Submission

Submission of the College of Nurses Aotearoa to the Health Workforce Advisory Committee on the ‘Fit for Purpose and for Practice: Review of the Medical Health Workforce in New Zealand’

August 2005

The College welcomes the opportunity to make comment on the Health Workforce Advisory Committee’s (HWAC) consultation document on the medical health workforce. The College agrees that the future of the medical workforce cannot be determined in isolation from the whole health workforce or from the changing context of health care delivery. Equally health care involves more than medical practitioners and requires consideration of all health professionals and workers who contribute to the delivery of health services and better health outcomes for health care consumers.

The current challenges for health workforce planning and development are well known as are some of the potential solutions that have been canvassed from the literature and other health jurisdictions. Apart from agreement that we have a health workforce crisis, there appears to be little agreement on what the future workforce skill mix, workforce numbers or priorities should be. In addition, there is no agreed process for making changes to the composition of the workforce, for the redistribution of work or the training and education required in order to achieve safe, quality health care. The College believes that HWAC should be taking a more active leadership role and providing policy advice that addresses this shortfall in the sector.

This submission makes general comments on the consultation document and provides more detailed analysis on specific aspects of the recommendations proposed. The College of Nurses Aotearoa is happy to clarify any of the points made face to face with Committee or the Medical Reference group at any time. This submission is intended to add to the debate and discussion about having the right person with the right skills at the right place at the right time that considers the evidence and the needs of health care consumers.

General comments

• While demand for medical practitioners (and other health workers) is forecast to outstrip supply, the immediate priorities for action outlined in the consultation document do not make any recommendations for identifying the numbers and skill mix we actually need to meet future health need.
• Furthermore, it is unclear what the medical workforce problem is that we are trying to address.

  For example:

  • Recruitment into undergraduate medical programmes is not the issue as medical schools generally have more applicants than places.
  • It is possible that student attrition is impacting on graduate numbers, particularly for Maori and Pacific students, for whom the attrition rate is higher.
  • Is retaining graduates the key issue and are effective strategies required to address the shortages?
  • Are inefficiencies and inflation of ‘demand’ such as increased service delivery volumes or changes in practice standards contributing to workforce shortages?
  • Are medical workforce shortages an artefact of industrial agreements? That is, does compliance with working hours and conditions within employment agreements contribute to the demand for medical resources?
  • Is sub-specialisation driving medical workforce shortages and contributing to inflexibility?
    
    
• Increasing the student cap on the medical undergraduate placements is a potential policy solution to address supply. However, it should be noted that the number of doctors in training has increased over recent years without any improvement in productivity, but has had significant increases in health sector cost. This approach has also led to issues in addressing junior doctor learning needs and appropriate access to senior medical supervisors, therefore increasing medical graduate numbers cannot be considered unless there are appropriate senior medical staff and resources (financial, teaching, and clinical) to do so, as well as addressing current medical undergraduate programme inefficiencies.
  
• Retention of medical and health professional graduates is an issue across the sector. While the government has signalled a major policy change in student loan interest payments that is designed to assist with the retention of graduates, the issue of turnover requires more analysis, and strategies to address retention more robustly explored and debated.
  
• Increasing pressure to comply with working hours and conditions within employment agreements has increased (or inflated) the need for more medical resources particularly junior doctors in hospitals. While the College supports all health practitioners working fair and reasonable hours and undertaking a reasonable workload, current industrial arrangements do not allow employers to make changes in service delivery models in order to achieve these outcomes.
  
• As in the United Kingdom following the introduction of the European Working Times Directive, aggressive approaches to managing junior doctor shortages need to be pursued along with some discussion on where junior medical practitioners do not need to be deployed.
  
• Sub-specialisation drives workforce shortages and sector costs. The College of Nurses believes that there needs to be more public debate on service prioritisation to inform where investment in medical workforce development should occur. The types of services including sub-specialities along with volumes and locality have a significant impact on the workforce required to deliver it. For example, is it sustainable to have a fourth neurosurgical unit when we are unable to staff the current centres safely? Questions need to be asked on whether investment in more neurosurgeons versus more general practitioners is a fair trade off in terms of opportunity costs and whether regional politics and parochial concerns should drive health service and workforce planning.
  
• Resource/cost constraints need to be included in the immediate priorities. This links with issues of prioritisation, but should include the cost of medical turnover and the cost of sub-specialisation (including opportunity costs) as well as changes in technology or changes in service delivery. Frameworks for health service prioritisation and major capital development projects should be inclusive of the workforce requirements to deliver whatever services are purchased.
  
• Under the factors that influence workforce development there will be increasing need and cost associated with compliance i.e. with legislation, quality standards, requirements to be accredited that should be noted. This includes standards imposed by Australasian medical colleges that are often used as the ‘gold standard’ for service delivery in some specialities, but may be impracticable in the New Zealand health sector and often unaffordable.
  
• Detail on governance responsibilities is lacking for medical practitioners. This is more than a responsibility for clinical governance and quality systems and includes clinician responsibilities and accountabilities to manage resources (people, time, expenditure) and public resources wisely to ensure optimal clinical performance.

Primary health care / general practice workforce

• The College acknowledge the shortages in general practice and in particular rural areas, but the document does not address some of the fundamental issues about how to use dwindling GP resource most effectively.
  
• The GP workforce is aging and some are experiencing burnout from high workloads or increasing compliance requirements. Nurse Practitioners are being prepared but not employed. General Practitioners remain concerned that Nurse Practitioners will practice (and prescribe) independently, interpreting this to mean that nurses will work in a competitive business model rather than a collaborative model and cause huge fragmentation in terms of patient care. Interestingly General Practitioners seem less able to recognise that their own private businesses subsumed in the PHO environment may well be a significant impediment to achieving collaboration and team work. While concerns regarding continuity of care are shared, the capacity of General Practitioners to achieve this is increasingly unlikely. Further dialogue with General Practitioners is required to explore primary health care models (inclusive of nursing and allied health professionals) that will address these concerns.
  

Increasing specialisation

• The consultation document does not address the impact for a small country of medicine becoming more and more specialised. For example when the current cohort of general surgeons retire there will no longer be general surgeons performing peripheral vascular surgery because such procedures are now tied to specialist credentialing. Therefore, there will suddenly be minimal expertise available in this and many other areas.
  
• The role of the ‘generalist’ or ‘hospitalist’ should be valued and explored as viable career options further. These roles may provide a non-vocational career pathway for medical practitioners who do not wish to commit to traditional speciality practice programmes or could potentially viewed as super-specialty practice roles.

Medical education

• The College contends that the medical curriculum at both undergraduate and post-entry level requires a significant review to meet the demands of a dynamic health system. No profession is beyond rigorous critique and investigation into ways to improve professional standards and practice in order to achieve a workforce that is fit for purpose. In this regard, the College agrees with HWAC that this is a key priority area and that major changes are required.
  
• Reviews of the medical curriculum must consider the risk of creating overlaps in primary health care where nurses are prepared to deliver effective services, and should focus on developing areas of expertise that need biomedical preparation. There is a need to review the preparation for general practice to deliver services in acute and complex health conditions so that the service provision of nurses and general practitioners are complementary and aimed at delivering effective health services to improve health outcomes of people and communities. The aim would then be to achieve collaborative practice between nurses engaging in health promotion, disease prevention, education, early detection and intervention/referral activities and medical practitioners who utilise their expertise to address acute and complex health issues within the community.
  
• The contribution that nurses and allied health professionals make to medical education should be formally recognised and further developed. Senior nurses in particular play a key role in teaching junior doctors and could be involved in skill and competency assessment that would address some of the training issues that have been identified within the sector.
  
• Compliance with Australasian College standards for medical training programmes and credentialing has a significant impact on health service delivery in terms of cost and time. There are also significant costs associated with teaching hospitals that are not well recognised. Both of these issues need to be addressed by the Clinical Training Agency, education providers, professional associations and district health boards so that both training and service delivery needs are met.

Making workforce changes and redesign

• 
  The College of Nurses is supportive of workforce re-design and a more inclusive approach to addressing health service delivery. Key questions that need to be asked are: What are the services most appropriately provided by medical practitioners? What work can be done by others? What are the barriers to making change?
  
• Short to medium term solutions will largely come from working and delivering services differently. Despite an apparent reluctance by professionals to proactively make workforce changes and redesign models of care/service delivery, the College of Nurses strongly believes there is a need to engage the health sector and the public in debate on alternative models of service delivery and funding models that support different ways of working and ways that barriers to service re-design work (attitudinal, legislative, industrial) can be addressed. There is significant potential in nursing, allied health and across the support worker workforce that is yet to be developed. As mentioned previously, the medical profession needs to enter a more open and collaborative discussion on how this may occur.
  
• The role of unions and industrial relationships are also a potential barrier to change. For example, industrial agreements prevent employers from making changes to skill mix/staffing within service models.
  
• The widely held belief that the doctor has sole responsibility for the patient and subsequently carries all medico-legal risk requires further analysis. Clarification of the legal and ethical accountabilities across all health professional scopes of practice are required between regulatory authorities, professional associations and stakeholders such as the Health & Disability Commissioner and ACC to understand medical practitioner concerns and to develop effective strategies to overcome them.

Teamwork – Fact or fiction?

• The need to work collaboratively needs to move beyond the rhetoric into the realm of meaningful action. This will need issues around boundaries and patch protection to be addressed by all concerned – that is, medical practitioners and other health professional groups – where the health needs of those using health services becomes the central concern. The College of Nurses notes that the active resistance by sections of the medical profession to Nurse Practitioner prescribing is an example where the needs of consumers are shadowed under the arguments based on patch protection. The following quote is one such example:

  ‘Prescribing by Nurse Practitioners is ‘loony’ and will put the public at risk says New Zealand Medical Association (NZMA) chairman Dr Ross Boswell’
  (New Zealand Herald, July 2005)

• Publicly sections of the medical profession have dispelled any illusions we might have about the collaborative and collegial intentions of medical lobby groups. Interestingly it has been recognised that many individual medical practitioner colleagues privately do not agree with this professional and public view. The public perpetuation of misinformation and scaremongering by members of the medical profession about Nurse Practitioner prescribing does little to instil public assurance that the various sectors of health ‘professionals’ will act collaboratively for their benefit. The impact of medical practitioners not working in collaboration with other health care professionals or consumers needs to be determined and considered in the development of the health workforce in general.

Summary

In summary, issues regarding the medical health workforce cannot be resolved by medicine alone. Solutions rely on multidisciplinary collaborative approaches based on mutual respect of what each discipline has to offer.
Nurses are currently ‘filling the gap’ for medical workforce shortages. Nurses are already practicing independently in nurse-led clinics and services both in cities and in rural areas and have been for many years. The aim – as always – is to provide quality health care in order to improve health outcomes for our communities. In order to achieve this, constructive and respectful debate and dialogue to progress workforce planning across the sector is urgently required.