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Hodgson:Health workforce sustainability conference

07 September 2006

Hon Pete Hodgson: Speech

Health workforce sustainability conference

Thank you for the opportunity to open and address this conference.

My congratulations go to the Counties Manukau DHB for organising this series of conferences. Counties Manukau finds itself at the forefront of change in many areas of endeavour, and now the DHB can add workforce development to those things where it seeks to make a difference.

Last month, during a day trip to this DHB I had the pleasure of listening to Counties Manukau staff speak about their vision for growing and nurturing their own, local health workforce. I won’t steal their thunder by describing their vision or their actions, but if I tease you a little with some powerful words from one of their recruitment adverts,

You have Counties written all over you!

you may get the idea of the sense of belonging local staff have, and how they are using that strength to attract young people to a career in health.

Not too many years ago health workforce issues or a health workforce debate did not much exist. A decade ago the prevailing ethos was that the market would provide. A decade ago we were preoccupied with short term productivity gains and somewhat 'deaf' to the idea of longer-term planning. A decade ago labour market planning was regarded as intrusive and wrong-headed.

A decade ago we had the Employment Contracts Act which meant that there was little room for union involvement in broader work issues, that career development was the responsibility of the individual, that unsocial hours were often not recognised in pay, and that flexibility became synonymous with a deterioration in wages and conditions.

Back then we trained fewer doctors and fewer nurses. By the time the nineties had come to a close we had stopped training dental nurses, or dental therapists as had come to know them, altogether.

To an extent the market did provide. People continued to join the health workforce, to further their education, and to immigrate and to emigrate. So the market does work to an extent, as all labour markets do.

But an over reliance on markets won't do. An over reliance on markets is how we came to run out of radiation therapists and is why we have a deterioration in the teeth of our children.

Moreover a reliance on labour markets does not give us an insight into how a future health workforce might be configured to meet the changing needs of our society – which is a topic I will return to shortly.

But first let us ask where a health workforce starts and stops. It's certainly an issue bigger than doctors, nurses, and allied health professionals. That is, it's bigger than the so-called regulated health workforce, even if they are at the heart of the health system. To that group of over 70,000 must be added many tens of thousands more – the so-called unregulated workforce. Their numbers are growing quickly, and too many are untrained.

It doesn't stop there. There is a fairly free flow of health professionals between countries. New Zealand loses professionals offshore and gains as well. We have high levels of overseas trained nurse and doctors in our health workforce, thanks more to Britain than anywhere else. We need to be mindful, for example, that Australia intends to lift its medical training rate from below ours to above ours. And we need to be attentive to the protocol developed among Commonwealth Health Ministers, which is designed to ensure that developing nations are not subject to poaching by developed nations. As I say that I acknowledge the rich partnership that exists between this DHB and some Pacific Island states, which is expressly designed to benefit all parties, and does.

Still on the issue of determining where the health workforce starts and stops there is the growing influence of the 'expert patient'. This trend is likely to continue as more of us survive or avoid episodes of acute illness, and go on to develop chronic disease. Someone with a chronic disease has the time and increasingly the ability and interest to learn a lot about that disease. Tomorrow's health practitioner may spend more time tutoring, and less time diagnosing and treating.

So when thinking of the health workforce let us please think broadly.

One other remark needs to be made about New Zealand's health workforce, which is both self-evident, and pivotal. It is a caring workforce; a workforce that gets out of bed each day to help others. There is a dedication in the health workforce that manifests itself each day in kind words, a smile or a tear, an extra bit of attention, an argument or a negotiation to ensure a patient gets the treatment they need. Curing, managing or preventing illness is why each of these workers chose their respective careers and each day, everywhere it shows.

The year after the change in Government the New Zealand Public Health and Disability Act 2000 was passed. The Act allowed for the establishment of the Health Workforce Advisory Committee – or HWAC – and in April 2001 HWAC was established by my predecessor Annette King.

That committee set about establishing momentum and debate around health workforce issues where previously rather little momentum or debate existed. The following year a stocktake was published. Progressively the debate grew, the committee membership changed and the debate grew further, along with the broad consensus on the direction of travel.

Other players joined the debate. By the time I became Minister four and a half years later I found myself wading through numerous reports.

A number of them were concerned in part or in whole with the medical workforce. The Chair of HWAC, by now my predecessor in Dunedin North Hon Stan Rodger, was keen to complete the report of the Committee's medical reference group. That report was released together with the Doctors in Training Roundtable report in May this year.

The New Zealand Institute of Economic Research had released a report, which, because of the way the economic assumptions were crafted, created something of a burning platform.

Colleges here and in Australia released a number of reports including the series from the Royal New Zealand College of General Practitioners. DHBs, last August released their five-year strategic plan entitled 'Future Workforce'. Over in Australia the blizzard of reports continued, including a report by their competition watchdog the ACCC and another large report by the Australian Productivity Commission.

Most, but not all, of these reports are predicated on the assertion or the reality of a shortage. We seem to be short of everything, which is logical enough when one considers that the health sector is an increasing proportion of every western nation's economy, as each of those western nations grows richer.

It is logical enough when one considers the endless points of vulnerability in the health system too. A specialist here, a midwife there, a GP here and there, a dental therapist in lots of places. Things stall in health because of a lack of theatre nurses or because of illness, or because the GP in a rural area has at last retired. They also stop, sometimes, because a low-paid home based support worker doesn't want to pay extra for petrol to fill the car.

But viewing health workforce issues as health workforce shortages has not always been the case and will not be again, sometime. Nurses used to travel to Saudi Arabia because there was no work in New Zealand. Australia reduced its numbers of medical trainees some years back, believing that an excess supply was causing a blow-out in costs. This supply-side analysis is still heard in parts of the US today.

I make these points in the hope that we will always remember that what goes around, comes around. A demand-side crisis, today's refrain, can switch to a supply-side surplus tomorrow, at least in some countries. It is best to remember that.

Let me return to the reports I just mentioned, not to describe their contents but to argue that we now have the momentum needed to quicken the pace of implementation. These three conferences are testimony to that.

That momentum shows that HWAC has demonstrably achieved its purpose. It has provided the forum by which advice is now flowing very freely indeed and it is time for me to give most members their lives back and to thank those members, past and present, for their efforts. There will come a time when another season of advice is needed. Workforce issues are not going to go away.

But right now it is the time to bring into practice the ideas and the general direction that has developed over that time, and the starting point is the medical workforce.

You will recall me mentioning HWAC's medical reference group's report and the report of the Doctor's in Training Roundtable, both of which I released in May. Those two reports have much common ground, but neither report has consensus and nor is there consensus between them.

That is we know roughly where we want to go but not precisely. So I intend to establish a group called the Workforce Taskforce to bring that to fruition. It will be chaired by Robert Logan who has distinguished himself in recent years as the chair of the National Health Committee.

He is joined by seven others who have distinguished themselves in many fields of endeavour – three of whom were on HWAC to ensure continuity.

The committee comes into being today. Their first task is to advise me how to focus current medical education and clinical training to produce medical practitioners who are fit for purpose in the minimum time period.

I am anticipating a report within six months, which will consider options that include:

- shortening the number of undergraduate years
- starting specialist training during undergraduate years
- moving to pay medical schools for outputs
- collapsing the first two years of postgraduate training into one
- recognising prior learning, and
- appraising the apprenticeship training model in light of modern service delivery

This is a tall order. These are the very issues that earlier reports examined, advanced, but couldn't reach consensus on. Both those earlier reports were appropriately critical of the Government, saying that the Health and Education Ministries needed to work more closely. This taskforce will, therefore, be serviced by both the Ministry of Health and by the Tertiary Education Commission.

Inevitably this work crosses into the tertiary education portfolio, and Michael Cullen is therefore as interested in the outcomes as I am. He has an additional question on his mind and that is whether to raise the cap on undergraduate medical training further, after it was last raised in 2004. If he does, it will be effective from the 2008 academic year.

There is plenty more going on. The Future Workforce document of DHBs that I mentioned earlier is progressively being implemented. I shan't dwell on their work because I'm sure others will. But I am happy to assert that DHBs have the networks and collaborative decision-making processes in place, and that their priorities and actions are strongly grounded.

Back at the Ministry a new policy group has been formed to tie the strands together to identify gaps as they arise, to service the taskforce and to advise me.

When the taskforce's medical work is complete they may well be redirected onto any number of new tasks. It is not a committee of permanent members looking at all health workforce issues. Rather it is a taskforce with what will probably be a series of defined short-term tasks, and with a membership that will change as each new task is defined. To repeat, it is time to move from advice to progress. I wish the new taskforce enlightened, sensible and speedy deliberations

I now want to talk about flexibility and to claim the word as a good word and not the bad word that fifteen years ago heralded the arrival of the Employment Contracts Act.

Our health workforce must be flexible, and the underlying reason is that we need to be able to respond very well to the changing health needs of New Zealanders. As people generally live for longer, our services will not only be called on to provide the acute care we as we do now, but will need to become much better at helping people to prevent, and when necessary to manage chronic conditions such as arthritis, diabetes, depression etc; better too at helping people become 'experts' themselves, with health professionals 'on tap' rather than 'on top'.

Healthline is a good recent example, but telecommunication can be used in a lot more ways than we are using it at present.

We should acknowledge that most of us as we get older want our usual care in our home, and that continuum of care that people like me keep talking about, requires a team that makes the older person the centre of specialised team.

This will require public health, community, primary and secondary health care providers to be more integrated with one another, and for multidisciplinary teams to work better together, and with patients and their families. Team work will not only better for the patient but will allow practitioners to take up specialty interests as part of that team- – a nurse practitioner with a scope of practice, a GP with a special interest, an optometrist who can prescribe an appropriate range of medications, a perioperative surgical practitioner, a radiographer who can read a proportion of images.

We should seek more of the professionalism and flexibility that allows a better work/life balance for health practitioners, for example so that a junior doctor's working hours better meet the needs of hospital patients, better meet the training needs of the junior doctor, but which does not take wages and conditions back by fifteen years when flexibility meant something completely different. Professionalism and flexibility that has a variety of well-developed career paths for medical officers, as well as medical specialists, for clinical nurse specialists, and for that large and possibly most flexible of all professional groups, nurses. Professionalism and flexibility that recognises and supports the special skills of rural practitioners, and expert generalists working in smaller centres.

We need the flexibility to deliver differently, to meet changing health needs, changing community expectations, and changes in what makes for a satisfying careers as a health practitioner.

And so it goes on, seemingly forever.

If flexibility is good, so is some rigidity. Quality and safety is not up for negotiation in discussions such as this. Neither is privacy, nor standards, nor regulatory oversight, nor professionalism, nor ethics.

But within that framework we can do a lot better for the patients or citizens who, after all, pay for our public health system in the first place. As each decade passes more and more

One last thought. Much of what I have spoken of is happening already, or beginning to happen already. Each year there are significant changes – the advent of digital radiography, the extension of prescribing rights, the outreach of a specialist in a reconfigured service, the development of a local or regional network.

It is very important that I acknowledge those many changes and the people who champion them. They effect change no matter what papers are written, no matter what conferences are held. But I sense that if there is one thing that the New Zealand health sector has developed a consensus upon, then that is that the pace of workforce change must quicken, now.

What you as clinicians, funders, planners and managers discuss over the next two days is not the models of the past. It is the vision for the future. How will health professionals respond to changing models of care, and changes in populations and demographics.

Thanks for your attention. I hope you have a mighty fine conference.


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