Terms of Reference: Review of Access to Health and Dental Services
Introduction
Research on the health needs of tamariki and rangatahi in state or agency care shows a prevalence of high health needs that may be undiagnosed and untreated1 Additionally, tamariki and rangatahi in care are less likely to report having good health or wellbeing and are almost twice as likely to report having a disabling condition; this includes long-term disabilities, chronic conditions, and pain that impacts their daily functioning2 .ResearchshowsthatenrolmentwithaPrimaryHealthCare provider(GP) and access to regular oral health services5 is linked to improved health outcomes and continuity of care3 For this reason, enrolment and access to a GP and dental service is crucial for tamariki and rangatahi in state or agency care.
Enrolment with a GP is an “entry point to accessing health services” and provides equitable access to health services6 For Māori and Pacific, having access to Hauora Māori and Pacific health providers means having access to wrap-around services in generalmedicaltreatment,familydoctors,nurse-ledclinics,vaccination,sexualhealth, dental care, family violence, budgeting and quit smoking
Itisimportantthatinadditiontoenrolment,tamariki andrangatahiincare haveaccess toannualhealthchecks Researchhasfoundthatsomecareexperienced tamarikiand rangatahi felt their health needs were not met while in care, and some reported that they should not be solely responsible to raise concerns as they are not cognisant of thehealthissuesthatneededaddressing7 Some alsoreportedbeingunabletoaccess health services when required2
It is imperative that tamariki and rangatahi also have regular access to preventative and restorative oral health services, as oral health is sometimes referred to as “a window to overall health”5. It is important to note that oral health behaviours in childhood continue into adulthood4. Ensuring tamariki and rangatahi have access to
dental services whilst in care can have both immediate, and long-term, positive health benefits. This is especially important as research suggests there is a prevalence in long-term negative health outcomes experienced by tamariki and rangatahi who have had state [or agency] care experience1
Research shows inequalities in health and dental outcomes for Māori and Pacific tamariki and rangatahi. Māori – tamariki and adults – have the lowest GP enrolment ratesinAotearoaandaremorelikelytohaveunmetneedsthannon-Māori6 Inaddition, four-year-oldPacifictamariki,followedcloselybytamarikiMāori ofthesameage,have the highest average number of dental caries (decay) compared to other tamariki4 Culturally relevant and meaningful approaches to health care service delivery are criticalforimprovingequityinindigenousandotherethnicgroupsandareessentialfor improvinghealthoutcomes8 Itwasnotedinourmostrecentreportonthe Experiences of Care in Aotearoa 2021/2022 that Oranga Tamariki does not currently record if tamariki and rangatahi have access to a health practitioner with knowledge and experience of the cultural values and practices of the child and/or Māori models of health.
Given the high health needs of tamariki and rangatahi in care, including a disproportionate number of Māori and Pacific tamariki who are more likely to experience poorer long-term health outcomes, it is crucial for tamariki and rangatahi in care to be enrolled and have access to GP and dental services and that these servicesare culturallyresponsive Thisisreflected in TheNational Care Standardsand Related Matters Regulations 2021 (NCS Regulations), which require tamariki and rangatahi in state or agency care to be enrolled with a primary health organisation or GP and have access to annual health and dental checks and to a health practitioner who has knowledge and experience of their cultural values and practices.
OurExperiencesofCareinAotearoa2021/2022reportreferencedOrangaTamarikidata that showed 47 percent of tamariki and rangatahi in Oranga Tamariki care are not enrolled with a specified doctor or medical provider. Open Home Foundation reported that 99 percent of tamariki and rangatahi in their care in 2021/2022 were registered with a GP. Furthermore, data provided to Aroturuki Tamariki for 2021/2022 showed that 35 percent of tamariki and rangatahi in Open Home Foundation care did not have an annual health check, and 41 percent did not have an annual dental check. Oranga Tamariki does notcurrentlyrecord iftamariki andrangatahi havehadanannual health or dental check. In relation to these findings, RNZ reported that ‘OT did not dispute the
monitor's report but said its files showed 88 percent of the children had their health needs assessed and a health plan’9 Considering the findings above, Aroturuki Tamariki, The Independent Children’s Monitor, is undertaking a review under section 26 of the Oversight of Oranga Tamariki System Act 2022 (the Act) on enrolment and accesstohealthanddentalservicesfortamarikiandrangatahiinstate oragencycare
Key objectives
• To clarify the number of tamariki and rangatahi in state or agency care who are enrolled with a GP and dentist.
• To understand the barriers to enrolling tamariki and rangatahi with a GP and dentist
• To understand how tamariki and rangatahi are supported to access a health practitioner with knowledge and experience of their cultural values and practices. For Māori tamariki and rangatahi this includes access to a health practitioner who has knowledge and experience of Māori models of health.
• Tounderstandthecurrentpracticeandpolicyofallagencieswithcustodialcare arrangements and how they address the health (GP) and dental needs of tamariki in care.
• Tounderstandhowmanytamarikiandrangatahi instateoragencycarearenot receiving annual health (GP) and dental checks, and why.
• To understand inequities in the availability of services – in particular, if inequity exists due to geographical location, resources, and what contributes to these inequities
• To understand how the Ministry of Health and the Ministry of Education, along with Oranga Tamariki, work together to facilitate access for tamariki and rangatahi to health and dental services and how OTAP supports this.
• To understand how iwi strategic partnerships with Oranga Tamariki may be supporting enrolment and access to GP and dental services for tamariki and rangatahi in state or agency care
• To understand s396 providers and other regional care partners may be supporting enrolment and access to GP and dental services for tamariki and rangatahi in state or agency care.
• To understand how Oranga Tamariki and Open Home Foundation are selfmonitoring to ensure children in their care have access to annual health (GP) and dental checks.
Approach
The methodology will mirror that of the Aroturuki Tamariki current mixed-method approach. This will include analyses of quantitative data gathered from agencies, along with qualitative analysis of interview data collected from professionals from relevant agencies. Interviews may also be conducted with government agencies indirectly identified as possible sources of information. Secondary research and other literature relevant to health outcomes for children in care will be considered in this review as context, and a point of reference in examining the response of government.
Data requirements
• Quantitative agency administrative data for tamariki and rangatahi in care, and for the population, that enables baseline comparisons.
• Access to interview tamariki, rangatahi, whānau and caregivers. This could include information that has already been collected from previous and current monitoring visits, or information that will be collected for this specific purpose. Information will be leveraged where possible.
• Access to interview Oranga Tamariki, Open Home Foundation National Office, regional kaimahi, and other relevant government agencies/organisations (i.e. College of GPs. Dental Care services), strategic iwi partners. This could include information that has already been collected from previous and current monitoring visits, or information that will be collected for this specific purpose. Information will be leveraged where possible.
1. Duncanson, M. (2016). Health Needs of Children and Young People in State Care. Retrieved from South Island Alliance: https://www.sialliance.health.nz/wp-content/uploads/2016-SIAPO-Health-needs-of-children-and-young-people-in-State-care.pdf
2. Archer, D., Clark, T.C., Fenaughty, J., Sutcliffe, K., Ormerod, F., & Fleming, T. (2022). Young people who have been involved with Oranga Tamariki: Community and contexts. The Youth19 Research Group, The University of Auckland and Victoria University of Wellington, New Zealand.
3. Silwal P, Lopez MI, Pledger M, Cumming J, Jeffreys M (2023) Association between enrolment with a Primary Health Care provider and amenable mortality: A national population-based analysis in Aotearoa New Zealand. PLoS ONE 18(2): e0281163. https://doi.org/10.1371/journal. pone.0281163
4 Shackleton N, Broadbent JM, Thornley S, Milne BJ, Crengle S, Exeter DJ. Inequalities in dental caries experience among 4-year-old New Zealand children. Community Dent Oral Epidemiol. 2018; 00:1–9. https://doi.org/10.1111/cdoe.12364
5. Han H, Lees AB, Morse Z, Koziol-McLain J. Child abuse knowledge and attitudes among dental and oral health therapists in Aotearoa New Zealand: a cross-sectional study. BMC Health Serv Res. 2022 Dec 10;22(1):1504. doi: 10.1186/s12913-022-08907-1. PMID: 36496403; PMCID: PMC9735273.
6. Irurzun-Lopez M, Jeffreys M, Cumming J. The enrolment gap: who is not enrolling with primary health organizations in Aotearoa New Zealand and what are the implications? An exploration of 2015-2019 administrative data. Int J Equity Health. 2021 Apr 6;20(1):93. doi: 10.1186/s12939-021-01423-4. PMID: 33823865; PMCID: PMC8025352.
7. Madelaine Smales, Melissa Savaglio, Heather Morris, Lauren Bruce, Helen Skouteris & Rachael Green (nee Cox) (2020) “Surviving not thriving”: experiences of health among young people with a lived experience in out-of-home care, International Journal of Adolescence and Youth, 25:1, 809-823, DOI: 10.1080/02673843.2020.1752269
8. Wilson, D., Moloney, E., Parr, J. M., Aspinall, C., & Slark , J. (2021). Creating an Indigenous Māori-centred model of relational health: A literature review of Māori models of health. Journal of Clinical Nursing, 3539-3555.
9 Pennington, P. (2023, February 10). Nearly half of children in state care not enrolled with a GP or medical centre. https://www.rnz.co.nz/news/alert-top/484020/nearly-half-of-children-in-state-care-not-enrolled-with-a-gp-or-medical-centre