New South Wales Nurses’ Association
                                                      In association with the Australian Nursing Federation

 
BH:AG

10 November 2005

Health Workforce Study
Productivity Commission
PO Box 80
Belconnen ACT 2616

Dear Commissioners Woods and Fitzgerald,

Please find attached our submission in response to the health workforce study position paper.   If you have any questions regarding this response please do not hesitate to contact Angela Garvey, Professional Officer, at this office.

Yours sincerely

BRETT HOLMES
General Secretary

		
New South Wales Nurses’ Association
                                                      In association with the Australian Nursing Federation

Response to

Productivity Commission

Australia’s Health Workforce

Position Paper (September 2005)

1.	INTRODUCTION

This response to the Productivity Commission’s Australia’s Health Workforce Position Paper (September 2005) is submitted on behalf of the members of the NSW Nurses’ Association (NSWNA).  The Association is the professional and industrial body which represents over 51,000 nurses in NSW.  The membership of the Association comprises all those who perform nursing work, including Assistants in Nursing, 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.

The Association’s response is structured to address the nineteen draft proposals outlined by the Productivity Commission in their Position Paper (September 2005).  The opportunity for consultation and comment on these matters is appreciated. 

2.	GENERAL COMMENTS

The Association welcomes the Productivity Commission’s focus on creating more effective frameworks and processes within which specific workforce initiatives can be developed and implemented.  As a stakeholder in the industry, the NSWNA does not dispute that significant reform and innovation is necessary to ensure all Australians have access to a high standard of health care.  For too long in this country health workforce innovation has been stymied by powerful sectional interests.  

The NSWNA will be pleased if a framework is established in which workforce redesign and innovation can be assessed on their merits.  The new agencies proposed by the Productivity Commission must be independent and avoid capture, and they must be open and transparent in their processes and deliberations, including adequate consultative processes.  It is critical however, that the reforms and innovations promoted by these agencies are developed within a framework that emphasises quality and safety as well as efficiency.  Safety and quality of patient care must be the meta-goal of any health system reform. 

Retention is a matter of particular concern in relation to the nursing workforce, which has been largely neglected in the Productivity Commission’s Position Paper.  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 frequently receive 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.  Research commissioned by the NSWNA to examine the factors that motivate nurses to leave the public hospital system in NSW provided clear evidence that it is exactly these frustrations that are behind their subsequent exodus from the workforce is resulting in critical shortages.  It is therefore clear that workforce redesign should not be attempted in isolation from remediation of the broader problems of the health system.

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 the nurses available in the ward or unit and provides in the case of reasonable workloads a principle of appropriate skill mix.  

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. 

3.	DRAFT PROPOSAL 3.1

The NSWNA agrees that endorsement of the National Health Workforce Strategic Framework by CoAG would be a positive step toward coordinated and effective long-term workforce planning. 

However, in relation to the issue of ‘national self sufficiency’, we are not convinced that it is appropriate for Australia to intentionally rely on overseas trained professionals to supplement an inadequate domestic workforce.  While we recognise that nursing is an internationally mobile profession and welcome overseas trained nurses and midwives working in this country, we do not accept that the importation of nurses and midwives from overseas is an ethical or effective first instrument to overcome domestic labour market shortages.  

Apart from the obvious ethical implications of recruitment of nurses from less developed countries, it is also important to consider Australia’s obligations to the international community.  The worldwide shortage of trained health professionals has resulted in widespread suffering in many parts of the world.  Australia is a rich country with excellent education and health infrastructure.  The Association is of the opinion that Australia has the capacity to produce at least as many health professionals as we need and it is inappropriate that we would deliberately exacerbate the global shortage.

4.	DRAFT PROPOSAL 3.2

The NSWNA supports this proposal.

5.	DRAFT PROPOSAL 4.1
The NSWNA agrees that the challenges facing the health workforce can only be met if job substitution and redesign options are systematically assessed and put in place when there is evidence to support their efficacy.   
These views are largely in accord with the National Health Workforce Strategic Framework, which notes realignment of existing workforce roles and the creation of new roles may be necessary to make optimal use of workforce skills and ensure best health outcomes.  
The NSWNA supports “an active approach towards transparently investigating job innovation opportunities in an unbiased and objective manner.”   The nursing profession has been brave enough to embrace reforms to the boundaries between registered and enrolled nurses.  Unfortunately, the same cannot be said of many groups within the medical profession who have shamelessly undermined the evolution of the nurse practitioner at the expense of many disadvantaged rural and remote communities.  

The NSWNA remains concerned however, about the substitution of unskilled workers for qualified professionals in some areas.  The most obvious example is the increasing use of unskilled workers in the delivery of aged care and disability services, particularly in relation to medication administration.  While there may be some very legitimate role substitution occurring in these areas in relation to some tasks, the NSWNA does not accept, for example, that untrained, unskilled and unregulated workers have a role in the administration of poisons.  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. 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. 

The NSWNA views workforce innovation as a crucial component of moving forward.  It is our strong recommendation however, that any workforce innovation promoted by this agency must be underpinned by robust evidence as to its efficacy and safety.
6.	DRAFT PROPOSAL 5.1 

The NSWNA would support a proposal to sensitise the allocation of funding across health disciplines to the needs of the sector.  It would be essential however, that funds allocated for education and training be strictly quarantined from the rest of Dept of Health and Ageing’s budgets.

7.	DRAFT PROPOSAL 5.2

The NSWNA agrees with this proposal, but we emphasise that membership would be crucial to this agency’s capacity to act as an “honest broker” and recommend that all disciplines, providers and consumers are represented.

8.	DRAFT PROPOSAL 5.3

The NSWNA supports this proposal.

9.	DRAFT PROPOSAL 6.1

The NSWNA supports this proposal.

10.	DRAFT PROPOSAL 6.2

The NSWNA supports this proposal.

11.	DRAFT PROPOSAL 7.1

The NSWNA supports this proposal.  The NSWNA agrees that uniform national standards for registration have merit and the Australian Nursing and Midwifery Council have developed national standards for registered and enrolled nurses that would support this arrangement.

12.	DRAFT PROPOSAL 7.2

The NSWNA supports this proposal.

13.	DRAFT PROPOSAL 7.3

The NSWNA has some concerns about the implications of this proposal in some circumstances.   If the delegating practitioner retains responsibility for clinical outcomes, then the decision to delegate must involve a judgement by the practitioner that the person to whom they are delegating is competent to carry out the procedure.  

NSWNA would be concerned if a regulatory framework for task delegation forced practitioners to delegate clinical tasks to unqualified workers.  An example of which is the use of untrained, unregulated workers in the aged care and disability sectors to administer medications and perform other health care procedures.  Registered nurses have frequently expressed concerns about these practices and indicated their reluctance to be responsible for clinical outcomes given that the decision to delegate is not predicated on them having confidence in the competence of the unregulated worker.

14.	DRAFT PROPOSAL 8.1

The NSWNA strongly supports this proposal.  We view access to the MBS for midwives and nurse practitioners as critical steps forward in the full implementation of these roles and the realisation of the many system efficiencies that are possible.  

15.	DRAFT PROPOSAL 8.2

The NSWNA supports this proposal.  Such arrangements already exist in relation to the role of the practice nurse.  Clearly, it is appropriate that GPs would delegate vital preventative and early intervention services such as immunisations, prenatal and postnatal clinics, asthma, diabetic and heart health education, wound care and general health counselling to qualified practice nurses.  The NSWNA would support expansion of such cost-effective measures to other areas of health.

16.	DRAFT PROPOSAL 9.1

The NSWNA supports this proposal: it is not appropriate for medical workforce planning to be conducted in isolation from the rest of the health workforce.  We recommend that the secretariat should include experts in health economics, workforce planning and representatives from DOHA, DEST and jurisdictional health departments, with subcommittees comprising relevant health professionals and key stakeholders.  Practising medical practitioners should not comprise more than one third of the members of any subcommittees.  In conducting numerical workforce projections, the secretariat should:
•	coordinate the health workforce data collection across all states and territories,
•	continually improve health workforce data collections,
•	put in place common language,
•	develop minimum data sets, and
•	ensure consistent data collection and process arrangement.

17.	DRAFT PROPOSAL 9.2

The NSWNA supports this proposal.

18.	DRAFT PROPOSAL 10.1

The NSWNA supports this proposal.

19.	DRAFT PROPOSAL 10.2

The NSWNA supports this proposal.

20.	DRAFT PROPOSAL 10.3

The NSWNA supports this proposal.

21.	DRAFT PROPOSAL 11.1

The NSWNA supports this proposal.