GUEST BLOG: Ian Powell – Colossal ‘porkies’ and band-aids don’t’ make a health workforce plan

On 1 August Minister of Health Andrew Little announced what he described as the start of a plan for the beleaguered workforce in Aotearoa New Zealand’s health system: Government’s 5 year late health workforce announcement.

In October 2017, when Labour became government with its two coalition parties, it inherited a health workforce crisis from the previous National-led government. As a consequence of a high level of inaction, partly due to a misplaced faith in restructuring as the solution, the situation has unfortunately further deteriorated.

Now other ‘c’ words are being used at the clinical frontline to describe the state of the workforce such as collapse and carnage.

In summary, the announcement involved:

• easing the process for recruiting overseas nurses and provision of up to $10,000 in financial support for overseas nurses for registration costs;
• meeting the costs of reregistration for New Zealand nurses who want to return to work;
• covering overseas doctors’ salaries during their six-week clinical induction courses and three-month training internships;
• coordinated and enhanced national and international healthcare recruitment campaign;
• training more doctors, nurses and radiographers; and
• dedicated immigration support services to make it easier for health workers to move to New Zealand.

Colossal ‘porkies’

The Health Minister’s announcement included a colossal porky in falsely claiming that the above measures could not have been introduced until his new health system established by the Pae Ora Act took effect on 1 July.

In particular, Andrew Little asserted:

Our changes to the health system only came into force a month ago, creating a single national health service. That means we can now have a single point of co-ordination and put some real heft into a national campaign to address the decades-old workforce shortage and ease pressure on the health system. These changes just weren’t possible under the old disjointed and bureaucratic structure.

 

Absolute balderdash! Minister Little’s claim that a single national health service only came into force a month ago is both senseless and untrue. A single national health service came into force as a result of the Social Security Act 1938. But give the Minister a break; he is only out by a mere 84 years!

Since that time Aotearoa has had a single national health service in which, of necessity, has been delivered locally, largely through public hospitals and general practices. That situation remains substantially unchanged today.

What has changed is that points of statutory decision-making closer to the provision of healthcare in these hospitals and practices have been removed. Consequently, our single national health service has seen its bureaucracy repositioned and much more centralised.

An even bigger porky

But there is an even bigger Ministerial porky than this. His final sentence states: “These changes just weren’t possible under the old disjointed and bureaucratic structure.” Absolute double balderdash!!

Prior to the establishment of Te Whatu Ora (Health New Zealand – HNZ), it was the Ministry of Health who had overall responsibility for the health workforce; not district health boards (DHBs).

On 1 July HNZ did not just replace the DHBs. It took over the Ministry’s national planning and funding functions. This included the Ministry’s responsibility for workforce planning and development.

The Labour led government could have required the Health Ministry to implement all the measures it announced on 1 August as early as October 2017. Instead it waited for nearly five years.

The sceptic might reasonably say this was done simply to make its health restructuring look good. The health professional at the clinical frontline might just as reasonably say the same thing.

Whether this appalling neglect was intentional or due to incompetence, the outcome was disastrous for the health system – patients and workforce.

Band-aids are not a workforce plan

The announcement itself, apart from being nearly five years too late, has some merit. Its individual elements are all useful. But, in the context of the seriousness of the deteriorating workforce crisis/collapse/carnage, they are band-aids. Band-aids can have a useful purpose but a treatment or cure they are not.

Band-aids are certainly not the start of a workforce plan (arguably “training more doctors, nurses and radiographers” is but only in an itsy-bitsy, partially embryonic, sort of way). What is needed are actionable workforce recruitment and retention strategies for the various health professional occupational groups.

Band-aids are certainly not the start of a workforce plan (arguably “training more doctors, nurses and radiographers” is but only in an itsy-bitsy, partially embryonic, sort of way). What is needed are actionable workforce recruitment and retention strategies for the various health professional occupational groups.

By health professionals I mean doctors and dentists, nurses, and allied health professionals (of which radiographers are a very small component; scientists, physiotherapists and psychologists are also examples among numerous other groups critical for the provision of safe quality healthcare).

The extent of the severe shortages among these health professionals largely varies from around one-fifth to one-quarter, depending on the specific occupational group (some are higher). The outcome ranges from presenteeism (working while ill) to fatigue to even burnout.

The consequence of this outcome is not just that the health of this exhausted workforce suffers. Too many patients are denied access to the healthcare that they need. Those that are fortunate to access healthcare receive it in sub-optimal conditions which increases the risk of errors leading to adverse patient outcomes.

Recruitment before retention

Usually, when considering recruitment and retention, more emphasis is sensibly placed on the latter. A workplace with high retention (ie, low turnover) is more attractive for recruitment than one that is not.

However, the shortages are now so severe (made more difficult than the aging of the workforce) that the greater emphasis needs to be on recruitment. Shortages have reached a point where the absence of sufficient recruitment is worsening retention.

At this point in time, improving recruitment will improve retention rather than the other way around.

Variability of health professional labour markets

While each of the multiplicity of occupational groups have severe shortages, there is much variability in their labour markets. Length of training is an influential factor. The shorter the training for an occupational group (say three years), the better the ability to address shortages by training more in New Zealand.

The longer the training (13 years minimum for medical specialists is the longest), the greater the reliance on international recruitment.

The variability of labour markets means that competition is also variable. It can competition include with the private health sector, outside the health system (for example, laboratory scientists are highly employable in the wine industry), or internationally (especially Australia) which is the case for medical specialists, nurses and  some allied health professionals.

Australia is important not just for its proximity and similar training. Although less severe Australia has its own shortages. By offering much higher remuneration and other conditions (in 2019 BERL estimated the basic 40-hour pay gap for medical specialists to be over 60%), Australia is able to recruit specialists and nurses from New Zealand). For the economy as a whole the average pay gap is around 25-30%.

But the effect of this is worse. Australia can easily compete with New Zealand when recruiting from other parts of the world. Te Whatu Ora will not be competing for specialists and nurses especially in Australasian labour markets; it will be competing in Australian labour markets.

What the Government through Te Whatu Ora needs to focus on is the expeditious development of practical recruitment strategies targeted at each of the labour markets that these different health professional occupations find themselves in.

Only then will Aotearoa’s health system be able to achieve improved healthcare and wellbeing for New Zealanders.

Ian Powell was Executive Director of the Association of Salaried Medical Specialists, the professional union representing senior doctors and dentists in New Zealand, for over 30 years, until December 2019. He is now a health systems, labour market, and political commentator living in the small river estuary community of Otaihanga (the place by the tide). First published at Otaihanga Second Opinion