Thanks to the tenacity of NZNO negotiators, the persistence of DHB nurses, a serious rethink by employers and shrewd political input, it looks like we have an agreed deal for the pay and conditions of our public-sector nursing workforce.

Pay and conditions of course, as we have acknowledged this is about more than just cash in the pocket. Rather, we have an immediate and staged cash injection, revised pay staircase, plus an agreement to fully implement safe staffing principles through nationwide implementation of the Care Capacity Demand Management (CCDM) toolset by 2021, backed by the ‘Accord’ between the Ministry, district health boards and NZNO.

Notwithstanding that DHBs have had over a decade to implement CCDM, with this now being pushed out for another three years, we now have a commitment from an ‘absolutely determined’ Dr David Clark that DHBs will deliver on this. This timeline takes us beyond the next election, yet it would be an errant minister, government of the day, or DHB chief executive that chose not to honour the agreement.

In a previous opinion piece, I alluded to the fact that nurses are a big-ticket item in DHB expenditure and stick out like a sore thumb on the balance sheet. Thankfully the agreed deal includes the employment of 500 more nurses. And nobody here has had the audacity of ministers over in the UK, who until recently insisted nurses each give up a day’s leave to fund their pay rise! Thankfully for our NHS colleagues, that notion was pulled after a spirited rebuttal by the UK’s Royal College of Nursing.

But somewhere down the line, and sometime quite soon, we require an honest conversation, a really honest conversation about how we here in Aotearoa New Zealand determine and pay for our nursing workforce going forward.

How many nurses do we need?

The first question is how many nurses we actually need. That might seem an obvious point but I am far from convinced we know the answer. For a start, the DHBs’ agreement to immediately employ an extra 500 nurses won’t go far across 20 DHBs.

Numbers can be a little misleading too perhaps? For example, World Bank 2016 data for global nurse (and midwife) to population ratios, has us here in New Zealand doing quite well at 11.1 per 1000 people – 40% more per 1000 than the OECD average of 7.9 nurses per 1000. We also ace Singapore’s 7.1 ratio, and the UK’s 8.4, only to be pipped by Australia’s 12.6 and mega-trumped by Iceland at 15.2.

However, it would be a fair bet to suggest that none of the countries with lower ratios – certainly not the 50% of WHO member states reporting less than three nurses per 1000 people – base those numbers on need; rather they are likely derived from what any particular country is prepared or able to pay for.

So, we do have to get some work underway to establish how many nurses we need.

This is not necessarily nonsensical if we know from the outset that it might be difficult to afford the nurses we actually do need – given the current pay agreement and those yet to come – but it will provide a baseline for that honest conversation.

What type of nurses do we want?

Just to add to the dynamism of this argument, need has a close cousin in the form of want and that is worth a mention too. Into the already complex nursing workforce analysis we can then add the type of nurse we need compared with the type of nurse we want, and in what number.

I am not sure that my dear friend and colleague Professor Jenny Carryer has forgiven me as yet for having the temerity, when serving as Chief Nurse, to work on bringing back a revised scope of practice for the enrolled nurse (EN), as championed by then Health Minister Tony Ryall.

Sure, I was aware of international evidence suggesting a nursing workforce comprised totally of registered nurses provided better patient care outcomes, yet the backstory here was that we were beginning to see unregulated health care assistants (HCAs) practising from a wider ‘scope’ than our existing ENs. Right then we needed ENs, who in reality could be doing a whole lot more if the health sector sought to employ them and their educational input updated.

Would New Zealand have been better off with a ‘whole RN’ workforce? More than likely.  But could we have afforded it? More likely not.

What are we prepared to pay?

Ah, we have added another word to our workforce lexicon – ‘afford’. We must undertake some solid work to ascertain what kind of nursing workforce we actually do need, then move to the next step of deciding what we are prepared to pay for that workforce.

This is not just a question of honouring the pay agreement, but honestly asking ourselves what we can afford.

This is by no means objective, rather what we can actually afford is more a reflection of what we as a nation are willing to stump up to employ the nursing workforce calculated to be the one we need – what percentage of our country’s GDP are we prepared to put into nursing care. Incidentally, Iceland’s GDP per capita is around a third more than ours, add an additional third onto our nurse-to-population ratio and, lo and behold, we are almost on a par with our Nordic friends.

But, if by some miracle our GDP increased by a third overnight would we actually want to increase our nurse numbers by a similar ratio, even if we needed to? This is where our elected representatives come in, having to make decisions as to the slice of the cake ‘Vote Health’ gets against education, housing, defence (remember the comments about the $2.3B bill for replacing the Orion fleet) and the rest.

All of this may seem a little doom-laden, but I am just trying to illustrate how hard, even with the best will in the world and the most sincere of Ministerial commitments, it will be to get CCDM fully embedded as the tool it is meant to be.

In that earlier opinion piece, I likened the current use of CCDM as smearing the nursing workforce we could afford to employ as thinly as possible in an effort to meet patient need. Yet we really haven’t done the required work to quantify need in pure terms before starting to think about how thin the spread of nursing is that we can tolerate.

We are so far down the track that any notion of ideal workforce has all but evaporated and until we have the honest discussion CCDM will continue to smear the nurses we think we can afford to provide a level of care those determining that affordability think is good enough.

I am no advocate of centralisation for the heck of it, but the complexity of the nursing workforce situation would seem to cry out for some form of overseeing entity, be this embedded somewhere in the current health system structure or standing alone.

Health Workforce New Zealand (HWNZ) is surely working hard on providing us with a health workforce for the future, and no doubt the wider Ministry of Health and our regulatory Nursing Council is too. And whilst not every DHB has a Director of Nursing in an executive role, I would like to think they are doing their best to identify what workforce determined by need would look like even as they face the compromise of having to deploy one based on available budget.

Embedding and monitoring CCDM nationally, working through the dynamic of need, want and affordability, and then coming up with a potentially politically charged and mediated compromise needs vision and focus.

Let’s regroup, start the conversation, and from the outset, be honest about it.

Dr Mark Jones was Chief Nurse at the Ministry of Health from 2005-2010 and is also a former head of Massey University’s School of Nursing.



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