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A Report from:
The College of Nurses Aotearoa (NZ) Inc.
 NPAC-NZ (Nurse Practitioner advisory committee –New Zealand)
NPNZ (Nurse Practitioners of New Zealand)
September 2009
This submission is deliberately brief confining its focus to key points of major importance.
We believe that this report correctly identifies a number of the major problems and barriers to innovation and efficiency in the health sector.
We support the Minister’s concern that clinical or front line health professionals should play the greatest role in determining the way forward. We offer a caution that the word clinician (used liberally through the MRG report) is not confused or seen as synonymous, as it is in this report, with the word doctor.
We support
- Commitment to a nationally planned and funded health system, led by health professionals (in collaboration with management) and focused on patient or people centred care.
- Improved infrastructure through investment over longer timeframes. Current short contracts are wasteful and counterproductive.
- A National Health Workforce Board, which we understand comprises the National Clinical Training Agency led by Professor Gorman. However we make the critical point that selection of the nursing reference group or however nursing input is constructed be firmly in the hands of the nursing profession. It is never satisfactory or effective to allow medical leaders to select nursing representation.
Focus on clinical leadership, clinical networks and particularly the recognition of the need to develop a “locally responsive and appropriate workforce that builds on the unique characteristics of existing professional disciplines and increases capability in their support” (Annex 2, p11)
- Regional Services Planning
- Alignment with Safe Staffing Healthy Workplaces Report.
We have reservations or do not yet have a view about:
- The need for a National Heath Board – It seems to us that there is significant potential for delay, duplication and diversion of funds from the frontline as this restructuring occurs. This may also reduce the notion of community engagement and partnership, which has been a positive feature of the current structures.
- Potential reduction in the number of PHOs on the basis of size. Many reviews over the previous years have addressed the question of “Does size matter?” The answer has been equivocal noting that savings on the one hand are outweighed by other losses. We would be concerned at the possible loss of strong community and iwi/ health partnerships, which have developed successfully especially in smaller PHOs. We would be strongly concerned at any return to GP driven IPA structures which do not have a good history of working in partnership with either the community or other key health professionals
We support the New Zealand Nurses Organisation in noting that the report does not address
- Commitment to partnership with Māori and recognition of Tiriti o Waitangi responsibilities.
- Commitment to reducing disparities and having equitable access to affordable healthcare (notwithstanding paragraph 32).
- Acknowledgment that New Zealand’s health services are performing well as indicated by OECD Economic Survey 2009 “New Zealand achieves relatively good health outcomes for comparatively modest health care outlays” i.e. not growing disproportionately to GDP.
- Analysis of the rapid rise in the unregulated workforce and its interface with the regulated workforce. Note: Lack of current data or research (Gorman Review of Health Workforce Training, 2009). Key challenges include training, qualifications, responsibility, public safety and employment.
- Recognition of the potential of the nursing workforce, comprising about 50% of the regulated workforce (DHBNZ, 2009), to lead change and increase productivity through improved patient outcomes.
- Analysis of numerous outstanding examples of nurse-led initiatives (e.g. Respiratory Clinic, HVDHB) which have delivered significant ongoing cost savings and improved outcomes, and why such innovation has not been implemented nationally. E.g. current business funding models for DHBs and PHOs are a significant barrier to the spread of innovation nationally.
- Recognition that cost effective holistic health requires a whole workforce approach.
- Recognition of the significant safety and cultural safety issues with overseas trained professionals as well as difficulties with their recruitment, retention and registration and strategies to address them.
- An equal focus on all service providers, including NGOs, private providers, and GPs not just DHBs and PHOs.
- Commitment to consistent employment practice and pay parity across all healthcare providers to boost productivity and reduce inequitable health outcomes.
- Recognition of the socio-economic determinants of health and the long-term productivity gains from investment in population health spending
Issues not adequately addressed by the MRG report
We believe that the role of Nurse Practitioner is a major and significantly neglected innovation in the NZ Health Service. In particular we note that:
- Time-consuming barriers to Nurse Practitioner (NP) service provision persist. These were first identified in 2002 and remain largely unchallenged causing daily wastage of time and energy by existing NPs and the barriers also act to discourage the employment of NPs by creating a sense that NPs cannot deliver the full range of services for which they are prepared. Our health system cannot afford this pointless and inexplicable wastage.
- Despite prolonged consultation and submissions over many years NPs remain as designated prescribers rather than as authorised prescribers thus limiting their potential usefulness and flexibility. Midwives are already authorised prescribers despite being substantially less educated than NPs. In addition registered nurses who are educated to exactly the same level as midwives could well be enhancing the flexibility and scope of their service with some degree of prescribing rights.
- No formal national funding process exists to guarantee the clinical and academic preparation of the NP workforce. The registrar training scheme for doctors is a taken for granted system of postgraduate preparation for producing senior medical clinicians. Given the internationally demonstrated outcomes and transformative nature of health service delivery by NPs it is unacceptable that no parallel exists.
We recommend:
- A rigorous cost/benefit analysis of the potential National Health Board.
- Urgent attention to the issues raised above which limit uptake of current and many potential Nurse Practitioners.
- Rural and urban Māori representation at all levels of any such structure.
- Inclusion of the nursing leadership voice at all levels, and in all domains, because nurses are the providers of healthcare 24/7 and the main interface between the public and other health professionals. This will require deliberative action to secure.
Contact for this report:
Professor Jenny Carryer, RN, PhD, FCNA (NZ), MNZM
Executive Director
College of Nurses (Aotearoa)
Clinical Chair of Nursing
Massey University / Mid Central District Health Board
PO Box 1258
PALMERSTON NORTH
Tel: 027 4491302
Email: J.B.Carryer@massey.ac.nz
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