Back to future for doctors and nurses

19:18, Jan 05 2010

Many New Zealanders criticise our health system and yet most like their family doctor and appreciate the nursing they receive when in hospital.

This is telling; health services are struggling to meet demand, but generally do so because of the goodwill and quality of the health workforce.

The demand is increasing. On the basis of our ageing communities alone, the need for health services will double in the next decade, and yet we are probably already spending as much on health as can be afforded by a small and relatively poor country.

The way in which we configure our services and our models of care will have to change. Systematic flaws need to be dealt with.

We have been told by the World Health Organisation that our reliance on importing health workers is unsustainable. About 70 per cent of psychiatrists, 40 per cent of all doctors and midwives, and 25 per cent of nurses and dentists working in New Zealand were trained overseas.

It is difficult to see how such a small country needs 21 district health boards and more than 80 primary health organisations. This perspective is shared by international reviewers. The result is a system resistant to change. Despite more than 50 recent reports recommending reform of the health workforce, no meaningful positive reform has happened.


The challenge then is considerable. Reform by way of innovation and clinical leadership is unavoidable and this is the mandate of Health Workforce New Zealand. The first task of the agency is to rationalise the 50 groups at present engaged in health workforce planning and funding.

The irony is that amid a plethora of new types of worker and new roles for existing workers, two major elements of the health workforce will be very much back to the future. These are the restoration of the primacy of general medical practice and bedside nursing.

Using agreed quality measures, the more doctors employed as general practitioners the better the care received by the community and at lower cost.

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Unfortunately, in the eight years since the Primary Health Care Strategy was legislated, there has been a loss of about a half-day of work per week for each general practitioner and four out of 10 doctors have stopped being on call after hours.

The Government has funding for 154 general practice trainees; only two-thirds of the places have been filled.

We need recruitment processes based on medical students and recently graduated doctors being exposed to positive general practice role models.

A high quality, employed and supportive training scheme is essential; retention will require careful remunerative incentives, a shift of emphasis and funding from hospitals to community health resources, a similar emphasis on population-based care and teamwork in integrated care centres, and increasingly diverse practice options, including special interests and hospital roles. This reform is overdue and under way.

Going back to the future also involves an affirmation of nursing roles. Both numerically and operationally, nurses are the core of a health workforce.

Nurses also have a privileged patient-centred-practice. Surprisingly given this role and the iterative rating of nurses as the community's most trusted members, the profession has been busy second- guessing what it is to be a nurse.

The nursing leadership is organisationally divided and some attempts at extending roles have not been politically savvy or necessarily sensible.

THE extraordinary change in vocational options for female school-leavers has also contributed to a significant dropoff in people wanting to train as nurses. The number of Maori nurses remains unacceptably low.

Again, reform is under way. The reinvention of enrolled nurses is an excellent start. The nursing leaders are aligning their agenda and, as with medical graduates, the concept of apprenticeship is again fashionable. Extended roles for nurses are essential, but are being rationalised. The nurse practitioner and the specialist nurse are vital elements of any health service.

However, these roles need to enhance the function of health teams and be actual extensions of core nursing skills and knowledge. It is pejorative to view nurses as being suitable to take on any unwanted or unfilled role in health, as it implies that nursing per se is not essential.

Given the imminent retirement of the baby-boomer generation of nurses, this also amounts to robbing an impoverished Peter to pay a poor Paul.

Although status is linked to remuneration, as is true for the medical profession, more important factors in affirming nursing by way of recruitment and retention include positive role models, clinical leadership, coherent and accessible continuing career progression and training, and practice diversity.

Our health system is under challenge and this will increase in the next decade. Things must be done differently and Health Workforce NZ has the task of facilitating this reform. Ironically, this includes a return to the past for both medicine and nursing.

Des Gorman is head of Auckland University School of Medicine, chairman of Health Workforce New Zealand, and a member of the National Health Board.