Access to Primary Health Services and Dental Care

Established in 2019, our role was expanded in 2023 under the Oversight of Oranga Tamariki System Act. We are responsible for checking that the organisations supporting and working with tamarikiClosetamariki
Children (plural) aged 0-13 yearsView the full glossary (children) and rangatahiCloserangatahi
Young person aged 14 – 21 years of ageView the full glossary (young people) are meeting the needs of those tamariki and rangatahi, delivering services effectively, and improving outcomes.

In this review we look at access to primary health services and dental care for tamariki and rangatahi in the custody of Oranga Tamariki and Open Home Foundation. It’s the second of our reviews taking a deeper look at practices to understand and improve outcomes for tamariki and rangatahi in state or agency care.

This review examines the National Care Standards (NCS) Regulations in relation to primary health care. The NCS RegulationsCloseNCS Regulations
(National Care Standards and Related Matters) Regulations 2018 View the full glossary are the minimum standards of care that anyone in care can expect to receive. In relation to primary health, the NCS Regulations require that the chief executive of Oranga Tamariki must ensure thatsupport is provided to address the health needs of all tamariki and rangatahi in their care, including taking reasonable steps to ensure that they are enrolled with a primary health organisation (PHO), have annual health and dental checks, and that their health and wellbeing needs are assessed and met. The NCS Regulations also state that reasonable steps should be taken to ensure that tamariki and rangatahi in care have access to a culturally knowledgeable and experienced health practitioner.

This review looks at what practice, services and supports are wrapped around tamariki and rangatahi in care to ensure that the health-related NCS Regulations are met. It is through annual checks that any further health and dental needs can be identified and treated. We know that unmet health need can be both costly and detrimental to wellbeing over the life course. Tooth decay, for example, is the most common non-communicable childhood disease in AotearoaCloseAotearoa
New ZealandView the full glossary New Zealand, but it is largely preventable. Poor oral health can go on to affect physical health, mental health, educational success and employment outcomes¹.

In this review, we look at what works well, and what doesn’t, to inform practice improvements within and across the oranga tamariki system. This includes tamariki and rangatahi in the custody and care of Oranga Tamariki and Open Home Foundation².

Just like our first in-depth review, Returning Home from Care, this review also considers the role that other government agencies play to support tamariki and rangatahi in care. It is not the role of Oranga Tamariki to deliver health services. It is imperative, therefore, that health providers are joined up with the system that supports tamariki and rangatahi in care.

We recognise the health initiatives underway as part of the Oranga Tamariki Action Plan³. In particular, the in-depth needs assessment into primary health care sets out the state’s “higher duty of care”⁴ for tamariki and rangatahi in care. We acknowledge that further work is underway to prioritise access to health care for this group. This review highlights additional areas for improvement.

Our heartfelt thanks go to the tamariki, rangatahi, caregivers and kaimahi (workers) who shared their experiences and insights with us.

Arran Jones Chief Executive

Nova Banaghan Chief Monitor

Foreword

Contents

Key findings

Introduction

Scope

Methodology

Access to primary health care

Enrolment

Barriers to enrolment and access to health services

Health practitioners with knowledge and experience of cultural values and practices

Annual health and dental checks

Policies and practices

Assessing health needs

Roles and responsibilities within Oranga Tamariki

Systems and tools within Oranga Tamariki

Open Home Foundation

Inequities around service provision

Government agencies working together

Information sharing

Roles and responsibilities within the public sector

Residences

Strategic partnership: Te Tohu o te Ora o Ngāti Awa

Strategic partnership: Te Kāika

Appendix One: Oranga Tamariki practice guidance on enrolments

Glossary

This review focused on the National Care Standards (NCS) Regulations relevant to enrolment and access to primary health services and dental care for rangatahiCloserangatahi
Young person aged 14 – 21 years of ageView the full glossary and tamarikiClosetamariki
Children (plural) aged 0-13 yearsView the full glossary in care. We are aware of wider concerns with accessing secondary health services such as mental health, and some of these are covered in our Experiences of Care in AotearoaCloseAotearoa
New ZealandView the full glossary report.

We found that the health-related NCS RegulationsCloseNCS Regulations
(National Care Standards and Related Matters) Regulations 2018 View the full glossary have not been implemented well. The experiences of tamariki and rangatahi were mixed. However, several clear themes emerged.

There is a lack of clarity regarding what the NCS Regulations require, what an annual health check is, and when parental/whānauClosewhānau
Whānau refers to people who are biologically linked or share whakapapa. For the Monitor’s monitoring purposes, whānau includes parents, whānau members living with tamariki at the point they have come into care View the full glossary consent is required. We heard in our monitoring visits that policies and guidance are not clear for Oranga Tamariki social workers, which means that caregivers are sometimes made responsible for arranging health care, and that sometimes they do not have important health-related information on the tamariki and rangatahi they look after. We did not hear from staff or caregivers about training, although Oranga Tamariki has since told us that training and information are available for both social workers and caregivers. While Oranga Tamariki has pointed to its practice guidance as evidence of clear expectations being set, we also heard from Oranga Tamariki national office that practice guidance is not embedded across the organisation. Our monitoring visits suggest that clear expectations have not been set from Oranga Tamariki national office to ensure tamariki and rangatahi have access to primary health services and dental care.

The NCS Regulations require reasonable steps to be taken for every tamariki and rangatahi in care to be enrolled with a primary health organisation (PHO)⁵ and receive annual health and dental checks. These regulations are in place because there is a prevalence in long-term negative health outcomes for tamariki and rangatahi in care. An annual health check provides an opportunity for further health needs to be identified early, and to properly inform plans and access to services.

Over the last year, Oranga Tamariki has taken steps to better understand the rate of enrolment that tamariki and rangatahi have with primary health services through data matching with Te Whatu Ora. The data matching found that 93 percent of tamariki and rangatahi in care were enrolled with a PHO as at 30 June 2023. Oranga Tamariki has also analysed data through the Integrated Data Infrastructure (IDI) to understand general practitioner (GP) visits. The IDI data from 30 June 2021 indicates that approximately 70 percent of tamariki in care had been seen at least once by a GP in the previous twelve-months.

However, Oranga Tamariki cannot see accurate enrolment data in its own systems, because its records are incomplete. This can impact on the ability to share important information with caregivers, whānau (family) and other social workers that may be working with the tamariki or rangatahi. There continues to be a lack of urgency to ensure that data collection by social workers is improved.

We also heard that Oranga Tamariki does not always collect health-related compliance data from care partners, which it would need to have oversight of the care being provided to tamariki and rangatahi in partnered care. Because of this lack of information, Oranga Tamariki is not able to share information with health providers to improve access to primary health care. This is despite the willingness we heard from health professionals to ensure that tamariki and rangatahi in care have access to the health services they need.

While we found pockets of good practice and heard from Oranga Tamariki that tamariki and rangatahi can generally access health care when they need to, better implementation and oversight across Oranga Tamariki is needed. Access to primary health care is vital because tamariki and rangatahi in care have poorer health outcomes than those who aren’t in care. It is through primary health that further health needs can be identified and met, resulting in better health outcomes for this group.

Our annual Experiences of Care in Aotearoa report examines broader compliance with the NCS Regulations. This includes the extent to which tamariki and rangatahi in care have their health needs assessed and supported beyond access to primary health care.

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In determining the topic of this review, we considered themes uncovered through our earlier monitoring work, including our two published Experiences of Care in AotearoaCloseAotearoa
New ZealandView the full glossary reports on compliance with the NCS RegulationsCloseNCS Regulations
(National Care Standards and Related Matters) Regulations 2018 View the full glossary. Our 2021/2022 report referred to data from Oranga Tamariki showing that only 53 percent of tamarikiClosetamariki
Children (plural) aged 0-13 yearsView the full glossary and rangatahiCloserangatahi
Young person aged 14 – 21 years of ageView the full glossary in its care were enrolled through a Primary Health Organisation with General Practice services⁶.

For both of our previous Experiences of Care in Aotearoa reports, Oranga Tamariki was unable to tell us whether the tamariki and rangatahi in its care were able to access annual health and dental checks as set out in the NCS Regulations.

When we spoke with kaimahi from Oranga Tamariki for our previous reports, we heard that it was difficult to get tamariki and rangatahi the health services and support they needed. Kaimahi attributed this to poor communication between government agencies, resources being unavailable in the areas where rangatahi lived, and services being overwhelmed or understaffed. We also heard from caregivers about their experiences in supporting tamariki and rangatahi to access health services. Some caregivers spoke about positive experiences, with good support from Oranga Tamariki in accessing health services. However, many caregivers told us that they did not feel supported to understand or deliver on the health needs of tamariki and rangatahi. They told us that they had to push for communication, access to information or other support from Oranga Tamariki.

We were concerned as broader research findings suggest a prevalence in long-term negative health outcomes experienced by tamariki and rangatahi who have been in care⁷. Tamariki and rangatahi in care are less likely than the general population 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 functioning⁸.

Research also shows poorer health and dental outcomes for Māori and Pacific tamariki and rangatahi regardless of care status. Māori of all ages have the lowest PHO enrolment rates in Aotearoa and are more likely to have unmet health needs than non-Māori⁹. Four-year-old Pacific tamariki, followed closely by tamariki Māori of the same age, have the highest average number of decayed teeth compared to other tamariki¹⁰. This is important because Māori and Pacific tamariki and rangatahi make up most of the care population in Aotearoa.

Unmet health need not only reduces wellbeing over the life course; it is also costly and difficult, if not impossible, to reverse. However, enrolment with a primary healthcare organisation (and thus a GP) and access to regular oral health services¹¹ are linked to improved health outcomes and continuity of care¹². For Māori and Pacific peoples (of all ages), having access to hauora Māori and/or Pacific health providers can mean having access to wrap-around services in general medical treatment, family doctors, nurse-led clinics, vaccination, sexual health, dental care, family violence prevention, budgeting, and smoking cessation. Culturally relevant and meaningful approaches to health care service delivery are critical for improving equity and are essential for improving health outcomes¹³.

Annual health checks, as set out in the NCS Regulations, are important for tamariki and rangatahi in care because they provide opportunities for further health needs to be identified. They also allow for health assessments and plans to be updated. These are important tools to ensure that tamariki and rangatahi in care are getting their needs met.

Given the concerns raised in previous reports, in November 2022 we met with senior representatives from the Ministry of Health. They told us about the commitments the Ministry of Health had made under the Oranga Tamariki Action Plan, published in July 2022, with a specific work programme for tamariki and rangatahi in care. The Ministry of Health also made the point that it is in the context of stable care placements that tamariki and rangatahi can best be supported – continuity of health care is difficult if care placements change frequently.

In undertaking this review, we recognise the wider context of workforce shortages across health services in Aotearoa¹⁴, their impacts on timely access to health care¹⁵, and the major health reforms that took effect on 1 July 2022. Government agencies recognise that managing the health needs of tamariki and rangatahi in care “is a litmus test for these reforms”¹⁶. Despite evident strains on the public health infrastructure, our report shows that improvements can be made, and need to be made, across the oranga tamariki system to ensure access to primary health services and dental care for tamariki and rangatahi in care. This is a group for whom the state, by definition, cares for in place of their parents. The state must therefore exemplify best practice and do everything possible to ensure the long-term wellbeing of these tamariki and rangatahi.

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We shared our Terms of Reference for this review with Oranga Tamariki and Open Home Foundation as agencies with tamarikiClosetamariki
Children (plural) aged 0-13 yearsView the full glossary and rangatahiCloserangatahi
Young person aged 14 – 21 years of ageView the full glossary in their custody and care. We also shared these with government agencies involved in the delivery of health services, as well as the New Zealand Dental Association and Royal New Zealand College of General Practitioners. The purpose of the review is to understand:

• the number and proportion of tamariki and rangatahi in state or agency care who are enrolled with GPs and dentists (NCS Regulation 35(1)(a))

• the barriers to enrolment

• how tamariki and rangatahi in state or agency care are supported to access health practitioners with knowledge and experience of their cultural values and practices (NCS RegulationsCloseNCS Regulations
  (National Care Standards and Related Matters) Regulations 2018 View the full glossary 13(1)(a), 13(1)(b) and 35(1)(c))

• the number and proportion of tamariki and rangatahi in state or agency care who can access annual health and dental checks (NCS Regulations 35(1)(b) and 35(1)(c))

• current practice and policies supporting tamariki and rangatahi with their health needs

• inequities around service provision

• how government agencies are working together to support tamariki and rangatahi with their health needs

• how Oranga Tamariki strategic partners, s396 providers and other regional care partners support tamariki and rangatahi in state or agency care with their health needs

• how Oranga Tamariki and Open Home Foundation are self-monitoring to ensure compliance with the health-related NCS Regulations.

This review focuses on the NCS Regulations relating to primary health services and dental care because our previous Experiences of Care in AotearoaCloseAotearoa
New ZealandView the full glossary reports show that compliance has been poor. Enrolments and annual checks are means to ensuring that tamariki and rangatahi have their health needs identified, understood and met.

Although there is evidence of increasing rates of mental distress in young people across Aotearoa, this review focuses on access to primary health care as an entry point for accessing further health services. Mental health is not in scope for this review and might be something we explore in a future review.

In all our engagements for the review, we asked people to talk with us about their experience and perspectives relating to the review’s objectives. We focused our questions on enrolments with primary health providers, and access to annual health and dental checks. Many people also spoke more broadly about access to health services, and particularly in terms of a lack of available services in their region.

We acknowledge these experiences and perspectives and have included them where relevant to the terms of reference of our review.

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The stories and voices of tamarikiClosetamariki
Children (plural) aged 0-13 yearsView the full glossary and rangatahiCloserangatahi
Young person aged 14 – 21 years of ageView the full glossary, and their whānauClosewhānau
Whānau refers to people who are biologically linked or share whakapapa. For the Monitor’s monitoring purposes, whānau includes parents, whānau members living with tamariki at the point they have come into care View the full glossary, caregivers and communities are at the centre of our monitoring approach. Effective and meaningful monitoring requires a mix of approaches and the use of quantitative (numbers) data and qualitative (experiences) information.

For the purposes of this review, we focused our engagement on a wide range of health professionals and people with direct experience of primary health services and dental care for tamariki and rangatahi in state or agency care. This included tamariki and rangatahi, and caregivers, as well as kaimahi from Oranga Tamariki and Open Home Foundation¹⁷.

We visited a mix of locations that were selected because of their previous year’s recorded PHO enrolment rates, provided by Oranga Tamariki, for tamariki and rangatahi in its care. We visited Te Tai Tokerau, Tāmaki MakaurauCloseTāmaki Makaurau
AucklandView the full glossary, Taranaki/Manawatū, Canterbury and Otago/Southland. Some of these regions were chosen because they had particularly low recorded PHO enrolment rates according to Oranga Tamariki data from the 2021/2022 financial year, and others were selected because the rates were higher than average for that year¹⁸.

We made a point of speaking with tamariki, rangatahi and kaimahi in Oranga Tamariki residences, and with tamariki, rangatahi, caregivers and kaimahi attached to iwiCloseiwi
TribeView the full glossary/Māori organisations that have strategic partnerships with Oranga Tamariki. We did this to understand some of the barriers and enablers around access to healthcare.

In July to September 2023, we met with:

The insights included in this report are primarily from the visits and huiClosehui
Meeting, gatheringView the full glossary that we carried out specifically for this review. However, we also considered insights from our three years of monitoring and have included these where relevant.

Over three years from 2020 - 2023 we heard from:

The data included in this report are from responses to a data request to Oranga Tamariki and Open Home Foundation that was made in addition to our annual data requests for our Experiences of Care in AotearoaCloseAotearoa
New ZealandView the full glossary report.

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The NCS RegulationsCloseNCS Regulations
(National Care Standards and Related Matters) Regulations 2018 View the full glossary require the chief executive of Oranga Tamariki and the director of a child and family support service with custodial responsibilities, to take reasonable steps to ensure that tamarikiClosetamariki
Children (plural) aged 0-13 yearsView the full glossary and rangatahiCloserangatahi
Young person aged 14 – 21 years of ageView the full glossary in care are “enrolled (in consultation with their parents or guardians) with a primary health organisation from which they can access medical services”²¹. Enrolment is the entry point to receiving primary health care.

Enrolments

We have requested data from Oranga Tamariki every year since we began reporting on compliance with the NCS Regulations. For the 2022/2023 reporting period, Oranga Tamariki data shows 56 percent of tamariki and rangatahi in its care were enrolled with a PHO. This is based on administrative data collected by social workers, and is slightly better than previous years, with 53 percent reported in 2021/2022, and 50 percent in 2020/2021²².

5,977 Number of tamariki and rangatahi in care

3,329 Number enrolled with a PHO

56% Percent enrolled with a PHO

93% Data matching with Te Whatu Ora found 93 percent of tamariki and rangatahi in the care of Oranga Tamariki were enrolled with a PHO.

Oranga Tamariki recognises that its administrative data is poor and most likely under reports actual PHO enrolments²³. Oranga Tamariki has worked with Te Whatu Ora on a data matching exercise, which found 93 percent of tamariki and rangatahi in the care of Oranga Tamariki as at 30 June 2023 were enrolled with a PHO. The Ministry of Health, with the support of Oranga Tamariki, also completed work using de-identified data on PHO enrolments in the IDI as at 30 June 2021, which again found high levels of enrolment (93 percent for males and 95 percent for females).

This data paints a more positive picture. However, we note that this data likely over reports current PHO enrolment rates because it won’t necessarily be updated when tamariki and rangatahi move until they re-enrol with a new PHO. This means, for example, that if tamariki are registered with a PHO in Wellington but then move to the Hawke’s Bay and are not registered with a PHO there, they would still show as enrolled with a PHO.

We are waiting for Oranga Tamariki to confirm with Te Whatu Ora how often its PHO enrolment data is to be updated. While this data has some limitations, it is encouraging to see evidence that PHO enrolment levels are much higher than the data from Oranga Tamariki systems would suggest.

Oranga Tamariki has told us that it currently isn’t practicable for the information from data matching to be directly used by social workers. Oranga Tamariki has stated there is ongoing work to determine how best to use this information to support practice, including whether it can be updated in the Oranga Tamariki case management system and other possible alternative uses.

Until Oranga Tamariki can see accurate enrolment data in its own systems, its own records will continue to be incomplete. This can impact on the ability to share important information with caregivers, whānauClosewhānau
Whānau refers to people who are biologically linked or share whakapapa. For the Monitor’s monitoring purposes, whānau includes parents, whānau members living with tamariki at the point they have come into care View the full glossary and other social workers that may be working with the tamariki or rangatahi. There continues to be a lack of urgency to ensure that data collection by social workers is improved.

Although enhancing the data match is one solution to improving records, the best source of data will come from social workers who have contact with tamariki and rangatahi, and who actively record when and how they are supporting their health needs. Rather than waiting to improve data matching, Oranga Tamariki could take steps now to encourage its own record keeping at the frontline.

Whatever the true rate of PHO enrolment, what matters most is that tamariki and rangatahi in care are having their health needs met. We know that tamariki and rangatahi in care have poorer health outcomes than those who are not in care, and a higher degree of unmet health needs²⁴. Access to primary health care and dental services can ensure that their health needs are assessed thoroughly, by health professionals, opening the door to any further health care that’s required.

Without clear guidance and communication, and better data and monitoring, Oranga Tamariki cannot know whether it is complying with the NCS Regulations regarding health care. It cannot know whether it is supporting the health needs of tamariki and rangatahi in care.

Barriers to enrolment and access to health services

We spoke to tamariki, rangatahi, caregivers and kaimahi from across the oranga tamariki system to understand what prevents tamariki and rangatahi in care from being enrolled with a PHO. It is clear from our engagements that the issue of consent is seen as a significant barrier to ensuring that tamariki and rangatahi in care are enrolled with a PHO and have timely access to primary health services.

Parental/whānau consent

We heard there is confusion around the need for parental or guardians’ consent in complying with the NCS Regulations. While it is important to involve parents in decision making, sometimes this can be challenging and should not result in delays for tamariki and rangatahi accessing services.

There are several pieces of legislation, including the Care of Children Act 2004, the Oranga Tamariki Act 1989 and the NCS Regulations that apply to guardians and caregivers when making decisions that affect the lives of tamariki and rangatahi. This includes the decision to enrol tamariki and rangatahi with a PHO or to access health and dental services. Requirements on Oranga Tamariki, as well as caregivers, may vary depending on orders made by the Family Court in respect of custody and guardianship²⁵.

When enrolling tamariki and rangatahi with a PHO, the requirement on Oranga Tamariki is to consult with parents or other guardians. Practice guidance for Oranga Tamariki social workers and other kaimahi reflects this, in that the views of parents and whānau or family “about who te tamaiti should be referred to” should be a consideration in enrolling tamariki and rangatahi with a primary health provider²⁶. This is listed as one of ten considerations and is also consistent with one of the Oranga Tamariki ‘manaClosemana
Prestige, authority, control, power, influence, status, spiritual power, charismaView the full glossary tamaiti’ objectives²⁷. Practice guidance also makes clear that it is the responsibility of Oranga Tamariki to enrol tamariki and rangatahi with primary health providers if they are not already enrolled.

Likewise, accessing annual health checks, or seeking treatment for routine health or dental treatment does not require the consent of parents.

However, the practice guidance for enrolling tamariki and rangatahi with PHOs is silent on matters of consent and does not make it clear that consent is not required. Similarly, practice guidance does not advise on what to do in instances where there may be disagreement or lack of cooperation from parents and guardians, and nor does it provide guidance about the extent to which consultation should be sought (and time to be taken) before enrolment should be progressed for the benefit of the child. A copy of the practice guidance on enrolments, which forms part of a longer piece on practice guidance on health, is provided in Appendix One.

This lack of clarity is likely to be a contributing factor to why we heard from many kaimahi across the oranga tamariki system that a barrier to enrolment was a lack of clear understanding of what agreements are needed from parents and guardians.

“They either have to wait or the social worker has to make a tough call to apply for additional guardianship for that purpose.”

“Had a particular father who wouldn’t give consent for caregiver to enrol with a GP or dental.”

“Also, enrolment is a guardianship issue. A number of tamariki have been with us for a number of years, and we try to keep them in the same health service provider.”

“Children in care have protections under the Children’s Act and other acts when in care which sometimes restrict the care provision that we can give with general practice within our other regulations. I’m just makinga point that bureaucracy is part of our problem. An example; I think the guardianship and then consent and then who has the rights to care for that child, there is a lot of legislation [for] something so simple to just access [medical] care.”

Similarly, with respect to seeking medical treatment and completing health checks, we heard that it is also not always clear to Oranga Tamariki kaimahi, caregivers or medical practitioners, when consent is required, or the extent to which consultation with parents is required before treatment can be sought. This is despite Oranga Tamariki practice guidance making a distinction between routine and non-routine medical procedures.

Routine medical procedures can be consented to by the day-to-day caregiver (where they hold custody) or Oranga Tamariki, and do not require the consent of parents.

Routine medical procedures are described as “procedures that a New Zealand tamaiti or rangatahi generally needs to have their day-to-day care met, for example, visiting a GP if unwell, and routine checks such as dental check-ups and Plunket or Well Child Tamariki Ora checks”²⁸.

Non-routine medical procedures are described in the practice guidance as those procedures that “include immunisation, injections, examinations under anaesthetic, internal examinations, examination of the anal/genital region, and examinations relating to alleged sexual abuse, and operations”²⁹. Non-routine medical procedures require consent from a guardian, all guardians and/or the rangatahi if they are aged 16 or above, depending on the procedure.

From what we have heard, increased communication, training and guidance would help kaimahi and caregivers to understand how to balance the needs of tamariki and rangatahi with those of parents and other guardians, and ensure that misunderstandings do not delay enrolment or access to health and dental treatment.

Lack of available services

The lack of availability of primary health services in some parts of AotearoaCloseAotearoa
New ZealandView the full glossary has been well documented, and this may impact on the ability of Oranga Tamariki and Open Home Foundation to comply with the health related NCS Regulations.

Te Whatu Ora published wait times in October 2023, showing long delays in the length of time tamariki across the country are waiting for assessments and treatment³⁰. General Practice New Zealand has published data on closed books due to workforce shortages³¹. Closed books means that these practices are not accepting new enrolments. We had intended to analyse Oranga Tamariki regional enrolment rates, and the availability of primary health services, to understand any correlation between the two. Due to the limitations of the administrative data provided to us, we have not been able to do that.

There have also been reported shortages in the oral health workforce, and particularly for oral health therapists, who work mostly with tamariki in public health settings. Tamariki and rangatahi in Aotearoa are entitled to free basic oral health services until they reach the age of 18³². Pre-school and primary school-aged tamariki are usually seen by a local oral health service, and rangatahi aged 13 years and above are usually seen at a private dental practice in the community.

When we spoke with caregivers and kaimahi with Oranga Tamariki, we heard that enrolment with dental services is often automatic through schools and some early childhood education services. This means that enrolments may be lost or disrupted where tamariki and rangatahi in care experience changes in their care placement if the changes necessitate a change in school. We also heard that tamariki and rangatahi are not automatically enrolled if they are with an Alternative Education provider, of if they do not have an educational placement. A regional health kaimahi told us:“We have good relationships with the schools – they have good enrolment details – the difficulty again, is the little people who are not engaged at a school – they might not be in a preschool – again it’s those 3-5 years we might not see a child – then we struggle at times to find those under 5s, its fine at primary school. We have those relationships with high school – but if they are not engaged in education, it’s hard.”

Health practitioners with knowledge and experience of cultural values and practices

The NCS Regulations state that the chief executive must ensure that “reasonable endeavours are made to ensure that the child or young person has access to a health practitioner who has knowledge and experience of the cultural values and practices of that child or young person”³³. For tamariki and rangatahi Māori, this means access to a health practitioner with knowledge and experience of Māori models of health.

Oranga Tamariki was not able to provide data on access to culturally knowledgeable and experienced health practitioners by tamariki and rangatahi in its care. However, we do recognise that Oranga Tamariki has established strategic partnerships with iwiCloseiwi
TribeView the full glossary and Māori providers to support the provision of culturally appropriate services – some of which may be health services – for tamariki and rangatahi.

We also recognise the challenges of meeting this regulation. Published workforce data shows that there are relatively low numbers of Māori and Pacific health professionals in Aotearoa³⁴. It is also difficult to assess whether a health practitioner is knowledgeable of, and experienced in, the cultural values and practices of tamariki and rangatahi.

Open Home Foundation told us that a health practitioner is considered to have appropriate cultural knowledge and experience “if (for tamariki Māori) they were enrolled in a Kaupapa Māori service, or if they have been enrolled with a medical practitioner who was trained in Aotearoa”³⁵. We asked the Royal New Zealand College of General Practitioners about training and support provided to GPs. They told us training on cultural safety and knowledge is extensive and continuous through medical schools and specialty training. For example, medical schools in New Zealand provide “extensive cultural training”, and specialty training has cultural safety and knowledge as a core component of the GP curriculum and assessments. This is aimed at ensuring all New Zealanders can access safe and culturally appropriate general practice care close to where they live.

Open Home Foundation data states that 100 percent of tamariki and rangatahi in its care had access to a culturally knowledgeable and experienced health practitioner in the 2022/23 financial year.

We also heard from regional Open Home Foundation kaimahi that the six-monthly reviews of individual plans include an assessment of whether the health provider is culturally appropriate for the tamariki, and whether there is a need for a new practitioner to ensure cultural competency. We heard that rangatahi are given the option if they would like to access a GP who identifies as Māori.

“I’ve got two young Māori people on my caseload, one is 15 and loves their GP and the other wants to go where their foster parent goes. They are given the option, if Māori want to access a Māori GP.”

Kaimahi from Oranga Tamariki told us that the cultural knowledge and experience of health practitioners is not a consideration in cases where it is difficult to secure any health provider. What is important is that tamariki and rangatahi have their health needs assessed and met. This was underscored by some of the rangatahi we spoke to, who said that accessing a culturally knowledgeable and experienced health practitioner is not important to them.

“They are there to work for our health, not our culture.”

“Not that important (to us), but for the older generation it is important.”

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Enrolment is one thing but being seen by a general practice and oral health service is what matters. The NCS RegulationsCloseNCS Regulations
(National Care Standards and Related Matters) Regulations 2018 View the full glossary require that a child or young person in care or custody “has (or has access to) an annual health check by a health professional” and “an annual dental check”³⁶.

Oranga Tamariki practice guidance for social workers outlines the importance of an annual health check. It states that the annual health check is an opportunity to support tamarikiClosetamariki
Children (plural) aged 0-13 yearsView the full glossary to have their health needs met, as well as “to talk with tamariki about matching the health professionals to their needs as these can change over time”³⁷. It also states that annual health checks for school-aged tamariki can be carried out by several healthcare professionals including a GP, practice nurse, school-based health provider, youth health service or a “Māori health practitioner”.

We requested data from both Oranga Tamariki and Open Home Foundation on the completion of annual health and dental checks for tamariki and rangatahiCloserangatahi
Young person aged 14 – 21 years of ageView the full glossary in their custody. We have requested this data every year for the past three financial years.

Oranga Tamariki was unable to provide data on annual health and dental checks being completed for tamariki and rangatahi in its care. However, other data provided by Oranga Tamariki, sourced from IDI analysis, shows that approximately 70 percent of tamariki and rangatahi in care were seen by a GP in the twelve months to 30 June 2021. Oranga Tamariki has also pointed to its health lead indicator, which looks at the completion of assessments and plans. However, without knowing that health checks have occurred, it is unclear whether Oranga Tamariki can assure itself on the quality and extent of these assessments and plans.

Open Home Foundation data states that 79 percent of tamariki and rangatahi in its care had an annual health check in 2022/2023, and 75 percent had a dental health check (or were not eligible due to their age).

We heard in our engagements that there is no standard approach to carrying out annual health checks for tamariki and rangatahi in care, and that this requirement in the NCS Regulations is poorly understood. We also heard that there is low awareness of the NCS Regulations among health professionals, with inconsistent views as to what constitutes an annual health check for tamariki and rangatahi in care. In one regional huiClosehui
Meeting, gatheringView the full glossary with health professionals, one kaimahi was unaware of the requirement for annual health checks for tamariki and rangatahi in care, while their colleague was able to describe what the health check should entail.

We also heard from Open Home Foundation that tamariki and rangatahi only go to see their primary care provider for health care when there is a presenting issue. We understand that Open Home Foundation records these visits as annual health checks. An Open Home Foundation kaimahi told us:

For dental provision, oral health professionals told us that an annual dental check is no longer the norm for tamariki and rangatahi across AotearoaCloseAotearoa
New ZealandView the full glossary (regardless of care status). To respond to a reduced workforce as well as those individuals with low risk, frequency of dental checks for tamariki and rangatahi is based on a caries risk assessment. We heard from some regional health services that some tamariki and rangatahi (regardless of care status) are still not getting regular dental checks despite this change. We also heard from Te Whatu Ora that tamariki and rangatahi in care would be considered a priority if they could be identified by kaimahi.

We cannot know whether compliance with the NCS Regulations would be better if there was greater awareness, among all professionals engaging tamariki and rangatahi in care, of the legal requirement for these tamariki and rangatahi to have access to annual health and dental checks. Nevertheless, there is a need for greater engagement between Oranga Tamariki and the health sector to ensure that kaimahi have a clear understanding of what the standard is, and whether it is being achieved. Annual health and dental checks provide an opportunity for further health needs to be identified, and for any delays in needed treatment to be addressed.

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This review sought to understand the policies, practice and supports that are wrapped around tamarikiClosetamariki
Children (plural) aged 0-13 yearsView the full glossary and rangatahiCloserangatahi
Young person aged 14 – 21 years of ageView the full glossary in care to ensure compliance with the health related NCS RegulationsCloseNCS Regulations
(National Care Standards and Related Matters) Regulations 2018 View the full glossary.

Assessing health needs

When we asked kaimahi from Oranga Tamariki about access to primary health care, we heard consistently that the health needs of tamariki and rangatahi coming into care are assessed through a Gateway⁴⁰ assessment, which covers both health and education needs. Health needs assessments are required by the NCS Regulations. Open Home Foundation also advised that it does not have access to Gateway assessments, despite requesting this from Oranga Tamariki since they were first implemented.

We also heard that the holistic wellbeing needs of tamariki and rangatahi are set out in Tuituia assessments, and that these assessments are used to inform individual All About Me Plans.

As discussed in our 2022/2023 Experiences of Care in AotearoaCloseAotearoa
New ZealandView the full glossary report, Oranga Tamariki has developed a self-monitoring framework to monitor compliance with the NCS Regulations. The framework currently includes 16 lead indicators⁴¹.

For health, the lead indicator measures the extent to which health needs of tamariki and rangatahi in Oranga Tamariki care have been identified and addressed in their individual plans. Oranga Tamariki reports that this has improved in 2022/2023 to 87 percent (up from 82 percent in 2021/2022, and 78 percent in 2020/2021) of plans including health needs assessments.⁴²

While we recognise there has been an improvement in assessing the health needs of tamariki and rangatahi in Oranga Tamariki care, we note that these assessments do not ensure compliance with the NCS Regulations around access to primary health care. As already noted, without knowing that health checks have occurred, it is unclear whether Oranga Tamariki can assure itself as to the quality and extent of these assessments and the source of health information.

Gateway assessments do not, for example, necessarily cover dental needs (we heard conflicting information on this from National Office and some sites) although Oranga Tamariki states that social workers may look to see when tamariki and rangatahi last engaged with dental care. We also heard that there is no requirement for a General Practice or specific health professional to be named in individual care plans. The health needs lead indicator is also an assessment of individual plans and does not guarantee that services and supports are in place.

Roles and responsibilities within Oranga Tamariki

Despite the completion of assessments and plans to address health needs, we heard from kaimahi in our regional engagements that there are no organisation-wide systems in place across Oranga Tamariki to ensure that tamariki and rangatahi are accessing primary health services and dental care.

Practice guidance for Oranga Tamariki social workers on supporting tamariki with their health needs makes it clear that it is the responsibility of Oranga Tamariki to enrol tamariki and rangatahi with primary health providers if they are not already enrolled or engaged with one. The practice guidance states that social workers will ensure appointments are made for annual health checks, unless they are scheduled directly by the health provider (this is more likely for Well Child Tamariki Ora and some school-based health services). However, we heard from Oranga Tamariki national office that practice guidance is not fully embedded across Oranga Tamariki, and in our visits we heard many instances where the responsibility for enrolments and annual checks has been passed from social worker to caregiver. A regional Oranga Tamariki kaimahi told us:

“The expectation that those needs will be met are put on the caregivers, this capacity is not fair on caregivers, they are often working and have their own whānauClosewhānau
Whānau refers to people who are biologically linked or share whakapapa. For the Monitor’s monitoring purposes, whānau includes parents, whānau members living with tamariki at the point they have come into care View the full glossary, there is a capacity issue in my opinion.”

Some social workers at Oranga Tamariki in Te Tai Tokerau told us that they don’t have the time to follow up on annual health and dental checks, particularly at sites where kaimahi report that they have high and complex caseloads where more immediate needs are prioritised. In some locations, this is coupled with a lack of available health services.

Data from a Medical Council of New Zealand workforce survey for 2022⁴³, shows that Te Tai Tokerau had 162 GPs for a population of 197,900. This equates to 82 GPs per 100,000. Nationally (based on 2021 population estimates), there were 85 GPs per 100,000.

This gap in Te Tai Tokerau is also seen with dental practitioners. Te Tai Tokerau has 43 dentists and dental specialists per 100,000, for those aged over 15 years. The national average is 61 dentists and dental specialists per 100,000 for those aged over 15 years.⁴⁴

While we heard that many instances of enrolments and checks had been passed to caregivers, many caregivers we spoke to were unaware of the NCS Regulations around primary health enrolments and annual health and dental checks, and said they were not clear about their own responsibilities around this.

As discussed in our 2022/2023 Experiences of Care in Aotearoa report, fewer than half of Oranga Tamariki caregivers are being visited to the frequency of their plans, and a recent caregiver survey shows decreasing levels of satisfaction with Oranga Tamariki. Low levels of contact with social workers may account for caregivers being unaware of references to the NCS Regulations in the ‘caregiver kete’, as well as some caregivers being reluctant to make medical appointments for the tamariki and rangatahi in their care for fear of overstepping.

We also heard from caregivers that Oranga Tamariki does not always pass on important health-related information about the tamariki and rangatahi in their care. We heard the same thing from caregivers during our broader monitoring visits, and our 2022/2023 Experiences of Care in Aotearoa report will show that vital health information, such as immunisation status and conditions such as epilepsy, has sometimes been withheld from caregivers. Some caregivers told us:

Systems and tools within Oranga Tamariki

Social workers can record health information including visits to health professionals in CYRAS, the database used by kaimahi at Oranga Tamariki. However, we heard from several kaimahi that there is no systematic way to report on annual health checks from CYRAS. This means there is no system reminder when annual health and dental checks are due.

During our engagements for the review, we heard that some Oranga Tamariki sites have regular care clinics that bring kaimahi together and focus on the NCS Regulations.

While this looks promising, the lack of data and monitoring from Oranga Tamariki limits the organisation’s ability to see if these practices are making a difference in ensuring that tamariki and rangatahi have access to primary health care and dental services. It is through data collection and monitoring that best practice can be identified and shared across the organisation.

Open Home Foundation

When we spoke to national office and regional kaimahi from Open Home Foundation, we heard that the IT system used by the organisation ensures that enrolments and annual health and dental checks are completed and recorded⁴⁵. We heard that Open Home Foundation’s OSCAR database supports good practice and can remind kaimahi when checks and other appointments are due. Kaimahi also told us that clear expectations are set by the leadership team to ensure compliance with the health related NCS Regulations.

We also heard from caregivers in one Open Home Foundation region that they receive annual training on the NCS Regulations, and that there are regular audits around compliance. These systems and processes mean that kaimahi are clear on their responsibilities and what is expected of them.

Open Home Foundation advised that it does not have formal, national annual training on the NCS Regulations. However, foster parents are kept up to date with any policy changes. It also uses six-monthly foster parent support plans to identify any support required for tamariki and rangatahi health and dental needs, and any further training foster parents may require.

Open Home Foundation kaimahi told us that six-monthly reviews of individual plans ensure that tamariki and rangatahi have continuity of dental care, even if their placements change. Several caregivers and social workers with Open Home Foundation told us that social workers will take tamariki and rangatahi to health and dental appointments if caregivers are unable to, or in some cases will provide transport.

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One of our objectives for the review was to understand where there may be inequitable access to primary health services. We wanted to look closely at PHO enrolment rates and the completion of annual health and dental checks in different types of care placement, different regions, and for different groups of tamarikiClosetamariki
Children (plural) aged 0-13 yearsView the full glossary and rangatahiCloserangatahi
Young person aged 14 – 21 years of ageView the full glossary in care. However, due to the shortcomings of the administrative data provided by Oranga Tamariki⁴⁶, we have been unable to do this.

In Open Home Foundation data, we were able to see that tamariki and rangatahi Māori in Open Home Foundation care have better access to annual health (84 percent) and dental checks (78 percent) than Pākehā European and other⁴⁷ tamariki in its care (73 percent and 70 percent respectively). While the numbers of tamariki and rangatahi are too small to draw firm conclusions, this data does at least suggest an absence of barriers to equity for tamariki and rangatahi Māori in this regard.

We looked at ethnicity because it is important to ensure equity of access for Māori tamariki and rangatahi, who make up a large proportion of the care population and have traditionally been poorly served by government agencies.

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Information sharing

We spoke with many health professionals as part of this review, including representatives from the three health agencies Ministry of Health, Te Whatu Ora and Te Aka Whai Ora. We spoke with clinical directors for oral health, directors of nursing, planning and performance managers, service managers, General Practitioners, nurse leads, practising dentists, and many others with roles in service delivery at both national and regional level. The vast majority said that they wanted to prioritise service delivery for tamarikiClosetamariki
Children (plural) aged 0-13 yearsView the full glossary and rangatahiCloserangatahi
Young person aged 14 – 21 years of ageView the full glossary in care because they recognise the high levels of unmet health need in this group.

Despite this willingness to ensure access to primary health services and dental care, we also heard from health professionals that they don’t have the information they need to be able to prioritise tamariki and rangatahi in care. Tamariki and rangatahi in caregiver placements (with whānauClosewhānau
Whānau refers to people who are biologically linked or share whakapapa. For the Monitor’s monitoring purposes, whānau includes parents, whānau members living with tamariki at the point they have come into care View the full glossary or non-whānau caregivers) are generally not known to health professionals, and there is an implicit expectation that they access primary health care in the same way as other tamariki and rangatahi do – that is, with an adult seeking and accessing services on their behalf.

This is an issue that has also been identified in the in-depth primary health needs assessment carried out as part of the cross-agency Oranga Tamariki Action Plan. The report, Primary Health Needs of Children and Young People in Care, states that tamariki and rangatahi in care are “invisible within” and often “bypass” the primary health system”⁴⁸, leading to more serious health concerns including hospitalisations for avoidable reasons (at twice the rate of the general population in 2020).

This issue would be resolved if the care status of tamariki and rangatahi in care were communicated by social workers at the point of enrolment with primary care providers as well as oral health services. What is needed is policies, practice guidance and clear communication in place to support social workers to do this.

In our engagements, we also heard that access to dental checks can be a particular problem when school-aged tamariki and rangatahi in care have a change in placement. Moving placement may mean that tamariki and rangatahi need to start at a new school, which may mean that they miss out on dental checks if the school-based dental services have already been and gone. For some tamariki and rangatahi, frequent changes in care placement may mean that they can go for several years without a dental check.

One regional dental service told us that they attempted to put a Memorandum of Understanding in place with the Ministry of Education, to ensure they could pick up any tamariki and rangatahi moving into the region. This was declined due to limitations of the Education and Training Act 2020. Although the Ministry of Education is currently working to improve information sharing within the parameters of relevant legislation, the dental service kaimahi who spoke about this were unable to prioritise or even just ensure service delivery to tamariki and rangatahi in care in the region.

When we spoke with officials from the health agencies, they were keen to see better information-sharing between Oranga Tamariki and the health system but are also aware of both the advantages and disadvantages of sharing information. Some kaimahi spoke to us about the discrimination and stigma that may be attached to tamariki and rangatahi in care, which could deter some primary health providers from taking them on as clients/patients. This perception differs from the health professionals we spoke with in regions. However, if this is an issue, it is something for the health agencies and the Royal New Zealand College of General Practitioners to discuss in order to ensure that it is not a barrier to receiving service.

Roles and responsibilities within the public sector

We heard from Oranga Tamariki kaimahi that there may be a perception among other government agencies that Oranga Tamariki should cover the cost of services for tamariki and rangatahi in its care, including primary health services. Although we heard a willingness for agencies to be working more closely together, kaimahi with the Ministries of Education and Health, as well as Oranga Tamariki, told us that agencies do not have a shared view as to who is responsible for ensuring tamariki and rangatahi in care have access to primary health services.

Although work is underway to ensure that government agencies work better together to support the health needs of tamariki in care, it seems clear that this is at an early stage. Many health professionals we spoke to for this review were unaware of the Oranga Tamariki Action Plan and wider efforts to have government agencies working more effectively together. Kaimahi in both Oranga Tamariki and Te Whatu Ora told us it was difficult for the two agencies to work together in a meaningful way.

However, we heard what’s possible when agencies work together. In one of the regional huiClosehui
Meeting, gatheringView the full glossary that we convened for this review, a clinical director heard from Oranga Tamariki about a four year old whose oral surgery had been long delayed – by the end of the hui, the clinical director had committed to ensure that the surgery would be fast-tracked for this child.

The need for greater collaboration is a theme that we have heard consistently over the last three years of monitoring visits to inform our annual Experiences of Care in AotearoaCloseAotearoa
New ZealandView the full glossary reports. However, during our monitoring in 2022/23, we did start to hear more positive examples of agencies working together at a local level.

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Oranga Tamariki is responsible for five Youth Justice and two currently operational Care and Protection secure residences. We visited four Oranga Tamariki residences for this review – three Youth Justice residences, and one Care and Protection residence.

Health and dental services provided to tamarikiClosetamariki
Children (plural) aged 0-13 yearsView the full glossary and rangatahiCloserangatahi
Young person aged 14 – 21 years of ageView the full glossary in the secure residences are delivered by contracted providers. The health providers vary from PHOs, public health nurses and youth health services. Oranga Tamariki told us:

Some of the Oranga Tamariki kaimahi we spoke to were full of praise for these health partners (they “have been amazing”). In some of the residences we visited, both residence leadership and the health teams talked about positive relationships that support service provision. We also heard that in several instances Oranga Tamariki sites have provided financial assistance for tamariki and rangatahi to receive overdue health services.

Service specifications for residential health provision state that a health assessment must be completed within 24-48 hours of entering the residence. We heard that the health needs of tamariki and rangatahi are assessed within this timeframe on a regular basis.

The health team in one residence described the positive relationships they had built up over several years with their colleagues in the community. They described “being lucky” that their local audiology department does free auditory processing assessments, so they send most of the tamariki and rangatahi there. This helps them understand how the brain is interpreting certain sounds or words, and how much tamariki and rangatahi are understanding and hearing, which supports their learning in school.

The same health care team also talked about how being part of Te Whatu Ora supports their access to the health records of the tamariki and rangatahi in the residence, so they can look at their history and see what assessments and services may have already been completed.

We heard from most of the tamariki and rangatahi we spoke to that they can access health care when they need it.

When asked if residence kaimahi talk to tamariki and rangatahi about their health when they arrive, a rangatahi said:

Although we heard mostly positive examples of these arrangements working well, we did hear about some barriers. We heard from one health professional who told us the example of a young person reaching out to them to request a health check as they hadn’t had one in ten years.

At the same time, Oranga Tamariki national office kaimahi told us about their efforts to ensure tamariki and rangatahi maintain consistency with their health and dental access when transitioning in and out of the residences.

For tamariki and rangatahi who come into a secure residence, there is an opportunity to connect them with health services, so they are there for them when they return to their community.

We heard an example, from a health professional, of a successful transition for a rangatahi from residence who was referred to a mental health service and a youth one stop shop, which included dental services and a counselling service. They described it as a “huge piece of work”.

The example shows how successful transitions can be achieved in practice. However, there is no clear guidance about how this is to happen and who has the responsibility within Oranga Tamariki.

We also heard that, while many tamariki and rangatahi in residences have good access to dental care, it can be inconsistent. We were told that a dental bus comes to one of the Youth Justice residences, and that one of the Care and Protection residences uses a private dental service (providing publicly funded care under contract to the local Te Whatu Ora district) to avoid waitlists.

Kaimahi from one dental provider told us that their capacity to deliver dental services to tamariki and rangatahi in one residence is constrained by their contract to deliver dental services in schools.

We also heard about difficulties for tamariki and rangatahi in other residences to access dental services, either because of the level of staff resource needed to take tamariki and rangatahi off-site, or due to the perceptions of some dental providers that there is a risk to their safety in providing these services. We heard that media reports may have led to these perceptions, and that some solutions had been put forward such as showing clinicians around the residence prior to offering any treatment.

When we asked Oranga Tamariki national office kaimahi about the behaviour of rangatahi when receiving dental treatment, we heard that tamariki and rangatahi in care are often coping with the effects of trauma, which can make it particularly difficult for them to receive dental treatment. In some cases, this can mean that dentists are avoided completely, and treatment is delayed over a long period. However, our residence visits showed what’s possible when health professionals work sensitively with rangatahi, and/or when they are equipped to work with individuals (regardless of care status) experiencing trauma.

We know that there are few dental specialists across the country who are trained and equipped to work with patients (regardless of care status) whose dental care is affected by trauma and/or may require sedation and hospital-based dental care. However, it is vital that tamariki and rangatahi in care are supported to access the dental care they need. The cost of prolonged unmet need is too great for these tamariki and rangatahi.

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Te Tohu o te Ora o Ngāti Awa (Ngāti Awa) shows what’s possible when there is good communication and collaboration across the oranga tamariki system. Oranga Tamariki has a strategic partnership⁴⁹ with the Eastern Bay of Plenty IwiCloseIwi
TribeView the full glossary Provider Alliance, made up of four iwi provider organisations including Ngāti Awa.

We met with representatives from Ngāti Awa to understand how their strategic partnership with Oranga Tamariki supports enrolment and access to primary health care and dental services for tamarikiClosetamariki
Children (plural) aged 0-13 yearsView the full glossary and rangatahiCloserangatahi
Young person aged 14 – 21 years of ageView the full glossary in their care. We heard how the culture and leadership of Ngāti Awa, together with its close relationship with the local Oranga Tamariki site, support enrolment with a PHO and facilitates the fast-tracking of services and supports for tamariki and rangatahi.

Ngāti Awa takes a holistic approach to health care, aligning with te ao MāoriClosete ao Māori
The Māori worldView the full glossary. Recruitment processes are in place to ensure kaitiaki (caregivers) share the same values and are able to apply Te Pou Mataaho Framework to their care practice. When tamariki and rangatahi enter Ngāti Awa care, they receive a mihi whakatau that further reflects the values of Ngāti Awa. Tamariki and rangatahi told us they feel well supported by their kaitiaki and kaimahi since coming into Ngāti Awa care, and that their experience has improved.

Ngāti Awa has a database to ensure that information about tamariki and rangatahi in its care is up to date. It includes information from Oranga Tamariki, including Gateway assessments. Kaitiaki can view these assessments and follow up on outstanding actions from the most recent multi-disciplinary meetings with service providers.

Working with Oranga Tamariki

Ngāti Awa kaimahi told us they have a very positive relationship with Oranga Tamariki at the local site, Whakatāne. We heard that Oranga Tamariki is responsive and helpful. When information about tamariki and rangatahi is needed, or actions need to be taken, a phone call to the social worker is usually all that is needed. The positive relationship has facilitated the fast-tracking of services and support for tamariki and rangatahi in care.

Enrolments with a PHO

We heard from Ngāti Awa that Oranga Tamariki is required to enrol tamariki and rangatahi with a PHO, and that 80 to 90 percent of tamariki and rangatahi are already enrolled before coming into Ngāti Awa care. The remaining tamariki and rangatahi are enrolled promptly, with Ngāti Awa and Oranga Tamariki working together to identify who is best placed to organise enrolment.

We heard from Ngāti Awa about the issue of whānauClosewhānau
Whānau refers to people who are biologically linked or share whakapapa. For the Monitor’s monitoring purposes, whānau includes parents, whānau members living with tamariki at the point they have come into care View the full glossary consent. Kaitiaki told us that, while they understand there are custody orders and sections Oranga Tamariki must adhere to, they want to be entrusted to care for the tamariki and rangatahi in their homes. This includes ensuring that tamariki and rangatahi receive necessary health services and supports in a timely manner, without necessarily waiting on consent from parents where it is not required by law.

Annual health checks

We heard from Ngāti Awa that it has not received information from Oranga Tamariki about the need for annual health checks. However, from their perspective, health needs were being met with tamariki and rangatahi having regular engagement with General Practice/primary care providers, but not for the purpose of annual health checks.

Dental checks

We heard that enrolment with a dental provider, and dental checks, are automatic when tamariki are enrolled at primary school. The experience of tamariki and rangatahi in Ngāti Awa care receiving annual dental checks was consistent with what we heard from health professionals – instability of care placements can mean that tamariki are not receiving dental checks through school. They also noted long waitlists for dentists have caused delays of 2–4 years. We also heard that rangatahi who have left school or who are with an Alternative Education provider are not automatically enrolled with, and able to see, a dentist.

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Oranga Tamariki has a strategic partnership⁵⁰ with Te Rūnanga o Ngāi Tahu. As part of this, a new model of care (Tiaki Taoka) has been co-designed by Ngāi Tahu and Oranga Tamariki. This sits within Te Kāika, a community healthcare hub based in Dunedin. We met with kaimahi and caregivers from Te Kāika as part of this review.

Kaimahi told us about their holistic model of care, effectively offering a one-stop shop that includes “clinical nurses, pathways for cancer patients, health in general education, dentists – just about everything”. They told us they are well-known in the community and that there is a lot of trust. However, we also heard that, despite the strategic partnership at a national level, there has been a breakdown in the relationship at local level between Oranga Tamariki and Te Kāika.

Caregivers associated with Te Kāika relayed some positive experiences with Oranga Tamariki, such as access to training sessions around trauma. However, they also told us about delays with Gateway assessments being completed, and that they have sometimes received inaccurate health-related information from Oranga Tamariki about the tamarikiClosetamariki
Children (plural) aged 0-13 yearsView the full glossary and rangatahiCloserangatahi
Young person aged 14 – 21 years of ageView the full glossary in their care.

The poor local relationship between Oranga Tamariki and Te Kāika was also referred to in one of our residence visits, where kaimahi told us that they have lost their connection with Te Kāika and therefore their connection with kaupapa Māori health services as a result. The services that Te Kāika has in place present an opportunity for a model to be developed for the benefit of tamariki and rangatahi. However, what the Ngāti Awa model shows is that its success relies upon having a trusted and close working relationship between leadership and staff at both the local Oranga Tamariki site and partners.

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The text below is an extract directly from Oranga Tamariki practice guidance on supporting tamarikiClosetamariki
Children (plural) aged 0-13 yearsView the full glossary with their health needs (as at 15 November 2023):

Enrolling with a primary health provider

The foundation for ensuring health needs are met is enrolling and engaging tamariki with a primary health provider. For most tamariki their primary health provider will be a GP.

If te tamaiti isn’t enrolled with a primary health provider or engaged with a GP we need to enrol them. Things to consider when enrolling tamariki include:

• what service does te tamaiti wants to be enrolled with
• availability of a Māori health practitioner who is suitable to meet the needs of te tamaiti Māori
• availability of a health practitioner who has knowledge and experience of cultural values and practices of te tamaiti
• what support does te tamaiti need to complete their enrolment
• is the information held by the GP up to date
• has te tamaiti moved out of the area and do they need a new GP
• who does te tamaiti and/or their caregiver want to attend the first appointment
• does te tamaiti want their GP to know they’re in care
• does the GP have a copy of their gateway assessment
• do parents and whānauClosewhānau
  Whānau refers to people who are biologically linked or share whakapapa. For the Monitor’s monitoring purposes, whānau includes parents, whānau members living with tamariki at the point they have come into care View the full glossary or family have any views about who te tamaiti should be referred to.

Tamariki can only be enrolled with one GP. If tamariki need to be seen by a GP and don’t have access to their usual GP or are in the middle of being enrolled, they need to attend an appointment as a casual patient. There may be a higher charge for rangatahiCloserangatahi
Young person aged 14 – 21 years of ageView the full glossary who are 14 years old and over.

If tamariki need to move GP, it’s our responsibility to advise the previous GP and enrol them with a new GP. It’s the responsibility of the GP to transfer patient notes.

There may be times when, due to capacity within medical practices, it is challenging to enrol tamariki with a GP. It is important that you explore all local options including contacting the clinical lead at your local Primary Health Organisation (PHO) or, the primary care portfolio manager at the local District Health Board (DHB) for assistance.

Matching services to te tamaiti

It’s important for any patient to have a good relationship with their health provider. Tamariki may have preferences for the type of GP they are likely to feel comfortable with and these preferences should be supported wherever possible.

It is important that health services have knowledge and experience of the cultural values and practices of te temaiti. For tamariki Māori, Māori health services are likely to be best placed to achieve this.

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All About Me Plan

The primary plan that Oranga Tamariki uses to support tamarikiClosetamariki
Children (plural) aged 0-13 yearsView the full glossary and rangatahiCloserangatahi
Young person aged 14 – 21 years of ageView the full glossary needs and objectives.

Care or custody

In relation to tamariki and rangatahi, being subject to an order for custody or sole guardianship or to a care agreement, in favour of the chief executive of Oranga Tamariki—Ministry for Children, an iwiCloseiwi
TribeView the full glossary social service, a cultural social service, or the director of a child and family support service.

Caregivers

People who care for tamariki and rangatahi in custody of Oranga Tamariki, Open Home Foundation or Barnardos. Caregivers can be whānauClosewhānau
Whānau refers to people who are biologically linked or share whakapapa. For the Monitor’s monitoring purposes, whānau includes parents, whānau members living with tamariki at the point they have come into care View the full glossary or non-whānau. They provide a range of care options including respite, short-term, or permanent care. Caregivers are sometimes referred to as foster parents or carers.

CYRAS

Oranga Tamariki administrative database (Care and Protection, Youth Justice, Residential and Adoption Services System).

Gateway assessment

An interagency process between health and education services and Oranga Tamariki to identify the health and education needs of tamariki in care, and how they will be supported.

IDI

The Integrated Data Infrastructure (IDI) is a large research database, maintained by Statistics New Zealand. It holds de-identified data about New Zealand people and households.

Iwi

Tribe

Kaimahi

Staff

Legal guardian

An adult who is responsible for making decisions about important decisions in a child’s life, for example religion and education.

NCS RegulationsCloseNCS Regulations
(National Care Standards and Related Matters) Regulations 2018 View the full glossary

Oranga Tamariki (National Care Standards and Related Matters) Regulations 2018. Came into effect on 1 July 2019, to set out the standard of care tamariki and rangatahi can expect to receive when they are in the care of one of the agencies.

OSCAR

Open Home Foundation’s administrative database and case management system.

Primary health

The Oranga Tamariki Action Plan defines this as health that is addressed at home, at school and in communities.

Rangatahi

Defined by the Oranga Tamariki Act 1989 as a young person or young people aged 14 years or over.

SKS Screens

Substance and Choices, Kessler and Suicide Screens. Screening tools used to evaluate whether tamariki and rangatahi are dealing with substance abuse, suffering psychological distress or are at risk of death by suicide.

Tamariki

Defined by the Oranga Tamariki Act 1989 as children aged under 14 years.

Tamariki Māori

Children of Māori descent.

Te ao MāoriCloseTe ao Māori
The Māori worldView the full glossary

The Māori world.

Tuituia assessment

An assessment used by Oranga Tamariki to capture information about the needs of tamariki and rangatahi. Tuituia focuses on holistic wellbeing of tamariki and rangatahi; capacity of their caregivers to nurture their wellbeing; and whānau, social, cultural, and environmental influences on them and their caregivers.

Whānau

People who are biologically linked or share whakapapa. For the Monitor’s monitoring purposes, whānau includes parents, whānau members living with tamariki at the point they have come into care (this does not include whānau caregivers) or whānau who are close to, and/or involved with tamariki on a day-to-day basis (this does not include whānau caregivers) and who have been involved in decision making about their care.

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1. www.health.govt.nz/system/files/documents/publications/good-oral-health-strategic-vision-2006.pdf
2. We did not include Barnardos in this review because of the very low numbers of rangatahiCloserangatahi
Young person aged 14 – 21 years of ageView the full glossary in Barnardos’ care, and the assurance that Barnardos has been able to provide in terms of compliance with the NCS RegulationsCloseNCS Regulations
(National Care Standards and Related Matters) Regulations 2018 View the full glossary.
3. The Oranga Tamariki Action Plan sets out how certain government agencies will work together to improve outcomes for tamarikiClosetamariki
Children (plural) aged 0-13 yearsView the full glossary and rangatahi “of interest” to Oranga Tamariki. These are those tamariki and rangatahi at risk of entering state care, currently in state care, and those who have transitioned out of state care up to the age of 25.
4. Oranga Tamariki Action Plan (OTAP) In-depth Needs Assessment Report, Primary Health Needs of Children and Young People in Care (June 2023), page 4.

Back to Foreword

5. In this report, we refer to enrolments with primary health organisations, and to tamariki and rangatahi in care seeing General Practitioners and health practitioners.

Back to Key Findings

6. In 2021/22, there were 6,317 tamariki and rangatahi in the care of Oranga Tamariki, compared with 79 in Open Home Foundation care and two in Barnardos care.
7. Duncanson, M. (2016). Health Needs of Children and Young People in State Care. South Island Alliance: www.sialliance.health.nz/wp-content/uploads/2016-SIAPO-Health-needs-of-children-and-young-people-in-State-care.pdf
8. Fleming, T., Archer, D., Sutcliffe, K., Dewhirst, M., & Clark, T.C. (2022). Young people who have been involved with Oranga Tamariki: Mental and physical health and healthcare access. The Youth19 Research Group, The University of Auckland and Victoria University of Wellington, New Zealand.
9. Irurzun-Lopez M, Jeffreys M, Cumming J. The enrolment gap: who is not enrolling with primary health organizations in AotearoaCloseAotearoa
New ZealandView the full glossary 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.
10. 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. doi.org/10.1111/cdoe.12364.
11. 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.
12. 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. pubmed.ncbi.nlm.nih.gov/36735678/
13. 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.
14. For example, General Practice New Zealand reported that 34 percent of general practices were closed to new enrolments in July 2022 (based on data from 853 general practices). There were regional variations with Marlborough, Northland and Taranaki among the regions most affected – none of Kaitaia’s general practices were taking new enrolments. gpnz.org.nz/publications/pho-closed-books-stocktake-report-2022
15. For example, clinical performance data from Te Whatu Ora shows that preventable hospital admissions, for illnesses that could have been treated earlier, had increased during the year to 30 June 2023, and particularly so for young children. www.tewhatuora.govt.nz/publications/clinical-performance-report-1-april-30-june-2023
16. Oranga Tamariki Action Plan (OTAP) In-depth Needs Assessment Report, Primary Health Needs of Children and Young People in Care (June 2023) page 7.

Back to Introduction

17 We did not include Barnardos in this review because of the very low number of tamariki in Barnardos’ care, and the assurance that Barnardos has been able to provide in terms of compliance with the health-related NCS Regulations.
18 According to Oranga Tamariki data for 2021/2022, North and West Auckland, Te Tai Tokerau and Central Auckland had the lowest recorded PHO enrolment rates at 37 percent, 38 percent and 40 percent respectively. Canterbury, Lower South and Taranaki-Manawatu had rates of 60 percent, 66 percent and 69 percent respectively. These regions had higher than average enrolment rates for the year.
19 These are iwiCloseiwi
TribeView the full glossary/Māori organisations that have strategic partnerships with Oranga Tamariki. Te Kāika is a community healthcare hub in Dunedin. It is part of a new model of care (Tiaki Taoka) co-designed by Ngāi Tahu and Oranga Tamariki.
20 We invited the Ministry of Education to engage in the review at a national level. The invitation was declined because the Ministry of Education’s position is that learners, whānauClosewhānau
Whānau refers to people who are biologically linked or share whakapapa. For the Monitor’s monitoring purposes, whānau includes parents, whānau members living with tamariki at the point they have come into care View the full glossary, services and schools know best how dental care is experienced and impacts on the tamariki in their communities. The Ministry of Education states that it is committed to facilitating connections with Aroturuki Tamariki, as well as providing advice and support to services and schools about Aroturuki Tamariki reviews. The Ministry of Education also supports communications about Aroturuki Tamariki so that schools have information about what the reviews might mean for them.

Back to Methodology

21 NCS Regulation 35
22 Our 2020/2021 Experiences of Care in Aotearoa report stated that 60 percent of tamariki and rangatahi in Oranga Tamariki care were enrolled with a primary health provider. However, due to differences in the way Oranga Tamariki has calculated its enrolment data in previous years, Oranga Tamariki now states that 2020/2021 had a 50 percent enrolment rate when applying consistent business rules.
23 Data from Oranga Tamariki includes an acknowledgement that the figures provided are “indicative that a specific doctor or medical centre has been advised and recorded. The values entered in this data source are ‘free text’ so are not consistent records that provide an indication of unknown, unregistered, to be confirmed or other non-enrolment that have been grouped as not being enrolled. Records marked as confidential are also not included in the supplied figure.”
24 Data from the Integrated Data Infrastructure shows that, for the year ending June 2021, tamariki and rangatahi in care had higher levels of Before School Check referrals (meaning that further health needs were identified during these checks), potentially avoidable hospitalisations, Emergency Department admissions, mental health treatment, substance usage treatment, and chronic conditions than tamariki and rangatahi in the general population.
25 In most cases (approximately 70%), when tamariki and rangatahi come into care, Oranga Tamariki become their guardian, in addition to their parents. While caregivers, as custodians, can make day to day decisions for the tamariki and rangatahi, some important matters are reserved for guardians.
26 www.practice.orangatamariki.govt.nz/our-work/care/caring-for-tamariki-in-care/supporting-tamariki-with-their-health-needs (accessed on 5 September 2023).
27 Oranga Tamariki manaClosemana
Prestige, authority, control, power, influence, status, spiritual power, charismaView the full glossary tamaiti objective one is to ensure participation in decision-making, with a measure around whether ‘a parent or other legal guardian was consulted as part of decision-making about health matters’. www.orangatamariki.govt.nz/ assets/Uploads/About-us/Performance-and-monitoring/Section-7AA/Section-7AA-2022-accessible-version-20230815.pdf
28 www.practice.orangatamariki.govt.nz/our-work/care/caring-for-tamariki-in-care/supporting-tamariki-with-their-health-needs/consent-for-medical-examinations-and-treatment (accessed on 5 September 2023).
29 www.practice.orangatamariki.govt.nz/our-work/care/caring-for-tamariki-in-care/supporting-tamariki-with-their-health-needs/consent-for-medical-examinations-and-treatment (accessed on 5 September 2023).
30 www.tewhatuora.govt.nz/publications/clinical-performance-report-1-april-30-june-2023
31 General Practice New Zealand surveyed 23 PHO members, covering 853 general practices, in July 2022. It found that 34 percent of general practices were closed to new enrolments. gpnz.org.nz/publications/pho-closed-books-stocktake- report-2022
32 Where tamariki and rangatahi are eligible for publicly funded health services (eg this may not apply to non-New Zealand residents).
33 NCS Regulation 13. Regulation 35 also states that the chief executive must take “reasonable steps” to ensure access to a culturally knowledgeable and experienced health practitioner.
34 For example, the Medical Council of New Zealand reports that Māori and Pasifika “are noticeably under-represented” in the medical workforce, with 5 percent of doctors identified as Māori and 2 percent identified as Pasifika (in 2022). www.mcnz.org. nz/assets/Publications/Workforce-Survey/64f90670c8/Workforce-Survey-Report-2022.pdf. Similarly the Dental Council of New Zealand reports that, in 2019, Māori made up 5 percent of the total practising oral health workforce. www.dcnz.org.nz/assets/ Uploads/Publications/workforce-analysis/Workforce-Analysis-2018-2019.pdf
35 Email correspondence, 18 September 2023.

Back to Access to primary health care

36 NCS Regulation 35.
37 https://practice.orangatamariki.govt.nz/our-work/care/caring-for-tamariki-in-care/supporting-tamariki-with-their-health-needs (Accessed on 5 September 2023).
38 Annual dental and health check data was provided from Open Home Foundation for 2020/21 but cannot be used for comparison with other years because different business rules were applied.
39 75 percent of tamariki and rangatahi in OHF care received a dental check within the reporting period (or did not need to receive one as they were two years old or under).

Back to Annual health and dental checks

40 A Gateway assessment is an interagency process between health and education services and Oranga Tamariki to identify the health and education needs of tamariki and rangatahi in care, and how they will be supported.
41 The purpose of the lead indicators is to enable Oranga Tamariki to assess compliance with the NCS Regulations and support continuous improvement. According to Oranga Tamariki business rules, the lead indicators are based on existing data sources, mostly casefile analysis, and offer combinations of measures that we have published in our last two Experiences of Care in Aotearoa reports. Because the lead indicators are based on existing measures, lead indicators have been calculated retrospectively for the 2020/2021 and 2021/2022 reporting periods.
42 96 percent of tamariki and rangatahi have a current individual plan.
43 www.mcnz.org.nz/assets/Publications/Workforce-Survey/64f90670c8/Workforce-Survey-Report-2022.pdf
44 www.dcnz.org.nz/assets/Uploads/Publications/workforce-analysis/Workforce-Analysis-2018-2019.pdf
45 Noting that Open Home Foundation consider visiting a GP in the last year as an annual health check.

Back to Policies and practices

46 Oranga Tamariki administrative data on PHO enrolment is recognised as poor and inaccurate, and there is no available data on annual health and dental checks.
47 Other includes Pacific tamariki due to the small number of Pacific tamariki in the custody of Open Home Foundation.

Back to Inequities around service provision

48 Oranga Tamariki Action Plan (OTAP) In-depth Needs Assessment Report, Primary Health Needs of Children and Young People in Care (June 2023) page 4.

Back to Government agencies working together

49 Oranga Tamariki strategic partnerships are intended to help tamariki and rangatahi Māori thrive in the care and protection of their whānau, hapūClosehapū
Sub-tribeView the full glossary and iwi.

Back to Strategic partnership: Te Tohu o te Ora o Ngāti Awa

50 Oranga Tamariki strategic partnerships are intended to help tamariki and rangatahi Māori thrive in the care and protection of their whānau, hapū and iwi.

Back to Strategic partnership: Te Kāika