The cruelty that lies behind the health equity adjuster

It's difficult to beat an implication that Māori will get preferential treatment for kickstarting both an irrational and rational public scrap. 

This was what happened when reports circulated that some Auckland surgeons were unhappy that they now had to consider ethnicity when prioritising patients for operations.

What is the equity adjuster score for?

Let's talk about the ‘equity adjuster score’. It's an algorithm being rolled out by Te Whatu Ora – Health New Zealand in the Auckland region with a view to rolling it out nationally.

The adjuster is not for acute surgery, which is surgery that can’t be deferred for very long or at all. 

Instead, it's for surgery that can be planned within a clinically appropriate period of time – at least that's the underlying premise, rather than the reality, with today’s severe workforce shortages. 

The adjuster’s score prioritises patients according to clinical priority, time spent on the waitlist, geographic location (isolation), deprivation, and ethnicity. 

Among ethnic groups, Māori and Pasifika are the highest ranked. 

The equity adjuster is a new clinical prioritisation measure, but considering ethnicity in health decision-making is nothing new.

Why ethnicity?

The justification for including ethnicity is that procedures or practices are institutionally racist, either intentionally or unconsciously. 

In 2019, statutory health watchdog the Health Quality & Safety Commission concluded that institutional racism severely harms and kills Māori in areas such as waiting times for specialist appointments and prescribing. 

The commission accepted that broader social factors like income and housing primarily influence people's health, but the health system itself not only doesn’t reduce inequities, but it may create further disadvantage for Māori. 

The alarm bell was rung by some surgeons in Auckland – but there's strong clinical support for the new equity adjuster. 

Surgeons had a big part in its development. It's been expressly supported by the Royal Australasian College of Surgeons. 

The adjuster is not managerially or ideologically driven.

Further, the starting point for the adjuster is clinical priority, based on medical diagnosis. That trumps everything else. 

When time on the waitlist, geographic location and deprivation are taken into account, there's limited scope for ethnicity on its own to have an impact.

In fact, deprivation alone is likely to mean there's little room for ethnicity to make a big difference. At least, in a health system that's not in crisis.

Inequities are largely due to what we call the "external social determinants of health", like income and housing.

Their biggest impact on healthcare is delayed or, worse still, denied access to general practitioners (GPs). Excluding emergency admissions, GPs are the gatekeepers for hospital care.

Once a person is admitted to hospital, the impact of inequities on healthcare access reduce but are not removed. Once clinical priority through specialist diagnosis is resolved, they diminish even more.

As much as anything else, the role of ethnicity in prioritisation is seen as a counterbalance to the patient's earlier disadvantage.

Another factor to be considered is average life expectancy, because it's a good indicator of ethnicity differences. Now, Māori life expectancy is seven years less than all other New Zealanders (six years for Pasifika). This is concerning.

But it has to be said that from 2002 to 2022, the average life expectancy of Māori increased at the same rate as the total average – more than four years.

Missing the analytical boat

The criticisms of including ethnicity as part of a priority score for planned surgery are a knee-jerk reaction with an implied racist underpinning. In terms of a rational yardstick, the proponents of the equity adjustor win hands-down.

But when we consider the context, both the opponents and proponents miss the analytical boat. The premise of 'planned' surgery is that it can be deferred, as long as it's done within a clinically assessed period of time.

It's been a long time since NZ’s health system achieved this objective. 

We can see this failure in the excessive time people are waiting to be diagnosed, the excessive time after their diagnosis when they're waiting to get on to the waitlist, and then excessive time if they're lucky enough to eventually get on the waitlist.

These excessive delays are mainly because of severe workforce shortages, due to neglect by both National and Labour-led governments.

They happen regardless of patients' ethnicity, or whether they live in deprivation or not. But they are compounded by Māori and Pasifika ethnicity – and compounded by deprivation.  

Prioritising planned surgery is not new. It started in the 1990s under Jenny Shipley’s watch as minister of health in the National-NZ First government led by Jim Bolger.

The intent was not to prioritise if patients needing planned surgery would get it. Instead, it was to prioritise when they'd get it.

There was some controversy about whether it would fudge unmet needs. But the prioritisation tool was clinically developed and evolved further under later Labour and National-led governments.

However, what's stuck in my mind was an astute observation by a leading cardiothoracic surgeon in the midst of that controversy. 

He was a supporter of prioritisation, who saw a lot of potential in improving access to planned surgery.

But there was a sting when he said prioritisation could be dangerous for patients, should public hospitals be underfunded. I have never forgotten this. 

From when to if

Public hospitals were not in the best state in the mid to late 1990s. They improved in the 2000s but have deteriorated since then to the point of crisis being their ‘business-as-normal’. 

Severe workforce shortages are behind this precariousness.

Since prioritisation of planned surgery started under Shipley, it evolved from working out 'when' patients would receive required planned surgery to 'if they would'.

I would say that everyone does their best to make sure prioritisation is objective. But, given the circumstances of those being prioritised and human nature, inevitably there will be subjectivity. This compounds the danger.

The equity adjuster should be seen in this cruel context. It's expected to decide who among those prioritised clinically for planned surgery will get it. This also means working out who'll be denied it.

Given the impact of location, income and housing on people's health and access to the health system in the first place, it gets worse. 

It will risk determining who among those who live in deprivation will get their operation and who won't, and ethnicity will be used to differentiate.

A comparison of healthcare access (including planned surgery) and air quality is apt. Both are public goods. 

Those who breathe quality air are not taking away others' right to breathe it.

But the equity adjuster as a tool in the current circumstances of the health system will be used to deny the right of patients to the surgery that they clinically need.

The adjuster is not the problem. The rundown state of our public hospitals is.

This column has been updated to remove incorrect information about the capitation system, at the writer's request.