Healthcare based on need trickier than you think Mr Luxon

If you are considering removing healthcare based on race, maybe you could review healthcare based on age

I was trying a break from the news last month, but the headline that punched through was “Christopher Luxon slams Hawke’s Bay doctors for prioritising young Māori and Pasifika” (RNZ, online 11 September). He went on to say he had a “very simple approach to healthcare, which is based off need, not ethnicity or race”.

Very simple indeed, Mr Luxon. Except you failed to say how you are going to assess need. Need is far from simple to define, Mr Luxon, and believe it or not, the health professionals you went on to call “out of line, out of order” have spent decades trying to work out how to direct healthcare to actual health need. It’s tricky.

Here are some simple examples of things that have been tried.

When you have osteoarthritis of your knee, your orthopaedic surgeon fills in a questionnaire (with great objectivity and no human bias) to give you a score to see if you meet the threshold for surgery. Sounds pretty fair. Except that, people who understand the system and feel entitled to healthcare know that it’s good to limp into the room, appear to be in terrible pain and overemphasise the disability and impact on their life. The patients who do this are seldom my Māori and Pasifika patients, who are more likely to sit quietly, say things aren’t too bad and not mention they have had to give up their job and now can’t pay the rent and are on a list for emergency housing. The questionnaire system also doesn’t count the people who couldn’t get to the appointment because they had no transport or money on their phone to postpone. So, the questionnaire score for need is okay but has some problems.

We know there are links between health need and social deprivation, so we have tried geocoding deprivation based on where people live. However, that is another blunt measure of need because sometimes wealthy people live in poorer suburbs, and you have to draw lines that say, “This side of the road is this deprivation, but just across the road is another deprivation level,” which seems a bit arbitrary.

We have used a Community Services Card to assess low income. And that kind of works, except that I have also been a GP in a very wealthy community where people have good accountants and multiple family trusts, and those people also have Community Services Cards. I have also worked in one of the poorest clinics in the country, where people who live on the street or in boarding houses, don’t have a Community Services Card because they can’t even get photo ID and the process of getting the card is so difficult, it just doesn’t happen.

Many were abused in state and faith-based care, which, on reflection, could be a very good indicator of health need. Perhaps you could commission some research on this, Mr Luxon?

We have a High Use Health Card, so if you had 12 consultations in a year with your GP, you get cheap consultations for the next year. The problem with that is that, frequently, the patients have recovered from the problem that required 12 visits and needed help when they were sick, not afterwards. Of course, that worked better in the good old days when getting 12 visits with a GP in a year was relatively easy.

One PHO created a chronic care health need assessment, which was probably okay at assessing need, but there were 212 questions. If you went very fast (16 seconds per question) and ignored the patient in front of you, it took one hour. That’s one hour we could have spent actually helping the person with chronic health needs. And, as I worked in a Māori and Pasifika practice with huge numbers of people with huge health needs, this was many, many hours of time just to get the funding to care for them.

One of the more bizarre health need tests I have struck recently was that to see a continence nurse, you need to lose more than 350ml of urine over a 24-hour period. It didn’t explain how one would measure this volume on wet clothing or running down a leg, but, hey, I guess we must quantify health need somehow.

Interestingly, we use age as a measure of health need, so that people over 65 get free prescriptions and cheaper GP visits. On scrutiny, age could be a very poor measure of health need; a large number of older people have no health problems at all, and a large number of very wealthy older people don’t need these subsidies. If you are considering removing healthcare based on race, maybe you could review healthcare based on age.

Governments have also, at times, assumed that health need is highest in communities that speak the loudest and hound the media. You have just opened a 24/7 staffed maternity unit in a wealthy rural town when they already had two such facilities within a 50-minute drive. I’m not sure this would pass my health need test. It sounds like a “nice to have”, especially if balanced against the much greater unmet health need in other communities. The people who demand healthcare may not have the highest need for it. It was a nice photo of you and Dr Reti, though.

Do you know one of the best measures of health need we have is Māori and Pasifika ethnicity? There is so much data on poor health outcomes in these groups that it should fill us with shame.

And, yes, there are some Māori with good incomes, just as there are older adults with good incomes, although the difference is that even Māori with good incomes still have higher health needs.

If you want to take away healthcare based on ethnicity, then what are you going to replace it with? How are you going to measure need?

Be careful, Mr Luxon, it is very easy to create healthcare based on demand or want rather than need. And that in my view, Mr Luxon, would be “out of line and out of order”. Not that I would speak to you like that.

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

Reporter Martin Johnston takes a look at how targeting by ethnicity was driven out of policies and details some areas which ethnicity is a factor

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