Editorial

Once again I apologise for producing an editorial that has already largely appeared in Nursing Review. Sometimes it's hard to meet all writing deadlines and also we all know that not everybody reads everything anyway; there simply is not time!!!

Shock waves rippled throughout nursing recently when it was reported in various media sources that the Chair of the Auckland District Health Board, Wayne Brown, had stated that sacking senior nurses and doctors was a useful way to manage impending budget deficit announcements in DHBs. First of all it needs to be said right up-front that Wayne Brown did not say any such thing; he was seriously misrepresented and has been at considerable pains to affirm his recognition of the critical input of senior nursing and medical clinicians.

But leaving alone the media's tiresome preference for shock and horror rather than the careful provision of accurate information and the equally tiresome challenge of political point scoring processes, there are matters here that warrant careful discussion.

It is a very real concern for a number of District Health Boards to address the unacceptable deficits that are forecast for the end of this financial year and beyond. The pressure to 'live within our nations means' and what this means in terms of health delivery is where we should focus the debate.

Currently it is clear that a great deal more money has indeed been endlessly invested in the health sector and that health is a bottomless sponge that will soak up however much money is directed towards it. The Primary Health Care Strategy is a serious and well directed attempt to limit health spending in the long term but it too has been very costly in the short term and its agenda is not yet complete. Government, the Ministry, health economists and of course Treasury, have made it very clear... there is to be no additional money.

Internationally, predicted areas of increased demand include rising cancer morbidity, an epidemic of diabetes, and other chronic diseases, the costly sequelae of diabetes, especially renal failure and the cost of our ever-growing ability to address complex injury and illness with improved technology. Alongside an ageing population and a dwindling workforce the spectre of escalating demand for health services is a grim scenario. Combine this picture with the need to control or limit spending and the scenario worsens.

During the 1990s when health managers were last charged with rigorous management of the “bottom line”, all eyes turned to the charmingly named “low hanging fruit” which of course was the large nursing workforce which makes up a significant part of organisational expenditure. At that stage many foolish and unfounded ideas prevailed, including the concept that substitution for registered nurses was safe and cost effective, that nurses could move from area to area on a casual basis because specialisation was irrelevant to quality and that with generic management in place nursing leadership was also irrelevant to quality.

What nursing has now done is to complete prolonged and substantial international research, which demonstrates beyond doubt, the intimate connection between the level and quality of registered nurse staffing and patient safety through the avoidance of errors. Just how costly such errors are has yet to be accurately quantified or costed but common sense tells us that adverse events are hugely expensive and they are, of course, unacceptable for people's comfort, well being and quality of life.

We are now able to promote, from a strongly evidenced basis, the direct and indirect benefits nurses make to health care, and the risks if we do not have enough. We can hope that as managers yet again turn their attention ever more closely to the bottom line that they will fully understand the short-sighted futility of decimating the nursing workforce at any level of service delivery.

Perhaps, however, it is not enough for us to simply defend our value and not to engage in the challenges beyond that point. As there is a serious challenge inherent in this country continuing to deliver a quality health service and as we are indeed the majority of the relevant workforce, we should not just engage in the debate but perhaps provide leadership and direction.

Some weeks ago a person who works in a funding and planning division of a DHB told me that “we have to realise that we simply cannot go on delivering more and more services to more and more people; rationing is inevitable and not all people will be able to receive whatever is deemed clinically to be the gold standard or treatment of choice”. This is a terribly easy thing to say if one works in funding and planning and therefore not charged with professional clinical responsibility and not faced on a daily basis with vulnerable human beings in need of help.

Can we expect individual clinicians to make such decisions? I don't think so. We need a national moral and ethical framework for any form of rationing and it will take careful inclusive discussion - a discussion that must engage consumers as informed partners rather than passive recipients at the mercy of a media frenzy when anyone seems to have missed out on the bottomless pit of health services. We will also need to move quickly to recognising that a person's quality of life can be substantially enhanced by comparatively low cost, well co-ordinated home based services. Such services may make more difference to quality of life than expensive high tech heroic life saving measures in acute settings. Clearly nursing should contribute to both the discussion and the implementation of such a direction.

In the meantime there are some simpler and more immediate debates to be had. Do we need 21 DHBs in this very small country? Is this not inherently inefficient, allowing costly replication of administration and bureaucratic services whilst precluding the sharing of expensive specialty services and treatments? Is there yet another expensive layer of bureaucracy gathering around the PHO environment? Are we clinging in vain to old ways of doing things at the same time as we signal their difficulties?

In this regard I think of the reported burn-out and decline of the GP workforce at the same time as we allow the majority of general practice patients to be seen by a GP regardless of the presenting problem. These and many other issues warrant urgent and fresh thinking. Nurses are on the ground in vastly diverse corners of the health service and hold a collective wisdom which has much to contribute. Health sector leaders need to get much smarter about harnessing that wisdom and we need to get much smarter about contributing it appropriately.

Harnessing our wisdom and making that contribution seems to be an ongoing challenge. Just as I noted at the outset that we have barely enough time to read everything, we are certainly challenged to do all of the things that need to be done. I remain convinced however that our strategy needs to be twofold. Firstly we need to develop and nurture emerging leaders and secondly every single one of us needs to make a commitment to contributing beyond the demands our every day jobs at least once in our career. Think what a force we would be!

Professor Jenny Carryer