The pitfalls and promise of transparency in health care

A kaupapa Māori perspective on transparency

Dr Matire HarwoodAssoc Professor University of Auckland/GP Papakura Marae

HQSC Open Forum 10 March 2020

Wellington

Overview

Te Pō - Context

Right to:• Equitable health outcomes (via

Crown-funded services)

• Decision making (process)

= Excellence

Systematic inequalities

• In health outcomes • In exposure to the determinants of health including racism

• In health system responsivenessAssoc Prof Bridget Robson, Eru Pomare

Te Whei Ao - Tensions

•Equity

•Data sovereignty

•Racism and privilege

Data Sovereignty

• Data is a living tāonga and is of strategic value to Māori.

• Māori data refers to data produced by Māori or that is about Māori and the environments we have relationships with.

• Māori data is subject to the rights articulated in the Treaty of Waitangi and the UN’s Declaration on the rights of Indigenous Peoples, to which Aotearoa New Zealand is a signatory.

Please don’t use data to ‘victim-blame’

Te Ao Marama -Enlightenment

When transparency ‘worked’• Counties Manukau DHB serves a unique

population of 245,350 people

• Majority are Māori, Pacific people and people living in areas of deprivation

• In 2012, 62,000 of people living in CM were smoking tobacco

• One third were Māori; one third Pacifica

Stink!

• For Smoking B+C in primary care, CMDHB ranked 20th of 20 DHBs

• CMDHB Board and Leadership endorsed a ‘SmokefreeStrategy’

• Clinical Champions appointed

What we did1. Collective responsibility (with $$ attached)

2. Call Centre

3. Quality Improvement Hui to share data (some more open than others!)

Brief Advice and Cessation Support in Primary Care

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ABCDE

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Mortality 1996-99

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CABG Angioplasty

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Ajwani et al 2003 Tukuitonga & Bindman 2002

Mortality rates males 1996-1999

Procedure rates males 1990-1999

We treat everyone the same except…

• When they smoke, are obese, have diabetes

• When they live too far from cardiac centres

• When they refuse

• When we think it won’t make a difference

Angiography and PCI Maori and non-Maori (2000-4)

CABG Risk of dying with underlying cause of IHD

How to achieve equity• Buy in from Cardiologists – excellent data, ‘their own’

• System issue

• Quality Improvement Programme – ethnicity, deprivation, DHB, discrimination are components

• Monitor through regular audits

“Well I’ll refer to certain doctors. After a while you sort of start to learn the doctors who will follow through on

your referrals and the ones who seem to decide that further

investigation isn’t required. I’m not saying that it doesn’t just happen

for Māori with those doctors. I mean it may be that they are the

same with Pakeha patients, but that certainly hasn’t been my experience.

And so I address my referral letters to certain doctors now.”

- GP J FG2

Koru - Hope….

Shift the gaze from ‘process’ to ‘outcome’

Build and disseminate evidence

Equity lens Call others up on their

actions…..and inactions

Key to change

• Indigenous leadership• Systematic monitoring & assessment of equity • Challenging institutional racism • Root causes• Equity-focused quality improvement • Partnerships with Māori

AP Bridget Robson and Dr Rhys Jones

Haka – the challenge

• Be a Player• Be the Coach• Be the Manager• Be the Ref• Be a Fan

• REFLECT ON YOUR ROLE

Mā te rongo, ka mōhio

Mā te mōhio, ka mārama

Mā te mārama, ka mātau

Mā te mātau, ka ora