Cultural safety in healthcare is not ‘ideological’ – it is saving lives

Introduced under urgency this month, the government’s latest proposed law change would increase the health minister’s powers to interfere in the work of medical registration authorities.

The Health Practitioners Competence Assurance Amendment Bill aims to “align health workforce regulation with patient needs […] and government priorities”.

This follows Health Minister Simeon Brown’s recent decision to replace the leadership of the Medical Council because he objected to the attention the council gives to cultural safety in medical practice.

Earlier, the minister also changed the composition of the Nursing Council, significantly reducing the number of nurses and Māori representatives on the board.

While the health minister is legally able to make all appointments to these registration authorities under current law, the convention for nurses and doctors has been that a proportion of the council is appointed from top candidates in an election by members.

Brown is the first to make significant changes to both councils on grounds of government policy, and the proposed changes would increase his ability to interfere with their work.

But despite the minister’s view that cultural safety and competence is an “ideological agenda”, these principles are deeply embedded in New Zealand practice and make a difference to health outcomes.

Cultural safety is a requirement

The concept of cultural safety is recognised worldwide as an innovation by New Zealand nursing academic Irihapeti Ramsden. The New Zealand Nursing Council was a leader in implementing culturally safe practice.

The nursing and medical councils are required under current law to set standards of cultural competence, including those to “enable effective and respectful interaction with Māori”.

However, following the minister’s appointment of a new chair, the Medical Council discontinued work on revising its existing statements on cultural safety, cultural competence and Hauora Māori services.

The concept is also an essential part of medical training. The Australian Medical Council accredits New Zealand’s medical schools and one of the expected outcomes is that students demonstrate culturally competent practice to deliver “safe, accessible and responsive healthcare free of racism and discrimination”.

Medical students in New Zealand cannot graduate without this requirement.

Cultural safety is also embedded in postgraduate training through the Council of Medical Colleges program. It ensures cultural safety is included in teaching, continuing professional development and curriculum development.

The difference cultural safety can make

During the 1980s, New Zealand recorded some of the highest rates of sudden unexpected deaths in infants (SUDI) globally.

A landmark research and prevention program between 1986 and 1992 prompted nationwide campaigns to address the four identified risk factors: infants sleeping prone, maternal smoking, lack of breastfeeding, and infants sharing a bed with another person. This worked for non-Māori, with rates dropping from almost four babies per 1,000 to 1.6.

But for Māori families, rates remained high (at 7.4 to 6.9 per 1,000). In 2008, a Māori team developed a culturally competent response that included education campaigns and the provision of portable infant sleeping pods. By 2015, Māori rates had dropped to three babies per 1,000.

Clinical guidelines are based on international and New Zealand research, but they often prioritise values and practices of the dominant cultural population, failing to take into account difference in minority groups.

In the case of SUDI, bed-sharing was a common practice for Māori. Telling mothers not to share the bed with their babies didn’t work, but introducing small pods (often woven from flax in traditional techniques) so a baby could sleep safely on the parents’ bed led to this dramatic decrease.

This is a clear case of lives being saved through culturally safe care.

There is still much to do in the care of people living with diabetes. As with SUDI, diabetes affects Māori and Pacific people disproportionately.

Our research on long-term conditions such as diabetes describes how treatment guidelines developed for the dominant culture remain ineffective in addressing high and rising rates of diabetes among Māori and Pacific people.

When new diabetes drugs were released, New Zealand’s drug-funding agency Pharmac included a provision for Māori and Pasifika to have prioritised access. But the government reversed that policy.

Bariatric surgery is another example. It is an effective treatment for severe obesity and is performed in public hospitals.

A recent study explored the rates of public hospital bariatric surgery in Counties Manukau, a district where Pacific people make up 23% of the population (Maori 15% and European 24%).

Pacific people have twice the rate of obesity compared with Europeans and yet, of all bariatric procedures performed, 46% were for Europeans, 27% for Māori and only 17% for Pacific people.

After adjusting for age, gender, body mass index, other health conditions and deprivation, Māori and Pacific people were 47% and 70% less likely, respectively, to proceed to having bariatric surgery.

The government has removed ethnicity as a relevant factor to target funding, saying public services should be “based on the needs of all New Zealanders”. But these examples highlight that ethnicity is an independent predictor of need.

Political involvement in the regulation of medical training and practice undermines public trust. Interfering with regulators’ attempts to redress ethnic disparities in health outcomes by requiring medical staff to be trained in cultural competence flies in the face of the evidence.

Ben Gray does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.