10 November 2005

Mr Mike Woods and Mr Robert Fitzgerald
Commissioners
Productivity Commission Australia’s Health Workforce Study
Locked bag 2 Collins Street
MELBOURNE Vic 3000

Dear  Sirs

Re: 	Productivity Commission 2005 
Australia’s Health Workforce Position Paper

Thank you for the opportunity to comment and please find attached the Nurses Board of Victoria’s response in relation to the above position paper.

If you have any further enquiries please do not hesitate to contact me on 03 8635 1236.

Yours faithfully

Ella Lowe
President

Submission

to 

 Productivity Commission
Australia’s Health Workforce 
Position Paper

from

The Nurses Board of Victoria

Nov 2005

Contents

Overview of NBV								4

NBV Responses								6

NBV Strategies								13

Conclusion									14

Overview of Nurses Board of Victoria

Nurses Board of Victoria is a self-funded statutory authority incorporated under the Nurses Act 1993.  The current Board is in its eleventh year of operation, having been constituted in July 1994, but our history can be traced to the establishment of the first Nurses Board in 1923.

The 12 member Board, appointed by the Victorian Government’s Minister for Health, sets policy and direction and is supported by an executive management.  The Board also establishes advisory committees to obtain expert advice on nursing and other matters.

Our Mission is to protect the public of Victoria through the statutory regulation of the nursing profession.  Through this legislation, we are fully aware of our duties not only as a statutory authority, but also as members of the wider community.  By regulating all fields of nursing, we protect the community by ensuring its care is in safe and competent hands.  We also ensure the wellbeing of the community of nurses, who play such a vital role in achieving our mission.

Our business is to regulate the profession, registered nurses and annually renew their status.  Only nurses registered by us are entitled to use the term “registered nurse” in this state.

Current Status

Registration
There are now 78,748 Registered Nurses in Victoria, an increase of 2.1 % over last year.  There have been increases in the number of nurses registered in division 1 and 2, while registrations in division 3, 4 and 5 have decreased (see table 1).

Table 1
Number of nurses registered by division at 30 June 2005
Division	2005	2004	Change %	
1	57,421	56,161	2.2%  ↑	
2	18,454	17,955	2.8%  ↑	
3	1,490	1,542	3.4%  ↓	
4	325	341	4.7%  ↓	
5	425	639	9.6%  ↓	

While the majority of nurses remain within the 36 to 55 year age groups, the trends have continued with significant increases in the over 56 year age groups (see table below).  Again there has been a large increase (7.2%) in the registration of nurses under 25 years of age.  As with last year, there has been a slight increase (2.8%) in male nurses, but the proportion of male nurses in the profession remains constant at 8.5% (see table 2).

Table 2
Gender and age of registered Nurses Board of Victoria
	2005	2004	Change %	
Male	6,730	6.545	2.8%  ↑	
Female	72, 018	70,599	2.0%  ↑	
				
< 25 years	5,740	5,352	7.2%  ↑	
26 – 35 years	17,093	17,404	1.7%  ↓	
36 – 45 years	22,789	23,312	2.2%  ↓	
46 – 55 years	23,133	22,098	4.6%  ↑	
56 – 65 years	9,115	8,233	10.7% ↑	
> 65 years	878	745	17.8% ↑	

A total of 6,017 initial registrations were recorded this year, a decrease of 0.8% on last year.  These included both Australian and overseas qualified nurses.  There has been a 4.2% increase in new registrants (4,517) who completed their education in Australia, with 3866 (86%) being educated in Victoria.

Over 1,500 first-time registrations were received from overseas nurses (see table 3) and for the first time in the past five years there has been a 13.4% decease in overseas registrations.  Whilst the decrease is reflected across all international regions there has been an increase in registrants from India (8.1%), China (44%) and USA (33%). 

Table 3
	Initial registrants’ country of educational preparation
Region	Number of Nurses by Country	
Africa	151	
Americas	59	
Asia	388	
Europe	680	
Middle East	6	
Oceania	216	
Australia	4517	

Accreditation
The Nurses Board of Victoria currently accredits over 200 separate courses and approves the campus where the course is delivered.  Courses are required to have accreditation prior to the course commencing.  In Victoria, nine universities are accredited to provide a Bachelor of Nursing degree (Division 1), including Charles Sturt University at Bathurst, which is accredited for Victorian students.  There are twenty two registered training organisations in the vocational education and training sector which offer the Certificate IV course (Division 2).

The Board implemented a monitoring program in 2004 of new registration application documentation submitted by education providers.  The program reviewed the documentation submitted against the accredited curricula.  Findings highlighted significant unapproved changes implemented by education providers.  The Board subsequently implemented a Case Management Program to support the education providers with their accredited courses.  In 2005, all accredited courses and campuses approved by the Board were listed on the NBV website, allowing for accurate and current course information to be readily available to students.

Our responses noted below are based on the experience of staff at the Nurses Board of Victoria and considers such evidence as appropriate in establishing a national consistency framework.

NBV Proposal Responses

3.1	In its upcoming assessment of ways to improve the level of integration within the health care system, the Council of Australian Governments (COAG) should consider endorsing the National Health Workforce Strategic Framework (NHWSF), subject to broadening of the self sufficiency principle, in order to enhance cohesion between the various areas and level of government involved in health workforce policy.	
NBV Response
The Board supports the proposal for the Council of Australian Governments (CoAG) to endorse the majority of principles of the National Health Workforce Strategic Framework. 

Furthermore, the Board asserts that the issues of migration of health professionals has been on the international agenda for nursing for an extended period of time, and has resulted in the development of codes and principles for the ethical recruitment of nurses and midwives.  

The Board continues to develop processes, which assess and maintain consistent standards within nursing in line with the Australian Nursing and Midwifery Council (ANMC).
The Board supports national consistent in relation to nursing and midwifery standards, codes of conduct, ethics and decision making frameworks.
	
3.2	CoAG, through its Senior Officials, should commission regular reviews of progress in implementing the NHWSF.  Such reviews should be independent, transparent and their results made publicly available.
	
NBV Response
The Board supports the need for regular reviews that are independent, transparent, and seek feedback as part of the review process.  In addition, the Board considers that reports from any review should be publicly available.
	
4.1	The Australian Health Ministers’ Conference should establish an advisory health workforce improvement agency to evaluate and facilitate major health workforce innovation possibilities on a national, systematic and timetabled basis.
•	Membership of the board should consist of an appropriate balance of people with the necessary health, education and finance knowledge experience.
	
NBV Response
The Board through its national body the ANMC supports the establishment of an advisory health workforce agency representing academic, clinical and regulatory nursing and midwifery professionals.

NBV Proposal Responses Continued

5.1	The Australian Government should consider transferring primary responsibility of allocating the quantum of funding available for university-based education and training of health workers from the department of Education, Science and Training to the Department of Health and Ageing.  That allocation function would encompass the mix of places across individual health care courses, and the distribution if those places across universities.  In undertaking the allocation function, the Department of health and Ageing would be formally required to:
•	Consider the needs of all university–based health workforce areas, and;
•	Consult with Vice-Chancellors, the Department of education, Science and Training, other relevant Australian Government agencies, the States and Territories and key non-government stakeholders.	
NBV Response
The Board supports the transfer of primary responsibility of funding to the Department of Health and Ageing.  The Board further considers that in doing so, appropriate academic, clinical and regulatory nursing and midwifery professionals, as well as non-government stakeholders are consulted, where applicable.

The Board believes that addressing the shortfall of funding for nursing in both the tertiary and VET sector should be a priority for whatever agency maintains primary responsibility for funding.
	
5.2	The Australian Health Ministers’ Conference should establish an advisory health workforce education and training council to provide independent and transparent assessments of:
•	Opportunities to improve health workforce education and training approaches (including for vocational and clinical training); and
•	Their implications for courses and curricula, accreditation requirements and the like.	
NBV Response
The Board supports the establishment of an advisory health workforce education and training council to provide independent and transparent assessments for nursing and midwifery education and training.   However, the Board is concerned that workforce shortages could force the lowering of professional practice standards and would seek academic and regulatory nursing expertise on the council, to mitigate this risk.

NBV Proposal Responses Continued

5.3	To help ensure that clinical training for the future health workforce is sustainable over the longer term, the Australian Health Ministers’ Conference should focus policy effort on enhancing the transparency and contestability of institutional and funding frameworks, including through:
•	Improving information in relation to the demand for clinical training, where it is being provided, how much it costs to provide, and how it is funded;
•	Examining the role of greater use of explicit payments to those providing infrastructure support or training services, within the context of a system that will continue to rely on considerable pro bono provision of those services;
•	Better linking training subsidies to the wider public benefits of having a well trained health workforce; and 
•	Addressing any regulatory impediments to competition in the delivery for clinical training services.
	
NBV Response
The Board is mindful of the ongoing tension that exists between the need to protect the public and the clinical training requirements for students.  The NBV Standards for Course Accreditation encompass a wide and diverse syllabus to ensure nursing students are adequately prepared to meet healthcare.

The Board continues to participate and support the development of funding models to assist clinical placement initiatives and supports the National Review of Nursing Education which stated that additional resourcing should be directed to the clinical component of the undergraduate nursing curriculum.
	
6.1	The Australian Health Ministers’ Conference should establish a single national accreditation agency for university-based and post graduate health workforce education and training.
•	It would develop uniform national standards upon which professional registration would be based.
•	Its implementation should be a considered and staged manner.
A possible extension to VET should be assessed at a later time in the light of experience with the national agency.
	
NBV Response
The Board pursuant to the Nurses Act 1993, accredits and monitors education courses that lead to registration.  A significant review was undertaken in 2002/2003 in consultation with the Victorian healthcare industry, relating to the Board’s Standards for Course Accreditation.   
The Board is supportive of a single national accreditation of courses program for undergraduate nurses and the development of uniform national standards upon which professional registration would be based and considers that the ANMC be considered as the body to coordinate the single national accreditation framework.  Currently the Board works collaboratively with the ANMC in the establishment, review and promotion of nationally consistent standards.
The ANMC has well developed national competency standards which have been accepted across all State and Territory registration boards and embedded within tertiary and VET sector accredited courses.

NBV Proposal Responses Continued

6.2	The new national accreditation agency should develop a national approach to the assessment of overseas trained health professionals.  This should cover assessment processes, recognition of overseas training courses, and the criteria for practise in different work settings.
	
NBV Response

Whilst the assessment of overseas trained health professionals occurs currently at a State and Territory level, nursing and midwifery has developed processes to ensure that nationally consistent standards are applied throughout the country.

The Board has already adopted from the ANMC national standards for the assessment of overseas trained professionals. The Board has worked collaboratively in the development of specific standards for some overseas countries.  In particular, the Nurses Board of Victoria specifically researched information and developed recommendations regarding education levels in China.  These recommendations have since been adopted by the ANMC and are available to all regulatory nursing and midwifery boards through the ANMC website.

Therefore, the Board believes that nursing, through the ANMC, could be considered as the model for a national approach for an accreditation agency. The Board also considers that established organisations such as the ANMC are well placed to take on this role.
	
7.1	Registration boards should focus their activities on registration in accordance with the uniform national standards developed by the national accreditation agency and on enforcing professional standards and related matters.
	
NBV Response
The Board believes that nursing and midwifery already demonstrates the application of national standards into its activities through its active participation in the development of, and the adoption of the standards developed by the ANMC.  Therefore the Board believes that this model has demonstrated its effectiveness in nursing and midwifery.
	
7.2	States and Territories should collectively take steps to improve the operation of mutual recognition in relation to the health workforce.  In particular, they should implement fee waivers for mobile practitioners and streamline processes for short term provision of services across jurisdictional borders.	
NBV Response
The Board has already adopted and implemented policies for mutual recognition between other Australian States and territories and with New Zealand.  This policy includes the waivering of fees has been in existence since 2000 and not as a reaction to the Productivity Commission report. 

Furthermore, the Board has reviewed its processes so that a nurse, who presents to the Board with all relevant documentation, can be registered pursuant to mutual recognition principles “on the spot” and commence employment.

The Board further supports the streamlining of workforce processes to ensure consistency of skills and qualifications of nurses and midwives.  The Board has worked collaboratively with the Nursing Council of New Zealand with the adoption of the New Zealand nurse practitioner competencies whilst the ANMC Nurse Practitioner Standards Project was underway.  The ANMC Nurse Practitioner Standards have now been adopted by the Board.  	

NBV Proposal Responses Continued

7.3	Under the auspices of the Australian Health Ministers’ Conference, jurisdictions should enact changes to registration acts in order to provide formal regulatory framework for task delegation, under which the delegating practitioner retains responsibility for clinical outcomes and the health and safety of the patient.	
NBV Response
The Board supports the existence of a national framework, which is in place for nursing and midwifery through the Australian Nursing and Midwifery Council.  The Board has adopted national standards and implemented these under local legislation.
	
8.1	The Australian Government should establish an independent standing review body to advise the minister for Health and Ageing on the coverage of the Medicare Benefits Schedule (MBS) and some related matters.  It should subsume the functions of the Medical Services Advisory Committee, the Medicare Benefits Consultative Committee and related committees.  Specifically, the review body should evaluate the benefits and costs, including the budgetary implications for government, of proposals for changes to:
•	The range of services (type and by provider) covered under the MBS;
•	Referral arrangements for diagnostic and specialist services already subsidised under the MBS; and
•	Prescribing rights under the Pharmaceutical Benefits Schedule.
It should report publicly on its recommendations to the Minister and the reasoning behind them.	
NBV Response
The Board supports the establishment of an independent standing review committee to address the current restrictions in both MBS and PBS and believes any such review should consider the expanded nursing roles such as nurse practitioner when considering prescribing rights. 
	
8.2	For a service covered by the MBS, there should also be a rebate payable where the provision of the service is delegated by the partitioner to another suitably qualified health professional.  In such cases:
•	the service would be billed in the name of the delegating practitioner; and
•	rebates for delegated services would be set at a lower rate, but still sufficiently high to provide an incentive for delegation in appropriate circumstances.
This change should be introduced progressively and its impacts reviewed after three years.

NBV Proposal Responses Continued

NBV Response
The Board strongly supports improvements to the rebate process.  In particular, the Board would seek the inclusion of rebates for nurse practitioners to enable them to work effectively to meet workforce deficiencies.
	
9.1	Current institutional structures for numerical workforce planning should be rationalised, in particular through the abolition of the Australian Medical Workforce Advisory Committee and the Australian Health Workforce Advisory Committee.  A single secretariat should undertake this function and report to the Australian Health Ministers’ Advisory Council.	
NBV Response
The Board supports a single secretariat ensuring that nursing and midwifery expertise is represented within the new committee.
	
9.2	Numerical workforce projections undertaken by the secretariat should be directed at advising governments of the implications for education and training of meeting differing levels of health services demand.  To that end, those projections should:
•	be based on a range of relevant demand and supply scenarios
•	concentrate on undergraduate entry for the major health workforce groups, namely medicine, nursing, dentistry, and larger allied professions, while recognising that projections for smaller groups may be required from time to time; and
•	be updated regularly, consistent with education and training planning cycles.	
NBV Response
The Board supports the addition of numerical workforce projections that will advise the government in relation to education and training requirements, in particular nursing and midwifery workforce requirements.
	
10.1	The Australian Health Ministers’ Conference should ensure that all broad institutional health workforces make explicit provision to consider the particular workforce requirements of rural and remote areas.	
NBV Response
The Board supports the provision of specific workforce provisions to ensure professional standards are maintained for rural and remote areas.
	
10.2	The brief for the health workforce improvement agency (see draft proposal 4.1) should include a requirement for that agency to:
•	assess the implications for health outcomes in rural and remote areas of generally applicable changes to job design; and
•	as appropriate, consider major job redesign opportunities specific to rural and remote.	
NBV Response
The Board supports the inclusion into the brief of the health workforce improvement agency requirements to assess rural and remote health outcomes and job redesign.

NBV Proposal Responses Continued

10.3	The Australian Health Ministers’ Conference should initiate a cross program evaluation exercise designed to ascertain which approaches, or mix of approaches, are likely to be most cost-effective in improving the sustainability, quality and accessibility of health workforce services in rural and remote Australia, including:
•	the provision of financial incentives through the MBS rebate structure versus practice grants; and
•	“incentive–driven” approaches involving financial support for education and training or service delivery versus ‘coercive’ mechanisms such as requirements for particular health workers to practise in rural and remote areas.
There should also be an assessment of the effectiveness, over the longer term, of regionally-based education and training, relative to other policy initiatives.	
NBV Response
The Board supports the initiation of a cross program evaluation exercise which incorporates incentives and long term assessment.
	
11.1	The Australian Health Ministers’ Conference should ensure that all broad institutional health workforce frameworks make explicit provision to consider the particular workforce requirements of groups with special needs; including: Indigenous Australians; people with mental health illnesses; people with diabetes and those requiring aged care.	
NBV Response
The Board supports the inclusion of broad institutional health workforce frameworks which includes specific requirements for groups with special needs.  The Board has incorporated recommendations from three ministerial taskforce reviews conducted by the Board into aged care, Indigenous health and mental health into the Standards of Course Accreditation ensuring that these areas are addressed within the content of undergraduate nursing curricula.

NBV Strategies

The Nurses Board of Victoria have undertaken a number of strategies in response to workforce issues, these include:
•	Addressing scope of practice issues.  The Board has developed Guidelines Determining Scope of Practice for Registered Nurses and Midwives.  The Guidelines provide a framework for registered nurses to make decision regarding their current scope of practice and to advance and expand their scope of practice.
•	Promoting nurse practitioner role within Victoria.  The Board holds regular workshops to inform and encourage registered nurses to expand and advance their career structure in this area.
•	Course development.  The Board has accredited several universities courses for direct entry midwifery and for undergraduate Bachelor of Nurses students to apply for registration as division 2 whilst completing their degree.
•	Expansion of Division 2 registered nurse scope of practice. The Board is working with the Department of Human Services to further expand the scope of practice of endorsed division 2 registered nurses to include intramuscular and sub-cutaneous injections.
•	Continuing to review standards. Guidelines developed for registration in Victoria are in accordance with the Australian Nursing and Midwifery Council to ensure national consistency is maintained.
•	Overseas Nurses. The Board has reviewed and implemented improved processes to assist nurses from overseas and interstate to obtain registration whilst still ensuring the public is provided with safe and competent practitioners through supervised practice and pre-registration courses.
•	National Support. The Board has actively supported the role of the Australian Nursing and Midwifery Council to ensure national consistency is applied in nursing and midwifery.

Conclusion
The Board supports the view of the federal government that the success with which health services are delivered across Australia is advanced to the commitment, care and professionalism of the Australian health workforce and believe that it is timely to review all the components that support the maintenance of this workforce.  

The Board believes that the nursing and midwifery regulatory bodies in conjunction with the Australian Nursing and Midwifery Council currently strive to ensure national consistency in many of the areas outlined in the draft proposals and will continue to do so.

The Board is pleased to be able to provide comment on the draft proposals and would welcome any opportunity to participate in any further work undertaken by the Commission.