Submission

on the 

The Health Workforce 

Productivity Issues Commission Paper

August 2005

Table of Contents

Introduction											1

Background											1

The Health Workforce Productivity Commission Issues Paper			2

Summary											2

Chapter 1 What is this study about?							2

Chapter 2 What are the immediate concerns underlying this study?		3

Chapter 3 What underlies these problems?						5

Chapter 4 Where to from here?								6

Conclusion											7

References											8

Introduction

The Nurses Board of Western Australia (the Board) is established under the Nurses Act 1992 (the Act) to protect the public of Western Australia through the regulation of the practice of nursing.  The functions of the Board include, but are not limited to, the approval of educational courses leading to pre-registration, the monitoring of professional standards and the registration of nurses.

The Board has only made comment on areas within the Issues Paper, which it believes is relevant to its role and function.

Background 

The Council of Australian Governments (COAG) commissioned the Productivity Commission in March 2005 to undertake a research study to, “examine issues impacting the health workforce including the supply of, and demand for, health workforce professionals, and to propose solutions to ensure the continued delivery of quality health care over the next 10 years” (Productivity Commission, 2005). 

The Health Workforce Productivity Commission Issues Paper is produced by the Productivity Commission as a condition of the Terms of Reference of the above study and to serve as an interim progress report to COAG. 

The purpose of the Issues Paper is to outline key tensions and constraints within the workforce arising from: 
•	The need to meet equity and access objectives in a fiscally responsive manner;
•	Fragmentation of roles and responsibilities across and within governments, education and training institutions, professional and regulatory bodies, and public and private providers of health care services; and
•	Tradeoffs between longer term requirements and short-term imperatives, and between the use of generalist and specialist skills in providing care (p 6).

The Health Workforce Productivity Commission Issues Paper 

Summary
The main points arising from the Issues Paper that the Board wishes to express to the Commission are that: 

1.	There was an absence of practical recommendations within the Issues Paper on how to improve the status of the health workforce in the short, medium or long term as identified within Appendix A Terms of Reference; Scope 4(a). 
2.	The nursing profession should be afforded stronger representation in workforce planning, policy development, and strategic decision-making in relation to health and the health workforce.
3.	The key tensions identified within the Issues Paper (p5 & 6) are accepted as potential and continuing constraints to achieving health workforce reform if not adequately addressed. 
4.	The Issues Paper lacked clarity and was at times difficult to read.

Additional points will be made under each chapter of the Issues Paper where it was felt relevant to do so.  

Chapter 1
What is this study about?

The Board supports continuous monitoring of the health workforce and factors that may influence or inhibit the ability of that workforce now and in the future to meet the demands and health needs of the Australian public. In addition, the Board is supportive of the development of different models of care that would reduce the focus on the traditional medical model of care and would encourage strategies that facilitated adoption of a multi-disciplinary approach to health care as a matter of routine. For multi-disciplinary team-based care to be effective, however, there must be significant inducements to attract the participation of doctors and allied health professionals.

Chapter 2
What are the immediate concerns underlying this study?

A primary concern is the ongoing shortage of nurses, midwives and mental health nurses.  Retention of the nursing workforce (p13 &14) however, as opposed to focusing solely on the recruitment of nurses to maintain a healthy nursing workforce should be a prime objective of health workforce planners.  Australian trained nurses and midwives are attractive to other employers for the skills they accrue irrespective of whether these skills will be used internally or externally of the health care industry, and irrespective of the length of time that the nurse or midwife may have been in the workforce.  The challenge facing workforce planners and employers is to make the environment that nurses and midwives work within more attractive to them in the short, medium and long term.  

Strategies that support nurses and midwives on graduation and onward up to 2 to 3 years post-graduation are deemed critical to retaining nurses and midwives; particularly younger staff.  Younger nurses and midwives are seeking different expectations from their careers and are less likely to remain in environments that stifle initiatives or subject staff to entrenched work place culture which precludes staff from realising patient care and career orientated goals.  Similarly, nurses and midwives returning to the workforce after a long absence, require the same degree of support.  Invoking the principles associated with magnet hospitals whereby nurses and midwives are attracted to and wish to remain in a working environment known for its excellence may be one solution for attracting and retaining nursing/midwifery staff.

The age of the nursing workforce (p15 &16) is of some concern given the average age of nurses nationally is 43.1 years (AIHW 2005).  In Western Australia, the average however, is 45.2 years.   An ageing workforce that is not supplemented and sustained by younger staff will not over time be able to meet public demand for health care services.  This is particularly relevant to the aged care industry where large numbers of the older nursing workforce currently work.

Exploration and applicability of different models of care to meet the needs of patients, clients or residents in different care settings is supported (p15).   Additional places for nurse practitioners particularly in the aged care sector are seen as workable measures to assist with the delivery of primary and secondary health care in times of work force imbalances (p15 &16). 

In terms of skills shortages and ’mal distribution’ of health care workers it was felt that care needed to be exercised that another level of unskilled worker was not introduced to fulfill roles that should be undertaken by skilled health professionals.  Therefore the suggestion that nurse practitioners (p15) be able to undertake advanced health care activities is worthy of further discussion.  Investigation of the potential to expand the scope of practice of skilled health care workers is warranted to identify activities that traditionally may have been done by one specialty that could be done by another to improve health service delivery.  

Whilst reference was made to the reasons for and possible actions to be taken to improve equity of access to health services in indigenous communities (p17 & 18) the Issues Paper appears to offer little in the way of suggestions of involving indigenous communities in resolving this issue or suggesting ways in which indigenous peoples can be attracted into the professions of medicine, nursing or allied health.  It is suggested that further work needs to be done in respect to offering learning environments that have a strong focus on indigenous health, are located within indigenous communities, particularly rural communities, but are co-hosted in conjunction with mainstream education or bridging programs for health care workers.  The recruitment of indigenous health academics to participate in such ventures may assist in attracting more indigenous peoples into the health workforce.  

It is our view that mainstream health practitioners and academics understanding of indigenous peoples, their history and current and future health warrants further investigation and inclusion of these factors within core health curricula of health professionals and academics.  Indigenous groups should be consulted and encouraged to communicate with one another to identify what they see as priorities in relation to health care and health education.  

The Board suggests reviewing how other health jurisdictions such as Queensland and New Zealand have addressed this problem.

Chapter 2 raises a number of issues in relation to recruitment, retention and age of the workforce that require proactive measures to improve the health of the workforce for the long-term.  Other factors of equal import are the use of nurse practitioners and the scope of practice for skilled workers in developing different models of care. Above all there should be equity in access to health workforce opportunities. 

Chapter 3
What underlies these problems?

It is our view that the comments within this chapter reflect the problems of supply, demand, and coordination of health service delivery between state and federal agencies, and between regulatory authorities.  Whilst the factors that influence work force planning such as market forces and funding arrangements are acknowledged it was felt that the Issues Paper was lacking in that no potential solutions were provided.  

In relation to the pressure impacting on work force supply (p27) the Board would suggest that shift work in the health workforce and safety issues associated with shift work should be noted as a shortcoming.  Paperwork, whilst identified as being burdensome, is essential to health care for many reasons such as recording care planning, outcomes of an episode of care or an adverse event.  In addition to streamlining paperwork where possible, we viewed the provision of support and resources to complete essential paperwork as important factors in easing the burden of paperwork on health care professionals.

The Board is of the view that education and training of health professionals (p28 &29) should be maintained at the highest possible standard and should be retained within tertiary education settings as opposed to the use of training models undertaken within technical institutes.  Education forms the basis of practice and nurses in particular should be provided with greater recognition for their skills in critical thinking as well as their willingness and ability to use technology to enhance patient care or health service management.  For instance, nurses in Western Australia have successfully used digital imagery of diabetic and neuropathic foot ulcers in the Kimberley’s to reduce the incidence of amputation, which resulted in significant cost savings (Santamaria N et al, 2004).

The Board agrees that there are dichotomies in relation to funding education programs, availability of places within programs, and opportunities for clinical placement. However, it was felt that more could be done to resolve these territorial issues and that greater emphasis could be placed on creating more educational opportunities in remote and rural areas, more bridging courses for health professionals, and more assistance in the way of travel and accommodation grants to attract people into the health profession, or to further their education.

It is agreed that evaluation of health care delivery (p32) is critical to providing effective, efficient and sustainable health services.  Nurses and the nursing profession are just as able as other health professionals to undertake such critical examinations.  Nurses, if adequately resourced to the same degree as doctors for instance, would be able to facilitate and conduct meaningful evaluation or research of health management practices across the spectrum of health services.  

Meeting the needs of consumers of health care is an onerous task, which requires constant review and evaluation coupled with the proffering of workable solutions.  The Board is of the opinion that nurses are well placed to contribute to these processes.  

Chapter 4
Where to from here?

The Board supports in principle the National Health Workforces Strategic Framework for guiding national health workforce policy and planning (p34).  We are of the opinion, however, that the nursing profession is under utilised in respect to health workforce planning and determining priorities for health service delivery as outlined within the Strategic Framework, and would suggest that consultation in this area with the profession should be strengthened.  

Conclusion

Review and reform within the health workforce is seen to be essential in order to sustain and continue to deliver world-class health care to the Australian people.  Including more options for reform to address the tensions and constraints identified would have been useful. 

We are appreciative of the opportunity to comment on the Health Workforce Issues Paper and would be interested in receiving further reports emanating from this process.

References

1.	Productivity Commission 2005. In: The Health Workforce Productivity Commission Issues Paper: Appendix A, p 49. 

2.	Australian Institute of Health and Welfare. Nursing and midwifery labour force 2003.  Australian Institute of Health and Welfare cat. No. HWL 31. Canberra, 2005.

3.	Santamaria N, Carville K, Ellis I & Prentice J. The effectiveness of digital imaging and remote expert wound consultation on healing rates in chronic lower leg ulcers in the Kimberley region of Western Australia. Primary Intention 2004; 12(2):62-64,66-68,70.