Our DHB recently released a report on Health Equity in Hawke’s Bay, or the lack of it. The cover depicts the crowd at a Magpies game. There’s a lot of laughing, clapping, some drinking, a fist pump, a few kids. The strapline says “We have all got a role to play.”
Of the one hundred people in the photo there’s about five brown faces. They look impassive, drawn, waiting to see what will happen next.
It’s a fitting picture. In Hawke’s Bay your health is determined by where you live, how much you earn and what colour you are. Maori are six times more likely to die of lung cancer than non-Maori. Nearly half of all pregnant Maori women smoke. One in every two Maori adults is obese. The rates of hazardous drinking in Maori are twice that of non-Maori. Maori die eight years earlier than non-Maori. One quarter of Maori and Pasifika die before they turn 50.
It’s not a stretch to call these ‘third world’ health statistics.
But before white folks tune out, the prognosis is not great for them either. Hawke’s Bay in general is fat, lazy, intoxicated and has far too many bad habits. Compared to NZ averages we have more people dying younger, more mental health issues, more smokers, more drinkers, more teen pregnancies and fewer people who are physically active. We should eat three servings of vegetables a day; we eat two (same as the rest of NZ).
Health Equity is a valuable, much-needed statement of the problem. However, it is far from a blueprint of solutions.
Focus on family
The DHB is now convening an interagency working party to come up with a plan. To turn these figures around there must be serious conversations across our councils, police, Health Hawke’s Bay (who look after GPs), education providers, social agencies, business and employees, iwi and the communities themselves.
George Reedy is one year into his role as chief executive of Te Taiwhenua O Heretaunga (TTOH), who facilitate wellbeing and social programmes for Ngati Kahungunu. He sees three things as integral ‘fixes’ to the health picture.
“Income is number one,” says Reedy. “Everyone deserves to have the opportunity to develop abilities to get an income.”
“Number two is we need education for our youth, and that has to be a focus from the community. We need to support them to support themselves. Three, we need a whanau-focused approach to services.”
One such approach is Whanau Ora, which wraps a number of services around the needs of the whole family rather than particular individuals. It also works with whanau and with hapu (wider family groups) to develop plans based on a family’s aspirations rather than its ills.
Whanau Ora contracts have been around now for four years. Many of the contracts come up for renewal every three years with no guarantees the relationship between the Ministry of Health, the service provider and the client will continue. This is despite the fact that many families need ongoing support on a variety of levels for far longer than the three-year contract period allows.
Te Kupenga Hauora Ahuriri holds a number of Whanau Ora contracts. It is a registered charitable trust based in Napier providing health and social services across Hawke’s Bay.
“Whanau Ora is not a new concept,” explains Audrey Robin, CEO of TKH. “In many cultures it is just the way they raise their families.”
“But we have taken the value out of the concept because of the way the government delivers services, their silo approach.”
One of the major disadvantages of the contract model TKH works with is it is very prescribed and specific.
“Rather than the DHB saying, ‘These are the results we want to see, we want them in a year, and here’s some resources to do it’, they say ‘Do it like this’, and they do it in bits and pieces,” Robin explains.
Robin would like to see the DHB working closer with communities to find out what their aspirations are before rolling out health promotions.
“But I don’t think it’ll happen. I think they’ll come up with something themselves.”
Rob Ewers is a nurse and the service manager at Central Health in Waipukurau. His staff work across Central Hawke’s Bay and have hands-on experience of how a whanau/community-owned solution can have real pay back. (One of the communities he works in is Porangahau, whose story is highlighted as an adjunct to this article.)
Ewers explains he is sceptical of health campaigns that fail to take into account the needs and aspirations of the people themselves.
“As health promoters and providers we’ve always got a good idea. But if people have not actually asked for it then they won’t be interested and it won’t work,” he says.
“We have to find the things that ring their bells and work with that. But it is far quicker and more comfortable to sit around with work mates and come up with ideas you all think are great. It is more messy, difficult and time consuming to go out into the community and find out what is really needed from the people themselves.”
Rob Ewers describes Central Health as designed for Maori but open to all ethnicities. He says there is mistrust of a western health model in many communities he works with.
“There are trust issues; you tell them they need it, they don’t believe you. They don’t feel it works for them. They say ‘I don’t want to come to your surgery, I don’t want to do it like that, so I won’t bother.’ We need to find out how they do want to do it,” he says.
The problem with ‘solutions’
George Reedy, CEO of TTOH, would like to see buy-in from as many parts of the community as possible, and knows turning things around will take many agencies working in unison. “This report should be a wake-up call for Hawke’s Bay. It’s such a complex issue, so complex that attempts to address it have failed. There’s no particular one point you can look at and begin to fix,” he says.
Patrick Le Geyt is General Manager of Health at TTOH, which has an onsite general practice clinic.
“The difficulty the health service has in applying a whanau-oriented service is they are accountable to the Ministry of Health, who have packaged a whole range of indicators into different services rather than integrating them. It’s tied to the financial model.”
“There needs to be a translation system that works for family,” Le Geyt explains. “We need to translate the way government does things into a format that works for people and their families, into a delivery method whanau will respond to.”
Le Geyt also knows it is the protective factors that should be the focus alongside the risk factors.
“Our patriarchs, our matriarchs. Good diet. Parenting. Education. Good healthy relationships. If New Zealand doesn’t start bringing back the sense of community to our neighbourhoods then we’re in real trouble.”
Ownership from across the community is a call put out by the DHB too.
“It’s only an insurmountable problem if it’s left to one or two people or one or two organisations to fix,” says Dr Kevin Snee, chief executive officer of the HBDHB. “There’s quite a lot of good community leadership in Hawke’s Bay; it just needs to be harnessed to a common purpose. And it’s that common purpose we lack.”
“We need to move away from being very parochial and just focusing on one bit of our community,” agrees Kevin Snee. “We need to start thinking what can we do as a community of Hawke’s Bay, as a region … because it’s a problem that goes from one end of Hawke’s Bay to the other.”
Dr Caroline McElnay is the DHB’s director of population health and the author of the Health Equity report. She knows that the solutions are complex and that many of the factors of inequity are outside the health board’s remit.
“There’s a whole lot of factors that influence health and we tend to assume that a health issue is automatically for the health board to fix,” she explains. “Essentially we are a treatment facility, but once you start looking at prevention you have to look at all those other factors that influence health. That’s where you start looking at education, employment, the social connectedness of the communities. Everyone’s got a role to play, it’s not just one organisation, or one agency.”
George Reedy is vocal in linking poor health outcomes for Maori to housing and jobs. He also blames a Euro-centric model of treatment.
“The big issue is we’re looking at health in isolation rather than looking at the whole needs of individuals and whanau,” he says. “We’ve put a bandaid on what is out there. It’s a western medical model. It works while you’re in the care of the hospital, but once people leave they fall back into unhealthy lifestyles.”
Caroline McElnay sees virtue too in a whole of whanau approach.
“Looking at the needs of families and then trying to meet those needs on their terms is vital,” says McElnay.
In many cases one whanau has a number of interwoven issues that are being overseen by a multitude of service providers.
“Often it is the same 10% we are addressing the needs of, but we are addressing them as separate organisations. If we put all our information together it’s the same families that we’re seeing, the police, MSD.”
McElnay wonders: “If we’re working in a cross-agency way, then we’ll be thinking, ‘How can we work with other agencies to address that need?’ rather than, ‘What is my institutional response?’”
One of the issues that has fallen out of institutional response is MoH contracts. These are let and managed in short bursts with no guarantee of renewal, and they are let for specific services rather than in support of an holistic approach. This means that an on-the-ground health worker may visit a client for one specific reason and although they may then recognise a range of issues in the home it is not within their remit, ability or resource to help. (In many cases they do anyway because, more than anyone, they are acutely aware of the situation and the ramifications if no support is available.) This also means that some clients can be visited by a number of agencies in a single week, sometimes up to thirty agencies could be involved with one family.
TKH is one of a few on-the-ground services that have established strong relationships with the families they work so closely with.
“We have the ability to get into houses because of the trust and rapport we have built up together,” explains Chief Executive Audrey Robins.
“The children are the cause of our greatest concern but it is the whole family we help. We find ways to provide the additional support a family may require so children can grow in a safe and nurturing environment.”
The DHB do meet with TKH regularly but it’s not often with additional support and resource.
“They come and tell us they won’t be renewing our contracts, that they’ll be delivering the services themselves, then they take our staff. Staff we have trained, and worked with for years.”
“The DHB culture is changing though. They are moving away from counting widgets, away from outputs and towards outcomes. But they do need to be brave enough to invest in change,” says Robin.
As much as the Health Equity report is a watch-dog document, it is also a kick-starter and a call to action.
Kevin Snee explains: “When you put it all on the table, even some people who are quite senior are surprised about the level and the extremes and the scale of the problem that we need to tackle. This report is about raising consciousness that there is a problem that needs to be solved.”
Bringing people together to begin solving those problems is also part of the DHB’s role.
“We’ve been instrumental in pulling together local agencies, local territorial authorities, the police, TPK, MSD, Business HB, just to look at what are the things we need to do as a group to help improve the lot of local communities,” Snee says.
From talk to action
Shifting the focus from ‘all talk’ to ‘more do’ should happen in 2015. But it remains to be seen whether an ambitious, punchy, actionable plan – commensurate to the problem – will emerge.
George Reedy believes much of the solution lies with Maori themselves. “Sometimes we don’t need you to solve things for us. Sometimes we just need you to get out of our sunlight and let us solve it ourselves.”
TTOH GM of Health Patrick Le Geyt agrees: “I do have faith in the DHB,” says Le Geyt who sits on the DHB’s Maori relationship board. “We can’t sit back and throw stones and blame everyone else, we have to roll up our sleeves and find a way to contribute.”
“Our approach has to be focused on prevention and early intervention over treatment. There is also a need for people to become literate and responsible for their own health. We need to ensure messages are being delivered in a way people understand and feel comfortable with.”
Grand vision needs to be replaced by practical tactics.
George Reedy: “You can have the policies but it needs to meet the ground. We need to be talking to people out in the field. Whanau have told us they hate bureaucracy, but at least we come with the right approach.”
Kevin Snee promises plan attack in 2015.
He too recognises that the way forward cannot be paved with good intentions.
“You can all get together and have a nice conversation and feel good about how we all think it’s a terrible problem and we need to do something, then go away with a warm glow. But (a solution) takes commitment and hard action and hard work, and that’s a challenge for other agencies and the broader community,” he says.”We need to be clear about the actions we need to take, that they are well managed and well monitored.”
Accountability is something Snee is acutely aware of: “How are we going to stand up in front of the community and say, ‘This is what we said we’d deliver and we have’, in one year, two years, three years time?”
A multiagency meeting took place in mid December and a preliminary way-forward will be decided in the first half of 2015.
Dr McElnay says although the DHB will lead the march, actions need to be owned and rolled out by as many agencies as possible and also by members of the business and philanthropic communities.
“It will be a plan to start and it’ll evolve as we go along,” she says. “We’ll make our full contribution, but we can’t do it all by ourselves.”
Patrick Le Geyt knows there is a lot of work ahead of Hawke’s Bay to turn health equity statistics around but he is optimistic changes can happen.
“We need a cohesive community working in unison and involving people. It’s no good dreaming up ideas, we need to ask the community. We have to engage opinion leaders and go neighbourhood by neighbourhood”
He congratulates the DHB for publishing the report.
“But a report is just a report, it’s the action that happens next where the magic really lies,” he says.
Note: Local film maker Kathleen Mantel has made a terrific documentary on Whanau Ora in Hawke’s Bay. It screened on Maori Television in late October 2014 and can be viewed online at http://bit.ly/1vDuA3g.
Top causes of preventable premature death in Hawke’s Bay: ischaemic heart disease (reduced blood supply to the heart), diabetes, lung cancer, road traffic injuries, suicide, breast and bowel cancer.
- 46% of Maori pregnant women smoke compared to 11% of non-Maori.
- Maori are six times more likely to die of lung cancer.
- One in four adults in HB is a hazardous drinker – Maori rates are twice that of non-Maori.
- 24% of Hawke’s Bay adults are hazardous drinkers. The NZ average is 15%.
- 58.9% of Maori men are hazardous drinkers compared to 26.3% of non-Maori; 33.7% of Maori women are hazardous drinkers compared to 11.1% of non-Maori women.
- One in three adults is obese.
- One in two Maori adults and two in three Pasifika adults.
- 43% of Hawke’s Bay adults do 30 minutes of exercise a day compared to 53% across New Zealand.
- 77% of Maori die before the age of 75 (compared to 39% of all deaths).
- 25% of Maori die before the age of 50 (compared to 5% of all deaths).
- Rates of death from ischaemic heart disease are four times higher in Maori than non-Maori.
- Rates of death from lung cancer are six times higher in Maori than non-Maori.
- Rates of death from diabetes are four times higher in Maori than non-Maori.
- Teenage pregnancy rates are higher than the national average and three times higher in Maori than in non-Maori.
- 65% of Hawke’s Bay adults (84% of Maori) never visit a dental health worker or only visit for toothache.
- Avoidable hospital admissions for Maori are twice that of non-Maori.
- The rate of serious assaults resulting in injury in HB is twice the NZ average.
- 20% of adults in Hawke’s Bay have suffered from mental health issues compared to 16% across NZ.
At the southernmost point of Hawke’s Bay, on the edge of the ocean, sits the tiny settlement of Porangahau, a village of about 100 houses and 240 people.
The population is 58.3% Maori and 20% speak te reo (compared to 6.9% across Hawke’s Bay). 47% of adults have no formal qualification (31% across HB). The median income is $19,000 and 7% of adults are unemployed. There are about 50 kids and 27 over age 65s.
In the last three years huge changes have happened in Porangahau, thanks to a collaborative, whanau-focused, community-owned health programme. It ticks all the boxes and although it’s small there may be some lessons to learn for our bigger towns.
Central Health has led the initiatives, but three quarters of the Porangahau community are actively involved. The aims, set three years ago, were clear: reduce health inequalities, improve access to health services, and improve the overall health of the Porangahau population. Now, the community is seeing real changes in their own wellbeing, and the programmes initiated have been done in a self-sustaining way so the benefits are set to be realised for many years to come.
Central Health has been delivering services to Porangahau for many years, but with little traction. In 2011 they began making big changes to the way they do things. The emphasis became collaboration across disciplines. Services are now delivered in partnership with the community and built on the strengths of the people involved. Rather than focusing solely on treatment, Central Health looks at the holistic wellbeing of individuals and families from what they eat and how they exercise, to how their health is monitored. Central Health began with a series of hui asking Porangahau residents what they needed to improve their health.
“The critical component is identifying people in the community who are leaders, who have a vision for the community,” explains Central Health’s Rob Ewers. “At Porangahau Doug Hales, the principal of the school, was already very driven and had a vision for a school kitchen. All we needed to do was support, facilitate and find a little bit of money. Same with Kim Steffert at the community garden and Piri Galbraith with waka ama, without those kinds of people you can’t make it work.”
Porangahau identified six priority needs: a community garden, waka ama, a kaumatua group, a nurse-led clinic at the school, a community nurse clinic and a school kitchen. All six have come to fruition. There’s a waka ama group with all members also now engaged in other physical activities. The community garden is 235 square metres in the middle of town and accessed by over one hundred people. Education programmes are also run out of the space.
From 50 nurse consults in 2011/12 there are now over 200 a year. Cervical, cardiovascular and mammogram screening numbers have all improved.
The school kitchen has gone from offering a once weekly cooking class for older students to being used by every student for every school meal. Students can access the kitchen whenever they need it and often take leftovers home for tea.
The kaumatua group runs regular nurse clinics, tai chi and other activities.
When the project began in 2011 Central Health and the Porangahau Community couldn’t have dreamed of a more positive outcome. Rob Ewers explains, “Our initial response was one of ‘maybe we’ve bitten off more than we can chew’. But we’ve been able to establish and sustain a community-wide initiative that has had a major impact on everyone.”
Along the way Porangahau has been asked its views and what it needs to keep its people healthy. There have been vaccination clinics, women’s health days, installation of a basketball court, a youth sexual health clinic, mental health workshops and an alcohol and drug clinic.
Rob Ewers: “If we can work with whanau to help them set goals based on their own aspirations, then work together with them to achieve those, we are likely to see a much greater level of engagement and success.”
The conversation between provider and community continues, for the good of both. As a microcosm for the positives that can happen when policies and plans are translated into practical solutions, Porangahau is a real winner.