Intentionally delivering equitable musculoskeletal care in Hawke’s Bay has seen a reduction in pain for the 400 participants, as well as improved mobility, fewer GP and specialist visits and better ability to work. Dr Andy Phillips from Hawke’s Bay District Health Board presented on the programme at the Choosing Wisely forum in Wellington in May 2019.
Dr Phillips was one of a team that worked with the Hawke’s Bay community to design the programme to provide Māori and Pacific peoples, and those living in the most deprived areas, with care for musculoskeletal conditions customised to their needs.
The trial which began last year and finished in February 2019, has been so successful it is likely to receive short term Ministry of Health funding so more in-depth analysis and evaluation can be done to enable Hawke’s Bay DHB to fund it long term.
Barriers to equity
'Every public health study published shows Māori health is poorer than the health of most other populations and WAI2575 confirmed the lack of impact on Māori health despite billions spent in the health sector,' Dr Phillips says.
'Implicit bias and the impact of intergenerational trauma are continuing to result in poor health outcomes for Māori.
'If we are going to have equitable outcomes, we need to remove barriers people face to receive care. We are collectively responsible for the conditions whānau face including poverty, discrimination, powerlessness, and lack of access to health care. We have erected barriers to high-quality health care including difficulties in navigating complex systems, limited cultural competence of providers, health literacy, lack of transport, out-of-pocket costs and co-payments for GP services.'
Dr Phillips and the team used the musculoskeletal programme as a way of informing wider system change to address health inequities.
'We wanted to identify the really serious health inequities. And while heart disease and cancer were the main causes of death, the biggest issue impacting on wellbeing of our Māori whānau was osteoarthritis.'
Musculoskeletal issues in Hawke’s Bay
'We have a history in Hawke’s Bay of Māori and Pacifica working in freezing works and similar heavy manual labour tasks that have damaged their bodies. More than a quarter of our people have musculoskeletal issues, and Māori and Pacific adults here are 1.3 times more likely to have arthritis than non-Māori, non-Pacific peoples.
'Musculoskeletal injuries are therefore a huge problem across Hawke’s Bay. They impact on people’s ability to work; to look after their whānau, to participate in everyday life.'
Dr Phillips says even though these issues are over represented in Māori and Pacific peoples, historical and current health care service pathways are inequitable.
'In common with most other studies we found that whereas Māori are more likely to have disease and more likely to have greater severity of their condition with greater pain and poorer function when they present, they are less likely to have surgical treatment.
'When we looked into it further, we found there were very few offerings for people with musculoskeletal issues other than surgery. And surgery can be difficult to access – the DHB is contracted to do about 400 surgeries a year for hips and knees, and we decline many more than that.'
Mobility action programme set up
Working with the local community, the team codesigned a kaupapa Māori programme to address health inequities and reduce pain and disability. The Hawke’s Bay programme is one of a number of mobility action programmes in place in different parts of Aotearoa, using specifically allocated government funding.
The Hawke’s Bay programme was a partnership between the DHB, Health Hawke’s Bay PHO and Ironmāori. The team worked with a number of agencies, including the Ministry of Social Development, local employers, the Mananui Māori Healthy Lifestyle Collective and local Māori physiotherapists. An individually tailored programme was provided for up to three months for people with painful joints or muscles, with physiotherapy, an exercise programme that included swimming, and education and support including self-management support.
The Mananui collective provided tailored activity programmes. The Stanford Self Management Programme, adapted for Māori, provided weekly workshops where people could learn how to resolve pain, fatigue and isolation, use medications effectively and engage with family, friends and health professionals to gain their support.
The programme was available for Māori and Pacific peoples and all people who lived in quintile five areas within the region, who had experienced joint pain for more than three months and did not qualify for ACC.
Dr Phillips says the service was very intentionally set up for the people who would benefit from it most.
'If we had offered the service to everyone, the people in Hawke’s Bay who were already advantaged in this area were going to be advantaged further. It was a very deliberate kaupapa Māori service designed by the community for the community to address inequity in musculoskeletal health.
'The models of care used were relevant and customised to the local environment, with an emphasis on building relationships, and participation in your own care. Care was available close to home, from culturally competent providers.'
Applying system change learnings
Dr Phillips says the three partners wanted to learn as much as possible about effective system change from the programme, and apply these learnings more broadly.
'A key take-out for us was the person must be at the centre of everything we do; it’s about sharing power authentically between parties. We want to use this to inform the entire system of health in Hawke’s Bay including how you work with people across sectors.'
He says what he is most pleased about is the programme’s genuinely intentional approach to equity.
'We didn’t just start something and then add in equity; the intention right from the start was to put the power into the hands of the community and have an equitable service. That transfer of power was the critical thing. The DHB and PHO were facilitators to make sure communities were able to design and deliver programmes that were important to them.
'Other things that can be applied more broadly are the focus on self-management support programmes, learning from patients’ own experiences, developing a shared record so patient information could be securely shared among health professionals, and having ‘virtual’ consultations with GPs – so people didn’t have to travel.'
He says there were also lessons learnt. 'Something we would do differently next time is devote more management resource to supporting the smaller providers.'
Six key points summarise the approach of the Hawke’s Bay mobility action programme:
- Use of kaupapa Māori models of care
- Programme intentionally delivered to quintile five populations in urban and rural Hawke’s Bay
- Focus on partnerships and education, relationship-centred care, education and support
- Care is well coordinated and provided close to home by culturally competent practitioners
- Disparities in access, health outcomes are identified and reduced
- There is evaluation of patient experience, clinical outcomes, value for money.
An early evaluation of the national mobility action programme found:
- Reduction in pain
- Improvement in functionality and mobility
- Improved ability to self-manage conditions
- Financial savings for health system and people
- Reductions in GP visits and specialist referrals and visits
- Programme slows progression time to orthopaedic surgery
- Increased productivity – employed participants less likely to report that their work was negatively affected by their musculoskeletal conditions
- Participants significantly less likely to report they were unemployed for condition-related reasons
- Participation in volunteer and family roles increased.