What does sustainability look like?

We talk throughout this plan about changes to models of care and service delivery models as tools to get our workforce working better, alongside needed growth.

When we talk about changes to models of care or service delivery models:

• These changes complement the growth which we will need in our workforce over time – but will not avert it. Our workforce is always going to have to grow, and we will always need highly skilled specialist workforces for certain kinds of care.
• Changes to models of care can alleviate pressure where it is most acute and shift where the burden of growing demand falls across different workforces. Using different workforces can be more efficient, and can let us better support workforces which are hardest or slowest to grow.
• “Top of scope” practice must be about freeing up time for higher impact work, allowing both more productivity, and more time to practise safely and manage workload. It is not about asking our people to work harder.
• Change must be clinically driven and led. Clinical networks will be our champions of model of care change – and safe, evidence-based practice must always underpin our shifts in model.

In this Plan we refer to, or explicitly identify, needed model of care changes in a range of service areas. In most cases we do not outline in detail the model we are working towards, because we still have work to do in designing these models based on clinical expertise.

Shifting to these models of care will take time, and may change what we ask of our workforce in some services – including rosters, workforce and skill mix, and what kinds of services are delivered in different places. As we shift to those models, we’ll ask our people and unions to come with us in working differently – and work through in partnership the implications for, the work environment, terms and conditions, and how we deliver care.

We will need ongoing growth in workforces across our health system to provide New Zealanders with exceptional care. But historically, relatively more of our workforce investment has flowed to hospitals, rather than to primary and community settings, or to public health workforces.

Over time we need a shift in relative investment towards public health, primary and community care, and services which focus on avoiding or mitigating conditions early. Doing so means New Zealanders can stay healthier, and that we can reduce some of the demand for care we otherwise expect in future.

Growing these services requires a workforce to match. To make this shift possible, we need to:

• Develop better ways to work with the primary and community sector to understand their workforce needs – and then collaborate to grow the right blend of professionals. At the moment our workforce planning systems for the community sector are weak, and we lack good data about the workforce needed to meet future demand.
• Health NZ needs to do more to support the funded sector to grow and recruit workforces for the primary and community sector. We also need the primary and community sector’s help to improve our data on workforce demand, and to expand training opportunities in the community.
• Grow workforces which are oriented towards public health, primary care and community care – such as public health physicians and nurses, GPs, allied professionals represented in comprehensive primary care teams (like physiotherapists and pharmacists), kaiāwhina, and rongoā practitioners.
• Build workforces which help us target drivers of poor health, and priority long-term conditions.
• Ensure we support whānau as first-line carers for a range of conditions, particularly those which are chronic or still preventable.

Much of this shift needs to be driven by the way we design and deliver services – reinvesting towards early intervention, prevention and community-delivered services. But by focusing on getting the right workforce ready early, we can move more swiftly to those models than if we have to wait to grow new workforces.

For a sustainable health workforce, we need to change a few things about how we work as a health system today:

• We need to better value our people’s time – improving their experience of work and lifting our health system’s productivity.
• We need to grow our workforce across a range of areas – some long-term, some immediately.
• We need to ensure relatively greater growth in our primary and community workforce over time, with a greater focus on prevention, public health and early intervention in our workforce models.
• We need to manage workforce cost, so that as we grow the size of our health workforce overall we continue to live within our means.
• We need to improve the diversity of our workforce so that we are able to tailor our approaches to delivering care to meet the needs of high need groups, and so that all our communities are represented by the people who care for them.
• We need to grow our workforce’s capability in a range of other areas over time, including more consistent experiences of good customer service, in compassionate care, and in having the ability to deliver care using increasingly complex technology.

This section outlines more about what we need to change in each of these areas – and how we might get started tackling these challenges.

Our workforce data 

Before looking at the features of our health system which we need to shift over time, we need to have a clear understanding of our workforce. To be able to accurately plan, we need to know:

The Health Status Report articulates part of the picture of the first area – though we still have significant planning yet to come to build a clear picture of what the future of health services will look like.

The data in this Plan reflects our best estimates of current and future states, but are not targets. Rather, the data demonstrates why we need to change how we work today - and where we need to focus growth short-term.

Our workforce data is imperfect. As you will see in this Plan:

Over the coming three years, we will work to improve the quality and breadth of our workforce data so we can improve on these estimates in future.

Productivity is often misunderstood. In its simplest form, it is an indicator of the output produced for a given set of resources: people, technology, infrastructure, knowledge. If measured properly it should also account for changes in the quality and safety of care provided. 

We can achieve improved health outcomes for New Zealanders by ensuring our health services are productive. For example, technology changes can allow more effective treatment of diseases; conditions that currently require treatment in hospital settings can be cared for closer to home, such as in primary care; and concentrating specialist services which New Zealanders need relatively less frequently in few settings can be more effective and productive than spreading them across many sites.

Improving productivity requires a range of shifts across our services, including:

• Better balance of investment in buildings, equipment and technology infrastructure that can shift care to primary and community settings and free up bed capacity by supporting care at home sooner.
• Scaling existing technology across regions and/or communities to improve flow of patients e.g. electronic medical records, clinical information systems accessible across multiple hospital sites.
• Sustainable staffing of teams/services to invest in permanent staff and reduce need for costly locum or contingent staffing.
• Investment in tools that make better use of time by reducing administration burden, streamlining business processes and supports, and enabling practice at higher scopes.
• Rapid introduction of new technologies including medicines that can improve patient care and enable clinical workforces more interventions to care for people.

Aspects of this challenge will be addressed elsewhere in the New Zealand Health Plan. Unlocking productivity is part of why this Plan focuses both on workforce growth and on improving models of care.

As we add people to our health workforce, it is important to ensure we can afford to employ more people in our health service. The thesis at the heart of our Workforce Plan is that a sufficient health workforce is safer, provides better care, is more productive – and is more affordable.

Evidence on the relationship between workforce sufficiency and health system expenses is limited. But we know that it is expensive having an unsustainable workforce. Not having enough people working in our health system drives costs up over time:

• We often have to fill gaps in our workforce with short-term supply. This might mean paying locums (clinical contractors) at much higher rates than we pay full-time staff, or spending more on penal rates (such as overtime pay, or payments to organise cover at short notice) because we have a smaller number of people working harder.
• Every person we have to replace means higher costs of training or recruitment; and often a less efficient skill mix in our clinical teams.  How work is organised needs to enable people to undertake their work in the time they have available and with minimal risk to themselves.
• It is wasteful. Because our teams need a range of professionals working together, being short one or two people can make whole teams work much less efficiently. For example, missing one member of a surgical team might mean that a surgical list doesn’t proceed. It goes without saying that this is not productive.

Our health workforce does not reflect the diversity of our communities. We know that:

• Māori are underrepresented across all workforces, except kaiāwhina and support roles.
• Pacific peoples are likewise underrepresented across all workforces, except kaiāwhina and support roles.
• We have poor data on the proportion of our workforce who identify as disabled, tāngata whaikaha or whānau haua. This makes it hard to measure how well disabled people are represented in our workforce; but we know they are consistently underrepresented.
• Asian communities are inconsistently represented in the health workforce; and the aggregation of ethnicity data to “Asian” disguises significant underrepresentation for some communities.

This matters because if people can’t see themselves in the health workforce:

These factors all mean that a more diverse workforce produces better health outcomes for New Zealanders.

Te Mauri o Rongo | The New Zealand Health Charter lays out the pou or values that are important to us. We will do more work in this coming period to embed these in how we work.  Building healthy workplace cultures enable workforce to come to work every day and work in a team environment that enables them to do their best.

Capability and capacity shortages in our workforces mean our services don’t deliver as well for patients and whānau. We will be looking to address these challenges through this Plan over the short- and long-term:

• Pockets of poor culture in some of our teams across the health system, whether stemming from insufficient workforce or poor leadership – which we need to address.
• A need to achieve culture change and to ensure we always work in collaborative, interprofessional teams, in line with best practice.
• A need to grow our workforce’s capability in some areas – such as digital capability – to allow us to seize opportunities for the future of care.
• For many of our enabling workforces, we need to move to a smaller footprint to live within our means – but will need to retain specialist skills to best support frontline service delivery.

Through our ‘Pulse’ surveys of employee sentiment in December 2022/ January 2023 and March / April 2023, we can see positive trends in the experience of Health NZ staff at work – with an overall increase of 3% across our measures of culture and engagement. However, real scores remain low in areas which matter to us a lot – so we need to see continued improvement to culture over time.

Working on culture and capability is important to improving quality and safety of care for patients.