A call for genuine accountability: How do I explain health equity to the ACT Party and Mr Luxon?

I read half of an article on health policy by ACT’s Brooke van Velden and felt sort of dizzy with rage. It was a deceptively compelling appeal to the notion of health equality: that a fair system has equal access to all or, as prime minister-elect Christopher Luxon puts it, healthcare based on “need”.

What isn’t understood is that access to healthcare is only equal in theory and political slogans. In the “equal” world, many people fall behind. The grim truth is that the healthcare delivered is rarely based on need.

You must work in healthcare to understand this. You must work with the wealthiest and the poorest to feel the sting of inequity punch you in the face and make you squirm with shame.

You will not understand the problems with equality from the comfort of one of your seven houses or from a café in Epsom where the most disenfranchised thing is a ponytail on a waitress.

From behind your high fences, you will only understand your people who are also my people: white, entitled, demanding, always with the unspoken threat of a complaint in the offing if things are not done right in our way – the right white way.

White people get health services because we know how the world works. We know how to ask in a way that prompts action; we know how and when to intimidate and how and when to be gracious. We know when to pack a sad and how to get sympathy. We just know how.

In our communities, we can use the media to pressure politicians to get services. We have cousins who are lawyers, mates who run the banks and old school friends in high places, so our communities get what they “need”.

And we never go to those other communities, so we never meet people who own less than one house, let alone rent a house or live in a motel. Those people are the theoretical “other”. We never go there, unless we work there.

The grim truth is that the healthcare delivered is rarely based on need

And when we work there, we understand that funding is not based on need. We see a wealthy tourist town get a medically unnecessary birthing unit fully staffed 24/7 for the comfort of women who could afford a maternity hotel and not flinch.

And we know that where we work, pregnant women live in cars or, if they are lucky, a motel with no kitchen, just a toaster and microwave and a bathroom basin to wash their dishes in, never mind the breach of tika in that.

We understand that a wealthy Pākehā practice with 100 diabetes patients gets essentially the same income as a Māori-Pasifika practice of the same size with 500 diabetes patients. Funding does not follow need, Mr Luxon. It follows entitlement.

The whānau I work with have no sense of entitlement to anything. They will not demand or expect to be at the front of the queue. They will not complain about living in a car; they are grateful for the squashed leftover savouries from your election party rubbish bin. But these people redefine graciousness.

And if they have a health need, they come late Mr Luxon.

No, not at the first whiff of pain but later, much later, when they are crippled by medical requirement. Then they must wait the same time as your people because everyone has to wait equally the obligatory four months to see a specialist.

They might not get to that appointment because they don’t have a car or a stable address to send the appointment letter to or a phone to ring and reschedule. They might not even know that ringing and rescheduling is a thing. The stress on their whānau is so great, the intergenerational trauma so raw, that something other than their health need must take priority on the day of that appointment.

Or maybe they don’t get there because they can’t face another round of racism. When they enter that outpatient clinic, they are not like you and me; among our people, they are in a hostile world where brown faces are judged or, at worst, ignored.

At this point, Mr Luxon, you may be feeling magnanimous because you and your people have medical insurance or, like me, can afford to pay for a hip replacement because of the overinflated value of our boomer houses. You might even feel reassured knowing that the wealthy aren’t taking up space in the public health service, leaving more resources for others.

But think again, Mr Luxon, because when you get your hip replacement, which I estimate will be about three years before anyone in the public health system would get one, you will be using up a scarce resource called an orthopaedic surgeon who, if they weren’t operating on you, might have time to operate on my patient who has had to give up her caring job, due to the pain of her osteoarthritis but doesn’t complain even though she still doesn’t seem to meet the need criteria for surgery.

Meanwhile, she can’t afford the rent on the mouldy house owned by your mates and my neighbours, who own dozens of mouldy homes. She is now homeless. And she won’t be the one getting a tax break. Perhaps she isn’t trying hard enough?

You see, nothing is equal or fair in our health service, Ms van Velden. We must give more to those with greater need – that is equity. We must let them decide what they need and how to deliver it. Healthcare will only be fair and equitable when those with the greatest need, who demand little, have a voice. And they only have a voice now because of Te Tiriti o Waitangi.

Don’t take away the only thing that gives us any hope of better and fairer health outcomes. Tino rangatiratanga. Te Aka Whai Ora. May you squirm with shame if you dismantle it.

In the name of fairness.

Lucy O’Hagan is a medical educator and specialist GP working in the Wellington region