OraTaiao Executive Board member, Steve Grimson, has written an opinion piece in response to the red flags in the Ministry of Health's consultation on 'Putting Patients First: Modernising health workforce regulation'. Removing cultural requirements from health workforce regulation compromises the quality of care and takes us backward from progress made toward health equity. Steve shares his thoughts on the proposed changes.
When I was seven, I entered my first ever school athletics carnival, and lined up to run my first ever 400 metre race. I was on the very inside lane. The other kids and I all took our starting positions, and I noticed they were all standing ahead of me. I turned to my teacher, who was trying to figure out the starting gun, and yelled, “Hey, sir, how come they get to start all the way up there?”
He looked up, chuckled, and said, “It’s a staggered start. They’re on the outside lanes, so they have further to run, so to make up for that, they start further ahead.”
I was a bit suspicious at the time, and my suspicions were reinforced when I never caught up to anyone anyway. But now I get it, though I didn’t realise just how important a lesson it would be.
I’m a junior doctor in Tāmaki Makaurau, Auckland, about to complete my training in general practice. I grew up and went to medical school in Australia before marrying a Kiwi (we still can’t watch rugby or cricket together), making the move across the ditch, and starting GP training in South Auckland.
When I started training with the Royal New Zealand College of General Practitioners, the quality of cultural training I received was like nothing I’d experienced before. I was used to cultural education being a footnote or the subject of a single tick-box lecture; here it was the most important item of the agenda and framed all of our other learning. I learned to say my pepeha, karakia, and sing waiata. I learned about whakawhanaungatanga, the art of creating a connection or common ground between people, and how to weave it into a medical consult. I learned about te Tiriti o Waitangi and the history of colonisation, and how it directly affects health and healthcare in Aotearoa. I learned about Te Whare Tapa Whā and the Meihana model of Māori health, which hold that a person’s health rests on the four pillars of spiritual, emotional, physical, and social wellbeing, is built on the whenua, and is influenced by the winds of colonisation, marginalisation, racism, and migration. I learned the difference between equality and equity. And I learned about cultural safety, how to be mindful of my own attitudes and assumptions, and those of my patients, and how they are shaped by our culture and background.
I can say without a shred of doubt that I am a much better doctor thanks to this training. I can make better connections with patients from different cultures to my own, forging a more effective therapeutic relationship with me and with the health system. I make sure I call people what they want to be called, and pronounce it correctly. I make sure I know and document people’s whānau and social situation, and meet their whānau if I can. I still get that pang of frustration when I get the all-too-common message that someone hasn’t shown up to the appointment that they really, really needed to go to. But now, instead of patient-blaming, I follow up with them, find out what the barriers are, and figure out the best way forward together. I can think of half a dozen times off the top of my head where these skills have averted a hospital admission, keeping that person healthier and saving taxpayers tens of thousands of dollars each time.
In March, the Ministry of Health put out a document called “Putting Patients First: Modernising health workforce regulation”. This concerns the rules and governing bodies that dictate how healthcare workers, including doctors, nurses, allied health workers, psychologists, paramedics, and others, get registered, and the standards they need to meet. The government wants to streamline and reduce these regulations. There seem to be two goals in mind here. Firstly, they want to make it easier and faster to train healthcare workers, and import and accredit them from overseas. This is fair enough. Our population is aging fast, and if we want to maintain the standard of health care to which we’ve become accustomed, we’re going to have to import a lot of healthcare workers over the coming decades. But I’m concerned that the second goal may be more ideological and cynical. It appears to be part of a broader push by the current government to characterise most regulation as bloated and inefficient bureaucracy, even when it serves a clear and important purpose; and also to erode the tino rangatiratanga of Māori guaranteed by Te Tiriti and replace it with a libertarian version of “equality”.
When I read the document, a couple of red flags stood out. Firstly, it asks the question, “Do you agree that regulators should focus on factors beyond clinical safety, for example mandating cultural requirements, or should regulators focus solely on ensuring that the most qualified professional is providing care for the patient?” This question betrays a deep misunderstanding, or a deliberate misrepresentation, of cultural safety as something outside of clinical safety. We have decades of evidence that shows that culturally safe care produces better clinical outcomes, particularly for Māori and Pasifika people, who have the worst health outcomes of any group in our country. If I had been “imported” without the cultural safety training I received, I would not be nearly as effective as I am today. If cultural training requirements are removed across the country, as is implied, our health workers will be poorly equipped to care for the most vulnerable groups in our society.
Secondly, Te Tiriti o Waitangi is not mentioned once in the document, despite the proposed reforms having real and serious repercussions for the relationship between the Crown and Māori. Health workers, especially those working for the Crown, need to be aware of the history and meaning of Te Tiriti, their obligations under it, and the historical drivers of inequity in this country. This is a grave omission, and I do not think it was made in error. It’s hard to deny that a key goal of the current government has been to erode the meaning and effect of Te Tiriti, as evidenced by, for example, the Treaty Principles Bill and the wholesale destruction of Te Aka Whai Ora (the Māori Health Authority).
Thirdly, the discussion document uses leading questions and misleading language. It co-opts language used by health professionals, such as “patient-centred” and “clinical safety”, to reinforce proposals that may actually reduce patient safety and patient-centred care. It characterises regulation as "overly bureaucratic," "red tape," and an "unnecessary cost" without providing any evidence to support these claims. It presents a false dichotomy between maintaining professional standards and improving healthcare access, ignoring the fundamental role regulation plays in ensuring patient safety and quality care.
Health professional organisations have opposed this review. The New Zealand Society of Anaesthetists has opposed the review on a variety of grounds. The New Zealand Nurses Organisation has called it an attack on health workers. The Association of Salaried Medical Specialists laid a complaint with the Public Service Commission.
I have no doubt that there are reasonable efficiencies to be found in the regulation of the health workforce. But these proposals go well beyond these to threaten the things that make our health workforce world-class and effective in our national context. They go hand in hand with the gutting of the staff of Te Whatu Ora (Health NZ); one can see the spectre of Elon Musk waving his chainsaw and roaring in triumph. They are the product of the philosophy espoused especially by ACT, which enshrines the equality of giving everyone the same treatment regardless of their circumstances. This sounds good at first glance, but it’s like starting the 400 metres with everyone lined up right next to each other. The kids in the outside lanes would never stand a chance. Instead, we need to recognise that people have different needs, and in order to realise their potential, some people need more help than others. This is the difference between equality and equity. Cultural training is what can make our health workers part of the solution to inequity instead of part of the problem.
Health care affects every single one of us. Write to your MP and the health minister. Don’t let our health system slide backwards into a one-size-fits-all system.