhomes in the rest ofWanganui were mortgage-free, reflecting the different age structures. Renting, whether from Housing New Zealand .or private landlords was higher in the core than the rest ofWanganui. I I _____Key health issues
Overall health status I The overall health status of people in Wanganui as measured by mortality and hospitalisation statistics is I lower than other parts of the Central region.
While death and hospitalisation rates are in themselves incomplete measures of health status, they do give I some indications ofserious conditions. In many instances, high mortality or hospitalisation rates identified from data sources were confirmed by health care providers and others as being important health issues in Wanganui. Many ofthe issues identified are also of concern in other parts ofthe Central region as well as I nationally.
• Wanganui had a 10 percent higher total death rate than the region as a whole. The difference was more I marked within Wanganui, with the core area having a 30 percent higher total death rate than the rest of Wanganui. I • Ofparticular concern were the higher rates ofinfant mortality in the core area, double that ofthe regional average, (the number of deaths in the rest of Wanganui were too few to make comparisons with the core). I • Higher death rates of 25 year olds and over were found in the core area in comparison to the rest of Wanganui. I Mortality data suggest that the overall health status in the core area might be worse than other parts of the region. The majority of respondents (82 percent) in the consumer survey, regardless ofwhere they lived in I Wanganui, considered their health was good or very good. Self-assessed health status was lower in the Wanganui survey than that found for Central region as a whole, where 91 percent ofthose over 15 reported having excellent or very good healthY I
Hospitalisation rates were higher for Maori than non-Maori in both the core and the rest of Wanganui. However the difference was less marked between Maori and non-Maori resident in the core. As has been I found in other studies, ethnicity and socio-economic status are closely associated with differences in health status. I I 4) New Zealand Health Infonnation Service 1994. Summary ofdata from the New Zealand Health Survey. op cit. I Poutama Whirinaki - Interwoven Paths 144 I I Asthma Asthma was commonly identified as a health issue in Wanganui. The hospitalisation rate was found to be one and a halftimes the regional average, and was highest in the core area. The consumer survey found that I a third ofsurvey households reported having a member who had an asthma attack in the past year. (This was similar to that found in a household survey conducted in Porirua in 1994.) The survey confirmed hospitalisation data that a higher proportion ofhouseholds in Wanganui with an asthmatic were located in I the core area.
Hospitalisations for asthma were greatest amongst those aged 1-14, making up 62 percent ofall admissions I for asthma. This is similar to the regional pattern ofhospitalisat ions. However, caution in interpreting these figures should be used, because data on hospital admissions and (especially) deaths, is said to be very inaccurate under age five (where it is hard to diagnose asthma) and over age 35 (where it is confused with I bronchitis). In addition overall changes in asthma management are not reflected in the data.
Maori rates ofhospitalisation for asthma were higher than non-Maori in the core and in the rest ofWanganui. I Whatever the prevalence in the population, the effects ofasthma appear to be more severe among Maori, as measured by hospitalisation rates. These differences may also reflect differences in the management of I chronic asthma between Maori and non-Maori. The higher rates of hospitalisation for asthma found in Wanganui are consistent with other sources of I information. Providers and consumers also identified asthma as a health issue of concern in Wanganui. In considering strategies to reduce the level of asthma, environmental and socio-economic factors such as damp and/or over crowded housing, must be taken into account. It is also important to look at asthma I management at the primary care level, in particular the adequacy and appropriateness of information and education services, especially for Maori. Whether or not a person with an acute asthmatic attack is admitted to hospital is also influenced by the primary treatment source. People who go to A&E services at a hospital, I are more likely to be admitted.
Key providers ofservices for people with asthma in Wanganui include Good Health Wangamii, the Asthma I Society and general practitioners.
Asthma education services are provided by GHW. There is currently one asthma educator who provides a I service for the Wanganui eRE area. Given the higher hospitalisation and (possibly prevalence rates) among Maori, it is proposed that greater attention will need to be given to the needs of Maori.
I GP and pharmaceutical costs associated with use of inhalers were raised by consumers and providers as barriers for some in getting proper care when needed. Successful asthma management involves enabling the individual to self-manage their condition by the provision of adequate and appropriate information, the I reduction of financial and cultural barriers to accessing early medical treatment when needed and the co I ordination of primary and secondary care services. Smoking
I Nearly half of the households surveyed in Wanganui had a smoker, with Maori rates double that of non Maori. Providers were concerned with the high proportion of young Maori women who smoked during I pregnancy. Smoking has been shown to be strongly associated with such conditions as asthma, lung cancer, chronic respiratory/circulatory diseases, higher incidence of SIDS, and lower birthweight in babies born to I mothers who smoke. National targets have been set to reduce identified risk factors, in order to achieve the goal of reducing smoking-related deaths. The Public Health Unit ofGood Health Wanganui is working to meet these targets.
I 145 Poutama Whirinaki - Interwoven Paths I
The service aims to:
• reduce the uptake ofsmoking by young people I • prevent exposure to environmental tobacco smoke I • assist in enforcing the Smoke-free Environments Act 1990 • promote smokefree pregnancies and smoking cessation. I Te Oranganui through its support service for young mothers, promotes and works toward smokefree environments for new babies. Others in the community need to be actively involved ifsmoking levels are to be reduced in Wanganui. These include parents, schools, employers, local authorities, general practitioners, I Maori organisations, and organisations such as the Asthma Society, Cancer Society and Heart Foundation. I Diabetes I Diabetes prevalence in New Zealand has been estimated at around 3-4 percent, about half of which is undiagnosed. The prevalence among Maori and Pacific Islands people is estimated to be four to six times that of Europeans. Surveys conducted in Auckland and Tokoroa have shown diagnosed diabetes among I Maori to range from 6-9 percent. Among those who participated in the consumer survey in Wanganui, 10 percent ofhouseholds were reported to have a diabetic. This proportion was higher even than the 6 percent found in a household study in Porirua in 1994. The higher prevalence found may be associated with the I higher Maori population and/or the lower socio-economic status ofmany households in Wanganui.
The death rate from diabetes was 36 percent higher in Wanganui relative to the region as a whole. (There I were too few deaths to compare Maori and non-Maori rates). However other studies have shown that Maori death rates are higher and that Maori die at a younger age from diabetes. I The higher death rate in Wanganui relative to the rest ofthe region was not matched by higher hospitalisation rates. In contrast hospitalisation rates for both Maori and non-Maori Were lower than the regional average. I The Maori rate of hospitalisation while substantially higher (three times) than that ofnon~Maori, was also less than the regional average for Maori.
Diabetes was identified as a specific health issue for Maori by those providing primary health care services I for Maori.
Central RHA does not currently purchase a specific diabetes service as such in Wanganui. Hospital inpatient I and outpatient medical care for diabetes are purchased as part of other general services. There is currently no specific diabetes education service in Wanganui. I
Sudden Infant Death Syndrome (SIDS) I
SIDS was the major cause ofdeath (36 percent) among infants in Wanganui. While three ofthe four deaths from SIDS occurred among babies from the core area, the numbers are too few to draw conclusions. Similarly, I there were too few Maori deaths from SIDS (one) to make comparisons. However, other studies have shown that the Maori death rate for SIDS is double that ofnon-Maori in the Central region. Other information suggests that both Maori and non-Maori SIDS rates in Wanganui have been higher than the national rate. I
Key providers in Wanganui whose services can impact on reducing the infant mortality rate include general practitioners, midwives, specialist obstetricians, Plunket, and the Kaiawhina programme, (Maori health I worker and registered nurse). I Poutama Whirinaki -Interwoven Paths 146 I Plunket is the major supplier of infant and early childhood services in Wanganui. Providers, community I organisations and consumers considered that Plunket is no longer able to meet the need of families in Wanganui. The major factor was considered by them to be that Plunket in Wanganui did not have adequate resources to do the job. While Central RHA contracts with Plunket at a regional level to provide services, I the criteria for distribution ofresources is internal to Plunket.
I Ear problems
Acute ear infections are a common cause of sickness in children, and a frequent reason for a visit to the I doctor. These problems are often associated with upper respiratory infections Sixty percent of survey respondents with children under five years (a quarter ofthe sample) reported one oftheir children having an I ear infection in the last year. Almost all ofthese infections resulted in a visit to the doctor. Disorders ofthe ear were the major cause ofhospitalisation among children aged 5-14. It should be noted that hospital data significantly underestimate the prevalence ofacute infections as well as repeated episodes I of acute otitis media with effusion (glue ear). Children in Wanganui had a 1.7 times higher rate of " hospitalisation with disorders of the ear than the regional average. Similarly, children resident in the c3r{ I were 1.8 times more likely to be hospitalised with ear conditions than children in the rest ofWanganui. The rates ofgrommets surgery for children with glue ear in Wanganui was higher than the regional average. However in contrast to the regional average, Maori children aged 1-4 in Wanganui had lower rates of I surgical intervention for treatment of glue ear. This is despite the fact that Maori children have almost double the failure rate for hearing tests on preschool and school entry of non-Maori children. The Public I Health Unit reports that the referral rate for hearing function in Wanganui in 1991 was twice as high for Maori as for non-Maori children. These findings suggest that Maori children may not be getting the level of I access to grommets surgery needed. Hearing-related services are provided by a number of providers in Wanganui. Services include health promotion and education programmes from the Public Health Unit, hearing testers from the Audiology I Department of Good Health Wanganui, Maori community health workers, and general practitioners. Screening of young children has been carried out at preschools and Kohanga Reo by hearing testers from Good Health Wanganui and Maori community health workers for some time. A screening service for under I three year oids registered in their practices is being established by general practitioners in Wanganui.
I Intentional and unintentional injuries
, Suicide rates among young males, and intentional self-harm among young females were similar to the I average for the region. The reduction in death and injury among young people in the Central region from such causes is an important priority to be addressed.
I Alcohol and drug abuse are also likely to contribute to the higher than average rates of hospitalisation in I Wanganui for motor vehicle crashes, intra-cranial injuries and assault. I Mental health problems Wanganui has higher readmission rates than the region as a whole for certain serious psychiatric conditions, namely affective psychoses and schizophrenic disorders. Providers considered that these conditions as well I as alcohol and substance abuse were of particular concern amongst Maori and/or young men. Differences also existed within Wanganui, with higher rates of admission for affective psychoses and schizophrenic
I 147 Poutama Whirinaki - Interwoven Paths I conditions found in the core area. Both Maori and non-Maori in Wanganui had higher overall rates of I admission for such conditions to mental hospitals than the rest ofthe region.
These higher rates of admission are likely to reflect in part the tendency for people who have been in I psychiatric hospitals or prisons near to Wanganui to remain in the city after discharge or release, as families have often relocated. I Alcohol-related problems
Health, social and justice issues related to the abuse of alcohol and drugs are thought to be increasing in I Wanganui. While admissions to mental health institutions for alcohol- and drug-related conditions were similar overall to the regional average, rates were higher in the core area than the rest ofWanganui. Other hospital admissions for a range of medical conditions are also likely to be influenced by excessive alcohol I consumption. I _____Sexual health issues I Consumer, community and provider groups emphasised the need for ready access to information and appropriate services when needed. These issues affected all age groups. I·
Intermediate school children I
Those working with intermediate school children considered there was a need for more appropriate programmes for this age group, in recognition ofthe earlier age at which some children will become sexually I active. More appropriate puberty programmes are being developed by the Public Health Unit of Good . Health Wanganui for delivery to form 1 and 2 levels. The focus ofthe programme is on reducing risk taking behaviour and promoting healthy lifestyles through encouraging the development oftrusting relationships I and positive body images and a sense ofwellbeing. I Adolescents
Most young people are healthy. Their needs relate primarily to information and education so they can I develop life skills. In particular, information about sexual health and ready access to contraceptives is important in this age group. Sexual health issues such as unwanted pregnancies as a result of unprotected sexual activity, as well as exposure to STDs and AIDS, require programmes especially designed for this I age group. I, Young people felt that the current STD service provided at the hospital did not adequately meet their needs. They preferred a service which was located in the community rather than at the hospital, and where the hours of opening better matched the needs of the clients. The Youth Advice Centre goes some way to I meeting these needs by providing advice and education on STDs.
The Youth Advice Centre was perceived by providers as having improved access to health care for young I people. However despite the availability of a more accessible service, providers considered that teenage pregnancy rates remained high in Wanganui. (In 1991 the teenage pregnancy rate in Wanganui was three times the national average.) Providers and young people felt that reduction in the cost of contraceptives I may reduce the risks ofpregnancy and STDs as a result of unprotected sex. I Poutama Whirinaki -Interwoven Paths 148 I I Adults Questions were raised as to the adequacy of family planning services for adults in Wanganui, particularly women from low income households. Failure to provide adequate, accessible and appropriate services is I likely to result in a higher proportion of unwanted pregnancies.
Women in Wanganui were perceived to have less choice of provider and may experience higher costs and I other barriers to obtaining contraceptives. Most women get contraceptive advice and management through their GP. Contraceptive services are also available at the family planning clinic at the hospital, though its hours of opening were felt to be somewhat limited. Family planning advice is also available at the Well I Women's Clinic. Family Planning Association provides a service at the Youth Advice Centre. I _____ Dental services
I Dental health providers reported that too few preschool children were having dental checks prior to beginning school. However no data was available to verify this claim. A number ofparents considered that an annual visit by primary school children to the dental nurse was insufficient to maintain good dental health. Until I 1992, primary school children visited the dental nurse twice a year. Parents were not convinced .that an annual visit to the dental nurse was sufficient to meet their children's dental needs. Cost was an issue for I those parents whose children needed orthodontic treatment. The need for affordable dental care for those on low or fixed incomes was considered to be a high priority I in Wanganui. Waiting times for hospital services were felt to be too long. A significant proportion ofthose using hospital services did so for relief of pain and infection. Prevention of serious dental problems by regular visits to a dentist was considered to be the better approach. The groups particularly affected were I Maori, young adults and older people.
I _____Children and family health services
I There was a strong concern that the health and wellbeing ofsome children in Wanganui was at risk because their parents were unable to adequately provide for their developmental needs. Factors contributing to this I situation included: • lack of money to purchase basic necessities and/or health services I • parents not knowing how or lacking motivation to keep their children healthy • acceptance of the 'normality of'ill health' I • parental ill health and/or low personal esteem • insufficient or inappropriate support for families with problems.
I The adequacy ofservices in Wanganui for children with behavioural problems was questioned by providers. Neither health, education nor welfare agencies were felt to be taking responsibility for children with such problems. This placed an unmanageable burden on families and voluntary agencies. There were long I waiting lists reported for the Child Adolescent and Family Service. Few families, however, could afford I private professional help.
I 149 Poutama Whirinaki -Interwoven Paths I
A need was identified by primary and secondary providers and the CYPS for residential care for short or long term stay for children and adolescents in Wanganui. Safe accommodation for children and young I people in crisis was considered a priority for service improvement. It was felt that psychiatric day facilities should be available locally for children or adolescents. I Easier access to counselling services, particularly for children, young people and families under stress, was identified as a need by all groups. It was felt that earlier access to counselling services might prevent the development of a serious mental illness. The availability of such services was not seen as adequate in I Wanganui. Counselling services do not form part ofthe core health services purchased by regional health authorities. Such services are purchased by the Community Funding Agency. 1 The adult mental health service is primarily concerned with providing a service to people with diagnosed psychiatric problems. It does not provide programmes or assistance to people coping with less serious mental health problems which might be alleviated by counselling. While private counselling and psychological I services are available in Wanganui, it was felt that cost was a major deterrent for many people. I -----Services for older people I The health and disability support needs of an ageing population were also identified in interviews with providers, focus group discussions with older people and from the survey of community organisations. I, Services in Wanganui for older people are provided by the CHE senior service and by voluntary sector groups such as Age Concern. Te Oranganui provides a Maori liaison service for Kuia and Koroua in and surrounding Wanganui. I
A common theme which emerged was that services should enable and assist the older person to remain living in the community. Maintenance ofsight and mobility in the older person were seen as key factors in 1 this. There was a perception that in Wanganui there were unacceptable delays in access to publicly funded surgical procedures such as cataract surgery and joint replacements. (This is also discussed under Specialist Services). I
Affordable, safe housing was also seen as a key to independent living. There were concerns from some providers that some older people lived in unsafe environments. The risks of this were accidents, which I would result in admission to hospital or other health services, or earlier and often unwanted admission to a rest home. Some older people felt that the safety ofthe older person would be made possible, if financial assistance to modify their homes as advised by the CHE home assessment service, was available. I
A major concern regarding personal and home support services in Wanganui was to ensure the older person and theirfam ily had access to information on what was avai lable, by whom and at what cost. Both providers I and consumers considered that some older people in need of such services would miss out because they were unaware oftheir rights. Ifthey could not get access to such services it was likely to result in potentially I preventable costs to the health services. Health and disability service providers were also seen as needing to be better informed and educated on the I needs of the older person, to ensure the availability of appropriate services. This included services in the community as well as in institutions such as hospitals or rest homes. I For many middle aged and older people, issues to do with the availability and right of access to adequate and appropriate services reflect a concern with future need. Much of this concern related to financial eligibility for services. Certain funding criteria were identified as potentially preventing some older people I from getting appropriate care when needed. Older people affected inc1uded those who lived alone, or who I Poutama Whirinaki Interwoven Paths 150 I lived with relatives. It was considered an anomaly that the level of income/asset testing for home support I was higher than that for rest home subsidy.
I _____Specialist services I Waiting times
I There was a general belief that people in Wanganui had to wait an unacceptably long time for planned surgery. The main areas about which concern about access were expressed were waiting for cataract surgery, hip and knee replacements, colposcopy and ENT surgery, especially grommets surgery. When respondents I in the consumer survey were asked what changes they would most like to see in the way health services were delivered in Wanganui, reduction in surgical waiting times and numbers ofpeople waiting was at the I top of the list. Waiting times included waiting to see a specialist in the first place and then waiting for surgery. Long waiting times for outpatient appointments were reported by about a quarter ofthose surveyed in Wanganui. I The vast majority felt such waits to be unacceptable, in that the person waiting was subjected to pain and anxiety which could have been prevented, and in some cases lost their independence.
I The 1996/97 Ministry of Health Policy Guidelines, require RHAs to reduce waiting times for non-urgent first specialist assessment at first to within six months and by July 1998, the target is that 90 percent will be I seen within two months ofreferraL The proportion ofthose waiting more than six months for an outpatient appointment at Good Health Wanganui at 30 September 1995 (the latest period for which data is available) I was lower than other CHEs for orthopaedics but higher for ophthalmology and ENT outpatient servi<:es. For those people who had been placed on a surgical waiting list at Good Health Wanganui at 30 September 1995, there was an average wait of:
I • six months for ENT surgery, less than the estimated average for the region (7.7 months) I • 7.9 months for gynaecological surgery, more than the estimated average for the region (6.5 months) • 11.2 months for orthopaedic surgery, higher than the average for the region (9.6 months).
I In the same time period the average waiting time for cataract surgery was 4.8 months, the shortest in the region. Sixty-nine people were waiting for a hip replacement. Fifty-four percent were waiting more than six I months, less than some other CHEs and similar to most. I Gynaecology service There were differing perceptions ofthe access women had in Wanganui to colposcopy procedures. Some I providers reported long waits while others considered the service was adequate . .Health promotion services purchased as part ofthe National Cervical Screening Programme are coordinated by a Regional Coordinator for Manawatu-Wanganui area based in Palmerston North. Women referred for I assessment and treatment are seen at Gynaecology outpatients at Wanganui hospital. The Ministry of Health has laid down strict waiting time criteria for women requiring colposcopy treatment as the result of being registered on the national surveillance programme. Good Health Wanganui meets the targets set for I colposcopy_
I 151 Poutama Whirinaki - Interwoven Paths I Mammography service I Mammography is not available at Good Health Wanganui, but is available privately. The need to travel to Palmerston North for a publicly funded service was considered to be a problem for a number of women particularly older women. I
Visual impairment I
Eye sight issues were raised in a number of different contexts by both parents and providers. Private optometrists and CRE providers interviewed were concerned that too few children with visual problems I were being referred. Undiagnosed visual impairments, as with hearing impairments, were considered likely to result in learning difficulties and increase the likelihood ofbehavioural problems. I All providers working with children considered it an anomaly that hearing devices and other disability aids are subsidised, yet spectacles are not. The cost of spectacles at around $200-300 was seen as a major cost barrier for many parents, and delays in obtaining spectacles for the child was likely to be the result. I
Ophthalmology I The lack of a low vision clinic in Wanganui was raised as an issue by some community organisations and I providers. I, Termination of pregnancy
The lack ofa locally-provided service was identified by some women and providers as a major gap in health I care available for women in Wanganui.
Access to abortion services has historically been an issue for women living in the Wanganui area. At the I present time there are no certifying consultants available in Wanganui, with the nearest consultants located in Palmerston North. I Interim arrangements for Wanganui women to use publicly funded termination of pregnancy services in other centres have been made. Work is currently being undertake.n to investigate ways in which the current service arrangements can be improved on a longer term basis. While ideally Central RHA would aim to I, make comprehensive services available in each major city in the Central area, further improvements to ease historic difficulties with this service may be a more realistic aim in the short-medium term. I Mental health services I Despite the prominent media coverage ofmental health issues in Wanganui over much ofthe period ofthe needs assessment review, in particular the closure ofLake Alice, and the increase in community housing for I former residents ofpsychiatric hospitals, these were not issues which were raised in the focus groups or the consumer or community organisation surveys. Mental health issues were not raised as issues ofconcern by consumers, unless either they or their family had experience of someone with a mental health problem. I Similarly mental health issues were only raised by those providers who were working directly in the mental health field, by general practitioners or by iwi and Maori community groups providing services for youth. I General concerns were expressed by providers that de-institutionalisation, with a reduction of inpatient beds, had not been accompanied by adequate resourcing ofcommunity mental health services in Wanganui. I Poutama Whirinaki -Interwoven Paths 152 I The existing services would not be able to adequately cope with acute problems. This was seen as detrimental I to the individual, their families and the community at large. A wide range of mental health services are provided in Wanganui. I Alcohol and drug services
I The adequacy and appropriateness of existing alcohol and drug treatment programmes in Wanganui for young people was questioned by both providers and young people themselves.
I Mental health providers considered there was a shortage of specific mental health programmes for Maori, especially young Maori. Conditions of most concern to providers were dual diagnosis, alcohol abuse, I schizophrenia and affective disorders. Amongst Maori there was particular concern at the lack ofappropriate alcohol and drug treatment services for young Maori. Current services were not considered to meet their needs. Young Maori males in the I Central region have been shown to have the highest rates of first and readmission to mental institutions for alcohol and drug abuse. Concerns about levels ofalcohol and drug abuse were raised at a number ofthe hui held with iwi and Maori community groups. Many Maori present reported having or knowing of a young I person with an alcohol and/or drug problem. The provision ofsuch services by Maori for Maori adolescents was considered to be an area which needed development.
I The Public Health Unit ofGood Health Wanganui provides a health promotion service to prevent alcohol related harm. In providing this service, it works with other health promotion programmes, other health I services including antenatal and alcohol and drug services, district licensing agencies, and the police. There are a number of small community groups funded by a variety of agencies to support delivery of I services. Eliminating fragmentation ofservices needs to be taken into account in order to ensure improved service delivery. I Primary health care services
I The extent to which services are used in a community is influenced by many factors, including the socio economic and demographic characteristics ofthat community, availability oftransport, where services are I located, who the providers are and when they are available. There was no real evidence of under servicing in terms of the total number of general practitioners in Wanganui, though there was a slightly lower practice nurse:GP ratio than other parts ofthe region. However I people in some parts ofWanganui, Castlecliffin particular, were considered to be less well off in terms of access to primary care services relative to other parts ofWanganui. There was only one general practitioner in the area. Getting to other services was made more difficult, because fewer people, particularly solo I mothers with preschool children, had access to private cars, and public transport was felt to be less than adequate.
I Benefit claims provide one measure ofservice utilisation in a community, even ifonly a crude one. Benefit claims tended to be lower in Wanganui relative to the regional average. Expenditure on GMS was 4 percent I lower, adolescent dental benefit payments 11 percent lower and pharmaceuticals 7 percent lower than the regional average.
I The vast majority of respondents in the consumer survey reported contact with a health professional over the past twelve months. Chemist and general practitioner services were the most commonly used. The
I 153 Poutama Whirinaki -Interwoven Paths I central role ofthe general practitioner in primary health care services was clear. When people went to other commonly used services such as chemists, practice nurses and laboratories they had usually first had a visit I to a GP.
The Wanganui community mostly had positive attitudes to their health services. Community and consumer I survey results showed that people felt there was a choice ofGPs, that most GPs provided a good service, and that access to after hours medical services had improved in Wanganui. A satisfactory GP service was described by many as a caring and friendly doctor who listened. But people were unhappy about long waits at I appointments to see a doctor. It was felt that doctors should better manage their time, in order to provide a prompt and efficient service. I Older people were particularly appreciative ofthe care they were given by their general practitioner and by the home delivery and advice service provided by a number ofcommunity pharmacies. I There was overwhelming support from schools for the work done by public health nurses and a unanimous request that this service be increased or at least maintained at the present level. I Cost of services I Consumers, community organisations and providers reported that the single most common deterrent to using health services when needed, related to the cost ofvisiting a doctor and user charges on prescriptions. I Reducing medical costs and prescription charges was given as the greatest priority by participants to improve access to primary health care services. Financial barriers were also cited by providers as reasons why people delayed visiting their doctor until they were so sick they needed more intensive treatment or I hospitalisation. GPs considered that more people now delay visiting their doctor when they have a health problem than was the case in the past. I Cost was considered to be more of a deterrent for some groups than others. Community organisations surveyed considered that women, children, young people, and people on low incomes, particularly those who were not eligible for a Community Services Card, were most affected. I
Cost was reported as a deterrent to using primary health care services by a substantial proportion of the respondents to the consumer survey (43 percent). It was a particular issue for Maori and for people living in I the core area. The most common services for which cost was reported to be a barrier were general practitioners, pharmacists and dentists. I Cost was reported to be such an issue for a significant number ofpeople surveyed that they reported either not using the health service needed or seeking alternative and less costly treatments. I Transport I Getting to or from the doctor or hospital was reported to be more ofa problem for people living in Castlecliff than other parts ofWanganui city. The proportion of people owning their own car was lower in areas such I as Castlecliff and the availability ofpublic transport was considered to be less adequate. Transport can also be a deterrent to seeking help when needed for people living in rural communities, particularly for Maori living up the Wanganui river. I I
Poutama Whirinaki Interwoven Paths 154 I I I Information and communication Clear, accurate and easily accessible information was seen by consumers as a key to maintaining good health. Too often, however, consumers felt they were unable to get access to such information. People said I they wanted to be able to get information about what their entitlements were, what services were available and how to get access to them when needed. In particular, people wanted to know what services were available in the community, for example on discharge from hospital, and to be linked into those services. I They wanted to know how to manage their health problem when they returned home, whether from hospital, Accident and Emergency Service or GP. It was often difficult for people to know where to go or who to approach for such information. A number ofcommunity organisations and key informants considered that I many general practitioners were not always fully aware of the range of support services available in the community. In particular it was felt there was need for better coordination between hospital and primary I care providers. I Appropriateness While providers expressed general and specific concerns about Maori health and identified a number of factors associated with this (including health attitudes and behaviour and socio-economic factors), few I suggested that part ofthe problem may be with the services themselves. On the other hand, a number of Maori interviewed expressed strong opinions on what they saw as the failure ofmany health service providers in Wanganui to recognise and accept the concept of cultural safety. There was strong support from Maori I for an increase in the range ofhealth and disability services provided for Maori by Maori in Wanganui. I A growth in services provided by Maori providers was welcomed by most Maori interviewed. However there was also an indication that Maori would use existing services more readily, ifprogrammes or services were provided in a way that enabled people to feel comfortable. The proportion ofMaori health providers I remains small in Wanganui.
I _____ Summary
I Some clear and consistent health and health service issues have been identified in Wanganui. Many ofthese issues are common to people, especially poorer people, across the region. These issues have been highlighted in Wanganui for a number ofreasons. The key issues largely reflect the Government's health gain priority I areas of Maori health, child health and mental health. Particular inequities have been identified in the relationship between demonstrated health need and service provision in Wanganui relative to the rest ofthe region. In addressing these issues in Wanganui, it is considered that there is potential for achieving health I gains. I I I I
I 155 Poutama Whirinaki -Interwoven Paths I STRATEGIC FRAMEWORK I
The strategic framework is built on the premise that building fences at the top of the cliff rather than I providing more ambulances at the bottom, will achieve more health gains for the additional resources being allocated in Wanganui. In developing the strategies particular emphasis has been given to the health gain I priority areas of child health, Maori health and mental health. The approach adopted takes a long term view. It recognises that there is no quick fix for poor health, so I changes in health status of a community do not occur overnight. Many factors other than health service delivery contribute to health such as income generation and housing. Influencing these factors requires the involvement ofother agencies at both central and local government levels. I
Laying the foundation for a healthy community in the future is dependent on ensuring healthy homes, schools and workplaces in the present. Many ofthe health issues identified by this needs assessment project I are recognised as being potentially preventable and/or reducible in terms of the impact on the health and wellbeing of individuals, their families and the wider community. I The strategies proposed here both build on existing services, and offer the potentia) for the development of new services to meet the needs of particular populations. A key feature ofthe strategies is that they create the potential for new ways of working, between different health service providers, regional and local I authorities, and health providers and other agencies including education, welfare and justice. Central RHA is committed to working with local organisations including the Iwi Health Authority and the Wanganui District Council in developing and implementing health strategies in Wanganui. I I _____ Macro issues I Maori I "Maori in Wanganui have worse health status than non-Maori, evidenced by higher rates ofmortality and hospitalisationfor a number ofconditions. " I Central RHA wishes to ensure that appropriate, acceptable and accessible services are available for Maori in Wanganui. Strategies to improve the health status of Maori in all age groups in Wanganui will continue to be pursued. Central RHA will continue to encourage the provision of services by Maori in Wanganui. I Protocols which monitor the delivery of services by mainstream providers to Maori, will be expanded.
The draft three year strategic plan for Maori health, identifies three key strategies: I • to increase participation by Maori in the purchasing arrangements (services provided by Maori for Maori)
• to improve and further develop mainstream services that will be effective for Maori through increasing I access to services by Maori • to provide support for future training and workforce development with Maori providers throughout the I region. Currently, Central RHA contracts with Te Oranganui Trust, an Iwi Authority which has been given the I mandate by the tangata whenua to deliver health services on behalf ofand to Maori within Wanganui. I Poutama Whirinaki - Interwoven Paths 156 I I It is recommended that: • During 1996/97 Central RHA consults with Maori in the Wanganui area as part ofthe wider consultation plan for the year. Consultations will include the Wanganui needs assessment report, sub-regional plan, I draft regional strategies, proposed service changes and future purchasing ofhealth services in Wanganui. • During 1996/97 Central RHA consults with representatives of Wanganui and other iwi to ensure that further services to be purchased for Maori are appropriate, accessible and meet the needs ofall Maori in I Wanganui.
I Education I "A higher proportion ojpeople in Wanganui District had no educational qualifications in comparison to the rest ojthe region. This was particularly so jor people in the core area. "
I Educational level is closely associated with health status. Health education programmes are more likely to be effective, if people have literacy skills, the ability to access and interpret information and apply it to I benefit their own or their family's health. It is recommended that:
I • During 1996/97 Central RHA discusses with the Ministry of Education, the health implications of the higher than the regional average proportion of adults in the core area who have no formal educational qualifications. Further research may be needed into the characteristics, eg age, gender and ethnicity of I people with little or no formal educational qualifications in Wanganui and the most effective way to provide appropriate health educational programmes.
I Preschools and schools are important settings for the delivery ofhealth education and promotion programmes (for both children and their families), screening services as well as primary health care services. Central RHA is committed to enhancing the 'Healthy Schools' programme which is already established in the I Wanganui area.
I User part charges I "The costs oj GP visits and obtaining prescription drugs was the single most common deterrent reported. Reducing GP costs andprescription charges was rated as the highest priority to improve I access to primary health care services. " The research findings suggest there is a need for Central RHA to review and refine the current system ofpart charges, in order to ensure that those in most need of general medical and pharmaceutical services are not I denied access because of cost.
Adjustments to the user charges regime have already been made in Wanganui, with members ofPHI providing I free GP consultations for under five year olds from savings made in the management oftheir pharmaceutical budget.
I It is recommended that:
• This initiative be evaluated, (and ifso how), to establish whether similar initiatives should be undertaken I elsewhere in the Central region.
I 157 Poutama Whirinaki Interwoven Paths I
• Other initiatives to reduce user charges such as direct doctor dispensing ofa limited list of medicines are explored with general practitioners and pharmacists in the Central region. I
The research findings suggest there is a need for a review of the criteria for eligibility for a Community Services Card, in particular the establishment of a more graduated income scale. I
It is recommended that: • Central RHA seek the support ofother RHAs to initiate discussions with the NZ Income Support Service I as soon as possible. I Unemployment
"There was a higher rate ofunemployment in Wanganui than the Central region as a whole. The I difference was particularly marked in the core area. "
The health risks for individuals associated with unemployment have been well documented. If the current I higher levels ofunemployment in Wanganui than the national average persist, this will have implications for the provision of health services in Wanganui in the medium to long term. I It is recommended that: I • Discussions are held with relevant organisations including the Department of Labour, Income Support Services, employer and trade union organisations on the development of strategies to decrease as much as possible the negative health consequences arising from unemployment I
Central RHA is closely following a Health Research Council-funded analysis of socio..,economic variables and health status being carried out by the Health Services Research Centre. Should the results ofthis work I be promising Central RHA may undertake or commission further work, including an assessment of the viability ofdirect inclusion ofsocio-economic factors in its equity model for purchasing. I It is recommended that in the interim:
• Central RHA monitor information on unemployment trends in Wanganui relative to the rest of New I Zealand and forecasts on economic growth and job creation in Wanganui to assist with planning for purchase offuture health services. I Information services I "Clear accurate and easily accessible information was seen by consumers as a key to maintaining goodhealth and independence. Too often however they felt unable to get access to information such as travel andaccommodation assistance, home support andvoluntary services available after hospital I discharge andfor elderly people. "
Both consumers and providers have information and communication needs. These needs include being able I to access information which can enhance or promote wellness, enable a person or family to get the right health and/or disability support services as needed, or a provider to give better service by knowledge of I other relevant services, and to ensure equitable access to services for all people regardless ofsocio-economic status. I
Poutama Whirinaki -Interwoven Paths 158 I I Information about services are provided by a number of different agencies in Wanganui, using different I media. There appears to be scope for development ofa strategy to ensure a more systematic, readily accessible service, oriented to providing information through a number of media, is available in Wanganui. Such a strategy would need to be developed in consultation with Wanganui District Council, the Citizens Advice I Bureau, Wanganui Disability Information Centre, local health providers and interested community groups.
It is recommended that Central RHA initiates a meeting of such interested groups to discuss the integrated I development of such a strategy. I ___--Health service strategies
I Family Support Programme
"Wanganui has a higher proportion offamilies who are likely to be at risk, evidenced by such indicators I as higher levels ofunemployment, single parentfamilies, persons on income support andlow income households. Health care providers and others working with children are concerned at the impact on children. Health andother agencies needto worktogether to enable families at risk to take control of I their own lives and to achieve health gains. "
Central RHA believes that providing support to families to ensure that children have a healthy, nurturing, I safe and supportive environment in which to grow and develop is an investment worth making. There are many different understandings ofwhat a family is and many different sorts of family structures. For some I children, life with one parent equals family. For others, family means Mum, Dad and other brotbers or sisters. The whanau or extended family, where children are the responsibility of grandparents, aunts and uncles as well as parents, is the environment in which many Maori children as well as non-Maori children I are brought up.
Some families are more vulnerable and need greater help and support than others to enable the provision of I a nurturing environment for children. There are a number of well identified reasons for this, including a parentis having limited personal and parenting skills, little or no formal educational qualifications, low income levels, low personal esteem and lack ofinformal support systems, such as own parents or grandparents I from whom advice might be sought.
individuals and families at risk tend to face multiple and complex problems. Complex problems do not have I simple solutions. Problems which such families face often involve multiple agencies such as Health, Social Welfare, Education, Police and Justice.
I Visiting families in their own home and providing services which are culturally appropriate have been shown both in New Zealand and overseas to reduce poor childhood outcomes. New Zealand has a long history ofprovision ofwell child services in the home by Plunket and public health nurses. Overseas home I visitation programmes such as the "Healthy Start" programme developed in Hawaii in 1985 and the "Healthy Families America" programme begun in 1992, have been described as perhaps "the most promising strategy I for developing or improving access to early intervention services that can help at-risk families become healthier and more self sufficient." 45 I A number of initiatives targeting the health, education or welfare needs offamilies, particularly those who are more vulnerable, have been or are being developed in New Zealand. These include: the support for I young Maori mothers service being piloted by Central RHA in Wanganui, the Tipu Ora programme which is "National Committee to Prevent Child Abuse 1994. Healthy Families America. Chicago.
I 159 Poutama Whirinaki -Interwoven Paths I jointly funded by Te Puni Kokiri and Midland RHA and Southern RHA, both ofwhich target young parents; Family Service Centres which provide integrated health, education and welfare services to disadvantaged I families with preschool children; the Homebuilders Family Support Programme and the Crime Prevention Community Funding programme which funds local projects and programmes through Safer Community Councils. New initiatives are being purchased by other RHAs, including North Health and Southern RHA. I
Collaboration between agencies is key for such initiatives to be effective. In developing a family support programme in Wanganui which targets the needs offamilies at risk, Central RHA wishes to complement and I build on existing programmes, using the strengths ofthe community cooperatively with other agencies. We do not wish to reinvent the wheel. I It is recommended that:
• In 1996/97 two demonstration programmes are purchased in the Central region to meet the needs of I families at risk. It is recommended that Wanganui and Hastings would be appropriate locations to evaluate the effectiveness, appropriateness and acceptability of such programmes. The health needs of these families have been identified through needs assessment projects as priority issues to be addressed. I
• The programme be developed with the communities it will serve in Wanganui, be culturally appropriate and have the capacity to meet the needs ofMaori and non-Maori. I • That Central RHA seeks the involvement of relevant agencies at national and community level in the planning and development ofthis initiative. I
The goal ofsuch a programme would be to enable families to take control oftheir own lives and to coordinate the activities ofhealth and other support services which aid this process. I
The key components of such a programme, its delivery and location would be planned and developed in consultation with communities in Wanganui. These might include direct provision of or referral to other I services for: • health education and promotion, including nutritional advice I • parenting skills • child development information I • anger management and development ofconflict management skills
• budgeting and life skills, eg cooking, house work I
• relationship skills to empower families to identifY their own needs
• problem solving capacities I • advice and advocacy support in dealing with other agencies I • liaison with community support people • strengthening ofnetworks I • liaison and referral to other social and health agencies.
It is envisaged that initially the service would begin on a small scale, targeting those families who have been I identified by health or other social agencies as in need ofadditional support services. The service would be geographically targeted to families residing in those parts ofWanganui which have been identified as having high health needs. I
Poutama Whirinaki Interwoven Paths 160 I I The programme would involve the assignment ofa specifically trained family worker to a particular family. I Such a person would need to be multi-skilled, able to recognise when to refer to existing services and to work closely with relevant health professionals.
I The family support worker would need to have skills in parenting and working in culturally appropriate ways with families in communities. The ability to liaise with existing services, such as Plunket, public health nurses, GPs, social workers, Maori community workers, education, social welfare andjustice services I would be essentiaL
I Development phases
• Consult with Maori and relevant national and local agencies in Wanganui, to establish their interest and I involvement in the design and development ofthe programme. • Develop service specifications which best meet the needs of families in Wanganui drawing on similar I programmes or services being provided in other parts ofNew Zealand or overseas and taking into account the views of community and other agencies. I • Invite proposals from potential providers. • Purchase a programme which is appropriate for Wanganui communities. I • Plan for possible increased use of other specialist services such as child and family counsellors, well child services, alcohol and drug services, mental health services as a result ofthe introduction ofa family support programme.
I • Build in a comprehensive monitoring and evaluation programme.
I SIDS I "The annual SIDS rate for both Maori andnon-Maori is unacceptably high. A decline in the number ofnon-Maori deaths has not been matched by a comparable decrease in Maori deaths. "
I Considerable health gains can be achieved through the prevention ofany SIDS death. The annual SIDS rate for both Maori and non-Maori in Wanganui is unacceptably high. High priority will be given by Central RHA to ensuring the decrease in the rate ofSIDS in Wanganui is in line with national trends. It is expected I that the development ofa Family Support Service and further strengthening of programmes to reduce the prevalence ofsmoking will also reduce the rate of SIDS.
I It is recommended that:
• During 1996/97 Central RHA reviews existing programmes designed to reduce the risk of SIDS and I where appropriate purchase additional services.
I Youth services
"Higher rates ofteenage pregnancy, perceived inadequacies ofSTD services, lack ofappropriate I alcohol and drugprogrammes for youngpeople, in particular Maori andlow uptake ofdental services I were considered to be issues to be addressed in Wanganui. "
I 16i Poutama Whirinaki interwoven Paths I 'One stop shop' I The 'one stop shop' service being provided by the Youth Advice Centre (YAC) is well accepted by young people in Wanganui. The further development of working relationships with other primary health care providers including PHI and Te Waipuna Health Centre and with relevant CHE services in the provision of I comprehensive care for young people in Wanganui will be encouraged and monitored through their contracts.
It is recommended that: I • a formal evaluation of services provided through YAC be undertaken as soon as possible. I It is recommended that:
Central RHA supports the expansion of services for young people provided by YAC and other providers in I Wanganuithrough: • increased provision of reproductive and sexual health services I • employment of a Maori youth coordinator or development of a complementary Maori service • increased capacity to deliver appropriate alcohol and drug education programmes and to liaise with I alcohol and drug and mental health services • provision ofdental education and some treatment services I • services for rurally-based youth including provision of sexual health services • stress management and anger management programmes I • tobacco control and smoking cessation programmes. I Mental health services I The lack ofappropriate services for young people in Wanganui will be redressed by the purchase ofadditional services with an emphasis on early intervention. These services will include: I • home-based and residential crisis respite services for suicidal young people and their families • provision of a specialised mental health service for 13-18 year olds by Good Health Wanganui Child I Adolescent and Family Service
• access to intensive short term drug and alcohol treatment programmes for adolescents such as a camp, retreat or family therapy I • provision of sufficient levels of long term ongoing community-based support I • suicide prevention services. I I I
Poutama Whirinaki - Interwoven Paths 162 I I I Maori youth "Problems ofalcohol and drug abuse among Maori, in particular among young people and the lack I ofappropriate services, were issues of concern to both Maori and health service providers. " It is recommended that:
I • high priority is given to the purchase of an alcohol and drug service from a Maori provider for Maori youth in Wanganui. I Service requirements
I It is expected that the service would have a whanau health focus and work with schools, relevant voluntary and public sector agencies.
I The service would need the support of local marae, but may be based elsewhere in the community.
It would be provided in a culturally appropriate manner and be able serve Maori youth and their families I who may not be affiliated with an iwi or marae, as well as those who are.
Although likely to start on a small scale, the service could expand its range of services over a three year I period.
I Development phases
I • Purchase of a "Train the Trainer" alcohol and drug education programme for Maori health workers. While this might be piloted in Wanganui, the programme would be used in other parts ofCentral region.
• Training ofMaori health workers in alcohol and drug education, referral and liaison to work in Wanganui I and other parts ofCentral region.
• Purchase of an alcohol and drug education, referral and liaison service for Maori youth in Wanganui. I This would include lifeskiIls and anger management programmes.
It is essential that the service works closely with other health care providers including Good Health Wanganui I Public Health Unit, and the Mental Health Team (Alcohol and Drug Service), the Youth Advice Centre, general practitioners and other Maori health providers.
I It is recommended that: I • Central RHA gives support to initiatives designed to increase the number of and employment of Maori psychologists, psychiatrists, nurses and other health professionals to provide mental health care services I for Maori, as part ofcomprehensive workforce development for Maori. I I
I 163 Poutama Whirinaki Interwoven Paths I Older people I "Being able to live andparticipate in the life ofthe community and hav{ng access to health services which enabled them to achieve that, was the main concern ofolder people. " I A number of initiatives set out in this report address issues of concern to older people in Wanganui, such as waiting times for orthopaedic and eye surgery. Other issues of particular concern for people in this age group are the availability ofappropriate and affordable services to enable the older person to remain living I in the community. This includes the provision of both health and disability support services for older people. In order to access such services, the older person must know oftheir existence and ofany financial support for which they might be eligible. I It is recommended that: I • in development of an information strategy in Wanganui that particular emphasis be given to both the health and disability support needs of older people I • while a physically safe home environment is important in promoting health and wellbeing in all age groups, it is particularly important for younger and older people. Central RHA will work with other national and local agencies to promote the safety of older people living in Wanganui. I
Smoking cessation and prevention programmes I "High rates ofsmoking were found in Wanganui, particularly among Maori andyoung women. " I It is recommended that:
• Central RHA further develops strategies aimed at reducing the prevalence ofsmoking, especially among I youth, in households with asthmatics, during pregnancy and among young mothers and in the workplace. In developing and implementing these strategies in Wanganui, Central RHA will need to work closely with the Public Health Unit, other providers and the Wanganui District Council I
• smoking cessation advice and counselling be purchased from GPs and other primary care providers in Wanganui, subject to evaluation ofthe introduction of a similar initiative in Porirua. I Educating young people not to start smoking is likely to reduce adult smoking rates significantly. I It is recommended that:
• the Ministry ofHealth works with the Ministry ofEducation in ensuring that education programmes are I integrated into all areas ofthe school curriculum and targeting environments frequented by young people I • Central RHA supports research initiatives designed to identify and develop effective health education programmes targeted at this age group. I I I
164 I I I Smokefree policies Education and health promotion programmes need to be backed up by enforcement oflegislative requirements. The Smoke-free Environments Act 1990 provides for the provision ofsmokefree workplaces, public transport I and other public places. Encouragement should be given to the work ofthe Public Health Unit in visiting workplaces and reviewing and where necessary enforcing the requirements ofthe Act, in particular reducing I underage tobacco sales. Work is in progress on an integrated smokefree programme in the Central region. I Asthma "Hospitalisation rates were higher in Wanganui than the region as a whole and even higher in the I core area. Rates were highest among children and Maori. " It is recommended that:
I • Central RHA develops an asthma management and education strategy to ensure early detection and effective management ofthe disease. In order to do that better information about the pattern of asthma I and its management is needed in different parts ofour region. • in developing an asthma strategy, Central RHA establish a number ofAsthma Task Forces, beginning in I Wanganui. Terms of reference ofthe Task Force might include: I • review of the scope and severity ofthe problem in Wanganui • identification of those factors which contribute to prevalence of asthma in Wanganui including I environmental and social factors • review ofcurrent management ofasthma including asthma education services in Wanganui in particular I for Maori and adolescents • an audit ofasthma hospitalisations I • review of successful models from other parts ofthe region • development ofa proposal to Central RHA to address the issues identified.
I It is recommended that:
• Discussions be held with groups at the local and regional levels in defining the terms of reference and I establishing the membership ofthe Task Force.
These discussions might include the local authority, iwi, Maori organisations, housing organisations, schools, I key providers of asthma services including general practitioners, the Asthma Society and specialist staff at Good Health Wanganui including the Public Health Unit, interested members of the community and the I Asthma Research Group of the Wellington School ofMedicine. I It is recommended that: • given the higher rates of asthma hospitalisation in Maori, that priority be given to the purchase of an I asthma education service from a Maori provider in Wanganui.
I 165 Poutama Whirinaki - interwoven Paths I Diabetes I "Death rates from diabetes were higher in Wanganui than the region overall. The prevalence and effective management ofdiabetes was identified as a special health issue for Maori. " I The need for better coordination of diabetes services in Central RHA region is acknowledged in a review undertaken in 1994. I Specific issues for diabetes purchasing strategy in the Central region include:
• adequate access to diabetes nurse educator, dietitian, podiatry and psychologist services, especially in I primary care • a coordinated team approach spanning primary and secondary care I • a system of patient recall for regular review and screening • structured care in general practice I • shared care between general practitioners and specialists
• services for Maori people I • services for Pacific Islands people I • quality assurance/audit systems.
Central RHA acknowledges there is no one "best way" in which to provide diabetes services. While a I number of elements essential to good diabetes management are generally agreed, there is considerable variation as to how these elements can be best provided. I It is recommended that:
• specific diabetes services be purchased in Wanganui, following consultation on the draft diabetes strategy, I with emphasis given to the development ofeducation and diabetes management services for Maori. The higher incidence of diabetes among Maori has been recognised by the establishment of a joint RHA initiative to train Maori health workers to educate Maori about diabetes. One Maori health worker will I be trained for the Wanganui sub-region in the 1996/97 financial year. I Hearing disorders
"Higher rates ofhospitalisationfor disorders ofthe ear than the region as a whole, andconcerns that I some children, in particular Maori children, with otitis media with effusion (glue ear) may not be getting access to early treatment. " I Early identification and treatment of otitis media with effusion (glue ear) in young children is particularly important and can be reliably detected by a simple tympanogram test. Hearing loss associated with this I condition can disrupt normal language acquisition and impede learning. Parents and teachers need to be aware ofthe symptoms ofdeficient hearing and ensure children have early access to relevant services. I Tympanometry screening of children under five years old registered with Progressive Health Inc. (Pill) doctors will soon be implemented. Pill intend to concentrate screening efforts in the 9-15 month age group. Tympanometry screening ofthree and five year olds is also carried out by the PubJic Health Service ofGood I Health Wanganui.
Poutama Whirinaki Interwoven Paths 166 I I I It is recommended that: • an evaluation ofthe Pill initiative be undertaken. The evaluation should incIudethe relationship between general practitioner and other-provided tympanometry services
I • Central RHA encourages development of otitis media with effusion treatment and referral protocols between general practitioners and specialists to standardise and facilitate the treatment and referral process I • the capacity of specialist ENT services in Wanganui is assessed prior to the implementation ofthe Pill initiative in order to ensure the service has the capacity to sustain a possible increase in referrals. If I considered necessary, additional outpatient visits and grommets procedures should be purchased • Central RHA reviews existing services for the early identification, referral and treatment ofMaori children I in Wanganui, who are most at risk ofdeveloping hearing problems from glue ear. I Breast Cancer Screening Programme "Lack ofaccess to a publicly funded mammography service in Wanganui was seen as a barrier to I early identification ofbreast cancer. This issue does not apply only to Wanganui. but is region wide. " Mammography (breast x-rays) can reliably detect early breast cancer. Pilot programmes targeted at women I aged 50-64 have been conducted in Otago/Southland and Waikato. A national advisory group, comprising women from the community and experts, is now advising the Ministry of Health on the establishment of a nationwide programme. Although the exact service requirements and I arrangements are yet to be confirmed, services for the screening, prompt diagnosis and treatment ofbreast I cancer will be purchased in the Central region in 1996. Family planning services
I "There are limited choices ofprovider andprovider availability for women in Wanganui. This has I particular implications for women from low income households. " There is a need to improve access to low cost, acceptable family planning services in Wanganui, in particular I for women from low income households and young people from rural areas. A regional strategy for women's health is being planned, in which issues related to contraception and abortion I will be addressed. It is recommended that:
I • Central RHA consults with interested organisations and existing providers as to how such services might be improved in Wanganui. Some options might be: I increase purchase ofservice from hospital clinic and ensure extended hours purchase services from well women's clinic I purchase services from Family Planning Association purchase ofvasectomy services
I purchase ofa rural reproductive and sexual health service.
I 167 Poutama Whirinaki Interwoven Paths I
A service developed to support young Maori mothers through pregnancy and up to the first birthday ofthat child was purchased by Central RHA late in 1995. I It is recommended that: I • this pilot be monitored and evaluated so that evidence is available to inform future purchasing of these services for young Maori women. I Surgical services I "Waiting times to see a specialist andsubsequent wait for surgery were the main issues ofconcern in Wanganui. " I Central RHA is undertaking a joint project with CHEs in the region relating to the development ofprioritisation and waiting time criteria for six surgical specialities; general surgery, orthopaedics, gynaecology, urology, ear, nose and throat, and ophthalmology. The project includes reaching agreement on an achievable approach I and timetable for the implementation ofthe scheduling ofpatients in priority categories who are to receive access to specialist assessment and surgery. I Services for people with visual impairment I "Issues identified in Wanganui included the adequacy ofreferral systems for children, the availability ofservicesfor people with visual impairment and waiting times for cataract surgery. " I It is recommended that: I • the current referral service for children with visual problems is reviewed with CHE providers and private optometrists I • Central RHA discusses the provision oflow vision clinics with interested parties in Wanganui and other parts of the region
• Additional cataract surgery be purchased in Wanganui in 1996/97. I
Dental services I
"Acquisition ofgood oral hygiene practices begins in the home and is reinforced at school. Though the cost ofgoing to the dentist should not be a deterrent for young people up to the age of18 years, I some youngpeople in Wanganui do not go for regular dental checkups. Cost has been shown to be a barrier to use ofdental services by adults in low income households, in particular older people. " I It is recommended that: I • Central RHA ensures that adults on low incomes are informed about their eligibility for subsidised dental services. It is proposed to purchase essential services for low income adults from 1996. Such services will include treatment for acute problems only, such as acute toothache I • priority be given to ensuring that dental education programmes purchased through schools and other educational centres are adequately meeting the needs ofchildren and young people. I Poutama Whirinaki - Interwoven Paths 168 I I Disability support equipment subsidies "There is concern about the cost ofspectaclesfor children in Wanganui. The subsidy for spectacles I is an issue which is addressed at national level. " People with disabilities have raised issues ofinconsistencies and anomalies in the subsidisation ofdisability support equipment in other consultations. As national consistency is needed in this area, any review undertaken I would need to involve and have the support of key government agencies. I It is recommended that: • Central RHA initiates discussions with the Ministry of Health on this issue. I I I I I I I I I I I I I I
I 169 Poutama Whirinaki Interwoven Paths I TIMETABLE AND ESTIMATED COST I I Recommendations with specific purchasing implications, are set out in the Three Year Implementation Plan below. It should be noted that these costs are estimates only, and will be subject to adjustment when more detailed service specifications are developed. At this stage of the planning process, they are indicative of I the level ofresources which are likely to be required. I Three Year Implementation Plan Year One 1996/97 I Initiative Estimated Cost I Family Support Programme $20,000
Children and Youth Services I - evaluation of GP tympanometry screening programme $12,500 - evaluation of free under five GP services $15,000 - additional services for youth through YAC and other providers $25,000 I - services for rurally based youth $40,000 - youth mental health services To be dete~ined ($2.5M regional) - dental health services $40,000 I Services for Maori I - family support programme Included above - youth coordination service $20,000 - alcohol and drug service for youth programme I development and training costs $40,000 ( portion of region wide cost) - evaluation ofyoung Maori mothers' support programme Regional allocation I Review of Family Planning Services To be determined
Smoking cessation advice and counselling service $20,000 I Asthma Task Force $12,000 I Diabetes education and management $75,000 I, Review levels ofprovision of orthopaedic, ophthalmology and ENT services To be determined
Development of health information strategy, I with local agencies $10,000
TOTAL YEAR ONE $289,500 I I I Poutama Whirinaki Interwoven Paths 170 I I I I I I Year Two 1997/98 I Initiative Estimated Cost Family Support Programme $120,000
I Children and Youth Services - evaluation of GP tympanometry screening programme To be determined in Year 1 - evaluation of free under five GP services To be determined in Year 1 I - additional services for youth through YAC and other providers $40,000 - services for rurally-based youth $40,000 - youth mental health services To be determined from ($2.5M regional) I - dental health services $40,000
Services for Maori I - family support programme Included above - youth coordination service $40,000 - alcohol and drug service for youth $54,000 I - asthma education service . $40,000 - diabetes education service Included below I - evaluation of young Maori mothers' support programme To be determined I Review ofFamily Planning Services To be determined Smoking cessation advice and counselling service $20,000
I Diabetes education and management $75,000
Review levels of provision of orthopaedic, I ophthalmology and ENT services To be determined in Year 1 I Development of health information strategy, with local agencies To be determined in Year 1 TOTAL YEAR TWO $469,000 I I
I 171 Poutama Whirinaki -Interwoven Paths I I I I I Year Three 1998/99 I Initiative Estimated Cost I Family Support Programme $240,000
Children and Youth Services I - evaluation of GP tympanometry screening programme To be determined in Year I - evaluation of free under five GP services To be determined in Year I - additional services for youth through Y AC and other providers $40,000 I - services for rurally-based youth $40,000 - youth mental health services To be determined from ($2.5M regional) - dental health services $40,000 I
Services for Maori - family support programme Included above I - youth coordination service $40,000 - alcohol and drug service for youth $54,000 - asthma education service $40,000 I - evaluation ofyoung Maori mothers' support programme To be determined - diabetes education service Included below I Review of Family Planning Services To be determined
Smoking cessation advice and counselling service $20,000 I Diabetes Education Services $75,000 I Review levels ofprovision of orthopaedic, ophthalmology and ENT services To be determined in Year 1 I Development of health information strategy with local agencies To be determined in Year 1 I TOTAL YEAR THREE $589,000
Total over three years: $l.3M I I I Poutama Whirinaki - Interwoven Paths 172 I I BIBLIOGRAPHY I Asher B, Fordham F, Pitcher D 1979. Health in the Wanganui Region: A Survey ofBehaviour and opinions. I Palmerston North: Massey University. Bailey J 1991. An Evaluation ofCommunity and Regional Programmes for the Control ofDrink-Driving Accidents in New Zealand Wellington: Chemistry Department, Department of Scientific and Industrial I Research.
Bailey J, de Jongh R 1987. The Wanganui Hospital Road Accident Survey 1986/87. Wellington: Chemistry I Division; Department of Scientific and Industrial Research.
Barwick H 1991. The Impact of Economic and Social Factors on Health. Wellington: Public Health I Association. I Cate B 1995. Beyond the comfort zone. North and South. Central RHA 1993. Report ofthe Maori Consultation Hul atKaiwhaiki Marae. Wellington: Central Regional I Health Authority. Central RHA 1993. Report ofthe Maori Consultation Hui at Ratana Pa. Wellington: Central Regional I Health Authority. Central RHA 1993. Report ofthe Maori Consultation Hul at Maungarongo Marae, Ohakune. Wellington: I Central Regional Health Authority. Central RHA 1994. Report ofthe Maori Consultation Hui at Paraweka Marae, Pipiriki. Wellington: Central I Regional Health Authority. Central RHA 1994. Report ofthe Maori Consultation Hui at Te Ao Hou Marae, Wanganui. Wellington: I Central Regional Health Authority.
Central RHA. 1994. Strong Links: the reportofthe Porirua needs assessment project. Wellington: Central I Regional Health Authority.
Central RHA 1995. Mortality and Morbidity Profile ofthe Central Region. Wellington: Central Regional I Health Authority.
de Jongh R, Bailey J. 1987. The Evaluation ofTwo Drinking-Driving Campaigns in Wanganui.Wellington: I Chemistry Division; Department of Scientific and Industrial Research.
Douglas D. 1989. Maori Health in the Wanganui Area. Wellington: Maori Workforce Development I Committee, Department ofHealth. I Kilgour R, Keefe V 1992. Kia Piki Te Ora. Wellington: Department of Health. Manawatu-Wanganui Regional Council 1991 RoadSafety Report.
I National Committee to Prevent Child Abuse 1994. Healthy Families America. Chicago.
I 173 Poutama Whirinaki - Interwoven Paths I NZSTA 1993. Healthy Schools:Drajt Conference Proceedings. New Zealand School Trustees Association. I O'Connor P 1989. Health Facts 1989: Health statistics/or theWanganui Area. Wanganui: Public Health Unit. I O'Connor P 1991. Asthma Prevalence Survey Among Form One and Two Students in the Wanganuil RangitikeilWaimarino Areas: A Report to School Principals. Wanganui: Public Health Unit. I O'Connor P. 1992. Asthma Prescribing In Wanganui: An Analysis of 29 General Practitioners in the Wanganui Area. Wanganui: Public Health Unit. I O,Connor P, Miller A. 1992 Review ofWanganui HospitalEmergency Department Attendances for Asthma in 1992. Wanganui: Public Health Unit. I O'Connor P, Miller A 1992. Population ofWanganui. Wanganui: Good Health Wanganui.
O'Connor P 1993. AttendancesforAsthma Care in Wanganui General Practices: Wanganui: Public Health I Unit, Wanganui.
O'Connor P 1993 Questionnaire Survey ofthe Experiences and Attitudes ojPeople with Asthma in the I Wanganui Area. Wanganui: Public Health Unit. I O'Connor P 1994. Population Management ofAsthma: A thesis submitted for the degree of Master of Public Health at theUniversity ofOtago, New Zealand. I Pomare E, Keefe-Ormsby V, Ormsby C, et al. 1995. Hauora Maori Standards ofHealth 111. Wellington. I Potaka U, Durie M, Ratima K, et al. 1993. Whanau Ora Health Status Assessmen. A report prepared for Te Runanga 0 Raukawa. I Public Health Association 1993. Beyond City Limits: Rural Health in the Manawatu and Wanganui Region; Issues and Action. Public Health Association Manawatu-Wanganui in collaboration with the Hunterville Community Health Group. I Wanganui and Palmerston North Public Health Units 1992. Manawatu-Wanganui: Health StatusReview. I Simon M 1991. Taku Whare My Home My Heart, Wanganui: Regional Community Polytechnic.
Statistics New Zealand 1993/94. Wanganui District Council Demographic Profile. Wellington: Statistics I New Zealand. I Statistics New ZealandlMinistry ofHealth 1993. A Picture ofHealth. Wellington: .
Thompson (Erihe) L. 1993. Politics ojHealth. Responding Personally: Developments in Maori He a Ith. I Wellington: Public Health Association ofNew Zealand National Conference, Wellington.
Wanganui Area Health Board 1987. Care in the Community. Wanganui: Service Development Unit; Wanganui I Area Health Board. I I Poutama Whirinaki - Interwoven Paths 174 I I ACKNOWLEDGEMENTS I Many people have been involved in the conduct ofthis needs assessment project, reflecting the title ofthis I report, Poutama Whirinaki: Interwoven Paths. The Central RHA project team included Patricia Donnelly (Project Leader), Fran Ashton, Alison Handley, Sue Hine, Owen Hughes, Cynthia Maling, Lucy Te Moana-Evans, Marcita Uy Hague-Smith, Sarah Wah, I Philip White, Wendi Wicks. Contributions were made by many other RHA staff throughout the project, in particular Neil Scotts, Research Manager.
I An important contribution to the project was made by members ofthe AdvisorylLiaison Group, in particu lar David Dale, who chaired the Group. A number of people assisted in its establishment, including Roger Williams (formerly Chair Health Task Force), Keith Safey (formerly Chair Community Health Group) and I Murray Gilbertson (Director ofPlanning and Operations Wanganui District Council). Administrative sup port was provided by the Wanganui District Council through Rosemary Hovey (Community Development I Officer). A wide range of individuals and groups were involved in various aspects of this project. These included I Wanganui people who took part in meetings and interviews, Ie Oranganui and PHI general practitioners who enabled the conduct of the consumer survey, staff and management of Good Health Wanganui and other providers who took part in interviews, public sector agencies, and voluntary and private sector organi I sations who took part in the postal survey. Contributions to the conduct of the research for this project were also made by, Sandy Brinsdon, Peter I Schmitz, Durga Rauniyar, Scott Metcalfe, Deborah McLeod, Jenny Neale and students from the Depart ment of Applied Social Science, Victoria University, Students of the School of Community and Health I Wanganui Polytechnic, Alison Gray Associates, GCS Ltd, Sonia Mason and Pip Baldwin. Comments were sought from external reviewers Peter Davis, Department ofCommunity Health, Auckland I School of Medicine and Mason Durie, Ie Pumanawa Hauora, Massey University. I I I I I I
I 175 Poutama Whirinaki 1nterwoven Paths I I I I I I I I I I I I I I I I I . I I I Poutama Whirinaki - Interwoven Paths 176 I I I I I I I I I APPENDICES I .:. I I I I I I I I I
I 177 Poutarna Whirinaki Interwoven Paths I APPENDIXA: ADVISORY/LIAISON GROUP I I David Dale Chairperson I Sara Casey Youth representative
Cindus Colunna Community representative I Fiona Donne Community representative I Jim Duthie Youth representative
Jackie Goldsbury Community representative I Rosemary Hovey Wanganui District Council I Joyce Lamont, Community representative
Robin MacLachlan Progressive Health Incorporated I Henry Ngapo, Community representative I Liz Noble Chairperson, Health Task Force I Patrick O'Connor Medical Officer ofHealth
Marilyn Rimmer Good Health Wanganui I Keith Safey Community representative I Jeni Sitnikoff Community representative
Tariana and George Turia Te Oranganui Iwi Authority I
Former members ofthe AdvisorylLiaison Group include: Dr Roger Williams, Health Task Force, Mike Smith, Youth representative and Kelly Foster, Community representative. I I I I I I Poutama Whirinaki Interwoven Paths 178 I I APPENDIX B: SOCIO-DEMOGRAPHIC TABLES
I Table B1: Usually resident population, Wanganui and sub-areas, 1981, 1986, 1991
I Population % change Numerical change
I Census Area Unit 1981 1986 .1991 1981-1991 1981-1991 CastlecliffNorth 2,466 2,535 2,451 -1% -15 Castlecliff South 1,536 1,623 1,578 3% 42 I Mosston 1,302 1,323 1,311 1% 9 Balgownie 378 402 432 14% 54 I Gonville West 1,764 1,809 1,833 4% 69 Laird Park 2,331 2,406 2,478 6% 147 Wanganui Central 1,344 1,443 1,434 7% 90 I Cooks Gardens 585 537 444 -24% -141 Lower Aramoho 1,983 2,043 1,971 -1% -12 I Upper Aramoho 2,496 2,463 2,448 -2% -48 Wembley Park 1,914 1,851 1,950 2% 36 Putiki 336 306 348 4% 12 I Core area 18,435 18,741 18,678 1% 243 Otamatea 762 729 834 9% 72 I Blueskin 1,005 1,083 1,170 16% 165 Tawhero 1,584 1,542 1,608 2% 24 Gonville South 3,099 3,141 3,204 3% 105 I Gonville East 1,245 1,197 1,308 5% 63 Springvale West 1,452 1,539 1,458 0% 6 Springvale East 1,056 1,515 1,824 73% 768 I Wanganui Collegiate 1,218 1,140 1,182 -3% -36
Spriggens Park 354 348 351 -1% -..)" I St John's Hill 1,998 2,118 2,097 5% 99 Williams Domain 2,085 2,169 2,079 0% , -6 Kowhai Park 2,322 2,295 2,343 1% 21 I Bastia Hill 642 678 693 8% 51 Durie Hill 1,449 1,560 1,512 4% 63 I Marybank-Gordon Park 483 567 558 16% 75 Rest ofWanganui 20,754 21,621 22,221 7% 1,467 Wanganui urban area 39,189 40,356 40,899 4% 1,710 I Maxwell 1,023 1,086 1,281 25% 258 Forde ll-Kakatahi 2,295 2,229 2,310 1% 15 I Rural Wanganui 3,318 3,315 3,591 8% 273 Wanganui District 42,510 43,707 44,604 5% 2,094 Central region 819,786 839,364 856,659 4% 36,873 I New Zealand 3,143,307 3,263,283 3,373,929 7% 230,622
I 179 Poutama Whirinaki -Interwoven Paths I Table B2: Usually resident population, Wanganui and sub-areas, by ethnic group, 1991 I European Maori Pacific Is. Other Not spec. Total % Maori
CastlecliffNorth 1,680 699 45 15 12 2,451 29% I Castlecliff South 975 519 12 39 33 1,578 33% Mosston 798 456 45 3 6 1,311 35% I Balgownie 210 216 3 0 3 432 50% Gonville West 1,176 576 48 18 15 1,833 31% Laird Park 1,905 480 60 15 18 2,478 19% I Wanganui Central 1,173 183 9 48 18 1,434 13% Cooks Gardens 330 78 12 18 3 444 18% I Lower Ararnoho 1,497 429 36 6 6 1,971 22% Upper Aramoho 1,887 525 21 12 6 2,448 21% Wembley Park 1,260 657 15 9 9 1,950 34% I Putiki 174 174 6 0 0 348 50% Core area 13,065 4,992 312 183 129 18,678 27% I Otamatea 789 24 6 15 0 834 3% Blueskin 1,107 45 3 12 0 1,170 4% Tawhero 1,359 204 24 12 6 1,608 13% I Gonville South 2,808 318 30 33 18 3,204 10% Gonville East 1,077 198 9 15 6 1,308 15% I Springvale West 1,305 108 18 24 3 1,458 7% Springvale East 1,716 51 6 45 6 1,824 3% Wanganui Collegiate 1,065 84 18 12 3 1,182 7% I Spriggens Park 294 48 9 3 0 351 14% St John's Hill 2,001 54 3 30 9 2,097 3% I Williams Domain 1,782 249 24 18 6 2,079 12% Kowhai Park 2,097 213 21 6 6 2,343 9% Bastia Hill 654 33 0 6 0 693 5% I Durie Hill 1,380 111 9 9 6 1,512 7% Marybank-Gordon Park 519 33 0 3 3 558 6% I Rest ofWanganui 19,953 1,773 180 243 72 22,221 8% Wanganui urban area 33,021 6,768 486 420 201 40,899 17% Maxwell 1,179 87 6 3 0 1,281 7% I Fordell-Kakatahi 1,707 516 42 12 33 2,310 22% Rural Wanganui 2,886 603 48 15 33 3,591 17% I Wanganui District 35,991 7,401 540 438 234 44,604 17%
Central region 687,153 107,271 29,427 26,415 6,390 856,659 13% I New Zealand 2,658,738 434,847 152,802 99,426 28,113 3,373,929 13% I I I Poutama Whirinaki Interwoven Paths 180 I I Table B3: Usually resident population by age group, by sex, Wanganui District and sub-areas, 1991 Core Area Rest of Wanganui Wanganui Urban Rural Wanganui Wanganui District Area I Male Female Total Male Female Total Male Female Total Male Female Total Male Female Total Under 5 996 936 1,890 765 759 1,527 1,722 1,695 3,420 207 165 369 1,935 1,869 3,804 5 to 14 1,650 1,533 3,177 1,680 1,644 3,315 3,318 3,174 6,495 333 327 657 3,657 3,507 7,164 I 15 to 19 798 804 1,605 867 771 1,638 1,668 1,575 3,240 111 108 222 1,794 1,698 3,492 20 to 24 693 762 1,458 612 648 1,263 1,320 1,407 2,727 147 81 231 1,476 1,500 2,976 I 25 to 34 1,299 1,596 2,892 1,389 1,557 2,952 2,694 3,147 5,841 357 318 675 3,063 3,471 6,537 35 to 44 1,095 1,104 2,211 1,515 1,635 3,129 2,610 2,733 5,343 318 258 576 2,934 2,994 5,931 45 to 59 1,095 1,242 2,346 1,611 1;782 3,405 2,709 3,036 5,748 279 225 501 2,994 3,264 6,255 I 60 to 64 414 381 798 558 630 1,188 981 1,011 1,989 75 57 132 1,059 1,068 2,127 65 to 74 573 786 1,353 903 1,203 2,109 1,482 1,980 3,462 90 72 162 1,569 2,052 3,624 I 75 to 84 294 495 786 471 828 1,299 768 1,314 2,079 21 24 45 789 1,341 2,127 85 & over 54 120 168 96 273 384 147 405 552 3 9 9 150 414 564 I Total 8,940 9,741 18,675 10,479 11,733 22,215 19,422 21,47440,899 1,941 1,647 3,585 21,426 23,178 44,601 I I Table B4: Population by age group, by ethnic group, Wanganui District, 1991 Age group European Maori Other Total (years)
I Under 5 2,601 1,086 117 3,804 5 to 14 5,088 1,806 270 7,164 I 15 to 19 2,550 834 108 3,492 20 to 24 2,229 663 84 2,976 I 25 to 34 5,034 1,272 231 6,537 35 to 44 4,992 756 183 5,931 I 45 to 59 5,499 642 114 6,255 60 to 64 1,959 138 30 2,127 65 to 74 3,435 153 36 3,624 I 75 to 84 2,055 48 24 2,127 85 and over 549 9 6 564 I Total 35,994 7,401 1,206 44,601 I I I
I 181 Poutama Whirinaki - Interwoven Paths I APPENDIX C: HEALTH STATUS TABLES I
Table C1: All causes ofhospitalisation by gender, ethnicity, and area, 1989-1994 I
Core Area Rest of Wanganui Wanganui Urban Central Region Area I Gender Ethnic No.* Rate** No.* Rate** No.* Rate** No.* Rate**
Female Maori 612 2,540 181 2,381 793 2,547 10,510 2,796 I Non-Maori 1,653 2,232 1,900 1,702 3,552 1,918 64,927 1,587 Total 2,264 2,293 2,081 1,727 4,345 1,988 75,437 1,692 Male Maori 375 1,835 133 1,663 508 1,795 6,261 2,051 I Non-Maori 1,244 1,828 1,496 1,462 2,741 1,603 47,219 1,276 Total 1,619 1,835 1,629 1,493 3,249 1,637 53,480 1,332 Total Maori 986 2,332 314 2,111 1,301 2,274 16,771 2,417 I Non-Maori 2,897 2,021 3,396 1,567 6,293 1,750 112,146 1,421 Total 3,884 2,059 3,710 1,599 7,594 1,805 128,917 1,502 I * Average number ofpublic hospital separations per year July 1989-June 1994 ** Rate per 10,000, age-standardised to New Zealand total popUlation 1991 I
Table C2: All causes ojdeath by age group and area, 1988-1992 I Core Area Rest of Wanganui Wanganui Urban Central Region Area Age No.* Rate** No."' Rate** No.* Rate** No.* Rate** I
Less than 1 8 2,114 3 - II 1,659 143 956 I 1 to 4 2 - 2 - 4 - 31 55 5 to 14 1 - 1 - 2 - 34 26 15 to 24 5 176 3 - 8 137 159 112 I 25 to 44 10 188 7 115 17 148 322 123 45 to 64 34 1,090 33 710 67 863 1,175 743 65 to 74 51 3,784 55 2,614 106 3,073 1,620 2,821 I 75 and over 90 9,476 157 9,362 247 9,382 3,484 8,858 Total*** 202 1,028 260 796 462 891 6,967 811 I * A verage number of deaths per year 1988-1992 ** Age-specific rate per 100,000 population *** Rate per 100,000 age-standardised to New Zealand total popUlation 1991 I I I I I Poutama Whirinaki - Interwoven Paths 182 I Table C3: Major causes a/mortality by gender in Wanganui urban area, 1988-1992 I I Female Male Total Causes of death No* Rate** No* Rate** No* Rate**
I Coronary heart disease 59 167 60 289 119 222 Cancer 48 166 56 271 104 206 Stroke 31 87 20 103 51 92 I CORD, excluding asthma 9 25 15 73 24 43 Pneumonia and influenza 14 37 8 38 22 39 Other heart disease 13 33 6 32 19 34 I Diseases ofarteries 5 14 6 31 12 21
'" Average number of deaths per year I ** Rate per 100,000 age-standardised to New Zealand total population 1991
I Table C4: Major causes a/hospitalisation/or in/ants under one by area, 1989-1994
Core Area Rest of Wanganui Wanganui Urban Central Region I Area Cause No* Rate** No* Rate** No* Rate** No* Rate**
I All Causes 186 5,041 131 4,688 317 4,866 5,637 3,769 Perinatal conditions 83 2,238 63 2,272 146 2,243 1,940 1,297 Acute respiratory infections 21 580 14 495 35 541 701 468 I CORD"''''* 12 314 4 - 16 243 132 ' 89 Congenital anomalies 10 271 10 358 20 307 463 310 Symptoms 11 298 8 280 19 289 433 290 I Infectious diseases 8 206 5 172 12 190 236 158 Abdominal hernia 7 201 4 - 11 169 192 <129 I * Average number ofpublic hospital separations per year July 1989-June 1994 *'" Age-specific rate per 10,000 population I **'" Chronic obstructive respiratory disease Table C5: Major causes a/hospitalisation/or children 1-4 years by area, 1989-1994
I Core Area Rest of Wallganui Wallganui Urban * A verage number ofpublic hospital separations per year July 1989- June 1994 I ** Age-specific rate per 10,000 popUlation **'" Chronic obstructive respiratory disease I 183 Poutama Whirinaki -Interwoven Paths I Table C6:Major causes ofhospitalisation for children aged 5-14 years by area, 1989-1994 Cause Core Area Rest of Wanganui Wanganui Urban Central Region I Area No* Rate** No* Rate** No* Rate** No* Rate- I All causes 305 960 246 742 552 850 8,243 645 Disorders ofthe ear 42 132 25 75 67 103 776 61 Other upper resp diseases 28 87 23 69 51 78 556 44 I CORD*** 32 99 19 57 50 78 576 45 Upper limb fractures 22 69 22 68 44 68 559 44 Head injury 16 50 12 37 28 43 414 32 I Symptoms 16 52 19 57 35 54 615 48 ...... Oral diseases 14 44 7 22 21 J.j 329 26 Congenital anomalies 10 30 8 24 18 27 336 26 I * Average number ofpublic hospital separations per year July 1989 - June 1994 ** Age-specific rate per 10,000 population *** Chronic obstructive respiratory disease I Table C7: Major causes ofhospitalisationfor males aged 15-24 years by area, 1989-1994 I Core Area Rest of Wanganui Wanganui Urban Central Region Area Causes No· Rate** No* Rate** No* Rate** No* Rate** I All causes 167 1,113 149 999 316 1,059 5,411 755 Intracranial injury 17 115 13 89 30 102 539 75 I Upper limb fracture 10 68 lO 70 21 69 198 28 Lower limb fracture 10 64 9 59 18 62 281 39 SymptQms 7 47 7 50 14 48 294 41 I Fracture of skull 6 41 7 47 13 44 285 40 Late effect injury/poisoning 6 43 5 31 11 37 330 46 Psychoses 4 - 6 43 11 36 106 15 I Neuroses 7 48 4 - 11 36 169 24 * A verage number of public hospital separations per year July 1989 - June 1994 I ** Age-specific rate per lO,OOO population Table C8: Major causes ofhospitalisation for females aged 15-24 years by area, 1989-1994 I Core Area RestofWanganui IvvanganuiUrban Central Region ! Area I Causes No* Rate** No* Rate- No* Rate** No* Rate** All causes 448 2,869 276 1,942 723 2,425 12,399 1,754 Pregnancy complications 90 579 40 282 130 437 1,790 253 I Labour complications 84 538 40 285 124 417 1,391 197 Normal delivery 70 451 37 258 107 359 2,527 357 I Female genital disorders 18 117 14 101 33 109 651 92 Preg with abortive outcome 17 109 8 59 25 85 917 130 Symptoms 16 100 9 63 25 82 625 88 I CORD * * * 10 64 6 45 16 55 226 32 Head injury 8 53 7 52 16 52 201 28 * Average number ofpublic hospital separations per year July 1989 - June 1994 I ** Age-specific rate per 10,000 population *** Chronic obstructive respiratory disease Poutama Whirinaki -Interwoven Paths 184 I I Table C9: Major causes o/hospitalisation/or males aged 25-44 years by area, 1989-1994 I Core Area Rest of Wanganui ~anganui Urban Central Region Area I Causes No'" Rate"" No'" Rate*'" No" Rate** No* Rate** All causes 304 1,263 248 854 552 1,041 9,252 719 Symptoms 22 93 16 56 39 73 693 54 I Neuroses 11 45 7 23 18 33 264 21 Psychoses 13 53 15 52 28 52 258 20 Late effects/poisoning 11 44 10 34 20 38 497 39 I Cancer 4 10 33 13 25 283 22 Head injury 10 43 9 32 20 37 309 24 Oral diseases 14 57 7 25 21 39 I Dorsopathies 10 42 8 29 19 35 297 23 Arthropathies 10 42 7 24 17 32 274 21 I * A verage number of public hospital separations per year July 1989- June 1994 ** Age-specific rate per 10,000 population I Table CIO: Major causes o/hospitalisation/or females aged 25-44 years by area, 1989-1994 Core Area Rest of Wanganui Wanganui Urban Central Region I Area Causes No'" Rate"'* No* Rate"'''' No'" Rate"'''' No'" Rate*'" All causes 714 2,644 643 2,020 1,357 2,30 27,453 2,069 I Pregnancy complications 100 370 86 270 186 316 3,132 236 Labour complications 85 313 95 297 179 305 3,394 256 I Normal delivery 95 352 93 293 188 320 5,801 437 Female genital disorders 63 232 56 175 118 201 2,211 167 Health services, reprod 37 139 30 95 68 115 2,094 158 I Pregnancy with abortive outcome 25 94 26 83 52 88 1,734 131 Symptoms 25 93 20 63 45 77 1,012 76 Cancer 17 63 12 36 29 49 438 33 I Benign neoplasms 17 63 12 39 29 50 349 26 Psychoses 16 59 17 55 33 56 309 23 Neuroses 12 44 10 30 22 37 302 23 I Oral diseases 15 56 10 33 25 43 * Average number of public hospital separations per year July 1989- June 1994 ** Age-specific rate per 10,000 population I Not a major cause ofhospitalisation I I I I I 185 Poutama Whirinaki - Interwoven Paths I Table ell: Major causes ofhospitalisationfor males aged 45-64 years by area, 1989-1994 Core Area Rest of Wanganui Wanganui Urban Central Region I Area Causes No* Rate- No* Rate** No* Rate** No" Rate** All causes 278 1,830 301 1,383 579 1,569 10,589 1,337 I Cancer 35 232 33 153 69 186 1,040 131 Ischaemic heart disease 26 171 31 141 57 153 1,200 152 Symptoms 21 140 26 118 47 127 927 117 I Other heart diseases 13 87 14 64 27 74 445 56 Arthropathies 10 66 13 59 23 62 298 38 other diseases of digestive system II 70 9 43 20 54 264 33 I Diseases of oesophagus/stomach etc 8 54 11 50 19 51 389 49 Renal and urinary diseases 6 41 9 42 15 42 351 44 I * A verage number ofpublic hospital separations per year July 1989 - June 1994 ** Age-specific rate per 10,000 population I Table e12: Major causes ofhospitalisationfor females 45-64 years by area, 1989-1994 Core Area Rest of Wanganui Wanganui Urban Central Region Area I Causes No* Rate** Noo, Rate** No* Rate*o, No" Rate** All causes 292 1,800 323 1,334 615 1,521 10,075 1,278 Female genital disorders 30 183 32 134 62 153 1,018 129 I Cancer 36 225 41 169 77 191 1,214 154 Symptoms 24 147 22 91 46 113 826 105 CORD*** 9 57 10 40 19 47 348 44 I Ischaemic heart disease 14 84 I3 53 26 65 431 55 Diseases ofoesophagus/stomach etc 10 59 9 38 19 46 285 36 Other diseases intestine/peritoneum 9 54 9 37 18 44 247 31 I Other diseases of digestive system 9 58 11 47 21 51 336 43 Other heart disease 5 32 7 30 12 31 245 31 Arthropathies 8 52 12 50 20 50 341 43 I * Average number of public hospital separations per year July 1989- June 1994 ** Age-specific rate per 10,000 population *** Chronic obstructive respiratory disease I Table CJ3: Major causes ofhospitalisation for adults aged 65-74 years by area, 1989-1994 I Core Area Rest of Wanganui Wanganui Urban Central Region Area Causes No* Rate** No* Rate** No* Rate** No* Rate** I All causes 434 3,206 523 2,478 957 2,765 14,767 2,572 Cancer 81 599 99 467 180 519 1,927 336 I Symptoms 24 177 26 125 50 146 958 167 Arthropathies 16 118 20 94 36 103 580 101 lschaemic heart disease 28 208 37 175 65 188 1,286 224 Other heart disease 21 155 21 98 42 121 748 130 I Diseases of oesophagus/stomach etc 21 155 23 107 44 126 479 83 Cerebrovascular disease 16 115 18 86 34 98 567 99 Renal and urinary diseases 14 103 14 66 28 81 399 70 I Disorders ofthe eye 14 106 18 87 33 95 538 94 Female genital disorders 7 55 9 45 17 49 I * Average number ofpublic hospital separations per year July 1989 June 1994 * * Age-specific rate per 10,000 population I Poutama Whirinaki -Interwoven Paths /86 I Table C14: Major causes a/hospitalisation/or adults aged 75 years and over by area, 1989-1994 I Core Area Rest of Wanganui Wanganui Urban Central Region Area Causes No'" Rate"'''' No" Rate"'''' No" Rate"" No" Rate"" I All causes 447 4,690 659 3,928 1,106 4,195 16,931 4,305 Cancer 57 600 98 587 156 590 1,708 434 Symptoms 26 275 35 211 62 234 976 248 I Ischaemic heart disease 28 289 42 248 69 262 1,035 263 Other heart disease 25 260 43 256 68 257 1,153 293 CORD*** 15 155 16 95 31 117 575 146 I Cerebrovascular disease 23 237 37 221 60 226 925 235 Diseases of oesophagus stomach etc 15 157 23 140 38 146 470 119 Disorders ofthe eye 21 222 32 192 53 203 781 199 I Lower limb fracture 15 157 26 156 41 156 711 181 * Average number ofpublic hospital separations per year July 1989 June 1994 I ** Age-specific rate per 10,000 population I I I I I I I I I I I I I 187 Poutama Whirinaki -Interwoven Paths I APPENDIX D: MAORI GROUPS I, Kaumatua Kaunihera I Mauri Ora Health Centre Putiki Maori Committee I Te Korowai Aroha Te Matariki I Te Runanga 0 Ngati Apa Whanganui River Maori Trust Board I Ngati Ruaka Hapu Te Kura Kaupapa Maori 0 Te Atihaunui-A-Paparangi Jo Maniapoto and Associates I Waiora Christian Community Trust Ratana Orakeinui Trust I Aka Te Korimako I Te Waipuna Maori Mental Health Whanau, Good Health Wanganui I Turakina Maori Girls School I I I I I I I I I Poutama Whirinaki - Interwoven Paths 188 I I 'I APPENDIX E: RESPONSES RECEIVED FROM COMMUNITY ORGANISATIONS I I Bell St Child Care Centre Campbell St Child Care Centre I Faith Academy Intermediate Schools, Dublin St and Toi St Kindergartens, Field St, Rogers St, Nile St I Playcentres, Tawa St, Cloag St Primary Schools, Carlton Avenue, Burmah St, Gonville Avenue, Keith St, Kiwi St, St Annes, St Johns Hill, St Marys, Wanganui East I Secondary schools, Sacred Heart College, Wanganui Boys College, Wanganui Collegiate School ADARDS I Arthritis Foundation Blind and Partially Blind Association I Cancer Society ofNZ Coeliac Society Counterstroke Wanganui I Hearing Association Miscarriage Support Group Multiple Sclerosis Society I Neurological Foundation Overeaters Anonymous I Parkinsonism Society Plunket Society Wanganui Natural Family Planning I Wanganui Asthma Society Country Women's Institute, East Branch I Senior Citizens Association Springvale Friendship Group Waiwere Probus Group (individual and organisation responses) I Child Cancer Foundation Chinese Association I Citizens Advice Bureau Federation of University Women (individual and organisation responses) Speld I Catholic Worn ens League Christian Social Services I Marriage Guidance Narcotics Anonymous Tofaamamao I Wanganui Foster Care Womens Centre I 189 Poutama Whirinaki -Interwoven Paths I APPENDIX F: WANGANUI PROVIDERS INTERVIEWED I I Good Health Wanganui Paediatrician - John Goldsmith, Neil McKenzie I Mental Health manager - Chris O'Brien-Smith Adult Mental Health Team - group interview Manager Women's Health and Maternity - Julie Foley I Obstetrician and Gynaecologist - Mr Doolabh Dentist - Dr McDonald I Manager Clinical Support Services Outpatient clinics - manager Manager of Adult Services - Jan Adams I District Nurses, Oncology nurse, Ostomy Nurses, Diabetes Educator - group interview Manager ofChild Health - Marilyn Rimmer I Child, Adolescent and Family Mental Health Service - group interview Manager Well Child Health, Family Planning and Sexual Health - Pam Day Child Health Nurses, Child Health Social Worker - group interview I Manager Senior Service - Brigid Burke Orthoptist I Primary Providers I General Practitioners - group and individual interviews Practice Nurses - group interview I Private psychologists - Ken Pearson, Barry Fry Naturopath - Kathleen Keith I Private physiotherapist - Bruce Bell Wanganui Plunket Nurses - group interview Wanganui Domiciliary Midwives - group interview I Youth Advice Centre - Group interview Pharmacies - Aramoho, Wanganui East, Castlecliff, Gonville, City, Taupo Quay I Dentist in private practice Optometrists I Other I Principal Nurses - Southern Cross Manager - Kowhinui I Children's and Young Persons Service - Roger Taylor and Alison McArthur St John's Ambulance - group interview Home Birth association I Medical Officer of Health I Poutama Whirinaki -Interwoven Paths 190