3.1 A Commitment to the principles of the Treaty of Waitangi

Māori health plan

A Māori health plan is essential in addressing equity. It describes how the practice plans to reduce disparities and includes the practice’s Māori demographics. The plan can be linked to the local district health board or other primary health organisation’s Māori health plan. Practices should consider how they establish priorities for Māori health with Māori members of the community or Māori health providers. Practice team members should use the plan as a tool to ensure health equity for Māori is a target for new and existing priorities.

The Māori health plan describes how the practice will:

• Commit to the Treaty of Waitangi and the principles articulated from the Wai 2575 claim. 
• Address Māori health equity priority areas and specific practice population issues for Māori to improve access to appropriate and affordable primary health services (the Government has identified a range of priority areas in He Korowai Oranga: Māori Health Strategy for improving Māori health).
• Implement measures to address equity priority areas as stated in He Korowai Oranga: Māori Health Strategy.
• Deliver targeted equitable services for the enrolled Māori population; ensure ethnicity data on Māori are available and robust; and establish priorities for Māori in the practice and set goals that will benefit their health outcomes.
• Demonstrate that they are making additional efforts to address the needs of Māori. These efforts might include:
  
  • Having specific targets and timelines, for example, measure statins in Māori versus non-Māori.
    
  • Encouraging enrolment of Māori patients on specific programmes such as Ministry of Health and district health board programmes in chronic care management.
  • Identifying and addressing any barriers for Māori to access the practice services (such as inaccessible appointments). 

What the Māori health plan should include

• Identification of Māori enrolled with the practice.
  
• The health status of Māori enrolled with the practice.
• Description of the use of data and audits to develop health equity initiatives
  
• Key linkages (local, regional and national), for example, with local Iwi.
  
• Strategies (both short-and long-term) to address equity issues.
  
• How progress will be delivered, monitored and evaluated.
  
• Examples of how collaborative relationships with Māori such as iwi and/or whānau ora collectives contribute to the wellbeing of Māori patients and whānau.

The plan should be reviewed by the clinical governance team annually (or earlier if needed) and then shared with the practice team. 

Developing collaborative relationships with Māori  
Whakataukī: Nā tō rourou, nā taku rourou ka ora ai te iwi - With your food basket and my food basket the people will thrive.

The relationships that general practices establish with Māori partners may be influenced by geographical location, access to opportunities and the kaupapa Māori and Whānau Ora services available.  

The Māori Health plan should include examples of how relationships with Māori and Māori health organisations have contributed, or could contribute, to the wellbeing of Māori within the practice. These efforts should be in context with the practice’s unique circumstances and appropriate to the needs the Māori population they serve.

For practices with low numbers of enrolled Māori, consider checking  Stats NZ to compare the percentage of local/regional Māori with the practice’s levels of enrolled Māori. If the results don’t tally, actions to improve this might involve the practice’s enrolled Māori patients and whānau. Some ideas may be; ensuring a friendly reception and greeting with the correct use of te reo, a welcoming waiting area, and culturally safe interactions. 

Working collaboratively with Māori and Māori health providers helps practices make the right changes to their systems to promote wellbeing and health equity.

North Island |Te Ika-a-Māui

Whānau ora collectives in Te Ika-a-Māui and Te Whatu Ora (Health NZ) are organisations which can provide access equitable health services for patients. 

South Island |Te Waipounamu

Te Pūtahitanga o Te Waipounamu  is the whānau Ora commissioning agency for Te Waipounamu and works on behalf of the nine Te Waipounamu iwi to determine the best ways to support whānau development. This includes partnership with the community to improve health literacy and access to health care for whānau living in Te Waipounamu.

Another useful site is Te Whatu Ora Southern, who list local Kaupapa Māori services and other resources.

Partnering or collaborating with local maraes and manu whenua (iwi and hapu) as well as other local health providers, as applicable, can assist with designing and delivering equitable patient services with a more local flavour. To find the local iwi and hapu (manu whenua) in your area, refer to the resources below.

Some things to consider when thinking about collaborating with Māori: 

• Take the time to formulate a collective vision.
• Agree on measures of success
• Clearly define roles and responsibilities
• Recognise your role within the system and choose to be solution-focused and strengths-based
• Revisit vision, roles, measures and the ‘why’ regularly. 

Using data to ensure equitable outcomes
Practices should use data to understand the specific needs of Māori in their practice populations. Practices should conduct regular audits of their ethnicity data to uncover any inequitable access, delivery, and outcomes in any existing and proposed services.  Inequitable audit findings: an example

A practice conducts an ethnicity audit on their referral rates for the last six months to see if all patients were referred in the same way. The audit reports inequitable referral rates. The practice team discusses the audit findings and decides to make necessary changes. They plan to monitor the data and conduct the ethnicity audit again in three months to see if any progress has been made to reduce the reported inequity. To fulfil this criterion, the team submits meeting minutes or notes from the discussion, the planned changes and the schedule for monitoring the data. 

Māori Health 
While Māori health is a practice-wide responsibility, it is important to designate one or more people to drive Māori health initiatives, and consistently provide a Māori health perspective. Leadership is essential to closing health equity gaps. A practice should ensure an equity champion is supported to be knowledgeable on the subject, can advocate for Māori health and contributes to the decision making processes within the practice. 

Rongoā Māori/traditional Māori methods of healing
The Ministry of Health has, in collaboration with representatives from the rongoā sector, developed a voluntary standard that provides clear requirements for providers. This standard defines a benchmark of excellence to deliver safe and quality rongoā services. The standard encourages and supports consistency of quality rongoā care and the ongoing development of the rongoā workforce. 

Gap analysis 

A gap analysis is a process that compares actual performance and/or results with expectations of performance and/or results. A gaps analysis is a way to identify missing or weak skills, capabilities, processes, practices, technologies, etc. The comparison between actual and desired performance/results highlights what elements need to be added or worked on within the practice. 

To conduct a gaps analysis:

1. Identify the area needed to be analysed (for example, recruiting a workforce who supports Māori patients)
   
2. Identify the current state of the organisation in this area (for example, does the practice have a strategic plan for recruiting a workforce to support Māori patients?)
3. Identify the ideal (for example, the practice has a GP fluent in te reo Māori
   
4. Compare the current state with the ideal to identify gaps (for example, the practice currently has one nurse who knows some te reo Māori)
5. Analyse the gap (for example, why does the practice only have one person who knows te reo Māori? Will having access to a language interpreter improve patient outcomes, or is there another, better way of using the current resources? What have patients said regarding lack of language interpreters in the current team?) 
6. Plan to address and fix gap (for example, support current team members to learn te reo Māori, start recruitment drive seeking candidates with language skills)
   1. Consider timelines, cost, priorities.

3.2 Te Tiriti o Waitangi

Training

There are a wide range of practices in Aotearoa, New Zealand, all differing in size, location and demographics. The College recognises that practices require different levels of Te Tiriti o Waitangi training and continuous professional development (CPD). The nature of the practice will determine the type of training or CPD the team requires. For example, general practices with high Māori patient and practice team demographics should demonstrate how they apply Te Tiriti o Waitangi principles in their practice. This may be captured in meeting notes and can be used as evidence. 

Another practice may need to learn the basics of Te Tiriti o Waitangi before putting the principles in action, in this case, team members should undergo specific Te Tiriti training which may be done in-house or through a training provider. 

Sometimes a mixed approach may suit the practice, for example, most of the team are demonstrating momentum in applying Te Tiriti o Waitangi principles while a few team members may require training in order to get them up to speed. In this situation the evidence presented may be a mixture of formal or in-house Te Tiriti o Waitangi training, alongside other documented evidence. 

Te Tiriti o Waitangi 
The College acknowledges Te Tiriti o Waitangi / the Treaty of Waitangi (Te Tiriti) as a founding document of our nation, and the rights and obligations that it contains. We recognise Māori as Tangata Whenua under Te Tiriti and that they are guaranteed certain rights in their relationship with the Crown under Article Two. We recognise non-Māori as Tangata Tiriti under Te Tiriti, who together with Māori as Tangata Whenua, are guaranteed equity rights under Article Three. 

Both Tangata Whenua and Tangata Tiriti share a joint citizenship under Te Tiriti, and under other elements of the constitutional framework for Aotearoa New Zealand. 
The College recognises and accepts the impacts of colonisation on Māori, and the impacts of systemic, institutional, interpersonal, and internalised discrimination on Māori and on other groups in the population.

HAUORA – the Report on Stage One of the Health Services and Outcomes Kaupapa Inquiry by the Waitangi Tribunal, published in September 2019, recommends that a re-defined set of principles of Te Tiriti o Waitangi be applied to the primary health care system. The Ministry of Health has utilised these principles in the recent re-development of its Māori Health Action Plan, Whakamaua, noting that they are applicable to the wider health and disability system and not just to primary care.

The College recognises these principles as articulated in HAUORA and Whakamaua and applies them to its work in all areas:

• Tino rangatiratanga: Providing for Māori self-determination and mana motuhake in the design, delivery and monitoring of health and disability services.
  
• Partnership: Working in partnership with Māori in the governance, design, delivery and monitoring of health and disability services – Māori must be co-designers, with the Crown, of the primary health system for Māori.
• Equity: Being committed to achieving equitable health outcomes for Māori.
• Active protection: Acting to the fullest extent practicable to achieve equitable health outcomes for Māori. This includes ensuring that the Crown, its agents, and its Treaty partner under Te Tiriti are well informed on the extent, and nature, of both Māori health outcomes and efforts to achieve Māori health equity.
• Options: Providing for and properly resourcing Kaupapa Māori health and disability services. Furthermore, the Crown is obliged to ensure that all health and disability services are provided in a culturally appropriate way that recognises and supports the expression of Hauora Māori models of care.

The College realises that understanding Te Tiriti is an evolving process, and that relevant work will from time to time need to be revised, based on these evolutions. 

Health equity in the context of our history
Understanding our history can help inform our future. The impacts of colonisation upon Māori are well documented, and include systemic, institutional, interpersonal, and internalised discrimination towards Māori and on other groups in the population. 

Some resources that will help practices to better understand the development of responses to this over time include:

He Ara Hauora Māori: A Pathway to Māori Health Equity from the MCNZ gives practices a clear outline of the rights-based and needs-based arguments for prioritising health for Māori.

As part of The Health Services and Outcomes Kaupapa Inquiry, the Waitangi Tribunal is conducting an ongoing inquiry into the ways the Crown has responded to health inequities experienced by Māori. The Stage One report examines how, despite the promise of the reforms, the Crown has failed to properly fund the primary health care sector to pursue equitable health outcomes for Māori, by failing to target funding where it is needed most and failing to ensure money earmarked for Māori health issues is used for that purpose. 

Many of the effects of colonisation on hauora, health, and wellbeing are detailed in an associated data report WAI 2575 Māori Health Trends Report (2019). 

The Ministry of Health website also carries  useful data for better understanding the long-term effects of colonisation on Māori health. 

The government’s Māori Health Action Plan 2020-2025, Whakamaua, sets the government’s direction for Māori health advancement over the next five years.

This is a sample of the information that practices can access to better understand the frameworks that the health sector is now working in. The College encourages practices to become familiar with key health issues relevant to each practice’s population groups, including Māori.

3.3 Te reo 

Pronunciation of te reo Māori is important because mispronunciation can change the meaning of a name or word. It's also a sign of respect; pronouncing a person’s name incorrectly can give the impression that you don't really care about them, or you value them less than others. A person’s name is an extension of who they are and is rooted in their language, culture, and identity so by pronouncing a name correctly, it affirms that person and may add to his or her self-worth. 

The Journal of Primary Health Care published a study on the value of te reo in primary care as a determinant of healthcare. The three main findings were:

• The participants reported that name mispronunciation led them to feel belittled or unwelcome in the clinic and discouraged them from attending again.
  
• The use of te reo helped form positive relationships with their general practice.
• Participants felt strongly that future health care for Māori should encompass the use of te reo.

Incorporating te reo into general practice

“A really easy thing that anyone can do to create an environment inclusive of te ao Māori is to learn proper pronunciation of Māori words, particularly names. A basic proficiency in te reo Māori is a good place to start – a love and respect for the language can lead people to act more courageously in medical practice," – Professor David Tipene-Leach 

Some ideas to consider: 

• Proper pronunciation – a person skilled in Te Reo assists the team with knowledge of correct pronunciation.
• Use Te Reo to label doors of rooms
• Have a word/sentence of the week
• Use Māori greetings
  
• Have a karakia to open and close meetings
• Encourage and assist team members to learn their pepeha