New Zealand’s health workforce policy and planning
New Zealand’s recent health workforce policy and planning has broadly evolved in three phases (see Table
2)
Table 2
Three phases of New Zealand’s health workforce policy
Implications of reforms for the workforce and service delivery | Focus | Centralised planning | Neglect | Markets | Asserting control | Rethinking |
Workforce governance responsibility | Department of Health | No identifiable organisation | Regional entities Employer-led | Ministry and various advisory entities | HWNZ, a dedicated HWP agency |
Impacts of reforms on policy and governance | Pre reform | Loss of structures and knowledge Use of advisory committees | Dispersal of governance to smaller operational entities | Fragmentation Duplication and ineffective responses | Consolidation Improved data management and integration Longer planning horizons |
Implications for governance and planning | Planning practice | Medical manpower based | None observable | Employer-led planning, based on operational needs | Data gathering and situation analysis | Some planning re-centralisation Provide sector leadership Wider view of the planning function |
Planning concerns | Mal-distributions, Unsustainable delivery paradigms | Increasing visibility of workforce problems | No wider or longer view Shortages Rising dependence on overseas professionals and workers | Poor industrial relations Planning inefficiencies Data gaps | Incorporating the new vision Introducing team-based care Resistance to change Conservatism |
Implications for methods | Principal methods | Stock and flow models Estimation of doctor numbers | No data available | Demand driven modelling Headcount based modelling | Aggregated demand models Improved data collection begins | Design thinking and workforce intelligence approach—integrated quantitative and qualitative data to meet future care scenarios and team-based workforces |
In the 1970s and 1980s, health workforce planning was centralised and largely medically focussed. Overseen by a DoH committee, with New Zealand Medical Council input, it reported directly to the Minister of Health, with plans informed by stock and flow modelling [
20]. The committee was conscious that medical manpower planning, i.e. doctor numbers, needed to be linked to the wider health workforce and acknowledged that productivity and mal-distribution improvement relied on introducing health team approaches as “in a publicly funded health service one of the few effective controls on the use of resources and the health expenditure is the number of doctors in the system” ([
20], p.8).
However, the steady progress to establish consistent workforce governance faltered after the reform programme commenced in the late 1980s. This signals the next phase of health workforce policy, which began with “a decade of health sector reform and relative workforce neglect” ([
21], p.105). Many health workforce structures and processes were lost in the DoH restructure as workforce planning was assumed by employing entities. By the mid-1990s, health workforce concerns had grown to the extent that the Minister of Health had established the Committee Advising on Professional Education (CAPE). Its report found inadequate attention was paid to health workforce issues due to a short-term financial and service efficiency focus. While the report proposed that a health education agency be established, this advice was not acted on. Thus, health sector employers continued to determine plans based on market needs [
21], with the MoH encouraged to stay on this course [
22]; employer-led planning continued into the 2000s.
By this time, persistent shortages of doctors and nurses had made the country increasingly reliant on overseas trained professionals [
16]. Austere funding had affected the workplace escalating to industrial action [
16], while tensions alienated clinical staff from DHB managers and both from government policy makers [
11]. These problems re-emphasised the importance of health workforce development and its associated policies [
23], and by the mid- to late 2000s, wage demands and training numbers had received some attention, though tensions remained [
16].
In the mid-2000s, a number of health advisory committees [
15] reported concerns over the ageing population and identified a range of cross-sectoral issues [
21,
24,
25], indicating that little gain had been made since the CAPE report. Regulatory reform progress was forwarded though, with the passing of the 2003 Health Practitioners Competence Assurance Act, and while it continued to take a profession-based silo approach, it did provide the possibility for new roles and/or overlapping scopes of practice [
26]. This led to the nurse practitioner role in 2004 [
23,
27] and was followed up by further detailed workforce analysis [
28].
While this progress was being made on understanding the health workforce environment, workplace conditions did not fare well. The health system continued to be troubled by mal-distribution and shortages, with specialist medical workforce projections predicting more of the same [
29].
This situation reveals the risk of employer-led health workforce planning: that with the substantial activity comes fragmentation and duplication and an ever-increasing focus on operational efficiency. This was reflected by the DHBs’ plans tending to favour hospital and specialist care, with PC workforces not well catered for [
15]. Despite this and without national supply monitoring, the MoH remained hopeful that solutions rested with workforce actor collaboration [
30], though little success was forthcoming.
The late 2000s also saw a revised focus on medical education [
30,
31], resulting in a new organisation providing oversight for New Zealand’s medical education and training [
32,
33], shortly followed by another review recommending a substantial reconfiguration of the whole of health workforce’s planning and funding [
26]. This review was opportune, as 2009 was a time of serious health workforce shortages [
11]. The review also reiterated many previous messages about workforce integration and productivity [
20], revealing the significant lack of workforce development progress over the past 30 years. The review noted that “a single agency, which has a whole of health and disability services workforce and whole of educational continuum responsibility, is needed if New Zealand is to have an affordable and fit-for-purpose health and disability services workforce” ([
26], p.5).
Thus, late 2009 heralded the third phase of workforce policy, with Health Workforce New Zealand (HWNZ) being established as a National Health Board (NHB) business unit, situated within the MoH. HWNZ’s aim was to provide national leadership for the development of the country’s health and disability workforce and overall responsibility for planning and development of the health workforce to ensure that it is fit for purpose [
34].
HWNZ implemented a workforce planning approach that embraced conditions of uncertainty [
35] and began to develop health system intelligence capabilities to conceive new visions of health services and their workforces [
35,
36] and realising these through a range of new initiatives. These initiatives included the Workforce Service Forecast (WSF), a clinician-led and patient-centred scenario, resulting in a forecast of future possible model(s) of care for a particular service aggregate [
14], reducing the system’s reliance on profession-by-profession forecasting while accommodating inherent uncertainty and promoting emerging workforce and treatment innovations [
34]. Other initiatives implemented by HWNZ were a comprehensive workforce forecasting model, incorporating variables such as workforce demographics, retirement patterns and immigration trends [
37]; the use of more qualitative intelligence through scope of practice analysis [
38] and a number of workforce innovation pilots [
34,
39,
40].
In the late 2018, HWNZ faced administrative change. In response to the poor achievement of its principal objectives, the HWNZ Board was disestablished [
41]. From a range of governance options, health workforce was made part of the MoH, headed by a Deputy Director General and supported by a non-executive advisory board [
41]. Reflecting re-centralisation, this consolidation was seen as a means to mitigate HWNZ’s slow goal achievement progress, for while HWNZ was successful in health workforce intelligence gains, it was less successful at addressing workforce problems, creating a clear strategy and future pathways and providing sector leadership. These failings have been attributed to policy and accountability tensions due to HWNZ’s position as part of the NHB, while being reliant on MoH resources [
42]. The fragmented nature of health care, the discipline-based lens’ of New Zealand’s workforce participants [
21,
22,
30,
43] and their conflicting priorities [
44] may also have contributed.