Des Gorman: Reform overdue for the birthright of healthcare

New Zealanders have a special regard for our health service. Along with universal literacy and numeracy, and effective social welfare, we consider world-class health services to be a birthright.

For Maori, health is a Treaty-enshrined taonga. The issue here is that the health birthright is threatened.

Most who seek healthcare are satisfied with the result. This should not distract us from recognising that for some, and for some regions and services, access to and the quality of services is less than desirable.

We will be challenged to meet future demand. Even allowing for effective preventive health measures, the ageing of our communities alone will double the demand for health services over the next decade.

It will be difficult to meet such a demand. Measures of health workforce productivity show a peak in 2001 and a steady decline since. Most strategies to increase diversity in the workforce have been unsuccessful.

Health accounts for 20 per cent of Government expenditure and half of the new money in the 2009 Budget was allocated to health.

In short, we face a doubling of demand at a time when the amount being spent on health is at or is close to the limit that can be afforded by a small and relatively poor country.

We already have shortages of many health workers, an unsustainable reliance on immigrant health professionals, and our workforce is not well distributed against need by way of discipline, ethnicity or demography.

About 40 per cent of doctors and midwives and 25 per cent of nurses and dentists working in New Zealand were trained overseas. The effect is most marked in mental health, which, ironically, is where the greatest need exists for a close alignment of health worker and community culture.

Over the past decade, there have been at least 50 reports on the health workforce. The degree of consensus about the problem faced and the remedy needed is high, yet almost no meaningful reform has occurred. The first reason for this failure is that the reports have been strategic and hopeful as compared to tactical and pragmatic.

The second is that our health system is unwilling and or unable to change. This is no surprise in that there are at least 50 "groups" involved in health workforce planning. There are another 30 groups, programmes or agencies involved in Maori health.

Thirdly, the number and mix of health workers in training at an undergraduate level is determined by the Tertiary Education Commission and the education sector is largely divorced from health system intelligence.

Fourthly, other than some specific contracts, the district health boards no longer have a mandate to educate and train health workers.

Finally, and remarkably for such a small country, there are 21 district health boards and more than 80 primary health organisations. Although the Government is the major funder of health services, more than half the health workforce is privately employed. Reform agenda, then, in the public sector may have little currency elsewhere.

The solution to the conundrum of our health system having to meet a doubling of demand over a 10-year period at current levels of expenditure, is that services will need to be reconfigured and new innovative models of care are essential. Simply, the status quo of health workforce planning, funding, deployment and employment is untenable.

This challenge has been taken up, and Health Workforce New Zealand has been given a deliberate across-sector and whole-of-education-and-training continuum responsibility. The intent is that the agency is operational and durable. The core ingredients of reform have been agreed as clinical leadership and innovation.

What will success look like? For one thing, the health worker community will look like the community it serves. Another is that health careers will be highly desirable and valued. If we are to retain our health birth-right, time is short for well-overdue reform.

* Professor Des Gorman is the head of Auckland University's School of Medicine, and the chairman of Health Workforce New Zealand.