Dealing to disparities and inequalities

“The best preparation for tomorrow is to do today's work superbly well”

Sir William Osler

The overall goal of the RNZCGP is “to improve the health of ALL New Zealanders through high quality general practice”. I always emphasise the “all” to remind us of the disparities and inequalities in health that exist within New Zealand society; something we should be constantly reminded of and something that has to change.

This was again brought home to me when I attended a presentation by Dr Rhys Jones recently returned 2005-2006 Harkness Fellow in Health Care Policy. Dr Rhys Jones (Ngati Kahungunu) was reporting the findings of his year-long research in the United States into racial and ethnic inequalities in health care.

Dr Jones, Senior Lecturer at Te Kupenga Hauora Maori - the University of Auckland's department of Maori Health, spent 12 months at Harvard Medical School examining American case studies of interventions designed to reduce ethnic inequalities in health care. His research took a particular focus on chronic disease management, having identified cardiovascular disease as an example of where inequalities exist in both countries.

What he reported on was his observations of the different ways organisations approached this problem. There was the Indian Medical Health Service which seemed to be a completely stand alone service. The Indian Health Service (IHS), an agency within the Department of Health and Human Services, is responsible for providing federal health services to American Indians and Alaska Natives. The provision of health services to members of federally-recognised tribes grew out of the special government-to-government relationship between the federal government and Indian tribes.

This relationship, established in 1787, is based on Article I, Section 8 of the Constitution, and has been given form and substance by numerous treaties, laws, Supreme Court decisions, and Executive Orders. The IHS is the principal federal health care provider and health advocate for Indian people, and its goal is to raise their health status to the highest possible level. The IHS currently provides health services to approximately 1.5 million American Indians and Alaska Natives who belong to more than 557 federally recognised tribes in 35 states. Some historical mirrors for New Zealand aren’t there but we have a different approach.

As well as that he looked at various other health delivery agencies that tried to target lower socio-economic groups. Often these needy areas coincided with areas of larger African-American population.

It got me thinking about how to address inequalities and the current New Zealand programme, which appears to target those groups with poor health outcomes. We are all aware of the statistics around Maori health. We are all aware of the research that shows Maori are less likely to be offered interventions such as cardiac catheterisation than non-Maori. This situation is mirrored in the USA and several research papers support this “physician bias”. So how to overcome this? Do you step up targeting? Do you have positive discrimination?

Dr Jones then reported another study which really caught my attention and I am paraphrasing . This showed the disparity of cardiac catheterisations for acute myocardial infarction between African-Americans and others against national guidelines. However, more importantly it showed that neither group was getting nearly enough. The study then followed the effect of efforts to improve the rate by using clearly defined protocols. The effect, without any form of targeting lifted the rate for all groups and the gap between the lowest and the highest narrows dramatically.

What did this say to me? Maybe you don’t necessarily have to target specific groups to address inequalities. Maybe by encouraging and assisting quality measures you will raise the outcomes for all groups and if quality is applied equally then the disparities will reduce of their own accord.

The seminar was chaired by Stephen McKernan, Director-General of Health and New Zealand representative for the Harkness Fellowships programme. He reflected on his time at Counties Manukau. He was aware of the disparity for procedures for Maori and non –Maori within the DHB. At the time the length of waiting lists was a major problem. The measures introduced to manage them involved consultants applying strict protocols so that priority was decided as far as possible by objective measures. He observed that the rates of procedures for Maori rose under this scheme.

I know this is rather simplistic but it echoes what we in the College have been advocating for a very long time - quality. Sometimes we say ‘doing the right thing right’. We believe every general practitioner should be vocationally trained – or at least on a pathway to Vocational Registration. We also believe that the quality of the practice that the GP practices in is just as important. Hence the development of Cornerstone as a properly researched and evaluated marker of quality practices. Cornerstone is now recognised internationally as a world beater. All this raises the chances of the right thing being done right.

I am constantly disappointed that debate around general practice in New Zealand continues to be focussed on the cost of going to the doctor. Not too many people seem interested in what happens once you get through the surgery door? Ministry officials seem to focus totally on reducing the costs to the public.

But do we want a cheap service or do we want a quality service?

Quality general practice must be properly resourced. You cannot reach the highest quality standards – as defined by Aiming for Excellence – without your practice being freed from the pressures of under-funding. It need not be expensive.

If we/they/all of us embrace quality then some of the inequalities will dramatically reduce.