Speech Notes On Health Workforce Development
Speech Notes On Health Workforce Development:Issues And Strategies
HEALTH SECTOR HUMAN RESOURCES CONFERENCE
TE PAPA – WELLINGTON
THURSDAY 16 OCTOBER 2003 IAN POWELL
ASSOCIATION OF SALARIED MEDICAL SPECIALISTS
The timing and subject of your conference is apt given the serious challenges currently facing the health system and, in particular, district health boards. There is no greater challenge facing the health sector than workforce development and planning especially in such a labour intensive service seeking to produce a universal public good and where the prime producer of value are health professionals.
There are two important background factors that should be kept in mind in considering this subject.
1. The lost decade of the 1990s in which New Zealand embarked fatally on a failed ideologically bankrupt market experiment. Workforce development and planning was neglected because market forces were supposed to sort things out. Further, the fragmentation of the system into competing crown health enterprises worked against the regional and national coordination necessary for effective workforce development and planning. Consequently New Zealand failed to anticipate and plan for the increasing international competition, including the impact of the European Working Time Directive, and consequential shortages which have expanded from initially psychiatry and anaesthesia to virtually all branches of medicine.
2. A national DHB MECA for senior medical staff. Nationally consistent employment conditions for senior medical staff are a prerequisite for effective workforce development and planning in order to recruit and retain, avoid unreasonable disparities, and avoid unproductive competition for labour. It is not appropriate to say any more on this subject with the current negotiations proceeding to mediation next week, except to note that based on the respective positions of the parties to date, the two most likely outcomes at this point in time are either a collapse of negotiations and return to abrasive single DHB negotiations or a less than national MECA covering perhaps around two-thirds of the DHBs with separate arguably abrasive single employer negotiations in the remainder. Neither outcome would assist workforce development.
If we put to one side the sentiments expressed in the kiwi tee-shirt with the imprinted words, “I support New Zealand and any other team that plays Australia’, we should be envious of Australia. The comparatively well resourced and supported Australian Medical Workforce Advisory Committee (AMWAC) is well advanced of what happens in New Zealand. Sometimes AMWAC has problems with getting numbers right but at least they are able to ask good questions and get insightful answers. I can only envy the fact that AMWAC can, for example:
conduct a longitudinal study on career aspirations of doctors-in-training;
investigate what are the number of pathologist positions needed, the number employed and the gap; and
undertake a similar investigation for emergency medicine and also examine the extent that patients should be treated in emergency departments without referral to another hospital service.
In New Zealand we can’t even ask such questions and expect to receive answers based on a reasonable level of reliability. I have now reluctantly accepted that our under-resourced and less independent Health Workforce Advisory Committee (HWAC) can’t match AMWAC. We need to accept that HWAC’s role is largely limited at best to scene-setting and promoting the importance of workforce development and planning. It is to other processes such as the Tripartite Forum and bipartite arrangements that we need to look at.
Driving Effective Change: Culture and Power Paradigms
One of the lessons that should have been learned over the years but, has not been sufficiently, is that top-down driven change does not deliver sustained effective outcomes. Government seemingly looks at DHB chairs as key instruments for ensuring that DHBs deliver on its objectives. This misplaced view ignores the reality that DHB chairs are significantly disconnected from operational and workforce reality. They have little impact on driving effective workforce issues except that they can assist in encouraging a constructive environment conducive to sustainable development and planning. Equally so, they can provide a negative environment obstructive to addressing workforce needs. The reality is that for a variety of reasons many DHB chairs appear to be searching for a Titanic to put their deck chair on.
Much of DHB management also falls within this framework. In my view, management is an administrative overhead that does not of itself produce value but can influence whether or not how effectively value is produced. DHB chairs and management can be scene-setters, and environment shapers; a facilitator for but not deliverer of effectiveness. Our former National President Dr Peter Roberts is fond of saying that bad policy is more harmful to patients than flesh-eating bugs. The same point can be said for bad management.
It is the developments and initiatives of health professionals that deliver effective sustainable change. This has been demonstrated in many areas over the years from the medical profession’s use of that remarkable drug, the aspirin, to prevention of infectious diseases (eg, TB) to day surgery to the development of emergency medicine to the use of anaesthetists in perioperative care. All these developments have an effective and sustained impact on workforce utilisation, more so than top-down bureaucratically driven change.
What is needed and what we do not have sufficiently engrained is the culture, values and presence of professionalism firmly located at the engine room of planning and decision-making over workforce needs. This means engaging health professionals in the engine room. Attempted top-down workforce initiatives, particularly when the mechanism is DHB chairs, boards and management, will fail with at best imposed changes that are ineffective in providing sustainable quality improvements. This will inevitably be the fate of the draft work plan from DHBNZ, which at this stage is at a phase of high level lines on paper, if it proceeds along a managerially centred approach based on current power paradigms.
To advance constructively forward a two-pronged approach is required recognising that the challenge, in a small country with a population of four million, is to achieve a mix of national objectives and coordination and local (DHB) adaptations and initiatives, supplemented by regional DHB alignments. In this context Australia also provides another useful lead. The independent health professional taskforce approach of the New South Wales government to reviewing acute metropolitan health services is producing several practical and sound incremental and affordable improvements.
New Zealand can’t copycat this approach because it is metropolitan and secondary care based and because Australia has an absurdly rigid obstructive demarcation between primary care (federal) and secondary care (state). But the approach of health professional based taskforces (but not exclusively health professional) could be adapted to New Zealand circumstances in which, at a national, regional and DHB level, services and workforce needs are rigorously examined and reassessed. In adapting the New South Wales taskforce approach, it is necessary to recognise that, because they are overwhelmingly unionised, unions are the most practical means of ensuring the effective engagement of health professionals.
At a national level this adaptation might involve a modification of the tripartite process to a bipartite CTU-DHBNZ approach to look at national matters and the facilitation and coordination of regional reviews and strategies. At a DHB level it could be joint health professional based staffing bodies to assess specific service and workforce needs and the development of workable strategies to achieve practical, identifiable and incremental goals.
Critical to this process would be the identification of unmet need in DHB communities noting the statutory requirement on DHBs to undertake needs analysis of their communities. We know that unmet need is not only delayed care but often more costly care.
It would also provide a better framework for addressing workplace related issues that, in the context of current power paradigms, end up as controversial demarcation issues. Nurse prescribing is an example. Had, for example, the NZNO, NZMA and ASMS (or a health professional taskforce approach based on them) been given the authority to work this issue out, I am sure a beneficial outcome would have been achieved with positive ramifications for medical and nurse workforce development. The same point applies to proposals such as nurse anaesthetists.
The relationship between what nurses and doctors respectively do is an evolving process with incremental changes around the margins that have a significant accumulative effect. It should be remembered that it was a long time ago that doctors gave up control of the thermometer and bedpan and they have no desire to reclaim them.
One advantage New Zealand does have over Australia is the DHB system which covers both primary and secondary care. Just as the nursing-medical relationship evolves through gradual incremental change, so does the primary-secondary care relationship. One is what the other is not. There are interesting initiatives that should be encouraged. For example, general practitioners are developing secondary special interests. This development, now under the standard-setting wings of the College of GPs, may serve to make general practice more professionally attractive and diverse with consequential recruitment and retention benefits.
Meanwhile our ‘homeless doctors’, otherwise misnamed ‘medical officers of special’ scale, are a resource that could be better developed and utilised rather than limited local managerial initiatives to create new doctors such as so-called ‘hospitalists’. These doctors need a professional home in order to achieve workforce development needs. The home may be the College of GPs which is developing an adapted MOPS and vocational training path for MOSSs and GPs with additional secondary care interests.
It is not inconceivable that the College of GPs role may expand from primary care to also include general secondary care. The implications of an available supply of vocationally-based generalist doctors working in secondary care are fascinating. Again there are potentially positive workforce benefits.
The important point is that these and other workforce developments must be professionally rather than managerially or bureaucratically developed if they are to be effective, high quality, and sustainable.
Relevance of Human Resource Management
Finally, it is appropriate to consider where human resource managers fit in. The short answer is that I do not know as human resource managers often resemble single bookends. The longer answer is that the role and relevance of human resource management is, ironically given the labour-intensive nature of the health sector, not understood and not generally valued. There are several reasons for this such as poor performance, disconnection from the health professional workforce, obsession with abstract process rather than practical workability, talking a language that no one else understands, high turnover, and being ‘scape-goated’ or undervalued by other parts of management. Sometimes I think that union officials are human resource managers’ best friends because they are the only ones that really know what you do or can do.
If human resource management is to be relevant to workforce development and planning then it is going to have to fully and comprehensively understand:
what drives effective quality change and what does not;
what investing in intellectual capital really means and what it can deliver;
the importance of effective engagement with and involvement in decision-making of health professionals through their unions; and
the importance of breaking down managerial power paradigms in order to shift to a more effective and efficient collaborative culture in DHBs.