4th March 2011, Volume 124 Number 1329

Peter Jansen, Kira Bacal, Stephen Buetow

Improving the health status of Māori relative to non-Māori and enhancing the experiences of all patients are features of successive government strategies for health.1,2

Māori are a special focus of government policy, not only because of their status as Treaty partners but also because they have a lower life expectancy, greater morbidity and higher rates of disability than other New Zealanders.3,4 A link between patient experience of poor care and reduced access to high quality services, for example in general practice,5,6 has been posited as a key cause of the inequalities in health outcomes.7–9

Regular reporting on surveys of patient experiences can assist health providers to track improvements to their services.10,11 Recent research has reported a Māori perspective of Māori experiences of health care,12,13 but few reports have compared the experiences of Māori and non-Māori.6,14

The New Zealand Health Survey 2006/7 reported that Māori and the total population had similar access to primary health care.14 Unknown however is how the 2001 Primary Health Care Strategy, and the subsequent funding and establishment of Primary Health Organisations, have changed inequalities between Māori and non-Māori in access to, and experiences of, general practice services.

Methods

A 2005 multi-phase studydeveloped an experiences-of-care survey tool for measuring health care consumer perceptions among Māori. (Note the distinction between ‘patients’ and ‘consumers’: ‘patients’ have engaged with the health care system whereas ‘consumers’ include both actual and potential patients.) The wider study sought to understand Māori experiences of care and the impact of experiences on intention to revisit the same provider. Overall results are reported elsewhere,15whilst the present report focuses on differences between Māori and non-Māori experiences of care in the GP setting.
The 2005 study surveyed a sample of 651 Māori, who had been identified from Māori electoral rolls,using a modified telephone interview. While not intended as a nationally representative sample, the sampling framework ensured participants reflected the geographical distribution of Māori.
Using the same questionnaire, the same telephone data collection service (Digipoll) and the same scripting for interviewers, a survey of a random sample of 400 non-Māori consumers was undertaken immediately at the conclusion of the Māori survey. This paper uses these data to compare Māori and non-Māori experiences in relation to access to general practice care.
A semi-structured personal questionnaire was administered in the telephone surveys of Māori and non-Māori consumers. It was used to gather information about issues that promote or constrain their use and experience of health and disability services. Development of the questionnaire was informed by a literature review of barriers to Māori and non-Māori use of the services, a qualitative phase involving hui (meetings), and review by Māori consumers and Māori health experts.
Before finalising the questionnaire, four Māori health professionals reviewed the questionnaire for clarity and validity. Respondents were asked about their last experience of receiving health and disability services in the 6 months before being contacted.
In the interview, we distinguished between respondents who were answering on their own behalf from those answering on behalf of another. Despite Māori households having higher numbers of children, Māori and non- Māori respondents in this survey reported answering on behalf on a child in similar proportions (11.6% vs 13.2%). Identical proportions were answering on behalf of another adult in both groups (4%).
Analysis of the quantitative data collected on access to general practice care involved the production of descriptive and inferential statistics through the use of statistical software (STATA version 7). Tests of differences in proportions (or means) between Māori and non-Māori were performed, first for sociodemographic attributes and then for variables describing access to general practice care at respondents’ last visit.

Results

Table 1 compares sociodemographic attributes of the groups of Māori and non-Māori respondents respectively. It reveals statistically significant differences between these groups at the 0.05 level. Compared with the non-Māori group, the Māori respondents on average were younger, had more household residents and were living in Census Area Units with higher relative socioeconomic deprivation.

The Māori group also reported proportionately higher levels than did the non-Māori group of unemployment, young households and low-income households, as well as proportionately fewer respondents with no chronic medical condition.

Table 2 compares Māori with non-Māori access to GP care at respondents’ last visit. Proportionately fewer non-Māori than Māori reported needing a visit on the day of their request. Regardless of ethnicity, most respondents reported being seen within this, or another, preferred timeframe, and getting an appointment at a time they considered suitable. However, the respondents who did not report visits with these attributes were more likely to be Māori than non-Māori. Of those who were given an appointment, proportionately fewer Māori said they were offered a choice of times or were seen on time. There was no reported difference between Māori and non-Māori regarding the mean waiting times in the clinic for those who stated they were seen late.


Table 1. Comparison of Māori and non-Māori survey participants on sociodemographic attributes
Variable
Māori
Non-Māori
Difference (95% CI)
P value
Mean age
44.9
48.4
-3.5 (-5.4 to -1.6)
0.000
Mean household residents
3.8
3.0
0.8 (0.6 to 1.0)
0.000
Mean Census Area Unit deprivation score
7.9
5.9
2.0 (1.6 to 2.4)
0.000
% Female
58.5
60.0
-1.5 (-7.6 to 4.6)
0.631
% Unemployed
9.7
3.8
5.9 (3.0 to 8.8)
0.000
% Households with mainly children
71.4
50.0
21.4 (15.4 to 27.4)
0.000
% Households with gross income ≤$20,000
21.4
12.5
8.9 (4.4 to 13.4)
0.000
% No ongoing medical condition
54.5
61.4
-6.9 (-13.0 to -0.8)
0.029
% Contact with GP in past 6 months
94.2
92.8
1.4 (-1.7 to 4.5)
0.366

Table 2. Access to GP care for Māori compared with non-Māori
Variable
Māori
Non-Māori
Difference (95% CI)
P value
% Needed visit as soon as possible
23.3
18.8
4.5 (-1.3 to 10.3)
0.139
% Needed visit on same day
36.1
28.1
8.0 (1.3 to 14.7)
0.022
% Seen in timeframe needed
93.0
96.5
-3.5 (-6.6 to -0.4)
0.042
% Had an appointment
87.4
86.1
1.3 (-3.6 to 6.2)
0.602
% Given suitable time
93.8
98.3
-4.5 (-7.2 to -1.7)
0.007
% Given a choice of times
68.3
77.8
-9.5 (-16.3 to -2.7)
0.008
% Seen on time
64.2
75.1
-10.9 (-17.9 to -3.9)
0.003
Mean wait (minutes) if not seen on time
33.4
30.4
3.0 (-5.2 to 11.2)
0.472
% Without appointment, told waiting time
86.5
82.0
4.5 (-6.5 to 15.5)
0.401

Discussion

The results of the multi-phase study of Māori experiences of health services included a pilot survey developed through literature reviews and a qualitative phase. This paper has compared data from Māori who were interviewed by telephone for this pilot survey with data for non-Māori who were interviewed immediately after the survey of Māori was completed.

As characterises the New Zealand population, there were sociodemographic differences between the Māori and non-Māori groups interviewed about GP contacts. The Māori group was younger and more likely to live in areas of high deprivation. A greater proportion of non-Māori than Māori were retired. While similar proportions of each group reported being in paid employment, a larger proportion of the Māori group stated they were unemployed.

In line with report six of the National Medical Care survey,6 a greater proportion of Māori than non-Māori reported an urgent health need at their last visit to a GP. What appears ‘urgent’ to one person is not necessarily ‘urgent’ to another, but the data indicate a difference between Māori and non- Māori in what they perceived to be an urgent health need.

Regardless of their ethnicity, most respondents reported seeing a GP when they wanted. This finding should be seen in the context of most Māori having a primary care provider they can go to when the need arises.16 Respondents who said they could not see a GP when they wanted were more likely to be Māori than non-Māori. Similarly, the 2006/7 New Zealand Health Survey found that Māori women were more likely than women in the total population to feel unable to see their primary health care provider within 24 hours when wanted.14

Unmet need for a GP was reported to be highest for Māori, after adjustment for age, in the 12 months before the Health Survey.14 These findings are consistent with lower mean annual exposure by Māori than Europeans to general practice care in New Zealand.17

In our study, Māori were less likely than non-Māori to report being offered a choice of appointment times. Other studies have similarly reported that practice staff demonstrate poorer communication with Māori than non-Māori, for example about their health care.14Further research is needed to test how (and why) experiences of, and access to, GP care have changed since our survey, particularly because changes to New Zealand health policy have continued to erode the "redistributive effect of the original needs-based formulas."18

It is also worth noting that in many general practices, the gatekeeping of timely access to the GP is controlled not by the clinicians but rather by non-clinical office staff such as receptionists,19 a distinction the present study could not make. Indeed, recent evidence from the United Kingdom exposes consumer concerns regarding the receptionist role in triage.20

Our findings may therefore reflect differences among office staff, rather than GPs, in offering access to primary medical care. For example Māori may have a cultural tendency to be noho whakaiti—to not cause a ruckus—and so may not appear worried, upset, or assertive to staff in the face of an urgent health need.15 All practice staff need to receive appropriate pre-service and in-service training so that they can communicate safely and effectively with consumers whilst addressing their needs.21,22

Our study was restricted to households with telephones. It also surveyed self-selected respondents, i.e. people who chose to participate and presumably wanted to share their experiences. Although many Māori prefer kanohi ki te kanohi (face to face) communication, we used telephone contact to maximise our geographic reach while minimising time and costs.

Lastly, since people’s recall of events is often flawed, reported experiences may have varied from their actual ones. We used identical methods with both populations to control for any potential bias, however, and have no reason to believe that either population was more likely to over- or under-report their experiences in a systematic fashion.

Our study was strengthened by our use of experience-based, rather than satisfaction-based, questions. The latter may not reflect true attitudes (i.e. some people, especially Māori, are reluctant to be seen as rude or critical) and/or may reflect an acceptance of inequalities (e.g. satisfaction is reported as high because expectations are extremely low). By inquiring about experiences, people's reports can be compared to best practices and assessed more objectively.

Despite years of political mandates to improve or eradicate health disparities, Māori still report being less likely to be offered choices at their general practice, to be seen on time, and to be seen within their preferred timeframe. These findings suggest additional work is needed to align Māori experiences of general practice care with those of their non-Māori neighbours.

Summary

Māori and non-Māori were interviewed via telephone about their experiences with general practice (GP) care over the past 6 months. Māori were more likely than non-Māori to need to see their GP urgently but were less likely to get to see the GP when they want. Māori were also less likely to be seen on time or to be offered a choice of times when they could see their GP. These findings suggest GPs need to do more to ensure Māori experiences of general practice care are equivalent to those of their non-Māori neighbours.

Abstract

Aim

To compare Māori and non-Māori experiences in relation to access to general practice care.

Method

A semi-structured personal questionnaire was administered in telephone surveys of random samples of 651 Māori and 400 non-Māori consumers. Differences in these groups of consumers' experiences of accessing general practice care were compared statistically.

Results

Compared with the non-Māori, the Māori respondents on average were younger and less advantaged in their socioeconomic and health status. Māori were more likely to report needing their last visit urgently. Most respondents reported seeing a GP when they wanted, but non-Māori were more likely than Māori to have this preference met. Fewer Māori said they were offered a choice of appointment times or were seen on time.

Conclusion

Māori still report high health needs and being less likely to be offered choices at their general practice, to be seen on time, or to be seen within their preferred timeframe. Additional work is needed to align Māori and non-Māori experiences of general practice care.

Author Information

Peter Jansen, Senior Medical Advisor, Accident Compensation Corporation, Auckland; Kira Bacal, Phase 2 Director, Medical Programme Directorate, Faculty of Medical and Health Sciences, University of Auckland; Stephen Buetow, Associate Professor, Department of General Practice and Primary Health Care, University of Auckland

Acknowledgements

Ngā mihi nui ki a koutou katoa. We thank all those participants who shared their experiences and insights. Special thanks to the Ministry of Health, the Health Research Council and the Accident Compensation Corporation who funded the study of Māori experiences of care.

Correspondence

Dr K Bacal, Phase 2 Director, Medical Programme Directorate, Faculty of Medical and Health Sciences, The University of Auckland, Private Bag 92019, Auckland, New Zealand.

Correspondence Email

k.bacal@auckland.ac.nz

Competing Interests

None known.

References

  1. He Korowai Oranga: Māori health strategy. Ministry of Health: Wellington; 2002.
  2. Minister of Health. 2000. The New Zealand Health Strategy. Wellington: Ministry of Health.
  3. Blakely T, Tobias M, Atkinson J, et al. Tracking Disparity: Trends in Ethnic and Socioeconomic Inequalities in Mortality, 1981-2004. Wellington: Ministry of Health; 2007.
  4. Ajwani S, Blakely T Robson B, et al. Decades of Disparity: Ethnic Mortality Trends in New Zealand 1980-1999, Wellington: Ministry of Health and University of Otago; 2003.
  5. Malcolm L. Inequities in access to and utilisation of primary medical care services for Maori and low income New Zealanders. N Z Med J 1996;109:356-358.
  6. Crengle S, Lay-Yee R, Davis P, Pearson J. A Comparison of Māori and Non-Māori Patient Visits to Doctors: The National Primary Medical Care Survey (NatMedCa): 2001/02. Ministry of Health: Wellington; 2004.
  7. Durie M. Whaiora Maori Health Development. 2nd ed. Oxford University Press: Auckland; 1998.
  8. Jansen P, Smith K. Maori experiences of primary health care. NZFP 2006;33(5):298–300.
  9. Harris R, Tobias M, Jeffreys M, et al. Racism and health: of the relationship between experience of racial discrimination and health in New Zealand. Soc Sci Med 2006; 63:1428–1241.
  10. Coulter A, Cleary P. ‘Measuring and Improving Patients' Experiences: How Can We Make Health Care Systems Work for Patients? ‘Measuring Up: Improving Health Systems Performance in OECD Countries. Canada: OECD; 2002.
  11. Picker Institute Europe. National Health Service Patient Survey’; 2005. http://www.pickereurope.org/page.php?id=45 
  12. Walker T, Signal L, Russell M et al The road we travel: Māori experience of cancer. NZMJ 2008: 121 (1279).
  13. Penney L. 2005. Māori and Health Practitioners Talk About Heart Disease. Draft Summary Report on Phase 1 Findings. Palmerston North: Massey University.
  14. Ministry of Health. A Portrait of Health. Key Results of the 2006/07 New Zealand Health Survey. Wellington: Ministry of Health.
  15. Jansen P, Bacal K, Crengle S. He Ritenga Whakaaro: Māori experiences of health services. Auckland, Mauri Ora Associates 2008.
  16. Jatrana S, Crampton P. Affiliation with a primary care provider in New Zealand: who is, who isn’t? Health Policy 2009;91: 286-296.
  17. Crampton P, Jatrana S, Lay-Yee R, Davis P. Exposure to primary medical care in New Zealand: number and duration of general practitioner visits. NZMJ 2007; 120(1256):U2582.
  18. Langton J, Crampton P. Capitation funding of primary health organisations in New Zealand: are enrolled populations being funded according to need? NZMJ 121;47-58.
  19. Arber S, Sawyer L. The role of the receptionist in general practice: 'a dragon behind the desk'? Social Science and Medicine 1985;20(9):911-921.
  20. McKinstry B, Watson P, Pinnock H, et al. Confidentiality and the telephone in family practice: a qualitative study of the views of patients, clinicians and administrative staff Family Practice 2009;26(5):344-350.
  21. Royal New Zealand College of General Practitioners (RNZCGP). Aiming for excellence : RNZCGP standard for New Zealand general practice. 3rd ed. Wellington: RNZCGP, 2008.
  22. Buetow S, Adair V, Coster G, et al. Qualitative insights into practice time management: does 'patient-centred time' in practice management offer a portal to improved access? Br J Gen Pract 2002 December; 52(485): 981–987.