Given that we are a few weeks away from a national election, the enticements to voters are flowing in.
In health, targets and workforce issues are popular topics; they are intertwined.
Targets are aspirational outcomes. They require an understanding of the complexity of the component processes that might allow them to be achieved.
These need to be identified and present from presentation to treatment. They should be obtained without compromise to other essential, but non-targeted health activities.
There are activities which already have some aspects of bench marking and quality thresholds.
These include the national "hip fracture registry" which has been established in New Zealand following strong clinician promotion and service integration (with little enthusiasm from the then Ministry of Health). There should be more.
Targets are worthwhile if, when achieved, they produce quality health outcomes.
Various strategies evolve, such as developing "ED-like" areas which are given different names; inpatients may need to be discharged prematurely to free up beds to allow movement within the hospital; and hospital avoidance strategies are promoted.
"Effectiveness" and "quality" dimensions to the delivery of healthcare are not highlighted by politicians.
"Hospital avoidance" is of interest, as delayed presentation of an illness might be prevented with earlier, effective assessment.
The data is limited, but a recent study in the UK concluded that: "The top-ranked problems were poor communication between secondary and primary care and the inverse care law, i.e. a mismatch between patients’ medical needs and healthcare supply".
If this conclusion was explored further, one could recognise the roles of effective communication, effective response, integrated "joined up" services and adequate financial support.
In New Zealand, we need to urgently dismantle the barriers to integration — at all levels. Between the health and social ministries (including Inland Revenue), between general hospitals and primary care (exploring and redefining respective roles and funding).
This set of barrier removals applies to private and public agencies, mental health and culturally specific services.
A comprehensive IT service is needed to enable such a reform — again, the lack of a developed strategy is to our cost.
Inadequate financing (under the guise of health "efficiencies") is a chronic problem.
The estimated District Health Boards deficit in 2017 was thought to have been over $885million.
Health workforce planning lacks coherent, cohesive and integrated approaches.
From 2009-18 the Heath Workforce New Zealand (HWNZ) existed but failed in its primary objectives, leading to its disbandment, and it was followed by an even less successful Ministry of Health-led process.
The Health Strategy 2016 referred briefly to an integration of planners, funders and providers but fell short of producing a meaningful recommendation.
Currently, the best one can find on current policy is from a little discussed Te Whatu Ora publication, Health Workforce 2023-24.
Within it, there are stocktakes of the current workforce along with projected deficits. The solutions contain no immediate sense of the impending emergency we are now entering.
It hopes to use various strategies to bring laudable cultural values and training into play — for example: "We need to reduce our reliance on classical, academic models of training to grow our health workforce. We need pathways that are adaptive, with easy transfer of skills between health professions and careers — including hauora Māori pathways that reflect te ao Māori across professions. Vocational learning is already a big part of training in health, and should become more prevalent."
Unfortunately, the work that would avert our current crisis should have started decades ago.
"Just in time" strategies of importing suitably trained work forces are now less of an option than they were in the past. There is also a "moral" issue of the active poaching of health professionals from countries that have shortages or struggle financially to train their staff.
It is notable that the provider views are only expressed through non-clinical staff.
When clinicians do comment or respond, it is usually from the comfort of retirement, in private statements or though unions’ outlets. Rarely do relevant colleges or societies make comment.
It is impossible to determine what level of clinical leadership or governance currently operates.
— Stephen Chalcroft is a retired geriatrician and a former clinical director at the Waitemata and Southern District Health Boards.
