Towards a Sustainable and Fit-for-Purpose Health System


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Professor Gregor Coster
Deputy Chair, Health Workforce New Zealand
Chair, Counties Manukau DHB

(Invited, Thursday 27, Ilott Room, 9.25)

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Towards a Sustainable and Fit-for-Purpose Health System

  1. 1. Towards a sustainable and fit- for-purpose health system Professor Gregor CosterDeputy Chair, Health Workforce New Zealand Chair, Counties Manukau DHB
  2. 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. 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. 4. The perverse consequence of effectivemanagement of acute disease and the increasein 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. 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. 6. Medical Research Health Socialised Disease medicine Industry A medical societyHealth service consumption by an increasingly affluent and health anxious well worried sick middle class 6
  7. 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. 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. 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. 10. Fourteen** = Daughter off- ** weekwork to drive Aunty to GP duration andappointments 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. 11. One hour duration Blood test unit in car – tests District and one provider and uploads results on Health Aunties 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 resultsLooks at results on their phone - - texts diabetesrings family doctor and nurse specialist and sends Physician results to them byand emails new insulin regimento pharmacist phone 11
  12. 12. District Health NurseAunty isunwell Advanced practice pharmacist 12
  13. 13. Diabetes Nurse PrescriberAunty isunwell 13
  14. 14. Current provider centred approach Mobile test units and electronic Reward system recordIncreased Patient Graded capitation.convenience, speedand safety; reduced centred Hospitalisation rates.cost to system, Aunty, approach Advanced care plans.her daughter, her Prevalence of diabeticsdaughter’s employer. in renal failure. 14
  15. 15. The affordability of the New Zealand Health Service 15
  16. 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. 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
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  20. 20. There are only two fundamentalresponses available to Government:a. Reduce the demand for health services; and, orb. Reduce the cost of meeting the demand for health services. 20
  21. 21. A triad of strategies: reforms ofgovernance and management; clinicianled reform of service configurations andmodels of care; and, reform of servicefunding and provider ‘reward’. 21
  22. 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. 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. 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. 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. 26. Underway Under construction DHB shared services 20 DHB Training Units Institute of Health 4 Regional Leadership Training HubsMatauraki Mental Te Pou Health Workforce Unified 16 Werry Centers RA Regulatory AuthoritiesTe 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. 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 andscenarios and disincentives stakeholder engagement Expert working Needs analysis – upper and lower group estimates 27
  28. 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 andscenarios and disincentives stakeholder engagement Expert working Needs analysis – upper and lower group estimates 28
  29. 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. 30. Our objectives1. Improve recruitment and retention2. Develop workforce with more generic skills3. Create new roles & extend existing roles4. Strengthen workforce relationships across health & education5. Ensure high quality, integrated and best postgraduate value training 30
  31. 31. Our objectives1. Improved recruitment and retention of key workforces to meet current and future service needs particularly in aged care, mental health and rehabilitationActivities 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. 32. Our objectives2. Development of a workforce with more generic skills to ensure maximum flexibility and integration between institutional and community settingsActivities 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. 33. Our objectives3. 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 homeActivities 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. 34. Our objectives4. 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. 35. Our objectives5. 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. 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. 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. 38. Career planningHWNZ requires career plans to be in place for all traineesit funds from January 2012Resources (guidelines, tools, enhanced workforceinformation) to assist trainees, mentors and employersdevelopedIntention is for a supportive process, with involvement ofsenior clinicians, owned by the traineeHWNZ is not prescriptive about the process used,however recommends that it should not to be linked toassessment or selection processes 38
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