4 Environmental trends and issues

Transcription

1 4 Environmental trends and issues The following trends and issues have been identified as having an impact on workforce development: globalisation technology and its effects demographics health of the population the economy education labour market social change consumer expectations service delivery developments recruitment of health workers retention of health workers workplace environment good employer issues gender. We will now look at each of these in turn. It is not possible to rank these trends and issues in order of importance to the workforce. Often these trends and issues interact in complex ways that vary from situation to situation and from time to time. 4.1 Globalisation Globalisation can be generally defined as a network of interdependence at world-wide distances.... it is clear that we live in a time of change where the movement of goods and services, transmission and impact of environmental events and biological agents, transfer of ideas and notions; and movement of capital and human resources are less restricted by geographic and jurisdictional barriers than in the past (Dauphinee 2001). Key impacts of globalisation on the health workforce include the following: Education and training: medical schools are increasing internationally (UK and Canada), and there is the potential for on-line curricula and assessment programmes, yet the number of students in nursing programmes is declining (New Zealand and Ireland). Licensure and certification: for example, Trans Tasman Mutual Recognition Agreement. Labour mobility: this is facilitated by the mutual recognition of qualifications: the increasing collaboration and internationalisation of standards for credentialling processes and training programmes, including the sharing of information on assessment techniques (Dauphinee 2001). The cultural appropriateness of service delivery if importing workforce: this issue has largely been ignored in New Zealand until the recent episode involving immigrant doctors not gaining New Zealand registration. The remedial programme developed may provide a good example of the type of cultural training that would benefit all immigrant workers to the 24 The New Zealand Health Workforce: A stocktake of capacity and issues 2001

2 New Zealand health service, as both the ethnic mix of our population and the origins of the immigrant health workers become more diversified. This is increasingly important to meet obligations to Mäori under the Treaty of Waitangi. E-based services: the value to workforce planning of better access to information via the Internet and tele-health. E-based services may be used to transmit images to distant locations, thus reducing the need for specialists in remote areas, and for interactive workshops and consultation. At the primary level it may be used to connect with the patient at home, and also used for continuing professional education (based on Dauphinee 2001) Issue Globalisation has led to an increasing loss of New Zealand-educated doctors, dentists and nurses in the early years after graduation. 4.2 Technology The WAVE project The WAVE programme s objective has been to produce an information and technology plan for the sector, with the aim of improving health outcomes, through effective use of information, at the least cost (The WAVE Advisory Board 2001). This New Zealand health sector knowledge management project has large, unquantified, implications for the health workforce. The gains in terms of integration and co-ordination between primary and secondary care may lead to a change in the workforce skill mix in the long term. In the short term, the programme may place heavy demands on providers to upskill the existing workforce to utilise and support the available technology. WAVE sampling 5 of primary care providers and software vendors has indicated: 57 percent of GPs use patient management systems (PMSs) to record and store prescription and some clinical data 71 percent will be using PMSs within two years 89 percent will be using PMSs within three years. This signals quite a shift over a short period. To achieve improved patient outcomes by using a knowledge management system, several things must occur. In the first place the technology must be easy to use as judged by those with limited understanding of technology and it must be quick to deal with the problem of slow access time in the provinces because of poor telecommunications infrastructure (for example, old-style telegraph lines and exchanges). Clinicians need to be willing to access information systems to increase their knowledge, and their attitudes to using it may also need to change. 5 A combination of questionnaires and site visits, conducted by the WAVE team, early See WAVE Advisory Board The New Zealand Health Workforce: A stocktake of capacity and issues

3 The proposed system will mean new business for the health sector, but it will take work to maximise the potential benefits. No research has been commissioned to assess the impact on the health workforce in terms of, for example, length of patient visits and the problems of transitional arrangements while clinicians learn to maximise the benefits the technology can offer. The WAVE technology itself may drive the need for a new type of health worker who requires specialised health knowledge but who may not interface with patients Other technology issues Other technology advances that impact on skills and the skill mix of the workforce include new diagnostic techniques, advances in surgical techniques, and drugs displacing labour-intensive modes of treatment. These will have a huge impact over the next 30 years. The availability from early 2002 of a mobile theatre unit in New Zealand, in addition to the mobile lithotripsy service, may affect service delivery in rural areas and provide opportunities for upskilling GPs and nurses and ongoing professional development Issues Lack of knowledge about the impact technology developments will have on the health workforce. Lack of infrastructure to upskill the workforce quickly to harness the opportunities provided by new technology in service delivery, continuing professional education and patient self-management. 4.3 Demographics Size and distribution of the population 6 New Zealand has a slow-growing, rapidly ageing population. The resident population totalled million on 30 June 2001, of which New Zealanders aged 65 years and over made up 12 percent. Population growth in the North Island outpaces that in the South Island. Seven regions experienced a population decrease in the previous year: Southland, Taranaki, West Coast, Wanganui Manawatu, Hawke s Bay, Gisborne and Otago. At 30 June 2000 more than three-quarters (77 percent) of New Zealand s resident population were living in either main urban areas (centres with 30,000 or more people) or secondary urban areas (between 10,000 and 29,999 people). 6 The information presented is derived from Statistics New Zealand (2001). 26 The New Zealand Health Workforce: A stocktake of capacity and issues 2001

4 4.3.2 Ethnic mix of the population Mäori Mäori comprised 15.6 percent of the New Zealand population in June The Mäori population is expected to reach nearly one million by 2051 and to comprise 22 percent of the total population. The Mäori population will undergo major shifts in age structure in the coming years. Given the prospects of lower birth rates, increasing life expectancy and the ageing of children born during the high fertility years of the 1950s and 1960s, the Mäori population will become progressively older: half will be over 32 years by 2051, compared with a median age of 22 in (This compares with 45 and 33 years respectively for the total New Zealand population.) In the main working-age group (15 to 64 years) numbers of Mäori are projected to rise 85 percent over the next 50 years. Although their share of the Mäori population should remain unchanged at around 60 to 61 percent, those aged 40 to 64 years should make up a larger proportion of the total number in the 15 to 64-year-old group by 2051 (Statistics New Zealand 2001). Pacific peoples Over the next 50 years the Pacific peoples population in New Zealand is expected to grow at a faster pace than the total New Zealand population. Its share of the total population is expected to double from 6 percent at the 1996 Census to about 12 percent in The current median age of the Pacific community is just 20 years well under the 32 years of the overall population. The impact of such growth will be significant. Auckland s job market and population growth are becoming dominated by Mäori and Pacific communities. Pacific peoples are one of four similarly sized large groups that make up Auckland. They provide nearly 30 percent of births and, in 20 years time will provide some 30 percent of new job entrants. Pacific peoples are a growing voting force. They also represent a large share of the growth in consumer markets and consumer-oriented education and health services, and by 2050 they will be one of the largest consumer groups in Auckland. Many of the social changes affecting the Pacific community are consistent with global trends and experiences. For instance, the older Pacific population in New Zealand will grow significantly. There are now around 6000 persons in that community aged 65 or over. By 2050 there will be 11 times as many, or 68,000. Now there are about 13 children under 15 years for every older person, but by 2050 there will be barely 2.5. The median age will shift from 21 years to 29 years. Pacific peoples will be 13 percent of the population, but 5 percent of the population 65 and over. Social and technical change is also bringing potential opportunities for young Pacific people to enter the labour market. The New Zealand labour force is ageing fast, at a time of huge technological change. Over the next decade the share of the labour force over 45 years will grow from 32 percent to 43 percent. Of the new entrants to the Auckland labour force in 20 years time, some 30 percent will be Pacific men and women. 7 7 See: The New Zealand Health Workforce: A stocktake of capacity and issues

5 4.3.3 Questions 9 Are current health workers appropriately trained to meet changing health service demands? 10 What workforce competencies are required to meet the needs of the increasing, and increasingly diverse, older population? Issues The population is increasing in size and diversity, with older people, Mäori and Pacific peoples increasing at a disproportionate rate to the rest of the population. The ethnic composition of school leavers available to enter health profession training will become increasingly diverse. There will be increasing demand for improved health outcomes for Mäori and Pacific peoples. 4.4 Health of the population Two key health outcome measures are mortality (deaths) and morbidity (illness). Overall mortality rates have declined dramatically over the last half century, and life expectancy at birth reached 74.3 years for males and 79.6 years for females in But overall life expectancy figures hide disparities between different social groups. Within New Zealand there are marked discrepancies in life expectancy between different ethnic groups and different socioeconomic groups (Table 4.1) (Ministry of Health 1999a). Table 4.1: Life expectancy of New Zealanders in years of age Ethnicity Age (years) Male Female Difference Non-Mäori Mäori Pacific Source: Ministry of Health 2001d Most New Zealanders now die of (often multiple) chronic diseases. In 1996 chronic disease accounted for 82.8 percent of all deaths, a proportion that has remained constant since Chronic disease mortality is dominated by cardiovascular disease and cancers. Normal pregnancy and childbirth are the leading reasons for hospitalisation, followed by management of chronic diseases, the leading one being cardiovascular disease, which accounted for 11 percent of hospital discharges in Injuries made up approximately 20 percent of discharges in 1997, with the highest rates found among older people (Ministry of Health 2001d). 28 The New Zealand Health Workforce: A stocktake of capacity and issues 2001

6 The increase in life expectancy, and increases in diseases such as diabetes and mental illness have implications for the health workforce overall and particularly the general practitioner workforce. The mix of skills required to meet the long-term support needs of older people and others with ongoing support needs is changing in the community. In terms of residential care workers, rest home residents are becoming increasingly frail on admission. The skill mix required to provide safe, quality services at an affordable price needs further work Determinants of health One of the key Government goals is to reduce inequalities in education, employment and health. The Ministry of Health has developed a specific framework for actions to reduce inequalities in health via intersectoral collaboration to influence the socioeconomic determinants of health, as well as directly through the health sector. The myriad factors that affect health outcomes are complex (Table 4.2). Many official reports and studies have shown significant relationships between health status and income, healthcare, education and smoking, and have indicated that factors such as educational level are as important as expenditure on healthcare services in reducing mortality. Table 4.2: Factors affecting health outcomes Fixed Social and economic Environment Lifestyle Access to services Genes Gender Ageing Poverty Employment Social exclusion Air quality Housing Water quality Social environment Diet Physical activity Smoking Alcohol Sexual behaviour Drugs Health and disability services Education Social welfare services Transport Leisure Source: Adapted from Our Healthier Nation, UK Green Paper (Department of Health, 1998) The mechanisms by which the structural conditions that is, social, economic and environmental features may ultimately affect health are illustrated in Figure 4.1. Structural conditions also impact on the ability of individuals to access services, as well as encouraging or inhibiting particular lifestyle or health-related behaviours. The New Zealand Health Workforce: A stocktake of capacity and issues

7 Figure 4.1: Model of the social and economic determinants of health Structural features of society, economy and environment: Low unemployment Clean, healthy environment Safe working conditions with high job control Low disparities in income and wealth Affordable, available education and health services Low crime Favourable economic conditions All ethnic groups feel able to participate in society Implementation of Treaty of Waitangi obligations Health-related behaviours: No smoking Moderate alcohol Regular exercise Adequate sleep Low-fat diet Safe sex Sufficient disposable income to afford: Stable adequate housing Nutritious diet Adequate health care Adequate educational opportunities Safe working conditions, with high job control Psychological coherence: Social support Spouse or confidant(e) Strong ethnic identity Open sexual identity Positive future prospects Perceived control Healthy individual family/whänau Healthy community/ strong social capital Source: Ministry of Health (2000c) 4.5 Economy The economic outlook for New Zealand will affect the health status of individuals and the proportion of gross domestic product (GDP) spent on health. Increasing health care demands in an environment of financial restraint will lead to pressure to deliver health services more effectively and efficiently, which may in turn lead to the need to reconsider the skill mix and opportunities for substitution within the health workforce Health expenditure New Zealand spent 8.0% of GDP on health in 1998, just above the unweighted Organisation of Economic Co-operation & Development (OECD) average of 7.9%. The proportion of health expenditure to GDP has increased from 6.5% in 1988 to 8.0% in In comparison, the OECD unweighted average over the same period increased from 7.4% to 7.9% (Ministry of Health 2000b). 30 The New Zealand Health Workforce: A stocktake of capacity and issues 2001

8 4.5.2 Question 11 Will current funding enable the continuation of the same health workforce skill mix to meet the needs of changing demands on the health service? 4.6 Education The Tertiary Education Strategy is seeking to build a tertiary education system that will meet New Zealand s future social and economic needs, and that will promote our development as a knowledge society. It is more explicitly aligning education with wider government goals for economic and social development. The tertiary education sector is changing from being driven by consumer choice to a focus on producing skills, knowledge and innovation, which New Zealand needs in order to transform the economy, promote social and cultural development, and meet the rapidly changing requirements of national and international labour markets. The Tertiary Education Advisory Commission (TEAC) was tasked with providing advice on the future strategic direction of the New Zealand tertiary education system. Its first report, Shaping a Shared Vision (Tertiary Education Advisory Commission 2000), set out a broad vision. Its second report, Shaping the System (Tertiary Education Advisory Commission 2001a), gave the steering mechanisms needed to utilise the capability of the tertiary education system strategically. These are: charters for publicly funded providers provider profiles, to avoid duplication and to focus each provider on their specialities and the needs of their stakeholders a Centres of Research Excellence Fund to foster excellence in areas of strategic importance a Tertiary Education Commission (TEC) to bring the administration of the whole system together under one agency. TEAC s third report, Shaping the Strategy (Tertiary Education Advisory Commission 2001b), recommends a set of strategic priorities for the tertiary system. 8 The fourth report, Shaping the Funding Framework (Tertiary Education Advisory Commission 2001c), is also of importance to the health workforce and planners Enabling access to tertiary education for Mäori and Pacific peoples Mäori health workforce development is largely accessed through mainstream education and training institutions, and there is an urgent need to promote and increase the number of Mäori joining these programmes. 8 The tertiary system includes learning in workplaces as well as classrooms and laboratories. It includes universities, polytechnics and new training and research establishments. It also includes full-time and part-time learners, adults and school leavers, learning in lecture theatres and learning by distance. The New Zealand Health Workforce: A stocktake of capacity and issues

9 The urgency to increase the Mäori and Pacific health workforce also requires the development of more fast-track bridging programmes for health practitioners, keeping in mind the effectiveness and quality of the workforce coming through. All tertiary education institutions have additional special supplementary grant funding to provide increased support for Mäori and Pacific students. These grants are focusing institutions on how best to extend and support access among under-represented populations. The Certificate in Health Science at the University of Auckland is a one-year foundation course otherwise described as a pioneers initiative which prepares Mäori and Pacific students for tertiary study in health and medicine. And it is achieving results (Maharey 2001) Students entering health-related training programmes Medical training There is currently a cap on the number of medical students entering training in New Zealand. This is set at 280 for the two universities offering undergraduate medical education. There is pressure from the universities for this cap to be lifted to enable cost efficiencies. The rationale, in terms of health demand, for increasing the number of trainees is unclear. The historical reason for the cap was to control costs by controlling workforce numbers. There is capacity (space and teachers) at both the Auckland and Otago Medical Schools to accommodate an increase in medical students. The optimal size of the specialist and general practitioner workforce needs to be considered to ensure that scarce health education funding is supporting the New Zealand health service rather than the international market. There is no indication that increasing the number of medical students will directly improve health outcomes in New Zealand. There is also increasing consideration being given to the origin of students entering training, and to the selection processes. There is evidence that student doctors from regional or rural areas are more likely to return to rural areas to practice. Another issue is the ethnic mix of students entering the programmes. While the number of Mäori and Pacific people entering training is increasing, the impact on the proportion within the workforce has been small. It is estimated that, with the current student population, self-identified Mäori will comprise 2.9 percent of the medical workforce in 2005 compared with 2.3 percent in Information on Pacific students is incomplete, but the number graduating from medical school is increasing, with 20 graduating in compared with 17 between 1994 and 1996 (Medical Council of New Zealand 2001b). The proportion of overseas-born, mainly Asian students has been around 30 to 40 percent of the student population in recent years. Nursing and midwifery There is no cap on the number of nurses that can be trained, although as with other degrees the Ministry of Education decides what proportion of the total costs will be subsidised and applicants largely determine the number of undergraduate nursing students. The number of students entering education programmes for nursing is currently around 1100 per annum, down from approximately 1400 before 1995, with a further 100 per annum entering direct-entry midwifery. Similar decreases are reported in other jurisdictions (for example, in Ireland student numbers decreased from 1370 in 1993 to 1095 in 1998 (Irish Nurses 32 The New Zealand Health Workforce: A stocktake of capacity and issues 2001

10 Organisation 2000). It seems inevitable that New Zealand will follow international trends whereby a decrease in the number of trainees increases the likelihood of shortages emerging and increases the time it may take to resolve these. Ethnicity information on nursing students is not readily available. Dentistry training The number of dentists in training is capped at 55 new entrants per annum. Other health professional groups The numbers of students entering other health education programmes varies, and is adjusted in response to demand; for example, training programmes for medical radiation therapists have been extended in response to increased linear accelerators being commissioned nationally and internationally, and the consequent extreme demand on the supply of medical radiation technologists. General Consideration needs to be given to selection criteria and their impact on and alignment with selection processes. Submissions from education providers indicate that for many undergraduate programmes, limitations on trainee places are in effect established by public sector providers (DHBs), who decide on the volume and frequency of clinical placements available for students at various stages of the programmes New developments at the undergraduate/pre-entry level Development of a second-level nurse programme The Minister of Health recently announced that a programme to train second-level nurses would commence in Northland in Second-level nurses will be called enrolled nurses. Review of undergraduate training The Nursing Council of New Zealand recently reviewed the undergraduate training programme for nurses. The review provides some insight into the extent that undergraduate programmes are meeting the needs of the sector. Recommendations from the Strategic Review of Undergraduate Nursing Education (Nursing Council of New Zealand 2001) that have application across other professions include: national education frameworks for: entry criteria selection processes recruitment and promotion of discipline clinical funding rural incentives increased auditing of programmes increased depth/quality of clinical placements rather than quantity and/or variety The New Zealand Health Workforce: A stocktake of capacity and issues

11 increased mechanisms for peer support preceptor/apprentice models comprehensive education early in programmes specialisation in the last year improved quality of teachers increased funding to postgraduate/ongoing education removal of specialty topics already covered by other disciplines. The UK has recently developed a new model of nurse education and training, described in their nursing, midwifery and health visiting strategy, Making a Difference in Primary Care: the challenge for nurses, midwives and health visitors (Department of Health 2000b). It emphasises improving access, developing practical skills earlier in training, and stepping-off points at the end of the first year. It will be rolled out nationwide, and by autumn percent of all nurse training organisations were expected to have been operating under the new arrangements. By autumn 2002 it will be standard across the whole of England. Similar principles will be applied to education and training for the other health professions and health scientists (Department of Health [London] 2000). Medical undergraduate education The University of Otago is currently considering a merged model allowing for entry of undergraduates to a six-year course, or graduates to a four-year programme. The two streams merge for the last four years. Graduate entry models are operating in Australia, and have been the norm in the US for many years (Donald 2000). The UK is also considering this option as part of the radical review of the role of the General Medical Council, together with proposals for shortening the medical undergraduate course to three years for existing graduates and four years for others (Department of Health [London] 2000a). Access to clinical experience The availability of clinical experience provided by some DHBs is an education and safety issue, highlighted by several education providers in recent submissions. Clinicians report that providing clinical experience for students is an added work pressure Professional development The submissions to HWAC raised issues about the lack of retraining (return to work) courses for most professional groupings, and misalignment between ongoing education and career pathways. The information available largely relates to nurses. First year of nursing clinical practice The CTA is piloting, for a one-year period, a first year of nursing practice programme in three or four locations. 34 The New Zealand Health Workforce: A stocktake of capacity and issues 2001

12 National purchasing and prioritisation framework for post-entry nursing training The Ministry of Health has set up a sector reference group to: develop a prioritisation framework for funding post-entry clinical nursing strengthen sector understanding of the CTA s process for prioritising funding of post-entry clinical nurse training develop a national purchasing strategy for post-entry clinical nurse training. Nurse practitioner role Nurse practitioners will be unique health care providers, making independent and collaborative health care decisions in partnership with individuals, families and communities across a number of settings. They will be expert clinicians who incorporate advanced knowledge and skills into practice within a specific scope of practice, such as family health, adult health, child health, health of older people, women s health, occupational health and mental health. They will respond to complex situations in a diversity of contexts, demonstrating leadership as a consultant, educator, administrator and researcher. They may choose whether or not to be nurse prescribers. Nurse prescribing The Medicines Amendment Act 1999, enacted on 15 October 1999, allows the extension of prescribing rights to nurses and other health professionals, and the use of standing orders. Regulations are now being developed for the first nurse prescribers and to set out the requirements for standing orders. Nurse prescribing should provide opportunities for health and disability services to be delivered in more flexible ways, improve access to services, and subsequently reduce secondary illnesses and hospital admissions. Other groups Allied health workers need to be aligned with the New Zealand Health Strategy; for example, clinical psychologists work mainly in the hospital environment rather than the community. Consideration of how best to deploy allied health workers in the primary/community setting will be important to the success of the Primary Health Care strategy Questions 12 Who should undertake reviews of undergraduate health and disability education programmes? 13 Should health and disability education and training programmes offer more recognition of prior learning? The New Zealand Health Workforce: A stocktake of capacity and issues

13 14 Should more generic, entry-level health and disability education programmes be developed, with specialisation in the later years? 15 Should health and disability education programmes be looked at in isolation, or should there be a comprehensive review of major programmes to determine common competencies and opportunities for shared learning to meet future workforce needs? 16 How best can co-ordination between health and education sectors be improved, both nationally and regionally? Issues There is only a limited framework for review of undergraduate health and disability education programmes. There is a lack of an obvious linkage between development and implementation of the New Zealand Health Strategy and the New Zealand Disability Strategy and review of health and disability education programmes. There is a lack of knowledge about students ethnicity and completion rates for many programmes. 4.7 Labour market The Department of Labour recently explored the future of work in New Zealand and identified the following significant trends. 9 The years to 2010 will have influences similar to the last 10 years with globalisation, technology, demographic, social workplace and workforce trends continuing. This period will, however, provide New Zealand with the opportunity to build a strong base for the years 2010 onwards, a period in which demographic changes are likely to be even more pronounced. A key risk is the ageing population. In the short term New Zealand s labour capacity may increase, but as this ageing process continues labour market capacity could decline when people retire from the labour market and are not replaced by new entrants. There may be some reduction in the number of people willing and able to enter paid employment due to this changing demographic profile. As the pace of change quickens there is an increased risk that participants will not be able to adapt to change quickly enough. This could include the risk of emerging digital or geographic divides, with some groups or individuals having less capability to take advantage of new opportunities. 9 Information presented in this section is sources from Department of Labour 2001, except where indicated. 36 The New Zealand Health Workforce: A stocktake of capacity and issues 2001

14 As the population ages, there may be increased ability and incentives for younger people to enter the workforce earlier and with less formal training. This may reduce the average skill level of the workforce, and thus increase the risks of a lower level of adaptability in later years. More older people may choose to remain in the workforce for longer as they ease into retirement. Competition for skilled migrants could increase as other countries also seek skilled immigrants, due in part to an ageing population in many countries. This will include competition for skilled New Zealanders elsewhere. It has been suggested that this is the largest risk to New Zealand s ongoing labour market capacity. The following are a selection of underlying labour market trends. How people participate in the labour market is becoming more diverse fitting the needs of employers but also allowing employees life choices. The male participation rate is declining. There is increasing availability of skills from overseas. There is also an increased ability of New Zealanders to gain overseas experience or leave permanently. There are increasing differences between regions, as migrants usually locate near big cities. The capacity of recent migrants may be different and slightly mismatched to the New Zealand labour market in many respects, including language and work experience. There will be short-term adjustment costs. The unemployment rate in June 2001 was 5.2 percent (Department of Statistics Household Labour Force Survey (September 2001 quarter). This is low compared with recent years, and may impact on participation at the low-skill, low-remuneration end of the health workforce. It could also lead to higher turnover as workers seek better jobs as their experience and skill level increases Migration Many countries are currently experiencing shortages of health professionals and are actively engaging in recruiting internationally. The 13th Commonwealth Health Ministers Meeting in Christchurch in 2001 placed emphasis on developing an accord between Commonwealth countries to act ethically in their recruitment practices, and to seek a global understanding of international recruitment practices. The traditional reliance on immigration of doctors, nurses and midwives may no longer be sustainable as the demand for health care workers in other countries also increases, and there are decreasing numbers of workers trained in some professions. New Zealand has an increasing number of temporary doctors working within the system for between 3 and 18 months. Fewer medical practitioners are coming to New Zealand on a permanent basis, but those who come stay longer (MCNZ 2000b). The New Zealand Health Workforce: A stocktake of capacity and issues

15 4.7.2 Geographic distribution of jobs within the health sector (rural/urban) Mal-distribution of workers between rural and urban locations is a historical and international issue that is becoming of greater concern as the population of rural communities decreases. Increasing demands on the skill requirements of the reduced number of practitioners raises issues of training, oversight and relief from duties. Meanwhile, in urban locations there are also disparities between suburbs based on socioeconomic factors Questions 17 What will be the impact of labour market changes on the New Zealand health workforce over the next 10 to 20 years? 18 How will the low unemployment rate impact on the support/home care workforce groups? 19 How will we recruitment experienced health practitioners for rural areas? Issue The rural regions of New Zealand will experience a minimal growth or decline in population, which will stretch the ability of providers to deliver equitable access to health services in rural New Zealand. 4.8 Social change Values of the workforce The values of the young workforce are changing. Characteristics of work environments considered attractive to young employees include: anti-institutional service oriented non-hierarchical flexible and change-welcoming ethnically diverse committed to retraining increased importance that the workplace is a community merit promotion (Briggance 2001). 38 The New Zealand Health Workforce: A stocktake of capacity and issues 2001

16 4.8.2 Employment options Employment options have changed over the last few decades. For example, women have wider options of career choice and fewer may choose to enter the health professions. New skills and upskilling are constantly required, and need to be factored into employees jobs. 4.9 Consumer expectations Consumers have increasing access to knowledge via the internet and choice in terms of health providers, and in recent years they have displayed increasing expectations of health professionals. This is an appropriate development, driving a more patient-centred focus to health service delivery. It has also led to a number of high-profile cases coming before the Health and Disability Commissioner as consumers become more aware of their rights, as promulgated in the Health and Disability Services Consumers Code of Rights Service delivery developments The national trend for medical and surgical discharges from hospitals has increased over the 1990s, with increases even more pronounced over the last three years. The surgical treatment provided in hospital has also become more complex overall, due to new sophisticated surgical techniques, an ageing population and more treatment now able to be provided on an outpatient basis. The increasing complexity of patient conditions and increased throughput of patients in hospital settings requires an increasingly skilled workforce. From 1988/89 to the present, urgent medical care and non-urgent surgery have increased at roughly the same rate. Government initiatives for increasing the level of non-urgent surgery through the Waiting Times Fund, established in 1995/96, and additional funding for elective surgery from 1997/98 onwards, have led to a 6.6 percent per year increase in non-urgent surgery since 1996/97. Non-urgent medical discharges have continued to increase as well, with a 4.4 percent per year rise since 1996/97 (Ministry of Health 2001d). It is clear that although more services are being carried out in the community, this has not led to fewer people being treated in hospitals. More people than ever are presenting and being hospitalised, and this trend has been fairly consistent over the last decade as advancing technology enables better treatment. This increase is substantially greater than would be expected through demographic growth and an ageing population alone. Other trends include: decreased average length of stay from 6.6 days in 1988/89 to 3.2 days in 1999/00 (although this decrease appears to be levelling off) increased day case rates increases have been noted across all specialties, but particularly ophthalmology, ear nose and throat and urology reduction in aggregate bed days a 2.6 percent per year reduction in bed days over the last decade increasing outpatient attendances these have not been accurately and consistently recorded, but available evidence suggests that there has been a steady rise over the last 10 years an increase in activity in primary care settings The New Zealand Health Workforce: A stocktake of capacity and issues

17 a shift of care from hospitals to ambulatory and community-based settings new technologies and discoveries these continue to increase our ability to prevent, diagnose and cure illness and injuries increasing consumer expectations the medicalisation of conditions such as obesity and depression (Ministry of Health 2001d). The New Zealand Health Strategy and the Primary Care Strategy have adopted a population focus that encourages all providers to move towards improving health and reducing health disparities. As a result, it is crucial that New Zealand increases the capacity of the total health workforce to understand and put into practice the concepts of population health Health service delivery reform Reform is occurring internationally, with the intended outcome of containing costs, improving quality, and making more services available to more people. Different countries have pursued these goals through different aspects of sector reform, such as new organisational arrangements for: physical infrastructure financing provider payments information. No country has systematically undertaken a comprehensive reorganisation, restructuring, or rethinking of their workforce (De Geyndt 2000). Impacts in New Zealand have included a loss of nurse leaders in restructuring and the casualisation of the nursing workforce Skill mix within the health sector Skill mix may occur between professions, within professions (for example, between medical specialties) and between institutions. The most recent development is the announcement by the Minister of Health that enrolled nurse training will recommence in The education programme is being developed to reflect the current health sector demand for a second-level nurse practitioner. Financial rewards are generally higher for specialists than for generalists. This leads to problems attracting practitioners into the general practice and rural practice settings. Opportunities to provide services privately, with consumers accessing private insurance, affects the balance within medical specialities those services that do not attract high volumes of private practice are less attractive (for example, psychiatry and public health medicine). The Medical Council reported limited growth in GP numbers over the last three years and increasing divergence in general practice service levels across rural/urban divisions and between Health Funding Authority localities (Medical Council of New Zealand 2001). The RNZCGPs reports an effective decrease in GPs over the last five years as GPs move into other primary care service delivery. 40 The New Zealand Health Workforce: A stocktake of capacity and issues 2001

18 New Zealand is also becoming more reliant on a temporary, transient workforce. Seven hundred temporary overseas-trained doctors were registered in the 2001 year, 227 more than the previous year (MCNZ 2001). This has implications for service delivery when practitioners are unfamiliar with New Zealand health systems and the diverse cultural needs of the community. It places added demands on service providers to orientate and upskill these temporary workers continuously as they churn through the system Sub-specialisation within medicine Currently there are 29 recognised branches of medicine, comprising a mix of older specialties and newer branches, such as musculoskeletal medicine and sexual health. Permitting the formation of newer and smaller vocational branches enables the Medical Council to give assurances to the public that doctors are competent to work in small, well-defined areas. New vocational branches accepted by the Medical Council during the 2000 year were palliative medicine and family planning reproductive health. An application from accident and medical practitioners for recognition was approved in August. A three-year moratorium was placed on approval of new branches of medicine from July 2001 to allow review of the principles behind vocational branch recognition, plus a review of existing training and recertification programmes (MCNZ 2001). A recent study by the Internal Medicine Society of Australia noted that: The New Zealand medical workforce surveys show that over the past 10 years the ratio of subspecialists to generalists has increased from 2:1 to greater than 3.5:1. In addition the number of general physicians available to service the specialist needs of remote centres is approaching crisis point in some areas (Internal Medicine Society of Australia and New Zealand Royal Australasian College of Physicians Health Policy Unit 2000). Reasons for this include: matters relating to remuneration changes in technology and hospital practice lifestyle issues loss of academic departments of general medicine and general physician role models. One of the most significant outcomes from decline in physician numbers has been the compartmentalisation of care by medical subspecialty. This means that significant co-morbidity and patient concerns unrelated to the particular subspecialty are overlooked, misdiagnosed and inappropriately managed. Some hospitals are using sub-specialist services exclusively to deliver health care to populations with complex multi-system medical problems. This process may not always be in the best interests of patients, or cost effective for the organisation (Internal Medicine Society of Australia and New Zealand Royal Australasian College of Physicians Health Policy Unit 2000). Other impacts include: increased cross-referral between sub-specialists, resulting in patients seeing multiple providers and incurring increased costs patient inconvenience as a result of extra time visiting sub-specialists and longer hospital stays due to multiple referrals The New Zealand Health Workforce: A stocktake of capacity and issues

19 concerns about quality of care if other disciplines such as intensive care and emergency medicine assume primary responsibility for acute patient care under the banner of hospitalism increasing shortages of general physicians within metropolitan as well as regional and rural areas increasing costs of an excessive supply of sub-specialty services, which may not provide commensurate returns in terms of improved patient outcomes (Internal Medicine Society of Australia and New Zealand Royal Australasian College of Physicians Health Policy Unit 2000) Increasing investment in primary care and funding of primary care services One of the aims of health policy makers in recent years has been to encourage a move away from care in hospital-based settings to community-based facilities. This move has not been unique to New Zealand and is expected to grow significantly in the future. There are a number of reasons for this movement (some of which are contradictory): a recognition that the majority of individuals would rather remain in their own homes than be looked after in institutional care this is particularly true for the care of older people and for rehabilitation a movement away from institutional care for individuals to a belief in care within a community setting this is particularly true in the areas of mental illness and disability and physical disability a resource issue where there has been a perception that community care is cheaper than hospital-based care, although there is conflicting evidence as to whether this is the case technological changes, which have enabled many treatments that once required an overnight hospital stay to be performed on a day case basis or even in an outpatient setting (conversely, many ailments that were once untreatable can now be treated although they may require long hospital stays) the development of alternative models of care away from the hospital (for example, minor casualty units in primary care premises, consultant-run outpatient clinics in the community, lead maternity carer and nurse-led treatment services (Ministry of Health 2001d) Recruitment Reduced level of interest by school leavers in health sector careers The number of new entrants into nursing training programmes has declined over recent years, although the reasons for this are unclear. The Ministry of Health recently profiled the profession of nursing in a student publication distributed to all secondary school students in an attempt to increase enrolments. 42 The New Zealand Health Workforce: A stocktake of capacity and issues 2001

20 Recruitment of graduates into the health workforce In March percent of the medical graduates from the 1999 class year were active in the New Zealand workforce. The retention rate for New Zealand medical graduates in their first three years post-graduation in the New Zealand workforce for 1990, 1995 and 2000 shows a small but steady decrease (74.1, 72.9 and 70.7 percent respectively) (MCNZ 2000b). The College of Midwives report that while they attract an adequate number of Mäori students into the training programmes, graduates are not retained once they enter employment. Anecdotally it is suggested that they can not cope with the expectations that are placed on them by employers, and the lack of financial assistance for professional development Recruitment and re-entry of experienced staff Recruitment of experienced staff is considered more serious than recruitment of new graduates. For some occupations (for example, podiatry and medical radiation technologists), increasing demand from the private sector and/or minimal opportunities with public sector employers is part of the reason for the recruitment problems for some services and/or parts of the country. Employers report difficulty encouraging some practitioners particularly nurses to re-enter the workforce after time away. In the submissions to HWAC this was emphasised as a universal problem across all types of organisations consulted, and all categories of health practitioners. A survey undertaken in conjunction with the 2000 Nurses Council of New Zealand Annual Workforce Survey found that the most frequently reported factors that would assist registered nurses and midwives to return to clinical practice were: availability of return to work programmes provision of child care facilities salary increases more flexible hours of work. The submissions also commonly expressed concern about recruitment in rural and provincial centres, and the negative flow-on effects for rural and provincial centres when there are recruitment problems in the major centres. Recruitment into undergraduate courses of clinical academic staff was also identified as an issue by education institutions, including the medical schools. Serious recruitment difficulties exist in the unregulated caregiver and/or homecare workforce, with inadequate funding being cited as the main reason for the recruitment and retention issues across the disability/aged care sector Issues Recruitment of students into the health workforce and practitioners re-entering the workforce. Recruitment of academic staff for undergraduate health programmes. The New Zealand Health Workforce: A stocktake of capacity and issues