A Response to a Response Capital & Coast Has Hit the Target but Missed the Point

A response to a response – Capital & Coast has hit the target but missed the point

This is a response to the issues raised by Dr Ashley Bloomfield in his rebuttal of the paper Professor Don Matheson wrote entitled “From Great to Good” (http://publichealth.massey.ac.nz/assets/Uploads/From-Great-to-Good-Final.pdf). Dr Bloomfield’s text is in regular font. Prof Matheson’s response is in italics.

C&CDHB Capital & Coast District Health Board places a high value around equitable access to all its services. This is reflected in much of the documentation Dr Matheson quotes, and even he himself acknowledges the importance CCDHB holds to this ideal concluding, "…the Board has clearly attempted to continue to highlight equity in its high level statements…" (page 11). Prof Matheson Indeed it does. However, the “Great to Good” paper demonstrated C&CDHB was unable to translate those high order intentions into actions. The Board’s strategic direction would be fulsome in its commitment to equity and issues such as the obesity epidemic, then follow with budgetary decisions to reduce funding for services providing care to low income people, and cut the money going into health promotion for improved nutrition. This difficulty in translating good intentions about inequity into actual improved services for low income, Māori and Pacific communities has also been identified in a review 1 of a number of Boards published in 2011. C&CDHB Dr Matheson uses spending by the DHB on PHOs which target vulnerable populations as a key indicator of the Board's commitment to these populations. The amount spent by individual PHOs who target vulnerable populations in no way reflects the total commitment of the DHB to these populations. In the past three to four years the DHB has made significant improvements in quality and access of its services for all populations, including Maori, Pacific and vulnerable. Prof Matheson Mr Bloomfield is, I suspect, referring to access to hospital services and spending on hospital services: not access to primary health care. The point in the “Great to Good” paper was to highlight the increasing access crisis in the primary care sector. The Board’s own “equity” report 2 pointed to serious issues for some populations in both the primary and the secondary care sector. How does this relate to “significant improvement” for the populations involved? Quotes from the Board’s own CPHAC paper: Elective surgery for Māori in both DHBs ... the number of elective surgeries provided each year has increased, rates for Māori have fallen. First Specialist Assessment (FSA) rates have remained relatively unchanged for Māori in Capital and Coast and have decreased for Hutt Valley. Surgical DNA rates in CCDHB have worsened for both Māori and Pacific. (Page 21) Pacific breast feeding rates decreased. (Page 15)

There has been an increase in the number of CCDHB primary school children not receiving their scheduled dental examination from 12 % to 16%, and Hutt Valley children from 7% to 28%. The biggest impact for CCDHB has been for Māori and Pacific children, while for Hutt children the increase is across all Ethnicities. (Page 16)

PHO’s Māori and Pacific children have slightly lower consultation rates than children of European and other ethnicities.[Despite a much higher disease burden!] They also have significantly higher rates of ambulatory sensitive hospitalisations. ASH rates in Capital & Coast DHB are ... Pacific children under five have a higher than average rate. Hutt Valley DHB has ASH rates higher than national for most groups; with especially high rates in the under five age group. (Page 19)

C&CDHB He also says that there is greater spending emphasis on hospital services. This is not the case. Despite making substantial savings to reduce its deficit over recent years, primary care spending has remained stable at 6% of overall CCDHB expenditure. It is important to note that increases in hospital expenditure include funding for specific Government initiatives (for example to reduce cancer waiting times, increase the number of elective surgical procedures) and also includes work done for other DHBs as part of Wellington Hospital's regional services. In contrast, primary care services are just for the population of the Capital & Coast district. Prof Matheson The current level of funding for primary care is inadequate as demonstrated by the persistent Ambulatory Sensitive Hospitalisation rates for Māori, Pacific and Low income people. Maintaining primary health care spending at 6% is inadequate to address this. Furthermore, that 6% is being re-distributed within the primary care sector, as the services that provide for low income communities are having their funding cut and are not in a “stable” environment. This situation was highlighted in one of the papers prepared by the C&CDHB’s planning and funding unit in 2010 and released under the OIA1. It showed PHOs serving high need populations looked after 9% of the population with only 1% of the available income from capitation and copayments. Recent decisions by the Board to trim back funding for PHOs serving high needs patients will have made this worse.

1 Systematic PHO Funding Gap and Sustainable Funding. Planning and Funding Management Team, August 2010. Figures released under OIA:

The papers released under the OIA also showed hospital spending was increasing, as was hospital activity both planned (which is good) but also unplanned, which may indicate inefficient use of reassures. C&CDHB This DHB's high childhood immunisation rate has eliminated significant inequalities for Māori and Pacific children who now enjoy similar immunisation rates to other children. This was not the case 5 years ago. CCDHB has one of the best immunisation rates in the country. Prof Matheson I have no argument with the C&CDHB achieving targets – it’s what is being lost outside of the targets that the “Great to Good” paper was focused on. The paper was called “Great to Good” not “Great to Bad”. I would be interested to know how much of that improvement was due to relaxation of the burden of proof required about past immunisations, and how much was due to more children being immunised. C&CDHB CCDHB was the first DHB nationally to offer free after-hours medical care for all children under 6 years of age. The DHB has also shown a commitment to reducing rheumatic fever rates in a cluster of disadvantaged communities and this intersectoral approach will continue until we have reduced the burden of rheumatic fever. Similarly the DHB has an excellent record in the management of diabetes in the community, for both mainstream and vulnerable populations. Prof Matheson Once again these are “good” things the Board is doing. C&CDHB Since the Ministry of Health's targets came into being the DHB has achieved a much improved performance for its health services and quarterly results are monitored where possible by ethnic group to ensure all groups are receiving the services and achieving the target. The Ministry's targets show that we are providing more services at an increasingly improved rate of cost and benefit to all populations. For example, with 100% of all patients receiving radiotherapy or chemotherapy within four weeks, all groups in the population are now receiving speedy and equitable access to these important services. Prof Matheson These are also good results. But two provisos are needed. Firstly, as the Board’s own papers told us, elective surgery and first specialist assessments are not equitably accessible. Secondly, for those services that are, the proviso needs to be added “once they get to the hospital, then they are receiving speedy and equitable access to these important services”. The evidence points to major discrepancies and late presentation for Māori with cancer, hence the problems created by barriers at the primary health care level. The Ministry2 emphasised this in its publication “Unequal Impact” which contained the following statement that demonstrated the severity of the access to care problem leading to cancers in Māori being at a much later stage before they are treated: Among those for whom stage information was recorded, Māori had significantly lower odds than non-Māori of being diagnosed at a localised stage, and higher odds of being diagnosed at a distant stage for most of the key cancers (breast, cervical, colorectal, lung, and prostate cancers).

C&CDHB A DHB project focused on reducing "Did-not-attend" (DNA) rates has been underway over the past year with the aim of reducing non-attendance rates to outpatient clinics, with a focus on Māori and Pacific Island patients in particular. While there is still more work to be done there has been a reduction in Māori, Pacific and our overall DNA rates. Prof Matheson Good. But once again it misses the point. C&CDHB needs to extend this to ambulatory sensitive hospitalisations and access to primary health care more generally. C&CDHB Where the DHB has had to make savings to remain within budgets, such as with providers including PHOs and practices, there has been a sharp focus on minimising the impact on vulnerable populations. Prof Matheson This “sharp focus” is not apparent in the documentation provided by the board. The Board’s decisions were quite blunt, as it only had discretion over a small part of the primary care funding, so tended to be cutting services that a few years previously they had established to address equity issues. Furthermore, the Board’s “sharp focus” as revealed through the paper released under the OIA, was primarily on itself, followed by the impacts on providers, with the impact on vulnerable populations seldom getting past the level of rhetoric. The deficit is the top priority: The top priority must be living within our means/ living within our budget. (April 12 Board meeting) The providers were asked to identify savings –the Board appeared to abdicate to the providers its responsibilities for vulnerable populations, without addressing the conflict of interest that entails:

2 Robson B, Purdie G, Cormack, D. 2010. Unequal Impact II: Māori and Non‐Māori Cancer Statistics by Deprivation and Rural–Urban Status, 2002–2006. Wellington: Ministry of Health. PHOs were given the opportunity to work with their providers and to indicate areas where they believe services can be reduced or cut with the least impact on vulnerable populations or front line services....Purchasing must be relationship driven where the funder/provider rapport is deemed as important as the results being sought. (C&CDHB Planning and Funding Team, 2011)

C&CDHB CCDHB continues to strengthen its focus on equity and the Board has received annual 'Equity' reports for the last two years. Along with Hutt Valley and Wairarapa DHBs, we are now developing a set of equity indicators of key aspects of health and health care for vulnerable populations, which will be monitored regularly. This is part of a greater sub- regional focus, which is a clinically driven initiative designed to make services more accessible across the three DHBs. It is a further reflection of our collective pursuit of the principle of equity and, importantly, tangible reductions in health inequalities. Prof Matheson I will be looking forward to seeing these equity reports when they emerge. I became engaged in researching the decisions of the DHB because of the gap between what the people in the Newtown community were experiencing and what the Board was publicly saying. To regain credibility I suggest that equity reports are in the public part of the Board’s meeting so that more active dialogue can occur about these vital issues between the Board and the community it serves. I also suggest that it takes a “health of the people of C&CDHB” approach, rather than one focusing only on the DHB and its narrow targets. The last New Zealand Health Survey had alarming statistics about the problems people are experiencing in gaining access to primary health care (almost 1 million New Zealanders experiencing significant barriers) and the recent Quality of Life report3 indicates it is a serious problem for C&CDHB as the quote below shows. Quality of Life Project Barriers to GP usage Just under one in six (15%) Wellington City residents and 20% of Porirua residents had an occasion in the last twelve months when they wanted to see a GP or doctor about their own health, but didn’t get to see a doctor at all. Not getting to see a GP was because it was too expensive or costly to go accounted for 44% of these in Wellington. In Porirua the main problem was they were unable to get an appointment including the doctor being too busy.

This is the sort of information that should be regularly reviewed and addressed by the Board, in a transparent way, and not only managed as a PR embarrassment. To address this requires a nuanced and local response- the core rationale as to why Boards were established. In this instance, the people of Wellington have primary care services but are unable to access them due to price. In Porirua, the problem is different; there is a lack of supply of services.

3 http://www.qualityoflifeproject.govt.nz/pdfs/2012/Quality_of_Life_2012_Wellington.pdf C&CDHB For these reasons, and many more, we believe Dr Matheson's analysis provides a rather limited and therefore inaccurate view of the performance of this DHB and ignores much of the hard work DHB staff are doing in the hospital and in the community to ensure we reduce inequalities in health delivery. Prof Matheson By all reports the Board’s staff are indeed working hard, that was never in question. “Great to Good” was a description of the Board’s decision making from a primary health care and equity perspective, in an attempt to understand why a Board that is on paper committed to reducing inequities would cut services to its most vulnerable citizens. The paper identified serious inconsistencies in leadership and governance, brought about by an external environment where responsible and coherent governance has been displaced by a focus on a small set of narrow targets, allowing health concerns of its most vulnerable citizens to wither on the vine. 1. Sheridan N, Kenealy T, Connolly M, Mahony F, Barber PA, Boyd MA, et al. Health equity in the New Zealand health care system: a national survey. International Journal for Equity in Health. 2011;10(1):45.

2. C&CDHB. Combined Health Equity Report 2011/2012. Wellington Capital and Coast District Health Board; 2012.