The future Primary health care rural workforce

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The Health of New Zealanders

• Depends on collaborative primary health care
  teams.rural and urban.
• Mia Carroll
• July 2007

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Will primary care doctoring soon be extinct?

• Chronic disease and self management
• Availability of evidence to all, guidelines and
  electronic decision support.
• Plethora of health workers all vying for market
  share and many cheaper to prepare and more
  acceptable and accessible to consumers
• Doc is now provider, patient a client, and
  the relationship an encounter. Which may only
  be 10mins
• Long term relationships harder to maintain as
  technology is becoming the diagnostician and risk
  assessments are done by others

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Will rural primary care doctoring soon be extinct?

• Pluralistic multicultural society harder to
  know and engage and diagnosis often more
  context related .patients/clients know best.
• Locums harder to secure
• Docs older and wanting to sell practices
  incomes reducing
• New generation dont want to work 24/7
• Patients aint what they used to be
• Convenient Care Clinics are growing in response
  to consumer demand and are cheaper

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Tribalism. Do you know it?

• The complex nature of the structural power
  relations in health care and the profound
  hierarchies and historical tribal behavior
  identified by Sage et al ( 2001) , make health
  care arenas an inevitable site for conflict and
  competition.
• Carroll,
  2003

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Hierarchies in every tribe
Specialists
Status
Missionary Rural GPS Nurses
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Specialists .Generalists
Deep specialty knowledge for specific DRGs
Narrow Scope
Broad generalist knowledge life span or age
specific
We need it all
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Are we in a paradigm shift?

• Populations
• Care palliation
• POEMS, PEARLS AND GEMS
• Concordance
• Client/ Consumer is in charge (self management
  )
• Professional is therapeutic partner/ facilitator
• Emphasis on inquiry competence
• Flexible, responsive interdisciplinary
  education
• Cooperation / collaboration breeds resources
• Overt rationing with community debate and
  ownership of decisions

• Individuals
• Cure
• DOES
• Compliance
• Patient is dependent
• Professional is authority
• Emphasis on knowledge
• Prescribed rigid uni-disciplinary curricula
• Competition and scarcity model
• Covert rationing

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• So Can we do it with fewer docs?
• Why would that primary health care world be any
  easier for nurses ?

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Are nurses simply grasping any task or role if it
gives us our own place in the market ?
MLC,2006
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Not everything is as it seems

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There is enough work for all and we know ..

• Improvement in the quality of care for people is
  dependent on teamwork.
• Teamwork is jeopardized by the communication and
  collaboration barriers between nurses and
  physicians
• These barriers are attributed not only to a shift
  in the power differential between nurses and
  doctors but also a growing gap between nurses
  and physicians views of what patients need.
  Zwarentsein and Reeves (2002)

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And still.

• Education curricula in most health care
  disciplines focus on the knowledge and skills
  they believe important to their discipline, not
  on health care delivery as part of a team.
• Whilst sociology of health care may be a small
  part of student learning, emphasis continues to
  be on the development of independent autonomous
  practitioners rather than interdependent team
  players (Henneman, 1995).

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And ..

• the reality of modern health and social
  services is that the care we get depends as much
  on how professionals work with each other as on
  their individual competence within their own
  field of expertise
• Not only does the care we get depend on
  interprofessional working, so do the costs of
  what we get.

Ovretveit et al (1997),
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SOIs it REALLY the demise of the Primary Health
Care G. P.?
MLC,2006
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Perhaps the life cycle really is all backwards.

• We should start out dead - just get it right out
  of the way
• Then wake up in a senior care facility and start
  feeling better every day
• We get kicked out of there for being too healthy,
  go collect our pension, then start work and get
  the gold watch on our first day.
• We work 40 years until we're young enough to
  enjoy our retirement.
• Then we go harddrink alcohol, party, and are
  "generally" promiscuous and we get ready for High
  School.
• After High School, its back to primary school,
  where we are simply kidsplay or nap all day no
  responsibilities.
• Then we become a baby with no cares whatsoever.
• The last 9 months we float peacefully with
  luxuries like central heating, spa treatments,
  room service on tap, larger living quarters
  everyday...and then...
•  
• Then finally we finish off as an orgasm!
•  

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• By changing nothing we hang onto what we
  understand, even if it is the bars of our own
  jail
• John le Carre ,1990

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Workforce Model
PLANNING
Health Gain Reduction of inequalities
Population Need
E VA L UA T I ON
E VA LUA T I ON
Effective Service Delivery
Evidence Based, Effective , Intersectoral
Solutions
Education / Training Collaborative teams
Work Required i.e. Skill sets competencies
Workforce skill mix skills mix to respond
PLANNING
Mia Carroll, 2006
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If our purpose is to meet population health needs

• we must ensure we have a responsive primary
  health care rural workforce team
• Providing services and interventions that are
  accessible, acceptable and effective for the
  specific population we serve
• And that changes all the time! We are certainly
  not doing the things we used to do 25 years ago.
  Nor should we be.

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The purpose of nursing is to work to improve
health

• Nurses are part of teams who work for health
• We do not have a monopoly on caring any more
  than docs have monopoly on the process of
  clinical inquiry and diagnostic reasoning
• All this health work is to remove actual or
  perceived obstacles to people being able to live
  to their full potential.not just to manage
  illness and prevent disease
• Patients/ clients / consumers do know best.
• Nurses thrive in good relationships within teams
  and nurse retention is strongly correlated to
  positive relationships with doc colleagues

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Roles usually respond to gaps in service delivery
or specialist knowledge

• The Nurse Practitioner, Clinical Nurse
  Specialist and other advanced nursing roles
  arose in response to
• underserved populations
• gaps in clinical care paths/ quality,
• medical specialisation,
• consumer demand
• DHB debt and chronic disease burdens
• Health movements i.e. womens health, public
  health
• Government Strategies

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The success score card should be outcome
focused and include
Patient/ consumer/ whanau satisfaction
Costs / Resources
Functional improvement (SF36 or MacNew)
Clinical effectiveness
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Collaboration is the key?

• Enshrined in every government strategy
• Essential..A health care imperative
• Ethical maximising resources
• A public goodbuilds cooperative societies
• Desired and done by all health professionals
• yeah right !
• The rhetoric goes on but does anyone really do
  it?

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Levels of Partnership

Collaboration
Cooperation
Coordination
Communication
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Is it the quest for the holy grail ?

• Collaboration is not an innate skill. It has to
  be learned
• It requires respect and trust for the skill and
  competence of others and a shared purpose

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Can we rekindle collegiality and mutual respect
.can we collaborate?
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So what is collaborative practice ?

• Collaborative Practice is an
  inter-professional process for communication and
  decision making that enables the separate and
  shared knowledge and skills of care providers to
  synergistically influence the client/patient care
  provided.
• (Way, Jones 1994, p.29)

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Collaboration is

• about positive working relationships among
  professionalsand it is much more.
• Its a way of working, organizing, and operating
  in a manner that utilizes the provider resources
  to deliver health care in an efficient and
  effective manner to best meet the needs of the
  patients/clients being served
• (Way, Jones, Baskerville, 2001).

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Can we see the same old landscapes with new eyes
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A core model for establishing successful
collaborative practice
Busing , Way and Jones ( 2000)

• Framework or structure that comprises seven
  essential elements
• Process for identifying roles and functions of
  the team
• Funding model that reflects the equality of the
  partners ( preferably not employer-employee)
• Driven by the
• population we serve
• geographical location of care
• talents and skills of the collaborating team

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The elements of structured collaborative
practice

• responsibility
• accountability
• co-ordination
• communication
• co-operation
• assertiveness
• autonomy
• and mutual trust and respect
• These serve as a framework or structure.

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Collaboration grows resources

• Integration of individual approaches
  synergism
• 1 1 3
• Collection of individual approaches
• addition
• 1 1 2

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Mutual Trust and Respect

• Without trust and respect, co-operation cannot
  exist.
• Assertiveness becomes threatening, responsibility
  is avoided, communication is hampered, autonomy
  is suppressed and co-operation is haphazard
  
  (Norsen, 1995).

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How do we do it ?

• The process for determining roles and functions
• Individual collaborative practices are different
• Driven by work required by the needs of the
  practice / community population
• The culture of the population served ..
• Skills, knowledge and competencies of the team
• Skill mix of the team i.e Doc? Nurse? Community
  Support Worker etc
• Day to day functions and operational logistics
• The site and remoteness of service
• Legislation and scopes of practice
• Funding streams
• Policies

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Can we see opportunity in challenges ?
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• In reviewing the role and functions of the
  team it is necessary to understand the distinct
  and overlapping strengths, and the unique talents
  and preferences of collaborating partners.
• It is not so much about professional
  boundaries as evolving relationships.
• It need willingness, effort, belief in the
  benefit of collaboration, and orientation to the
  model.

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As this conference reminds us

• It is not the strongest of the species, nor the
  most intelligent who survive but the most
  resilient to change..Darwin

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Nursing