Competency not enough to keep patients safe

Cultural safety can be an empowering approach for all of us

Māori health academic David Tipene-Leach is keen to counter any hesitancy GPs might feel as they consider embracing cultural safety in their practices.

GPs are in control of change and can do it well, and in a way that will address health inequities, says Professor Tipene-Leach (Ngāti Kere, Ngāti Manuhiri).

The Medical Council, working with Te Ohu Rata O Aotearoa – Māori Medical Practitioners Association, wants GPs to work in a way that is culturally safe for their patients.

Addressing the conference, Professor Tipene-Leach said: “If you came along today for an earbashing around how to do this thing, you are in for a disappointment.

“Because today I want to present a way that we can do things – about how cultural safety can be an empowering approach for all of us to be able to try and address the equity questions that are in front of us.

“Because cultural safety has arrived – there is no doubt about it.”

David Tipene-Leach is chair of Te ORA and professor of Māori and indigenous research at EIT in Hawke’s Bay. A former GP in that region, he gave up clinical practice three years ago and says academia has given him time to reflect.

Cultural safety is not difficult to do: most of the elements are in the control of practitioners, he says. It is being introduced under a high-trust model.

Council chair Curtis Walker has told him the council cannot enforce cultural safety but it’s trusting practitioners to go down this pathway and into the pro-equity area.

Attempts to introduce cultural safety to the nursing workforce in the 1990s were met with a big pushback, he says. “I am confident that is not going to happen to us.”

The Medical Council released its “Statement on cultural safety” in October 2019, in which culture covers indigenous status, age or generation, gender, sexual orientation, socioeconomic status, ethnicity, religious or spiritual belief and disability. An associated resource, “He Ara Hauora Māori: A pathway to Māori health equity”, provided a how-to.

“Inequity is not something we in the Māori community became used to since the introduction of the neoliberal economic change,” Professor Tipene-Leach says. “It is something that we in our community have been aware of for a long period of time.”

The evidence shows GPs give Māori patients less time, do fewer investigations for them, make a diagnosis less often, give less treatment, give fewer prescriptions and make fewer referrals, he says. “And, when our people (Māori) get to the end of their referral, they get fewer interventions.”

Consequently, and again general practice research backs this up, GPs think Māori patients are sickly and non-compliant, and make poor lifestyle choices. It should not be surprising patients feel dissatisfied, untrusting and untrusted, don’t stick to their treatment and are less likely to get followed up.

“Health inequities are for real. According to research, we give poor services, we have dissatisfied patients, they get poorer outcomes and, for heaven’s sake, we blame them, we think it is their fault.”

The causes of inequity are historical trauma, social determinants of health, institutional racism and cultural incompetence, the latter being lack of competence to deal with the Māori person and their whānau.

Professor Tipene-Leach says the process of colonisation is essentially getting hold of other people’s resources and then shifting those people to another place.

In New Zealand, the new place was urban centres, where Māori were under-resourced and undereducated, living in poverty and deprivation, and exposed to events typical of deprived communities – violence and crime, addiction, abuse, incarceration and the uplifting of babies.

“In other words, we put them away and they will slowly self-destruct, and we can get on with doing our thing. And that is kind of what historical trauma is about.”

But: “Let’s get it straight, this is not about saying that you (the audience) are to blame...[You] can see the depression, the self-destructive behaviour, the anxiety, the low self-esteem of the people we are talking about arriving at your surgery, and the only thing you are being asked to do today is to acknowledge historical trauma in everything you do in the clinic.”

Institutional racism occurs when the prejudices and assumptions of individuals find their way into the rules and culture of institutions, so they produce outcomes that systemically put disadvantaged groups at further disadvantage.

Professor Tipene-Leach suggests thinking about some of the fundamentals of general practice: “Like, I expect you to come to me, I expect that you will be here at 9.15am, if you are late, you are out.”

How, he asks, does this work for people with two jobs, four kids, struggling to get food on the table? “Is it not just a way of denying access?”

DHBs decline to provide a renal transplant to anyone with a BMI over 35 but, says Professor Tipene-Leach, there is not a “skerrick” of evidence to support the 35 cut-off. Arguably, it’s designed “to keep brown people out and skinny white people in”.

“This is institutional racism and we need to be constantly alert to calling it out.”

In the 1970s, before cultural competency, there was cultural sensitivity, which Professor Tipene-Leach taught at the time.

Essentially, this covered being aware of ways of greeting, seating, eating, and treating the other person – the skills of any good Kiwi, he says.

Cultural competency is about the attitudes and skills health professionals need if they are to function effectively when providing care to somebody of a different culture.

The health professional is directly responsible for this competency. And it remains important: “This is not about cultural competence going out the door and cultural safety walking in.”

Cultural safety goes further than competency, however. It was born out of research by Irihapeti Ramsden, a nursing and midwifery educator from the 1980s through the 2000s.

Dr Ramsden called on health professionals to engage in self-reflection and to look at the power relationship that pervades a consultation.

As Professor Tipene-Leach puts it, she told professionals “to take your biases, your assumptions, your stereotypes and your prejudices and look and see what they do to you and, in doing something to you, what they do to the patient, client, whānau who are in [your] rooms”.

“She wanted us to think through what are the patient’s rights in a consultation and what are their rights to get treatment, and she predicated her approach to cultural safety on the basis of getting best outcomes for Māori.”

As Dr Ramsden saw it, cultural safety is saying, “actually you have got to account for these outcomes”. The Medical Council doesn’t go quite this far.

But Professor Tipene-Leach says it’s necessary to look at outcomes at a PHO, clinic and individual level and to systematically monitor them by ethnicity.

Acknowledging historical trauma is not difficult to do, says Professor Tipene-Leach. Read a decent history book with an open mind and apply some of that to the people who walk through the door.

While GPs do pretty well on social determinants, “we are probably not that good at rooting out racism” and that is a challenge everyone needs to work on. Professor Tipene-Leach says colleagues under the age of 30 are pretty good at it.

Cultural safety means acknowledging, being an advocate, being bold and being competent.

It is a set of behaviours pertinent to people across cultures.

General practices can create a culturally safe environment and culturally safe practice, and they can ensure cultural safety is defined by the client, Professor Tipene-Leach says.

“This is actually not too difficult to do. We just have to get off our high horse, so to speak…

“It could well be the bedrock of us being able to do equitable Māori health outcomes and it could be a regime that is not arm-twisting because, frankly, I think we have all had enough of that.”

But the colleges and the council will be in the background, pushing it along, he says

Cultural safety is underdeveloped, in that it is not enshrined in government policy nor in the policy of health authorities. “It does not have a political champion,” he says.

“I am expecting that you and I, in our everyday practice, will take this thing on board, or grapple with it, and be champions for cultural safety.”

An audience member asked about getting patient feedback. Professor Tipene-Leach said asking for feedback was the first step.

If you are in a consult that “is not your everyday cup of tea”, ask the patient what could have made the consultation better for them.

And seek wider feedback. “If the people who are making the decisions about how we run our clinics are all privileged white people over the age of 55, then you will get a system for them.”

On the pending health system reforms, he says cultural safety could be a major part of doing things differently in the years ahead.

“People: this is our opportunity not to be pushed into something, to be able to tackle something that possibly we have not looked at very hard because we have not figured out how the hell are we going to do this thing.”

He calls on GPs to think: “I can chew on this thing, I can take my own time, I can get it done, I’m going to have the college behind me to make sure this is done.”

It was six years ago that the Te Ohu Rata – Māori Medical Practitioners Association board was “poking” the Medical Council on cultural safety, and the council took it up, says Te ORA chair David Tipene-Leach.

There followed symposia and hui and the creation of the council’s “Statement on cultural safety” in October 2019 and, soon after, the resource “He Ara Hauora Māori: A pathway to Māori health equity”.

The statement reviewed cultural competence and defined cultural safety, linking it to equitable outcomes for Māori, and recommending the profession take on cultural safety.

Cultural competence is not up to the mark: “It didn’t do the job,” Professor Tipene-Leach says.

Te ORA and the council have pulled together baseline data so they can look over the years and see what has changed (Baseline Data Capture: Cultural Safety, Partnership and Health Equity Initiatives, October 2020).

The medical colleges are also involved through the Council of Medical Colleges. A recent report reveals a wide range of progress on cultural safety in colleges’ vocational training programmes (Cultural safety within vocational medical training, May 2021).