Posted on June 19, 2023

Auckland Surgeons Must Now Consider Ethnicity in Prioritising Patients for Operations

Barry Soper and Jason Walls, New Zealand Herald, June 18, 2023

Auckland surgeons are now being required to consider a patient’s ethnicity alongside other factors when deciding who should get an operation first.

Several surgeons say they are upset by the policy, which was introduced in Auckland in February and gave priority to Māori and Pacific Island patients – on the grounds that they have historically had unequal access to healthcare.

Health officials stress that ethnicity is just one of five factors considered in deciding when a person gets surgery, and that it is an important step in addressing poor health outcomes within Māori and Pacific populations.

Te Whatu Ora – Health New Zealand has introduced an Equity Adjustor Score, which aims to reduce inequity in the system by using an algorithm to prioritise patients according to clinical priority, time spent on the waitlist, geographic location (isolated areas), ethnicity, and deprivation level.

In the ethnicity category, Māori and Pasifika are top of the list, while European New Zealanders and other ethnicities, like Indian and Chinese, are lower-ranked.

Some surgeons, who spoke on the condition of anonymity, said the new scoring tool was medically indefensible. They said patients should be prioritised on how sick they were, how urgently they needed treatment, and how long they had been waiting for it – not on their ethnicity.

One of the surgeons said he was “disgusted” by the new ranking system.

“It’s ethically challenging to treat anyone based on race, it’s their medical condition that must establish the urgency of the treatment,” the surgeon said.

“There’s no place for elitism in medicine and the medical fraternity in this country is disturbed by these developments.”

A document on the equity adjustor which was leaked to Newstalk ZB shows two Māori patients, both aged 62 and who have been waiting more than a year, ranked above others on the list. A 36-year-old Middle Eastern patient who has been waiting almost two years has a much lower priority ranking.

An email by Te Whatu Ora business support manager Daniel Hayes in April said: “Hi team, Heads up. This is going to be the new criteria for outsourcing your patients going forward. Just putting this on your radar now so that you can begin to line up patients accordingly. Over 200 days for Māori and Pacific patients. Over 250 days for all other patients.”

When contacted by ZB, Hayes said he would not comment until he had verified who he was speaking to. He did not return further requests for comment.

Health Minister Ayesha Verrall said when it came to prioritising healthcare, there were important reasons why ethnicity was a factor.

She pointed to the Government-commissioned, independent review of the health system in 2018, which found the system did not serve everyone well and produced unequal outcomes, particularly for vulnerable populations.

“The reformed health system seeks to address inequities for Māori and Pacific people who historically have a lower life expectancy and poor health outcomes,” Verrall said.

Sir Collin Tukuitonga, a leading expert in Pasifika health, said Māori and Pasifika patients could be moved to the front of surgical lines due to the inequalities in the previous stages of the health system, such as the referral process.

“Māori and Pacific people tend to linger on the referral list… and inevitably, I think people will say that there’s also an institutional bias, possibly a racism that doesn’t put them where they need to be in order to get the surgery,” Tukuitonga said.

“The referral pathways are not that straightforward.”

Tukuitonga specifically used the example of bariatric surgery, which helps to aid those with morbid obesity, which he said was “much more” prevalent in Māori and Pacific communities than in Pākehā. He said this could be another reason why these patients are being brought forward in the waiting times.

“For most of the surgical interventions, Māori and the Pacific people don’t get to get the rates of interventions that might be warranted given their conditions,” Tukuitonga said.

He added: “In other words, it’s not acceptable to have a group in the population where obesity is a major problem and yet they’re not getting the physical intervention that they require.”

Te Whatu Ora interim lead for Te Toka Tumai (the former Auckland District Health Board) Dr Mike Shepherd said the causes of health inequity were complex and required a sophisticated solution to reduce inequitable outcomes that already existed.

“It’s important to note that ethnicity is not the only element considered in the scoring system,” Shepherd said.

He said the equity adjuster waitlist score helps reduce barriers and inequities in the healthcare system, to ensure that people have equitable outcomes, regardless of their ethnicity, socio-economic circumstances or where they live.

“These adjustments are based on evidence which shows these groups often have inequitable health outcomes, which often begin at the start of their healthcare journey. Early analysis shows the tool is effective at helping to eliminate the existing inequities.”

Shepherd said the tool was rolled out in Auckland in February and, due to positive evidence that it is helping to eliminate inequities in the healthcare system, it is now being rolled out across the other northern region districts.

Before the Health New Zealand reforms came into force last year, around half of the then District Health Boards had considered or committed to prioritising Māori and Pacific patients for some elective surgeries.

A number of studies and reports show Māori and Pacific people are less likely to be referred or accepted for treatment in the first place, and once in the system generally get less treatment. The Auckland District Health Board’s own data show Māori and Pacific patients take longer after referral to have a procedure confirmed.