Setting Strategic Direction For Health Workforce

SETTING THE STRATEGIC DIRECTION FOR HEALTH WORKFORCE DEVELOPMENT

5TH ANNUAL HEALTHCARE MANAGEMENT CONFERENCE

STAMFORD PLAZA¡XAUCKLAND

THURSDAY 18 MARCH 2004

IAN POWELL

EXECUTIVE DIRECTOR

ASSOCIATION OF SALARIED MEDICAL SPECIALISTS

There is at least one issue upon which I would agree with the Minister of Health, Hon Annette King, without equivocation, which is her statement that the workforce is the New Zealand health sector's greatest resource. The health sector is labour intensive. The most sustainable gains and benefits in the health sector come from its workforce, particularly health professionals, which is responsible for producing a universal public good and which is the prime producer of value. The most critical players and producers of sustainable, rather than short-term, value are those who have spent some years of training in preparation and, at least when they commence their professional careers, have an expectation of a long-term vocational commitment and dedication to the health system. Karl Marx's premise that labour produces value might be controversial in economic life in general but it certainly has applicability in the health sector.

In this address I want to cover three broad areas:

- the issues that obstruct effective workforce development, particularly as they relate to senior doctors;

- directions for moving forward; and

- the importance of a paradigm shift to an underpinning generative culture driven by professionalism.

There are also four sub-plots underlying this address:

1. The concepts of "generative' and "bureaucratic culture' adapted from the literature on safety.

2. The concepts of "internal' and "external morality', also adapted from the literature on safety.

3. Macro-based analysis is not enough; micro-based analysis is also required.

4. Empowerment of health professionals.

My observations and conclusions are personal assessments and do not represent the official position of the Association of Salaried Medical Specialists, although I do not believe there would be much divergence. Further, they are based derived largely from the standpoint of senior doctors employed by district health boards (DHBs) although, perhaps with some modification, many of the points discussed in this address are likely to be applicable to other health professionals. They cover matters that by themselves might appear extraneous to the theme of workforce development; but in the context of a service that is based on interconnections, complexities and integration these matters are all interwoven with workforce development.

Some common but distinctive traits of senior doctors should be considered in the context of the theme of this address. Senior doctors:

- have completed lengthy training, often more than 13 years, before commencing employment as a senior doctor;

- comprise a distinct age cohort, largely between the mid-30s to the mid-60s;

- are responsible for the admission and discharge of patients, which also has significant resource implications and involves unique medico-legal responsibilities;

- have decisive influence in effective resource utilisation including the use of technology;

- have high levels of professionalism and motivation; fiscal motivators are not required;

- have primacy of responsibility to patients;

- make daily decisions that affect whether life is saved or not, harmed or not, and enhanced or not;

- are responsible to external ethical codes and standards of professional conduct, including the obligation to advocate patient rights and standards of care; and

- are at high risk of stress and fatigue.

One cannot begin to consider the strategic direction for workforce development in the health sector without considering briefly the recent historical context; the lost decade of the 1990s in which New Zealand fatally embarked on a failed, ideologically bankrupt, and intellectually weak market experiment. Workforce development and planning was neglected because of the erroneous belief that market forces would sort things out. Further, the fragmentation of the system into competing crown health enterprises worked against the regional and national coordination necessary for effective workforce development and planning. Consequently, as different CHEs competed against each other, New Zealand failed to anticipate and plan for the increasing international medical labour competition, including the impact of the European Working Time Directive, and consequential shortages which have expanded from psychiatry and anaesthesia initially to virtually all branches of medicine. Although this competitive ideology diminished somewhat towards the end of the decade, a new legislative framework was required if the situation was to be turned around.

The legislative framework was provided by the New Zealand Public Health and Disability Act 2000 which, among other things, created the statutory bodies known as DHBs, responsible for both primary and secondary care, and the Health Workforce Advisory Committee. Workforce development was now back on the agenda and an acceptable practice, not to be denigrated in the way it had been under the previous market ideology according to which it was akin to a pre-1989 Polish shipyard in Gdansk. But, as we know, providing a philosophic and legislative framework supportive of workforce development is inadequate on its own, particularly in a sector noted for its complexity and dependence on interactions between its numerous parts. Health services, particularly complex integrated bodies like public hospitals, are not hire-pool companies where new equipment can be quickly collected and utilised. Rather like the "Mainland Cheese' advertisements, things take time but, if done well, the maturation is worth waiting for.

THE ISSUES OBSTRUCTING WORKFORCE DEVELOPMENT

There are several issues presently affecting the workforce development of senior doctors in DHBs. My following observations are by no means exhaustive but more by way of a sketch. Underpinning them all, however, is the critical question of the culture within DHBs that is discussed towards the end of this address.

1. Shortages and the Medical Labour Market

We cannot understand workforce development and develop strategies for it without understanding the extent of the problem and the challenge. Unfortunately, in part as a consequence of the neglect of workforce development in the 1990s, there is a disappointing lack of data on the extent of the shortage of senior doctors employed by DHBs.

However, in its first report, The New Zealand Health Workforce: A Stocktake of Issues and Capacity 2001 (April 2002), the statute-based Health Workforce Advisory Committee (HWAC) made some pertinent observations. These include:

- the supply of junior medical practitioners is decreasing with the Medical Council reporting a drop in the number of second and third-year post-graduate medical practitioners working in New Zealand (p.73);

- student debt is having a significant effect with increasing numbers of New Zealand graduates moving overseas for "better working conditions and higher salaries'. Further, "medical practitioners in specialist programmes have always travelled overseas to gain or consolidate experience, but now the trend is for medical practitioners to leave New Zealand earlier and stay longer' (p.73);

- there is a highly competitive global market with other countries such as Britain and Canada facing doctor shortages and prepared to "pay highly to attract staff' (p.73); and

- senior medical practitioners are "increasingly under stress' because of insufficient junior medical practitioners and "intolerable workloads', worsened by factors such as increased requirements for professional development, audit and patient expectations (p.73).

HWAC's second report, New Zealand Health Workforce: Framing Future Directions (October 2002), included a strong emphasis on both providing good terms and conditions of employment, and working relationships. In the context of a public hospital environment, it noted that (pp.48-49):

- "Performance can be compromised by workload', including in relation to the ability to perform clinical work and keep up with other critical activities; and

- it is important, in order to enable staff to work to their full potential and deliver good results, that they are "rewarded by appropriate remuneration'.

In October 2002 the Royal Australasian College of Physicians produced a position paper, Recommendations toward Improving the Provision of Physician Services in Small Centres and Rural New Zealand, which made several pertinent observations. After introducing the paper with the statement that "the provision of specialist services to the regions is becoming acute', the College noted the following from among its many conclusions:

The exposure of rural and provincial hospitals to the free market in recent years has exposed the difficulty that these centres have in competing in the recruitment of appropriately trained staff as well as their retention. A high salary alone will not solve the problem. It will help however.

The general physician has traditionally been the mainstay of consultant physician services in provincial and rural New Zealand. The general physician is trained to provide services to patients with a wide range of medical problems and therefore is ideally placed to provide services in tertiary and secondary services as well as in the smaller centres.

Currently the number of general physicians available in New Zealand is inadequate and this creates an additional burden in relation to the staffing of smaller hospitals. At present, departments of medicine are actively recruiting general physicians for provincial hospitals as well as for hospitals providing secondary and tertiary care.

The small critical mass of medical practitioners in small centres, particularly specialist peers, inevitably leads to a sense of professional and social isolation.

Physicians should not be required to carry an excessive workload or a heavy on-call schedule¡K.An on-call schedule of one day in five is regarded as appropriate.

Despite the lack of reliable data these assessments reinforce the experience of senior doctors that New Zealand suffers serious shortages, the significance of which is not fully appreciated by their managerial and political masters. These shortages are most evident in the large specialty of psychiatry. There are few psychiatrists around now who would have any institutional memory or experience of what a reasonable and safe working environment was like. Shortages are, however, across the board in all specialties, large and small. This is evident in:

- the number of unfilled permanent vacancies;

- the excessive reliance on locums to sustain services, with consequential difficulties of variable skills and relative experience, high costs of recruitment and employment, lack of involvement in wider systems issues, and continuity of patient care; and

- the small field of suitable applicants for vacant positions, thereby leaving DHBs with no or minimal choice in appointments.

The nature of medical rosters also has an important impact. Although there is much variation my sense is that many senior doctors work in teams of three to six, usually with the after-hours call rosters rotating among them. When one position becomes vacant and unable to be quickly replaced, or replaced at all, this is not a staffing reduction of one out of 30 to 300 or so senior doctors; instead often it represents an actual reduction of between 16%-33%. This has significant implications for workloads, fatigue and stress.

But senior doctors in secondary and public health are not the only vulnerable groups. General practice, the critical gate-keeper that strengthens the diagnostic and fiscal responsibility of our health system, is struggling with the increasing difficulties of a service that largely functions on a small business model in a small country with a small critical population mass. The investment of the capital required for running a general practice is no longer producing the resale value that it once did. Alongside the impact of student loans (in effect, a mortgage before one contemplates buying a house and practice), there appears to also be an increasing desire among younger doctors to have a family friendly employment relationship that the pressures of running a small business do not lend themselves to.

Nor is the position of nurses untroubled. Senior doctors know from their daily experience that there is a shortage of experienced nurses in wards, theatres, intensive care units and in community-based services. The NZ Nurses Organisation estimates, based on a conservative 5% vacancy rate in DHBs, that there is a national nursing shortage in DHBs of about 2,000. However, according to the Nursing Council, in 2001 there were about 5,000 nurses holding annual practicing certificates but not currently working.

But the problem remains that we know so little in the form of hard reliable data. We know that something is wrong but we cannot quantify how wrong it is and we do not know enough about why it is so wrong. We should be envious of Australia in the area of workforce development. The comparatively well resourced and supported Australian Medical Workforce Advisory Committee (AMWAC) is well advanced compared with what happens in New Zealand. Sometimes AMWAC has problems with getting numbers right but at least they are able to ask good questions and get insightful answers. I can only envy the fact that AMWAC can, for example:

- conduct a longitudinal study on career aspirations of doctors-in-training;

- investigate what are the number of pathologist positions needed, the number employed and the gap; and

- undertake a similar investigation for emergency medicine and also examine the extent to which patients should be treated in emergency departments without referral to another hospital service.

In New Zealand we cannot even ask such questions and expect to receive answers based on a reasonable level of reliability. I have now reluctantly accepted that our under-resourced and less independent Health Workforce Advisory Committee (HWAC) cannot match AMWAC. We need to accept that HWAC's role is largely limited at best to scene-setting and promoting the importance of workforce development and planning. It is to other processes that we need to look if we are to develop a robust strategic direction that is capable of making a difference.

2. Failure to Capacity Build

Workforce development cannot be divorced from capacity building; institutions that allow or are forced to run down their infrastructure and resources are a disincentive for recruitment and retention and corrode workforce development. During the 1990s there were three overriding impediments to capacity building:

- the application of the Commerce Act to crown health enterprises and hospital and health services imposed rigid limitations. The legal requirement for anti-competitive behaviour did not mesh well with the need for longer-term service planning in a small country in which public sector dominance is inevitable while health continues to be seen as a universal public good;

- real per capita funding in public hospitals declined in the early 1990s followed, in the second half of the decade, by additional, but time-limited, funding for waiting list initiatives (which, in fact, kept the system going) that was not conducive to service planning; and

- a naive over-estimation of private sector capacity and under-estimation of the true costs of contracting out to compensate for run-down or under-capacity in the public sector.

3. Specific Employment Imperatives

To be effective workforce development must embrace critical employment imperatives for senior doctors. It is often considered that the salaries which doctors can earn overseas are superior to New Zealand's. Certainly as regards countries like Canada, the United States and to a lesser extent Australia there is some validity to this assertion. But there is a major qualifier, particularly with regard to our strongest competitor, Britain, which has a similar training system to New Zealand. Notional salaries are higher in Britain, but so is its cost of living: once real disposable income is taken into account it is not too dissimilar.

There are three main areas in which New Zealand is poorly placed to compete in an international market of shortages, however. Our small critical mass due to our four million population size and relative geographic isolation compounded by the unique medico-legal pressures on senior doctors reinforce these difficulties. In this context a workforce development strategy needs to focus in particular on the following three employment imperatives:

- the impact of after-hours emergency rosters which, in contrast with our larger competitors, are more extensive and intensive due primarily to both the small number of senior doctors on the rosters (ie, higher frequency) and the limited number of registrars, in some cases none (ie, less back-up and support);

- professional development and education, including medical conferences, secondment and sabbatical, is a critical "tool of the trade' for senior doctors but its full ambit is unable to be provided in a country the size of New Zealand. Support for undertaking some of these activities outside Australasia is required. In countries such as Britain much of this support can be provided in Britain itself or neighbouring European countries. In New Zealand a significant part of it requires crossing hemispheres. We are competing against countries that provide superior support and accessibility for professional development and education for senior doctors; and

- the nature of the responsibilities and accountabilities of medical work (ie, saving life, preventing harm and enhancing life) in a 24-hour, seven day essential service, leads to routine stress and fatigue. Consequently to maintain standards and safety senior doctors require time out for quality rest and recreation. In recognition of this our strongest competitor, Britain, has had six weeks annual leave available for many years.

4. International Competition

A strategy for addressing workforce development needs to take into account the extent of international competition for medical labour. International shortages in most branches of medicine are widespread. In terms of our strongest competitors New Zealand is confronted with specific challenges from much larger countries. In all these countries working conditions, including staffing numbers, staffing support and professional development are enhanced by the advantages of the much larger critical mass.

In addition, the United States and Canada can generally exceed New Zealand by some distance in remuneration, in part because of the influence of doctors over throughput. While not to the same extent, Australia's working conditions are enhanced by the effect on remuneration of the sizable and affluent private sector. Further, Britain is aggressively seeking to increase its doctor numbers largely because of the need to comply with the European Working Time Directive.

5. Avoiding Internal Competition for Medical Labour

The market experiment in the health sector of the 1990s, coupled with the now repealed Employment Contracts Act, was distinctly unhelpful for developing a strategic approach to workforce development. The combined effect was to break up the previous national consistent terms and conditions of employment for all health professionals, including senior doctors, and to lead to internal competition for this labour between state health providers in a country that was far too small to cope. This led to different value judgments between the providers over how to recognise doctors and employment conditions were shaped and influenced by particular bargaining leverages that arise from time to time. The complexity of health care requires national consistency and integration, inclusive of some level of regionalisation and clinical alliances between DHBs. Competition for medical labour within New Zealand, particularly in the context of international shortages, is an obstacle for effective workforce development.

STRATEGIC DIRECTIONS FOR MOVING FORWARD IN WORKFORCE DEVELOPMENT

There are several directions that can form part of a strategic approach in New Zealand which is also mindful of the obstacles discussed above. Again, underpinning these directions is the culture within DHBs.

The tripartite process involving the Council of Trade Unions, DHBs and government is a new initiative that provides a national umbrella within which some of the directions might operate. This process recognises the advantages of the high level of unionisation in DHBs, in particular among health professionals, for the development of effective collaborative relationships that can address service delivery and workforce development issues. The main issue to date has been the development of a draft code of good faith under the Employment Relations Act, but other activities being considered that are pertinent to workforce development include pay equity and student loans.

Of at least as much significance for workforce development and a framework for some of the directions discussed above is the consequential development of bipartite processes between individual DHBs, on the one hand, and unions on the other. Although even less developed than the tripartite process, this "bipartitism' is based on a framework agreement about engagement that will be followed through in joint management-union delegate DHB-based seminars. It is expected to lead to greater joint engagement over issues such as local workforce development, health and safety at the workplace, and involvement in the development of the legislative-based DHB district annual plans.

1. Capacity Building and Unmet Need

Capacity building has already been discussed in the context of an obstacle to strategic workforce development. Since 2000 some useful moves have been made by government including the removal of the application of the Commerce Act to the new state providers (DHBs), the shift away from time-limited funding initiatives to increased baseline funding, and the shift to longer-term three-year baseline funding packages. This improves the ability of DHBs to plan their service development including the deployment and utilisation of their workforce.

In addition to meeting more effectively known and predicted needs, capacity building is also important in order to address the potential fiscal time-bomb of unmet need. The extent of unmet need is unknown with significant implications, including fiscal, down the track for the health system. We know that many people have unmet needs in areas important to their health and safety but we do not know how many. We can reasonably anticipate that at some point in time many of these cases will turn up in some form, probably costing more than would have been the case if the unmet need had been met when it should have been. Denied or delayed care is not only unfair and inequitable care but often is also fiscally more costly care. Early intervention and prevention is safer and cheaper longer-term than delayed "ambulance at the bottom of the cliff' measures.

There should be an assessment of the unmet need within the communities that make up New Zealand and the consequential development of a nationally coordinated strategy, inclusive of implementation plan, to address it. This approach is consistent with the legislative requirement for DHBs to develop needs analyses of their communities and would provide a more reliable base to plan workforce development.

The government is likely to take a most helpful step in this direction with the expected announcement soon of new funding for increased orthopaedic volumes that will then be incorporated into permanent baseline funding. This is expected to be funding focussed on identifiable unmet need and linked to capacity building in the public sector. This is a positive step although it must be recognised that the public sector may not presently have the capacity to meet these increased volumes. But at least the right workforce capacity can now be planned for while transitional measures may be necessary to cope with the initial increased volumes. However, although orthopaedics affects a large part of the current unmet need, further strategies are required to address the full spectrum.

2. National Consistency of Employment Conditions

As discussed medical labour market competition within New Zealand is corrosive and contrary to effective workforce development. The Government, DHBs and senior doctors would be best served by a multi-employer (national) collective agreement which:

- is an effective tool for recruitment and retention;

- can address the specific employment imperatives that New Zealand is so vulnerable to in regard to international shortages and more favourable opportunities in key competing countries;

- facilitates workforce development;

- is consistent with the values and culture of professionalism; and

- provides a stimulant and framework for the future development of a strong collaborative relationship between senior doctors and senior management.

It is not appropriate to discuss this further because of the negotiations currently underway on this precise issue which commenced as far back as late April 2003 and are most delicately poised as I speak; except to note that it is important that DHBs do not allow the inevitably higher and uneven costs of transition to obscure the longer-term advantages of a national collective agreement and the new culture that it can help facilitate.

3. Bottom-up Approach

The District Health Boards Association of New Zealand (DHBNZ) has initiated discussion within and between DHBs on workforce development. This is significant because it is the first time for over a decade that such an issue is being discussed in this way. However, while positive, it is at a level of high policy, more macro in approach, and to date lacks effective engagement with health professionals where the real expertise lies.

Too often macro approaches are earnestly pursued without the insights and experience that can be provided at a micro level. A bottom-up health professional-based approach to workforce development would be a valuable strategic tool. Medical workforce development and planning at the level of each DHB requires specific work and focus. This could be achieved by establishing joint senior doctor-management workforce development taskforces to initiate:

- agreed staffing plans (including the support staffing levels and resources required to meet these needs);

- recruitment and retention strategies to support these staffing plans; and

- agreed plans for the effective provision of and access to high quality professional development and education, including continuing medical education, secondment and sabbatical.

Recognising the importance of national consistency and sharing of experiences and information, this activity should also be shared between DHBs on a nationally coordinated basis.

4. Nationally Coordinated Health Professional-based Approach

However, workforce development requires a national as well as local approach. In this context Australia provides another useful lead. The independent health professional taskforce approach of the New South Wales government to reviewing acute metropolitan health services is producing several practical and sound incremental and affordable improvements in service provision and workforce deployment.

New Zealand cannot copycat this approach because it is metropolitan and secondary care based and because Australia has an absurdly rigid obstructive demarcation between primary care (federal) and secondary care (state). But the approach of health professional based taskforces (but not exclusively health professional) could be adapted to New Zealand circumstances, by which services and workforce needs are rigorously examined and reassessed at a national, regional and DHB level.

At a national level this adaptation might involve a modification of the tripartite process to a bipartite CTU-DHBNZ approach to look at national matters and the facilitation and coordination of regional reviews and workable strategies focussed on achieving practical, identifiable and incremental goals.

5. Using Non-Vocational Doctors

DHBs have an under-utilised part of the medical workforce, senior doctors who are not in training programmes and who are also are general rather that vocational registrants, which could be better deployed in terms of helping to meet workforce needs and ensuring quality of care. There needs to be a coordinated shift in strategic direction by encouraging and supporting activities designed to address the vocational and career needs of these non-specialist senior doctors, currently inappropriately known as medical officers of special scale, so that they can be better utilised to provide generalised or special interest services in secondary care.

The College of General Practitioners has taken the initiative with the development of special interests (largely secondary care) based on a generalist training framework. This initiative deserves political and professional support but should not be allowed to be taken over by any narrowly focussed or short-term managerial or political agenda. To be successful and sustainable this shift in direction towards greater utilisation of non-vocational senior doctors must be professionally driven with managerial and political support.

6. Relationship with General Practice

General practice offers a key foundation stone in helping address the workforce needs of our public hospitals, including but not confined, to rural and provincial New Zealand. Along similar lines to the above discussion about non-specialist senior doctors and consistent with the government's objective of integration between primary and secondary care, general practice coupled with supplementary special interests may provide good quality generalist care that many of our secondary care settings would benefit from.

We also need to look at general practice from the standpoint of primary care itself, much of which is provided and provided well by the self-employed small business model. But there are serious limitations and risks in relying on this model alone as the basis of providing primary care. Workforce shortages among GPs and the associated recruitment problems are already well-known in rural New Zealand but our cities are also not immune. Even in the cities we learn of GPs having difficulties selling their practices and some walking away from them. Studies confirm high stress levels among currently employed GPs. It is increasingly evident that many younger and aspiring GPs do not wish to purchase a practice. They just want to practice medicine. It is not just their high debt that is behind this attitude. Other factors include changing gender composition, desire for a family friendly work environment, hassles of running a small business and the problems in business partner relationships. I also suspect that many currently employed GPs would welcome the opportunity to leave behind these frustrations and consider salaried employment.

It is in this context that the government would do well to actively encourage and facilitate an alternative career path for GPs by providing as a voluntary option, salaried employment by DHBs. In addition to guaranteed predictable income, the non-salary benefits would also be invaluable (eg, CME, annual leave, sick leave). Failure to do this will lead to a failure to anticipate and adapt to the changing demographics and aspirations of general practitioners. Salaried employment by DHBs should be considered as an option only. Compulsion would be detrimental. But allowing two options for career development¡Xthe current small business model and salaried employee status by DHBs¡Xwould provide flexibility in such a way as to better cater for today's and tomorrow's new GPs and to meet the workforce challenges confronting DHBs.

7. Democratic Clinical Leadership

Effective workforce development can be enhanced by the encouragement and growth of professional based democratic and mandated models of clinical leadership within DHBs. The objective is to provide an environment conducive to sustainable workforce development and to create an observable engagement culture that makes our DHBs attractive for recruiting, involving and retaining senior doctors. The most effective clinical leadership in an organisation is that which is based on the mana and mandate of its peers. This includes, by whatever locally agreed means, some form of democratic election/selection. This approach should apply to clinical boards within DHBs who should report to both the governing boards and chief executives. This recommended approach formed part of the report to the Minister of Health, Quality Improvement Strategy for Public Hospitals (September 2001) but which, unfortunately, gathers "dust' in cyberspace. There is an absence of motivation to follow it through. There should be a nationally coordinated strategy to facilitate this "clinical democracy' approach through at an individual DHB level and then to facilitate a sharing of experiences of its implementation.

A PARADIGM SHIFT TOWARDS A GENERATIVE CULTURE BASED ON PROFESSIONALISM

The last recommended direction, "clinical democracy', leads on to the next and final stage of this address, the need for a new culture within DHBs. One of the lessons that should have been learned over the years but has not been sufficiently, is that top-down driven change does not deliver sustained effective outcomes. Government seemingly looks at DHB chairs and the Ministry of Health as key instruments for ensuring that DHBs deliver on its objectives. This misplaced view ignores the reality that both these instruments are significantly disconnected from operational and workforce reality. They have little impact on driving effective workforce issues except that they can assist in encouraging a constructive environment conducive to sustainable workforce development and planning.

Much of DHB management also falls within this framework. In the health sector management is an administrative overhead that does not of itself produce value but can influence whether or not and how effectively value is produced. DHB chairs and management can be scene-setters, and environment shapers: a facilitator for, but not deliverer of, effectiveness.

It is the developments and initiatives of health professionals that deliver effective sustainable change. This has been demonstrated in many areas over the years from the medical profession's use of that remarkable drug, the aspirin, to prevention of infectious diseases (eg, TB) to day surgery to the development of emergency medicine to the use of anaesthetists in perioperative care. All these developments have an effective and sustained impact on workforce development and utilisation, more so than top-down bureaucratically driven change.

Our health system, like many comparable health systems, has no leader. Although we have a Minister and a Director-General of Health, in reality neither is in charge. They influence parameters but they don not make most of the decisions that determine what actually happens. This is a good thing because of the better alternative; ie, the system is driven by interactions between a phenomenal range of different bodies¡Xgovernment and statutory bureaucracies, professional organisations, statutory authorities and officers, unions, community organisations, pressure groups and, let us not forget them, politicians. What determines the effectiveness of these interactions are the overall legislative and policy parameters and the extent and substance of the interactions themselves.

It is interesting that when the Minister of Health decided this year to reduce the frequency of her scheduled meetings with our organisation, we were not offended; in fact, distinctly unfazed. This is because we see meetings with the Minister of the day as important but no more important than many of the other meetings we have with the other bodies and people we interact with. It is also interesting that there has been a shift in the nature of the issues that we discuss with her, from what we would like her to do to advising her about what we are doing. I suspect that this shift may have increased rather than diminished her occasional angst with us.

While we have a largely robust legislative and policy framework for the future development of our health system, unfortunately for those working at the front-line of health delivery there has not been a general discernible difference or improvement in the culture of the sector compared with the 1990s. This has a compounding effect as the longer a negative culture remains in place the more embedded and entrenched it becomes and it precludes the ability of the health system to use its greatest resource for ensuring quality of health care in an environment of funding constraints, the internal morality of health professionals including the medical profession. Our excessive reliance on the external morality of legislation and policy parameters to deliver means that our health system continues to function largely in crisis management and short-term modes of decision-making. The capacity to shift to a medium to longer-term approach has not yet been achieved despite the overarching parameters of our system requiring such an approach.

In the context of our health system and its connection with workforce development the theoretical construct of Professor James Reason involving organisational cultures (bureaucratic and generative) provides a valuable insight. His construct is in the context of the handling of safety information and also includes a third culture, unhelpful to this exercise (pathological).

In summary, the differences between bureaucratic and generative cultures are:

- may not find out necessary information (bureaucratic culture) compared with actively seeking it (generative culture);

- messengers are listened to if they arrive (bureaucratic) compared with training and rewarding messengers (generative);

- responsibility is compartmentalised (bureaucratic) compared with sharing responsibility (generative);

- failures lead to local repairs (bureaucratic) compared with failures leading to far-reaching reforms (generative); and

- new ideas often present problems (bureaucratic) compared with new ideas being welcomed (generative).

Unfortunately internal DHB organisational culture is still largely bureaucratic (some would argue pathological). Sustained pressures force DHBs into short-term decision-making in a sector in which the best and most effective decisions are made when done so on a medium to long-term basis. An inevitable outcome of "short-termism' is to resort to crisis management and short-sightedness at the expense of longer-term investment in human capital, of which workforce development is a critical component.

Effective workforce development requires a wider generative culture and, given the nature of the health system and who produces sustainable value, it requires a new internal morality based on the values of health professionalism. It would provide the basis for bridging the gap between macro intent and micro performance. The key issue is one of a working relationship of trust and confidence in which senior doctors and other health professionals are actively engaged and empowered in the engine-room of decision-making that goes beyond the level of rhetoric. Senior doctors are the most critical resource, strategically and by location, but also the most untapped resource that the health system has available to it. They are the glue that holds so much of the system together. They do not need to be motivated; they do not require crude incentives such as performance bonuses. Their motivation and the benefits that flow from it comes from being allowed to do what their professionalism drives them to want to do.

Effective and sustainable workforce development requires the empowering of professionalism. In broad terms, and there will be notable exceptions to this, in the 1990s the decision-making approach in the health sector was predominantly unilateral; since 1999 it has become more consultative; but it has not yet made the necessary transition to the level of engagement. If and when it does we will have an underpinning culture in DHBs conducive to real workforce development.

My observations in this address are what I have been preaching for some time. Based on this experience I have every expectation that the substance of this message, while receiving some tokenistic acceptance, will continue to be ignored. However, I adhere to the approach outlined in the "Mainland Cheese' advertisements¡Xthings take time. Nevertheless the government needs to be conscious that lack of progression, or maturation, can lead to regression, or mould, and, in this regard, the clock is ticking.

Ian Powell

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