Fair and just

Equity is the quality of being fair, just and impartial. Equity is fundamentally important for the people of Aotearoa New Zealand and for the nurses who serve their communities.

4.1 Equity issues within nursing

A fair and healthy society is underpinned by health workforce regulation that ensures:

• a living wage
• safe workplaces
• collective bargaining and collective agreements
• pay equity in all practice settings
• a nursing workforce that represents the community it serves.

Aotearoa New Zealand is undergoing a period of rapid change relating to pay equity in the health sector. After many years of campaigning for better pay and conditions in the aged care sector, unions (including NZNO) won a major legislative change in 2017 in the form of the Care and Support Worker (Pay Equity) Settlement Agreement. The agreement generated a seismic shift in pay rates and recognition of training for care and support workers. Further, legislation that would promote pay equity across other historically female occupations was introduced into Parliament in late 2017 in the form of the Employment (Equal Pay and Pay Equity) Bill. With a change of government the bill did not make it into law but new legislation will be drafted.

The NZNO Strategy for Nursing provides an overview of the direction and goals of the major areas of focus for NZNO members.

Gender biases

Gender biases in health care are both a labour market and a human rights issue. Gender biases undermine inclusive economic growth, full employment, decent work and the achievement of gender equality. They also create inefficiencies in health systems by limiting the productivity, distribution, motivation and retention of female workers who constitute the majority of the health workforce. New Zealand has ratified conventions on employment equity for women that are viewed as fundamental rights by the International Labour Organisation (ILO) and the United Nations. It is time that the intent of these international conventions are realised.

NZNO supports pay and gender equity across sectors, equal pay for equal work and equal pay for work of equal value.

Current actions

NZNO is advocating, in partnership, for:  

• pay equity across all sectors
• established pay equity rates in the DHB MECA
• established pay parity in all other sectors (Māori and Iwi providers and aged care) with the DHB pay equity rates.

Colonisation and structural discrimination

Disparities in Māori health in Aotearoa New Zealand can be attributed to our colonial history, in particular the impact of land loss through confiscation, legislation and war. The alienation of land and resources saw the loss of a cultural, spiritual, health, economic, and power base. The ongoing impact of colonisation can be seen with Māori often disadvantaged in the distribution of social, political, environmental and economic resources.

Defining structural discrimination

The New Zealand State Services Commission describes structural discrimination as occurring “when an entire network of rules and practices disadvantages less empowered groups while serving at the same time to advantage the dominant group”. This leads to socio-economic disadvantage and political isolation for people who are marginalised by this system. Structural discrimination can be unintentional and includes practices that are embedded in everyday organisational life and are part of the system.

Strategic actions

NZNO will:

Continue to work internally to:

• improve equity through scholarship, research, and publications
• promote cultural competence and contemporary understandings of our history
• promote and support the work of Te Runanga

Work with external stakeholders to ensure:

• health policy in Aotearoa New Zealand supports health and economic equity
• the “voice” of Māori and Māori nursing is heard
• structural discrimination in the health-care system is identified and corrected.

NZNO and pay equity

The Care and Support Worker (Pay Equity) Settlement Agreement

Kaiawhina (community support workers) and aged-care residential workers in Aotearoa New Zealand have been underpaid and undervalued for decades. In April 2017, work by a high level multi-sector working party and government agencies resulted in a $2 billion pay equity settlement for 55,000 care and support workers in Aotearoa New Zealand’s aged and disability residential care and home and community support services. Since July 1, 2017, workers have received a 15-50 per cent pay rise, depending on their qualifications and experience. Over the next five years, pay rates will increase to $19 - $27 per hour, increasing take home pay by at least $100 a week, or more than $5000 a year.

This settlement addresses the historic undervaluing of this workforce and will help to support increased qualifications and reduced turnover in the sector, resulting in better care for New Zealanders.

Many ENs working in aged care earn less than the increased top rate for caregivers ($27). The average pay rate for RNs in the sector is around $26-$27 per hour, which will be at the top end of the caregiver scale by 2021. However, pay equity settlements take account of all remuneration components. NZNO acknowledges that RN and EN pay rates need to increase.

NZNO sees collective bargaining as the best approach to resolve pay equity issues. NZNO will be advocating for pay rates for health care assistants, ENs, RNs and senior nurses that provide pay equity. NZNO has tabled a pay equity claim for nurses.

Primary health care

NZNO’s goal in primary health care will continue to be pay parity with the DHB MECA pay equity rate when established. Where NZNO has collective bargaining, significant progress has been made to achieve rates of pay very close to current DHB rates of pay.

Nurses employed by iwi providers

Pay for workers in Māori and iwi health providers lags significantly behind other primary health care providers and those working for DHBs. The pay gap can be up to 20-25 per cent. It is essential nurses working in Māori and iwi providers have pay rates equal to DHB pay rates, and - when established - the DHB pay equity rate. Of concern is that Māori women in general receive less pay than non-Māori,  and Pacific women even less.

Hospices

Hospices face increasing demand for services and this is set to increase with the ageing population in Aotearoa New Zealand. Their funding rate appears to range from 40-70 per cent of running costs, with fundraising required to make up the balance. This is another example of health underfunding in Aotearoa New Zealand. NZNO expects an equitable funding model for hospices. NZNO’s goal in the hospice sector will continue to be pay parity with the DHB MECA and, when established, the DHB pay equity rate.

4.2 Addressing inequity in Aotearoa New Zealand - nurses can make the difference

Health, social and economic inequity is growing in Aotearoa New Zealand.

With improved models of care and the full utilisation of nursing knowledge, skill and experience, nurses will be able to make significant positive impact on the health, social and psychological outcomes of New Zealanders, especially those with high needs.

The determinants of health

Many factors relating to circumstances and environment combine to affect the health of individuals and communities. The physical, social and economic environment and the person’s individual characteristics and behaviours all have considerable impacts on health.

Determinants of health are wide ranging, but commonly acknowledged factors include:

• Income and social status - higher income and social status are linked to better health. The greater the gap between the richest and poorest people, the greater the disparity in health.
• Education – low education levels are linked with poor health, more stress and lower self-confidence.
• Physical environment – safe water and clean air, healthy workplaces, safe, affordable and healthy houses, safe communities and safe roads all contribute to good health.
• Employment and working conditions – people in employment are healthier, particularly those who have more control over their working conditions.
• Social support networks – greater support for families, communities, whānau, hapu and iwi is linked to better health.
• Culture - customs and traditions, and the beliefs of the family and community all affect health.
• Genetics - inheritance plays a part in determining lifespan, healthiness and the likelihood of developing certain illnesses.
• Personal behaviour and coping skills – balanced eating, keeping active, smoking, drinking, and how we deal with life’s stresses and challenges all affect health.
• Health services - access and use of services that prevent and treat disease influences health.
• Gender - men and women suffer from different types of diseases at different ages.

The NZNO Strategy for Nursing includes the following additional determinants of health:

Commercial determinants of health

Commercial determinants of health can be defined as “strategies and approaches used by the private sector to promote products and choices that are detrimental to health”. An example is the lobbying undertaken by the global tobacco industry.

As noted by former WHO Director-General Margaret Chan, non-communicable disease prevention measures clash with powerful business interests.

Health outcomes are determined by the influence of corporate activities on the social environment in which people live and work: namely the availability, cultural desirability, and prices of food and drinks. The commercial and political environments contribute to lifestyle choices of individual consumers, -ultimately determining health outcomes.

Climate change

Climate change, health and equity are inseparable - human-caused climate change poses a serious and urgent threat to health across the globe. Water and food insecurity, malnutrition, extreme weather events and changing patterns of infectious disease will be key concerns internationally. Māori people and Pacific peoples will face disproportionate health impacts from climate change in Aotearoa New Zealand and new health and social pressures will arise through climate change related migration from the Pacific.

The NZNO Position Statement on Climate Change outlines nursing specific responses to climate change.

Current actions

NZNO is a signatory to Ora Taiao: The New Zealand Climate and Health Council’s call for:

• MoH to set greenhouse gas emissions reduction targets for DHBs, in line with commitments under the Paris Agreement
• MoH to mandate all DHBs to measure, manage and reduce their greenhouse gas emissions in accordance with the ISO 14064 standard
• DHBs to report progress towards greenhouse gas emissions reduction to the Ministry of Health annually.

Strategic actions

NZNO will:

• Become a corporate member of Ora Taiao: The New Zealand Climate and Health Council

These strategic actions will enable NZNO to advocate for and influence policy development on climate change. Collaboration with the health partners that comprise Ora Taiao and the Climate and Health Alliance will ensure NZNO has access to current knowledge, evidence and strategies that have been implemented effectively nationally and internationally.

4.3 Addressing disparity across the determinants of health

Disparity between people in Aotearoa New Zealand who can access and afford health care and those who cannot is growing. This is of critical concern to NZNO and the more than 49,000 members it represents.

Disparity affects everybody, but the greatest health, social and psychological needs can be seen in relation to Māori, Pacific people, children and young people, pregnant women and our elderly and dying. This is where an accelerated, culturally competent nursing response is required - through innovative models of care, nurses working to the top of their scope, providing cultural competency training and by ensuring nurses are at the centre of care provided to people as they grow, work, play, age and die.

Poverty

The burden of ill health and early death associated with poverty is undeniable and nurses witness the devastating effects of poverty in their daily work. NZNO views nursing as an integral part of the solution to poverty. Absolute attention to the implementation of the sections and themes of the NZNO Strategy for Nursing will position nursing to better meet the health and social needs of people in poverty.

 

Poverty in Aotearoa New Zealand – contextual changes over time

Historical	Contemporary
Poverty is seen to be caused by the individual	Poverty is a community, national and global concern and is multi causal and complex
Poverty is poorly defined and measured	Poverty is defined and measured according to the Aotearoa New Zealand context
Data is incomplete and not used effectively	Data and epidemiology inform models of health care and support across health and social sectors
Multiple and separate approaches	Intersectoral working to cohesively meet the needs of the whānau/household
Dependence on non-governmental (NGO) organisations and the voluntary sector	Integrated approaches utilising the expertise and knowledge of the NGO sector and evidence informed decision making
Health safety net created	Absence of a health safety net - a robust and responsive model of care to address unmet need is required
Poverty “will always be with us”	Poverty is actively managed and minimised

 

Affordability and access to health care in general practice

Access to GP practice teams continues to improve in Aotearoa New Zealand, with free visits and exemption from the standard $5 prescription charge for children under 13. However, one in nine New Zealanders are not getting the GP care they need because they cannot afford it. The latest New Zealand Health Survey estimates more than 500,000 adults have unmet health-care needs due to the cost of a GP visit.

Children with health issues are not in a position to choose whether they need to attend a GP practice team. People living in poverty do not access GP care readily. Children’s visits are fee-free, but a visit to the GP may take many hours in total, with factors such as finding caregivers for other family members or children, accessing public transport to and from the clinic and getting prescriptions filled.

There may be similar barriers for people in employment needing to see a doctor.

This situation is compounded if the person has an unpaid bill. Many health centres accommodate people with limited financial means, however people may feel ashamed and not attend.

Our children, Tamariki

New Zealand children living in poverty, especially tamariki Māori and Pacific children, have poorer health and education outcomes than those living in households with average and higher incomes.

Research is compelling that experiencing poverty in childhood has negative health impacts in adult years, especially in relation to long-term conditions. There is also an accepted relationship between poverty experienced in childhood and a greater likelihood of mental health problems through life.

The Child Poverty in New Zealand: Evidence for Action report  states that, compared with non-poor children, those living in poverty are:

• at 1.4 times higher risk of dying during childhood
• more likely to die of Sudden Unexpected Death in Infancy
• three times more likely to be sick
• more than twice as likely to be admitted to hospital for acute infectious diseases
• at least 1.5 times more likely to be hospitalised
• less likely to have fruit and vegetables
• more likely to skip breakfast and to consume fast food regularly
• hospitalised for injuries from assault, neglect or maltreatment at 5-6 times the rate of non-poor children
• less likely to participate in early childhood education
• less likely to leave school with NCEA level 2 – the entry level qualification to skilled employment.

Strategic actions

NZNO will:

• Support flexible and innovative models of care, enabling nurses to better meet the needs of people living in poverty
• Continue to support the living wage movement in Aotearoa New Zealand
• Advocate for change in health and social policy settings to promote improvement in the determinants of health
• Support greater investment in upskilling of nurses in mental health and addictions.

Our young people, Rangatahi

At 15.6 suicides per 100,000 people, the Aotearoa New Zealand suicide rate is twice as high as the US rate and almost five times the British rate. The most recent data from 2014 showed the suicide rate for Māori men across all age groups is around 1.4 times that of the non-Māori. Suicide rates are highest for young Māori and Pacific men.

The Mental Health Foundation of New Zealand has noted that high rates of school bullying and very high rates of family violence, child abuse and child poverty need to be addressed to tackle the problem.

Māori children and young people experience an excess burden of ill health, cultural alienation, socio-economic disadvantage and deprivation, institutional racism, poorer educational achievement and poorer access to health and social services. Much of this is preventable, unnecessary and a breach of children’s rights. These inequalities result in significant costs to our society.

Nurses are in an ideal position to respond through the “one-stop-shop” youth services they provide in schools. Nursing services are achieving good results in schools, however much more could be done in terms of wellness, health promotion, early detection and surveillance of mental and/or physical health.  Nurses in schools (including public health nurses) are spread too thinly and need to reach a critical mass to be effective. The number of nurses and the nature of services currently provided are variable, largely due to funding/employment/contractual models.

Māori and Pacific nurses are desperately needed to support rangatahi/young people through a Māori and/or Pacific world view.

The workforce section of this strategy provides more detail on the role of nursing in addressing the determinants of health in Aotearoa New Zealand.

Homelessness

“Homelessness is defined as a living situation where people with no other options to acquire safe and secure housing are: without shelter, in temporary accommodation, sharing accommodation with a household, or living in uninhabitable housing” ~ Statistics New Zealand.

At the time of the 2013 census 41,000 New Zealanders (at least one in every 100) were homeless, and over half of this number under 25 years.

Homeless people have far more mental health problems than the general population and are very susceptible to severe health problems. There are barriers to accessing health services targeting the needs of this population.  Clearly an alternative entry to the health system is needed.

Current actions

• NZNO endorses the recommendations of the Solutions to Child Poverty in New Zealand: Evidence for Action report from the expert advisory group on solutions to poverty (Office of the Children’s Commission New Zealand, 2012)
• NZNO is advocating for a critical mass of nurses (including nurse practitioners) who work with young people in primary, secondary and alternative schools and one-stop-shop specialist youth services. A critical mass of nurses and funded services is a pre- requisite to improvement
• NZNO advocates for increased investment (fiscal and human) to facilitate earlier access to specialised child and youth mental health services (inpatient and community) to improve access to and lower the triage thresholds of existing services
• NZNO supports working towards the elimination of homelessness
• NZNO supports a nationwide, independent, comprehensive review of mental health and addictions, funding and service provision.

Strategic actions

NZNO will:

• Identify nurses working with homeless people’s programmes and recommend model(s) of care that improve health care to this population
• Identify international professional nursing organisations that can contribute expertise, and evidence-based programmes in care and support of the homeless person(s)
• Further develop partnerships with existing agencies where homelessness is their core activity
• Develop innovative model(s) of care with mobile services that are free and accessible - providing a centre of care and support for people as they grow, work, play, age and die
• Advocate for greater nurse involvement in early intervention for mild to moderate mental health conditions, eg extend the primary mental health credentialing programme to school-based health care and well child/tamariki ora nurses
• Contribute proactively to the Government’s Inquiry into Mental Health and Addictions
• Conduct a one-day workshop to identify and disseminate examples of successful practice and strategies for initiating and improving inter-sectoral working
• Promote and disseminate training opportunities in assessing suicide risk that are available in New Zealand
• Advocate for affordable healthy housing.
   

‘Of all forms of inequality, injustice in healthcare is the most inhumane” ~ Martin Luther King