Meat in the Sandwich

Taima Campbell, RN, BN, Cert. Cl. Tchg (Maori), MHSc - Nursing, MCNA(NZ)

Executive Director of Nursing, Auckland District Health Board

In March, the Auckland District Health Board came under fire from the media and politicians after fronting the Parliamentary Health Select Committee. At the hearing, ADHB representatives answered parliamentary questions truthfully and factually in front of the Committee and the public, as is required under our parliamentary system. The fundamental purpose of these hearings is for Members of Parliament to examine the performance of organisations such as District Health Boards to ensure tax payer funds are being used judiciously. The other purpose it appears is for members of the opposition to ‘score points' against the government, exploiting any deficiencies in the system that they can detect. In effect, District Health Boards become the ‘meat in the sandwich' and the purpose of the process is lost amidst more newsworthy versions of the facts.

So what are the facts? The Auckland District Health Board had an underlying deficit of $104 million in 2004/05 – a position that was clearly unacceptable. A concerted effort to bring the deficit down saw it reduced to $65 million in the 2005/06 budget with the current forecast for year end (June 06) now standing at $50 million. This is a much improved position but by no means ‘out of the woods'. ADHB has identified the ‘root causes' of the deficit as infrastructure costs, funding levels and labour costs, and has a number of projects in place to ensure we live with our means. Reduction in the 8,000 people strong workforce has always been openly discussed as an option but not in the way that the opposition spokesperson reported, that is, bringing in younger staff to replace older more expensive staff. The latter comment prompted a number of staff to start lying about their age and hiding their reading glasses, and understandably did nothing for workforce morale.

I have stated previously that I believe the 'real issue' for ADHB and a number of other
District Health Boards, is the unacceptable deficits that are forecast for the end of this financial year and beyond. At the beginning of a fragile collation (coalition??) government term, the message is clear - operating deficits are unacceptable, there will be no ‘bail out' and ‘live within your means'. In addition, DHBs must maintain the current levels of service delivery, that is, DHBs can't do less work then (than??) they are contracted for or exit funded services. District Health Boards must also find more efficient and effective ways of working and improve their overall performance in order to break even.

Government, the Ministry, health economists and, of course, Treasury are concerned that 'productivity' is down in the sector, that is, there are less 'outputs' being produced for the price being paid. Nursing labour costs and recent wage increases obviously fit into this discussion along with anticipated demands for safe staffing levels in hospitals. This usually leads into the question I am frequently asked, ‘if nurses are being paid more, why is less work being done?'

The productivity question requires further analysis. Policy makers, boards and managers are quick to forget that DHB nursing salary increases were part of a ‘pay jolt' to remedy long standing pay inequity for nurses, a predominantly female workforce. It could be argued that DHBs and their predecessors have exploited this workforce in the past, and any salary increase was simply putting this injustice right. Secondly, it is unrealistic to expect salary increases will increase performance if no change is made to the system in which nurses work or the practice work environment is not changed to support nurses practising to their full potential. The primary health care environment is a case in point where the government has invested significantly in primary health organisations but achieved limited change in the primary health care practice environment for nurses and subsequent return on investment.

Turnover also impacts on nursing productivity. The International Consortium of Cost of Nursing Turnover research teams are starting to provide data on the direct and indirect costs of turnover which include opportunity costs such as productivity. The research is gaining recognition as many countries come to grips with the financial impact of nursing shortages or turnover on services as well as the quality of health care. For example, a small reduction in nursing turnover in a large nursing workforce such as ADHB has the ability to reap sizable financial benefits with a satisfied, stable and skilled nursing workforce more likely to achieve the desired level of organisational performance.

If the sector is going to tackle the issue of productivity and efficiency, I think we need to take a total look at the current system. What I have not heard nurses do is enter into the debate on the inherently inefficient 21 DHB argument, the need for rationalisation of speciality services and treatments in a country of 4 million people, the best way to fund these services and solutions for CEOs and Boards to address the root causes of their growing deficits that are not just about nursing.

I know from ADHB's point of view, that providing tertiary sub-speciality services requires a certain level of infrastructure that costs. This cost is not fully realised in average nationally pricing and leads into debate about how inefficient ADHB is and informal guidance on lean thinking principles. What is not discussed is any rationing of sub-speciality services (oncology services is one of the few areas where national reviews have rationalised regional centres), debate on what should be covered by the high cost treatment pool and increasing demand for publicly funded interventions such as bariatric surgery, but no guidance on what should be stopped in order to make this happen.

Contrary to popular opinion, nursing is not the target at ADHB, the deficit is. I, along with many of you, believe that nursing is part of the solution, but as a profession we need to move beyond focusing on 'terms and conditions' and work with policy makers, Boards and CEOs to address their real and growing concerns. Evidence, data and financial analyses that are communicated effectively are what we need to support this debate. I believe we have a major challenge ahead and agree with a growing number of people that we need to have some honest debate on what and how we can pay for health care in the future.