No, this isn’t an opinion piece about the vital organ (mispelt) of a 16th Century English monarch. Instead a reflection on an article, quickly read over a rushed coffee a week or so back, that had me a little perplexed.
The article was reporting that the Auckland region’s three district health boards were concerned that the ‘before school’ health check offered to children at four years old – the B4 School Check or B4SC – was increasing disparities in health.
Having worked on the introduction of B4SC at the Ministry of Health back in 2008 I was surprised to read what was felt to be an innovative means of improving the health status of pre-schoolers, was doing the exact opposite, at least for some.
And, there’s the rub – promotion of the now well embedded B4SC was great for some but not others.
The article went onto describe that ‘middle class and above’ families – who see their offspring’s developmental milestones as a highly competitive endeavour (i.e. whose child has the first word, unaided step, poop in a potty and all the rest) – are more likely to report their child’s difficulties or delays during the check and the most disadvantaged families (often Māori and Pacific) less likely.
This was not due to apathy or lack of motivation, rather these segments of our society have significantly different reference points for what is ‘normal’ when it comes to child health status and milestones.
The ‘middle class and above’ parents’ may panic when their child lags behind the neighbour by a week, measured against social media-inspired superlative developmental markers, whereas the developmental delays and health issues that can be found in disadvantaged Māori and Pacific communities can be the ‘norm’ for other families.
Tudor Hart’s inverse care law strikes again
This is where Dr Julian Tudor Hart comes in. He was a GP and researcher working in a Welsh coalmining community who died this year aged 91 and was most famous for his inverse care law, i.e. that the communities most in need of good health care are the least likely to get it.
Writing in the Lancet back in 1971 Dr Tudor Hart suggested: ‘The availability of good medical care tends to vary inversely with the need for it in the population served. This inverse care law operates more completely where medical care is most exposed to market forces, and less so where such exposure is reduced’.
So, what was intended to be a great addition to child health care – the B4SC – has seemingly succumbed to the inverse care law that many of us engaged in primary health care know so well.
In this case the market force is a well-informed, ‘middle class and above’ population group benchmarking itself against the highest attainable level of developmental progress (and demanding assistance in the case of any deviation). In contrast the disadvantaged families haven’t got the same drivers to seek maximum assistance for their children – due to their reference point being set against a lower community standard of what is ‘normal’ than their middle class counterparts.
Unfortunately, B4SC tripping the inverse care law is but one example in our health and social care system.
While we endeavour to increase access to a universal health care service through manipulation of cost (low cost access to GPs for example), access will continue to be anything but universal due to inequitable structuring of the system as recently highlighted by the 200 claimants to the Waitangi Tribunal firm in their belief the fundamental approach to health care delivery fails Māori.
Likely the WAI 2575 claims are well founded and well-intended, yet while the claims are rightly prioritised, due to the unique relationship between tangata whenua and the crown, other societal groups remain disadvantaged by a health care system in which one size definitely does not fit all.
How meet the health care needs of all?
So, what do we do about this? Aotearoa New Zealand is not alone in these challenges and international endeavour has come and gone with the likes of the Millennium Development Goals (MDGs) now morphed into the hopefully more achievable Sustainable Development Goals (SDGs), and any student of primary health care will remember the 1978 clarion call of Alma Ata seeking health for all by the year 2000.
Forty years on that aim has just been recalibrated as governmental health representatives returned to Kazakhstan in October to produce the Astana declaration seeking universal health coverage by 2030. Noble as the declaration is, there is nothing new in it really; just as it is was with the MDGs and now SDGs.
Back home we do need to get to grips with translating lofty aspirations into a system that truly can meet the health care needs of all. We actually do have what it takes.
Whānau Ora is, in my opinion, a neat example of joined-up health and social care policy that can deliver quality services tailored to the needs of diverse communities. Hopefully the current review will come to that conclusion too. Yet, the delivery model needs to be well funded and delivered by teams of highly competent people, working in equally competent organisations that are well networked with the communities they serve.
Wrapped up in a well thought-out nexus of social justice, educational provision, equitable employment and housing policy, Whānau Ora could well be the delivery mechanism to deliver the best possible care to all. Of course, the model was designed as a contemporary indigenous health initiative intended to address the iniquitous norms identified in the article we began with.
This aim has to be protected and the further tripping of Tudor Hart’s law guarded against; but a Whānau Ora system designed and defined as ‘an approach that supports whānau and families to achieve their aspirations in life … that places whānau at the centre of decision making and supports them to build a more prosperous future’ would surely make a significant contribution to the health care needs of all of us.
And we would have the pioneering work of tangata whenua to thank for that.
Dr Mark Jones was Chief Nurse at the Ministry of Health from 2005-2010 and is also a former head of Massey University’s School of Nursing.