NEW SOUTH WALES NURSES' ASSOCIATION

Health Workforce Study Productivity Commission PO Box 80
Belconnen ACT 2616
Dear Commissioners Woods and Fitzgerald,

In association with the Australian Nursing Federation ABN 63 398 164 405
In reply please quote:	BH:ABU
1 August 2005

Response to The Health Workforce - Productivity Commission Issues Paper

The New South Wales Nurses' Association (NSWNA) would like to thank you for the opportunity to participate in the Productivity Commission's study into pressures facing the health workforce. We welcome this chance to be involved in planning and developing health workforce arrangements that will address the health needs of all Australians now and improve health outcomes in the future.

The NSWNA is the industrial and professional body that represents over 50,000 nurses in New South Wales. The membership of the NSWNA comprises all those who perform nursing work, including assistants in nursing (who are unregulated), enrolled nurses and registered nurses at all levels including management and education. The members of the NSWNA are also members of the Australian Nursing federation (ANF), a federally registered industrial organisation, and form the NSW Branch of the ANF.

As such, we have considerable interest in ensuring the existence and promotion of a viable and productive health workforce. We have particular interest in contributing to the development of a working environment for the health workforce which enables health workers to deliver the best possible health outcomes for the community while providing them with satisfying professional opportunities. We therefore welcome the opportunity to contribute to the outcomes of this study.

NSWNA does not wish to reiterate the problems and pressures currently affecting the health workforce as we believe these have been clearly identified and well articulated in the Commission's issues paper. Rather, we would like to provide some comments on the possible approaches to amelioration of these problems.

As the Commission's issues paper contends, the benefits of a healthy community are self evident. We therefore believe that the creation of a healthy community, which necessarily means improving health outcomes, should be the primary purpose and goal of all those involved in health care, from clinicians at the 'coalface' to the Prime Minister. Health services, health policy, funding arrangements for health care delivery and health workforce education and organisation should be developed accordingly. That is, there should be a unified and coordinated health system, administered by the states and territories within a framework of national standards, focused on producing health and ensuring that health care is provided to those in need not just those who can afford it.

Address all correspondence to: General Secretary, 43 Australia Street, Camperdown 2050 (PO Box 40, Camperdown 1450)
Telephone: (02) 8595 1234 1300 367 962 Fax: (02) 9550 3667 Web: www.nswnurses.asn.au Email: gensec@nswnurses.asn.au

Unfortunately, it is quite clear that this primary purpose, other than nominally, is not the key driver for current health care delivery in Australia. The pervasive dislocation and fragmentation of the planning, organisation and delivery of health services across the country ensures that the health system fails to achieve this goal. The exclusion of clinicians from planning decisions ensures the disengagement of health workers, particularly nurses, frustrating them to such a degree that their subsequent exodus from the workforce is resulting in critical shortages.

While these points are acknowledged in the issues paper, the significance of the frustration of nurses and other health workers has not been sufficiently noted. The paper explains the problems that exist and the events that are occurring, e.g. the high attrition rates of health workers and resultant workforce shortages, and seeks solutions without genuinely examining the root causes of these problems and events. The questions being asked and specific solutions being sought therefore risk irrelevance. Unless the causes are addressed the mantra of 'looking for new ways to meet old objectives' is meaningless.

The way in which health services are organised and health care is delivered impacts enormously on the capacity of health workers both to perform their jobs and to enjoy their jobs. We receive frequent reports from our members regarding the intense frustrations they currently experience in their working environments which effectively paralyse the efforts they make in delivering quality care. These frustrations, which include wastage of time and other resources because of poorly coordinated and duplicated services and the pressures of working in an environment preoccupied with cost control rather than patient care while constantly being asked to do more with less, lead to disillusionment and despair. It is therefore clear that workforce redesign should not be attempted in isolation from remediation of the broader problems of the health system.

We would like to suggest that perhaps the most appropriate `new' way to address current problems is firstly to change the perspective from which our health system operates. The present and predicted problems outlined in the issues paper, while considerable, are most pressing within the illness/medical model of the Australian health system. Reorganising the way health care is delivered in this country, for example, by adopting a wellness/primary health care model could significantly ameliorate many of the problems within our health system. A wellness/primary health care model would necessarily involve a whole-of-government approach to health care delivery, which is essential; health policy cannot be effective if developed independently from social policy. However, until such change occurs the piecemeal approach of separately addressing identified problems, such as workforce shortages, will achieve little.

Clearly achieving this change will not be simple; it will require time, reallocation of resources, community engagement and, most significantly, political will and commitment. However, it remains necessary. And, within such an improved framework of health care delivery, effective and appropriate workforce redesign will be achieved more readily. (NSWNA does not intend to provide detailed directions of how these changes to the health system and the health workforce should be made, rather we would direct the Commission to the body of work currently available on this topic',2,3)

1 Duckett, S.J., 2005, Health workforce design for the 21" century, Australian Health Review, May, Vol 29, No 2.
2 Menadue, J., 2005, Health Sector Reform: Parts I & 2, New Matilda, available online at: http://www.newmatilda.com/policytoolkit 3 Buchanan, J., 2005, Recasting Australian employment law: implications for the health sector, Australian Health Review, August, Vol 29, No 3.

We are not, however, trying to suggest that necessary improvements for the health workforce cannot be made until systemic change has been achieved. In fact, significant progress in addressing the problems affecting the working environments of nurses has already been achieved. In NSW and Victoria measures, such as a reasonable workloads clause in the public sector award and mandatory nurse-patient ratios respectively, have been developed and implemented. These tools provide nurses with mechanisms to control their working environments by determining a reasonable and safe level of work and the number of patients that may be reasonably and safely cared for by one nurse.

These sorts of measures, negotiated between unions, governments and other employers, are critical in improving the working environments of nurses, the quality of the care they are able to deliver and, crucially, their job satisfaction and subsequent likelihood of remaining in the workforce. However, further developments of this nature must be implemented; currently in NSW there are several thousand qualified nurses who are not working in nursing and who are unlikely to return to nursing until they can be assured of safe, reasonable and satisfying working environments.

Although NSWNA broadly supports the approaches and recommendations outlined in the works mentioned above, a couple of issues require further comment. While these commentators recognise that the need for specialisation in the health professions will continue to exist and will most likely increase, and will need to be accommodated by appropriate education, they consistently emphasise a particular need for generic or generalist health workers.

We agree that a generalist health worker or health professional who acts as a point of central coordination in the delivery of care to patients adopts a useful and necessary role. However, we believe that this worker already exists within the guise of the general nurse. Nurses have always been responsible for coordination of services for patients, a feature of health care delivery which is unlikely to change. Nurses consistently assume the roles and responsibilities of the nine-to-five health workers, providing elements of physiotherapy, occupational therapy and other professionals' practice within the normal delivery of nursing practice and frequently the only constant for patients in what is often a bewildering experience. It is clear then that the general nurse is already the generalist worker within the health system.

We therefore suggest that rather than 'reinvent the wheel', the role of nurses in fulfilling this generalist role should be re-examined and, where appropriate, expanded. The propositions of this nature made by Stephen Duckett in his examination of health workforce redesign4 should be explored.

NSWNA appreciates that the compartmentalised structure of the health workforce may need to be dismantled and that further development of cooperative teamwork across traditional boundaries is required to build a more effective workforce better able to meet the community's future health care needs. We are not, however, advocating any deconstruction of the regulatory arrangements for the health workforce or the health system.

The first duty of the health system is the protection of public safety; this cannot be achieved without suitable regulatory arrangements. We do not consider that regulatory control unnecessarily restricts workforce flexibility, corrodes diversity or inhibits innovation.

Rather, we believe that regulation, which ensures a minimum standard of health care delivery and guarantees both the protection of the public and safe working environments for health professionals, is the only mechanism which can ensure protection of the public.

For example, the regulatory provisions for registration of health professionals outline the minimum professional standard and responsibilities expected both by the health system and the community and provide the means by which professionals may be held accountable for their practice. Relaxing this regulation would only serve to reduce the safety, and therefore the efficiency, of the health workforce and diminish public confidence in the health system.

Equally important to the efficient and effective working of the health system is legislation such as the various Poisons Acts of the states and territories. As with many health care activities and procedures, the administration of poisons to individuals is a risky activity which can prove costly when incorrectly managed. It requires considerable professional skill and knowledge and should only be undertaken by licensed health professionals. As above, the community has a right to expect that the health workers performing such activities are appropriately educated and prepared to do so and that mechanisms which ensure their accountability exist. This is only possible where good regulatory controls are in place.

We appreciate the need for education which will foster improved multidisciplinary health care delivery and the benefits that 'inter-professional learning' might engender. However, we do not believe that that these concepts are new; when the first nursing degrees appeared in then colleges of advanced education almost twenty years ago, nursing students shared much of the early years of their education with allied health students. However, although nurses have been amenable to this concept it appears not to have been widely adopted by the higher education system.

It is clear that a re-examination of the educational needs for health workers and health professionals is urgently needed. The pivotal point however, is that any consideration of the appropriate education for workers within the health system must not be conducted separately from other health service planning and organisation. As mentioned earlier, there must be a unified approach to health care planning and provision in this country; a key aspect of this is educational preparation. Therefore, design and development of education programs must be intrinsically linked with health and social policy and planning.

Our final comment at this stage is with respect to the need for community involvement in redesigning the health system, not least the health workforce. The role of an effective and efficient health workforce in creating a healthy community is undeniable. The key challenge for governments, however, is in developing and sustaining a health workforce which meets its community's expectations. NSWNA considers this to be the critical point in workforce planning.

The health workforce may easily be judged as effective or ineffective depending on the criteria that are used to assess its performance. We do not necessarily agree that conventional, quantitative indicators of productivity are the most appropriate measures to assess the effectiveness of the human services, most particularly health care delivery. Rather, it is frequently unmeasurable interventions and actions which have the greatest impact on patients. We believe that broader community expectations should determine the criteria that are used to assess the effectiveness of the health workforce. The best health service is one that delivers the health care that its community both needs and wants. It may also prove to be the one that develops the most and effective and

efficient health workforce.

Thank you again for the opportunity to contribute to this study. We look forward to the draft report of the Commission's study and further opportunities to contribute to this process. If you have any questions regarding this response please do not hesitate to contact Annie Butler, Professional Officer, at this office.

Yours sincerely,

BRETT HOLMES General Secretary