The first time tackling Māori inequity using a holistic framework

Clinical inertia is a pathological condition akin to the learned helplessness theory of psychologist and educator Martin Seligman.¹ It occurs when repeated failure to make a difference leads to a lack of hope that any advice, support or intervention will really help, and an acceptance of the clinical situation.

Most practitioners recognise that clinical inertia has impacted our ability to help people who are overweight, have poorly controlled diabetes or are determined smokers. When faced with such a difficult situation, causes we attribute that are “internal”, “stable” and “global” are more likely to lead to “learned helplessness” and create the conditions for clinical inertia.

The practitioner may believe:

• they (or the person) lack the capacity to make the necessary changes (internal cause)
• the conditions creating the incapacity are not going to change whatever we do (stable cause)
• this incapacity to make a difference is universal (global cause) – the person who reponds to our help is a very rare diamond.

The seven-year life-expectancy gap between Māori and non-Māori, the 30 per cent disparity in Māori and non-Māori lung cancer survival rates and the higher rates of cardiovascular, renal, diabetic – and almost every other – chronic and acute condition you can name, for Māori, present a really difficult situation.

Over many years, our inability to make a difference, as a system – with all the complex causes for this² – is repeatedly given internal, stable and global attributes. We try our best, but nothing changes. Rightly, this has led to the current significant health reform and an effort to “break the mould” with the development of Te Aka Whai Ora (the new Māori Health Authority).³

However, system change alone cannot be relied upon to really make a difference, and now is not the time to succumb to clinical inertia. If we take a moment to consider, we can do something; effort is rewarded, and starting small and building on successes is fine.

Within the Foundation Standard, the baseline for every general practice in Aotearoa New Zealand, are the requirements for an annually reviewed Māori health plan, Te Tiriti o Waitangi training and the application of te reo Māori. These are all important initiatives that should help make practices more welcoming – places where people do not feel they must leave their culture on the step outside.

The Whānau Ora Outcomes Framework, published in 2016 by Te Puni Kōkiri, arose out of extensive consultation with communities in 2009 by the Taskforce on Whānau-Centred Initiatives, led by Dame Tariana Turia. The framework provides one way to understand what really matters to Māori communities.⁴

The framework lays out the domains that underpin the concept of health for Māori and, arguably, for all people. It proposes that whānau ora (roughly translated as healthy families or communities) will be achieved when whānau are:

• self-managing and empowered
• living healthy lifestyles
• participating fully in society
• confidently participating in te ao Māori
• economically secure and successfully involved in wealth creation
• cohesive, resilient and nurturing
• responsible stewards of both their natural and living environments.

You are probably already doing a great deal towards facilitating whānau ora, and much of what follows should feel familiar – I hope so.

We can help whānau be self-managing and empowered through:

• patient-centred consultations
• shared decision-making
• goal setting for spiritual, emotional, mental and physical health in consultations (te whare tapa whā)⁵
• proactively planning for health emergencies
• using patient portals to provide access to notes/results
• making appropriate referrals to iwi/hauora providers.

We can help whānau achieve full and healthy lifestyles through:

• health plans that encourage self-management (eg, in eczema, diabetes, respiratory and cardiovascular disease)
• proactive care (eg, assessing cardiovascular risk)
• lifestyle support (eg, dietitian involvement and exercise management)
• smoking cessation services – ensuring they are utilised
• focused action in the areas of cervical, breast and bowel cancer screening; human papillomavirus vaccine uptake; cardiovascular risk; chronic kidney disease; diabetes; and rheumatic fever
• monitoring and continually improving clinical outcomes.

We can help ensure whānau are fully participating in society by:

• aiming for our patient population ethnicity to reflect the local community
• aiming for our patient population socioeconomic profile to reflect the local community
• ensuring te reo Māori health information is available in our practice
• ensuring all staff are trained in, and utilise, culturally safe practices
• ensuring patient participation groups actively involve whānau
• ensuring patient satisfaction surveys actively involve whānau.

We can help support whānau to confidently engage in te ao Māori by:

• having te reo Māori in everyday use in our practice
• using the hui process in consultations⁶
• having Māori iconography visible in our practice
• collecting iwi affiliations in the practice management system (enabling links with hauora providers)
• developing strong iwi/hauora relationships
• having a practice kaumātua actively involved in the team
• having the practice team involved in community events.

We can support whānau to be economically secure and involved in wealth creation by:

• ensuring patients return to work after an accident or illness at the expected time
• increasing the Māori workforce within our practice
• involving our practice in training the future Māori health workforce
• sensitively working to provide the lowest-cost access to services and reducing barriers to care for whānau.

We can support whānau to be cohesive, resilient and nurturing by:

• offering parenting support proactively, with appropriate referrals where needed
• offering relationship counselling services where needed
• identifying and addressing bullying, violence in the home, substance abuse and risk of self-harm
• partnering with patients and whānau to reduce impact of health problems on the educational wellbeing of tamariki.

We can support whānau to be responsible stewards of the environment by:

• being this ourselves, and role modelling through our teams
• adopting “green” approaches to utilities – reuse and recycle
• supporting community environmental activities (eg, community gardens)
• using Green Prescriptions
• using the healthy homes programmes.

Celebrate what you do. You are awesome and – even in the face of persistent poor outcomes – you are doing a great job; but now is not the time for clinical inertia.

Reflect as a team on The Whānau Ora Outcomes Framework: are there gaps? Give yourselves a score out of 10 for each action. Identify where there could be improvements and make a plan (earn some MOPS points along the way).

Note: The response to the framework described here was developed with Pinnacle GP leaders, including Māori health advisors, and in consultation with Māori providers.

Jo Scott-Jones is medical director for Pinnacle Midlands Health Network, has a general practice in Ōpōtiki and works as a specialist GP across the Midlands region