- The document discusses the need for a sustainable and fit-for-purpose health system given challenges of increasing demand, limited supply and affordability issues. - Health workforce planning is essential to address these challenges and ensure an adequate and appropriately skilled workforce now and in the future. - Reforms are needed to configurations, models of care, funding and remuneration to improve sustainability, affordability and meet future needs.

1. Towards a sustainable and fit-
for-purpose health system
Professor Gregor Coster
Deputy Chair, Health Workforce New Zealand
Chair, Counties Manukau DHB

2. Towards a sustainable and
fit-for-purpose health system
• Key requirement is a health system that
is sustainable and fit-for-purpose.
• Challenge of global demand, yet supply
and affordability mismatch.
• Health workforce planning is essential.
2

3. NZIER (2005)
NZ Population Projections by Age Cohort (Assuming medium population growth)
400,000
2001 2011 2021
350,000
300,000
250,000
200,000
150,000
100,000
50,000
0
0-4
5-9
90+
70-74
10-14
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
75-79
80-84
85-89
3

4. The perverse consequence of effective
management of acute disease and the increase
in access to often high-technology end-of-life
400,000
care
2001 2011 2021
350,000
300,000
250,000
200,000
150,000
100,000
50,000
0
0-4
5-9
90+
70-74
10-14
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
75-79
80-84
85-89
4

5. A promise of longevity and wellness
Medical
Research
Health
Socialised
Disease
medicine
Industry
A
Extensive medical Perverse
propaganda society remuneration,
defensive practice and
guild behaviour
5

6. Medical
Research
Health
Socialised
Disease
medicine
Industry
A
medical
society
Health service consumption by an increasingly affluent and
health anxious well worried sick middle class 6

7. Demand, supply
and affordability
• On the basis of feminisation, part-time work,
career choice, migration and retirement, and
using a head count of the practitioners and
trainees in 2010, none of the medical
disciplines will have enough practitioners by
2021 to meet NZIER’s best case scenario.
• Some workforces are already in critical
shortage and this has adverse personal and
societal impact.
7

8. Demand, supply and
affordability
• Consequently, we will need to do many if not
most things differently and this will
necessarily require a reform of service
configurations and models of care. This
recognition leads to the adoption of the
following core design principles:
• inclusive intelligence
• disruptive innovations as business as usual
• clinical leadership.
8

9. An illustrative vignette: Aunty
and her poor diabetes control
• The status quo.
• A virtual version of the status quo.
• A reformed model of care involving an
advanced care pharmacist.
• A reformed model of care involving a
diabetes nurse prescriber.
• Barriers to reformation.
9

10. Fourteen
** = Daughter off- ** week
work to drive Aunty to GP duration and
appointments six provider
contacts;
District three days
Health Lab off-work for
Nurse daughter;
and, two
hospital
Aunty is admissions.
unwell
**
Pharmacy GP
Physician Three month wait and
two hospital admissions
** for falls 10

11. One hour duration
Blood test unit in car – tests District and one provider
and uploads results on Health
Auntie's health face book contact.
Nurse
page and sends phone text No days off work
to GP for daughter.
No hospitalisations.
Pharmacy
Aunty is GP
unwell
Uses password Aunty
provided to go online
and look at her results
Looks at results on their phone - - texts diabetes
rings family doctor and nurse specialist and sends
Physician results to them by
and emails new insulin regimen
to pharmacist phone 11

12. District
Health
Nurse
Aunty is
unwell
Advanced
practice
pharmacist
12

13. Diabetes
Nurse
Prescriber
Aunty is
unwell
13

14. Current provider
centred approach
Mobile test units
and electronic Reward system
record
Increased Patient
Graded capitation.
convenience, speed
and safety; reduced
centred Hospitalisation rates.
cost to system, Aunty, approach Advanced care plans.
her daughter, her Prevalence of diabetics
daughter’s employer. in renal failure. 14

15. The affordability of the New
Zealand Health Service
15

16. Health spend at 9.2% GDP, 20% of total Government
spend and 50 and 40% of new money in the 2009
and 2010 Budgets respectively
16

17. $ billion Core Crown Revenue & Expenses
80
FORECAST
70
60
50
40
30
1998 2000 2002 2004 2006 2008 2010 2012 2014
Year ended 30 June
Budget 2010 Expenses Budget 2010 Revenue
17

18. 18

19. 19

20. There are only two fundamental
responses available to Government:
a. Reduce the demand for health
services; and, or
b. Reduce the cost of meeting the
demand for health services.
20

21. A triad of strategies: reforms of
governance and management; clinician
led reform of service configurations and
models of care; and, reform of service
funding and provider ‘reward’.
21

22. Status Quo is not an Option
• Increasing service demand – volume,
complexity and mix
• Tight fiscal environment
• Ageing workforce
• Service configuration, models of care and
workforce must reflect today’s world
rather than an accumulation of historical
decision
• Need to future proof changes so they are
sustainable
22

23. Health workforce
planning
• It is probable that the only truism in health
workforce planning is that we will inevitably
get it wrong.
• This recognition can either be seen as an
excuse to give up and resort to serendipity
and to rely on the vagaries of the market
place or as a stimulus to adopt principles that
enable planning under conditions of
uncertainty.
23

24. HWNZ’s planning
principles
• An affordable, sustainable and fit-for-
purpose health system can only be achieved
by way of a clinician-led and intelligence-
informed innovative reform of funding and
remuneration, and of service configurations
and models of care across the health and
disability sector.
24

25. Health workforce
planning
• Planning must be based on a dynamic
intelligence.
• Most of the health workforce needs to be
able to be flexibly employed, and quickly re-
trained and re-deployed (e.g. a generic
rehabilitation clinician).
• Slow to train and expensive health workers
need to be employed in as general a scope
of practice as is possible and must work “at
the top end of their licence”.
25

26. Underway
Under construction DHB shared services
20 DHB
Training Units
Institute of
Health 4 Regional
Leadership Training Hubs
Matauraki
Mental
Te Pou Health
Workforce Unified 16
Werry Centers RA Regulatory
Authorities
Te Rau Matatini
NZ College of
GPs / Community
NZ Medical
Health Workforce $40Million Colleges
~13 Committees Non–clinical Workforce
and Agencies Development Funding
18 Medical
Ministry of Health Colleges
26

27. The HWNZ Planning Process for 2020
Purchase intentions
determined by service
vulnerability and service load
Proposed Current
services Services
and Implementation plan and
models models
Aggregate of
patient
journey Barriers and
scenarios and disincentives
stakeholder
engagement
Expert working Needs analysis – upper and lower
group estimates
27

28. The HWNZ Planning Process for 2020
Capacity gains through
under-utilised workforces –
optometrists and
pharmacists
Proposed Current
services Services
and Implementation plan and
models models
Aggregate of
patient
journey Barriers and
scenarios and disincentives
stakeholder
engagement
Expert working Needs analysis – upper and lower
group estimates
28

29. Priorities
• Aged care, rehabilitation and mental health
• Bringing health services closer to home, and
self care
• Strengthening the health workforce through
expanded roles for nurses, primary care esp
general practice, and the upskilling the home
care and carer workforce
• Improving value for money
29

30. Our objectives
1. Improve recruitment and retention
2. Develop workforce with more generic skills
3. Create new roles & extend existing roles
4. Strengthen workforce relationships across
health & education
5. Ensure high quality, integrated and best
postgraduate value training
30

31. Our objectives
1. Improved recruitment and retention of key
workforces to meet current and future service
needs particularly in aged care, mental health
and rehabilitation
Activities include:
• Voluntary Bonding scheme
• Advanced Trainee Fellowship
• Reform of GP training
• Regional training hubs
• Career planning
• Advanced competency modules
• NZREX Preparation Placement Programme for
IMGs
• Modular and integrated training programmes …..
31

32. Our objectives
2. Development of a workforce with more generic
skills to ensure maximum flexibility and
integration between institutional and
community settings
Activities include:
• Mental health credentialing of nurses working in
primary care settings
• Reforming training so GPs can work in community
and hospital settings
• Integrating components of training programmes
for allied health
• Inter-professional learning and practice eg for
pharmacy and general practice 32

33. Our objectives
3. Development of new health workforce roles
and extension of existing roles to make best
use of all available skills, free up expensive
clinician time, provide better access to health
care for patients and provide services closer
to home
Activities include:
Nurse endoscopists
• Trainee Rehabilitation Associate role in home
and community support services
• Gerontology nurse in primary care
• Diabetes nurse specialist prescribing
• Pharmacist management of anti-coagulant
medications (wafrarin)
• Physician Assistants
• Upskilling ED workers to better respond to the
needs of Maori 33

34. Our objectives
4. Building and strengthening of workforce relationships
across the health and education systems to ensure
economies of scale, integrated training and sharing
good practice
Activities include:
• Tertiary Education Commission & HWNZ aligning
investment plans
• Careerforce & HWNZ on the unregulated workforce in aged
care
• Universities, Institutes of Technology & HWNZ connecting
learning across the education continuum
• Integration of HWNZ priorities into curriculum, eg
leadership, aged care, mental health, rehabilitation,
prevention, public health
• Centre of Excellence in Health Care Leadership
• Alignment with existing workforce development strategies
and plans – eg Te Uru Kahikatea – Public Health workforce
34
development

35. Our objectives
5. Ensuring high quality and best value clinical
training to contribute to improved satisfaction
for trainees and better outcomes for patients.
Activities include:
• Career planning
• Regional training hubs
• Advanced cosmpetency modules
• Public / private partnerships
• Integrated training – multidisciplinary approaches
35

36. Role of the education providers
• Train a workforce able to respond to shifts in
models of care and changes in service delivery
• Align education and training with changing
service needs
• Support development of
• new training programmes and career
pathways
• career pathways and courses for the
unregulated workforce
• Develop a collaborative approach to education
across professional groups and education and
service providers 36

37. Regional training hubs
• 4 regional hubs to co-ordinate and integrate health workforce
planning, education and training
• Underway July 2011
• Initial focus on medical training from PGY1 to vocational
registration; other groups to follow
• Professional colleges and registration authorities responsible
for content and accreditation of training programmes
• Integrates career planning, and administers Voluntary
Bonding scheme and HWNZ Advanced Trainee Fellowship
• HWNZ provides strategic direction on health workforce
priorities, and continue monitoring and oversight role
• links with Centre of Excellence in Health Care Leadership
37

38. Career planning
HWNZ requires career plans to be in place for all trainees
it funds from January 2012
Resources (guidelines, tools, enhanced workforce
information) to assist trainees, mentors and employers
developed
Intention is for a supportive process, with involvement of
senior clinicians, owned by the trainee
HWNZ is not prescriptive about the process used,
however recommends that it should not to be linked to
assessment or selection processes
38

39. 39