Growing the workforce: key sources of potential Pacific health workers 7
Training and qualifying Pacific people for the health workforce 8
Forecasts to 2020 for the Pacific health workforce 9
Clinical Scenario Modelling 9
Recommendation One – implement an improved model of care, initially through establishing demonstration sites in Auckland 10
Recommendation Two - leadership and coordination is required to effect an improved model of care 11
Recommendation three – Issues to do with the Pacific workforce training pipeline and its monitoring need to be addressed 12
Recommendation four- a focus in Auckland 15
Aims and objectives 17
The Approach 17
Section one - Pacific Health Workforce Vision 2020 19
Policy Context 20
Serau II and the Pacific Innovation Fund 23
Pacific perspectives of health 24
Pacific population demographics 25
Key Points 29
Total health workforce 33
Regulated and unregulated workforces 34
Participation by Pacific peoples in the regulated health workforce 34
Medical workforce 36
Nursing workforce 37
Other health professions 41
Participation by Pacific peoples in the unregulated health workforce 41
Pacific peoples as health managers and other support roles 42
Pacific health workers as a proportion of the Pacific population 42
Per capita ratios in New Zealand 43
Key Points 45
Pathways from school to tertiary education for medical and nursing trainees 47
Overseas trained Doctors 51
Overseas-trained Nurses 51
Adult learners 52
Section four - Training and qualifying Pacific people for the health workforce 54
Key Points 54
Pacific people enrolled in tertiary education 56
Students studying toward medical and nursing degrees 58
Enrolments and completions of medical degrees 60
Enrolments and completions of nursing degrees 62
Comparing the Auckland and Wellington regions 63
Clinical placements 64
Masters degrees 65
Key Points 68
Forecasting the Pacific medical workforce 69
The Pacific registered nurse workforce to 2020 73
Scenarios – Pacific registered nurses 74
Commentary on the scenarios 75
Section six: Clinical Scenario Modelling 79
Key Points 79
Health Needs of Pacific People 80
Accessibility of Health Services 86
The Misi Family 89
Mapping the Pacific patient journey through health services and recommended innovative workforce approaches 93
Proposed health system response 94
Section seven: Strengthening the current workforce 96
Appendix one – Innovation in the Pacific health workforce 111
Stocktake of Innovation Practice for the Pacific Workforce 111
Relevant Literature on International Workforce Innovations 119
Redesigning roles and matching the skill-mix 120
Increasing the flexibility of the health workforce 121
Key Themes 121
Appendix two –Project components 128
Project Components 128
Appendix three –Definition of Cultural Competence 130
Appendix four – Pacific people employed at District Health Boards as at 31 March 2012 131
Appendix five – Ethnicity of doctors and nurses 132
Appendix six – Ethnicity of other health professionals 133
Appendix seven – Percentage of Pacific school leavers with university entrance standard (2010), geographic and ethnic view 135
Table of Figures
Table of Tables
The rapidly rising demand for services combined with constraints on funding and the availability of professional skills has led to the need for innovative thinking about how high quality health services can be delivered for Pacific communities. Investing in a workforce that can improve the quality, timeliness and efficiency of services to Pacific people will inevitably be more cost effective, enabling the fast growing Pacific population to contribute positively to New Zealand’s economy and society.
The overarching objective of this Pacific health workforce forecast is to inform the development of policies and strategies that will strengthen and sustain a Pacific health workforce so that it can respond to the unique health and service needs of Pacific peoples and communities, contributing to their improved health outcomes.
The Pacific workforce forecast provides an assessment of workforce issues as they relate to meeting the health needs of the Pacific population. This review was supported by a Pacific Expert Group (PEG) of clinicians and specialists who provided expert advice in Pacific health, allied health, the unregulated health workforce, the clinical workforce, management and health workforce training.
There are seven sections to this forecast report. These are:
The Pacific health workforce vision to 2020.
The profile of the Pacific workforce.
Growing the Pacific workforce.
Training and qualifying Pacific people.
Pacific health workforce forecasts to 2020.
Clinical scenario modelling.
Strengthening the health workforce.
The Pacific health workforce vision 2020
The Pacific Expert Group (PEG) identified the following Pacific health workforce vision to 2020
A culturally competent workforce helping Pacific people live longer, healthier lives.
Profile: Pacific health workforce
Datasets were sourced from a wide range of agencies including DHB’s, Health Workforce New Zealand, Government agencies and registration bodies. A significant barrier to developing a clear and definitive Pacific workforce profile was that each dataset had different standards and bases for data collection and reporting.
According to figures provided by Health Workforce New Zealand, there were 165,615 people working for organisations whose self-designated primary purpose is related to human health in 2011. The dataset issues raised above, and further discussed in the report means there is less certainty about the number of Pacific people in the health workforce. However, it is estimated the regulated component of the Pacific health workforce comprises of 2,090 Pacific people. This represents approximately 2.3 percent of the total workforce.
The majority of people in the regulated Pacific workforce are nurses (77.8 percent). A further 8.6 percent are doctors. It is estimated that there are 283 Pacific people working in health professions other than doctors and nurses. There is considerable variation in the extent to which Pacific people are employed in the other health professions ranging from 2.9 percent (or 33 individuals) of all medical laboratory technicians, to there being no Pacific podiatrists.
It is difficult to ascertain the number of Pacific people in the unregulated workforce. However comparison of various datasets suggest that Pacific unregulated health workers may represent the largest group of Pacific health workers, and are likely to comprise the majority of the Pacific health workforce. The skill levels of this group, and their relatively large number, suggests that they represent one of the most significant opportunities for enhancing the Pacific health workforce- discussed in more detail as part of the section of the report dealing with training and qualifying the health workforce.
Key components: Pacific health workforce
Figure below is a diagrammatic representation of the key ‘stocks’ and ‘in-flows’ within the Pacific health workforce.
Starting from the bottom left corner we can see the number of students enrolled in tertiary-level degree programmes leading to careers as doctors, nurses and other health professions during the 2011 calendar year.
From this ‘stock’ of tertiary students we are able to discern the ‘in-flow’ of graduate doctors and nurses (that is, 16 students graduating from the Bachelor of Medicine and Bachelor of Surgery, and 73 from the Bachelor of Nursing degrees) in the 2011 calendar year. We were unable to determine how many students completed degrees leading to careers in allied health professions.
The number of medical and nursing ‘interns’ provides us with an indication of the ‘in-flow’ of graduates into the workforce as recent graduates undertake the basic vocational education and training required to develop full professional competency. During the period 1 July 2011 to 30 June 2012 we were able to identify 21 graduates of the Bachelor of Medicine and Bachelor of Surgery degree who were undertaking clinical training in preparation for registration as doctors. There were also 54 nurses enrolled in the Nursing Entry to Practice clinical placements.
The cumulative effect of these ‘in-flows’ over time is the current stock of Pacific health professionals excepting those with advanced clinical competencies, that is specialists, general practitioners, and nurse practitioners, shown in the central table in the diagram.
Current health workers may also undertake further or advanced clinical training. In the case of Pacific health workers we have identified 21 Pacific people studying toward the degree of Masters of Nursing, and approximately 180 who are undertaking postgraduate training in Nursing. We also estimate that there are 27 Pacific doctors undertaking clinical training as specialists with approximately 16 as general practitioners and 11 for other specialities. At least four Pacific people are undertaking clinical placements in the allied health professions.
The completion of advanced clinical training contributes to ‘in-flows’ into the group of general practitioners, specialists and nurse practitioners which are shown in the table at the top right of Figure .
Figure Inflow and Stock of Current Pacific health workforce
Notes: Specialist medical includes 51 General Practitioners, and 38 other specialists. Other health professionals made include some health professionals with advanced clinical training and competencies that could be grouped with specialist medical and nurse practitioners, however we were unable to source sufficiently detailed information to do so with confidence.
Care should be taken in interpreting this data because this diagram does not address the ‘out-flows’ from the health workforce or other ‘in-flows’ such as migration. In addition the source data may be limited either in scope (for example the number of clinical placements relates only to those funded by Health Workforce New Zealand or those we were able to identify through qualitative analysis) and quality (for example, we were unable to confirm whether those people undertaking masters and postgraduate study in Nursing are actually employed as nurses).
Nevertheless, the diagram does suggest that the ‘in-flows’ into the Pacific health workforce involve relatively few individuals, and these numbers reduce as these individuals undertake further advanced training. In addition, while Pacific nurses make up the largest component of the ‘clinical’ workforce our estimates indicate that by far the largest group of Pacific health workers are those employed in care and support roles. The circumstances, characteristics and career patterns of Pacific care and support workers are not well-understood despite the evident size of this workforce.
Ratios of Pacific health workers
Inequalities in the distribution of health workers are often described by comparing the number of health workers per capita. Per capita measures also provide a useful way to assess how many more Pacific health workers might be required to achieve per capita ratios that are consistent with those reported for the general population.
The ratio of Pacific doctors per 1,000 Pacific people was estimated to be 0.6 in 2010, compared to a ratio of 3.2 for the wider population. For Pacific nurses the relevant estimated ratio was 5.7 per 1,000 Pacific people. The ratio of ‘Pacific other’ health workers per 1,000 Pacific peoples was estimated to be 1.0 in 2010, compared to 4.2 for the New Zealand population.
Growing the workforce: key sources of potential Pacific health workers
Pacific young people are relatively less likely to transition directly from secondary school to the training required to attain registration as a doctor or a nurse. There were 350 Pacific young people aged between 18 and 24 enrolled in either the Bachelor of Medicine and Bachelor of Surgery, or Bachelor of Nursing degrees during the 2011 calendar year. These students represent approximately 0.9 percent of the 37,485 Pacific young people aged between 18 and 24.
The rate at which Pacific students attain university entrance, and the relevant ‘quality’ of that achievement to health careers, is therefore likely to be a significant (but by no means exclusive) determinant of their propensity to enter into the medical and nursing workforce.
The current mechanisms facilitating transition from secondary school to tertiary education are not resulting in significant numbers of Pacific young people accessing degree-level study.
There is a considerable group of Pacific people whose talents, skills and experience are under-utilised. The household labour force survey for the quarter ending June 2012 reported that for the 200,800 Pacific people over the age of 15:
17,900 were actively seeking work;
an unemployment rate of 14.9 percent (the comparable rates for European and Maori were 5.2 percent and 12.8 percent respectively); and
a labour force participation rate of 59.8 percent (equivalent to 80,722 Pacific people not being in the labour force) with the comparable rates for European and Maori being 69.5 percent and 65.6 percent1.
Pacific people overall are much less likely than the general population to hold a degree-level qualification, and much more likely to not have any secondary school qualification2.
Providing effective and meaningful opportunities for adult Pacific people to attain degree-level or higher qualifications could make a significant contribution to the numbers of Pacific people able to participate in key health workforce groups.
In addition, the unregulated health workforce provides a large potential pool of workers engaged in relevant employment who could be prepared for employment in the regulated health workforce. Initiatives aimed at improving the skill levels of workers in the unregulated health workforce by providing clear pathways to relevant education and training, for example the Bachelor of Nursing (Pacific) at Whitireia Polytechnic. In addition, these pathways could be pursued by workers seeking to enhance and develop their skills with the income differentials between the regulated and unregulated health workforce providing a strong incentive.
Training and qualifying Pacific people for the health workforce
Within the tertiary education system there were approximately 37,826 students3 who identified with at least one Pacific ethnicity enrolled in the 2011 calendar year. There is a reasonably large group of Pacific tertiary students (2,521) who are undertaking study toward programmes at Bachelor degree level or equivalent in health-related fields of study. There were approximately 25,139 Pacific students enrolled in tertiary education at levels below degree-level. The number of students undertaking study in the field of study of Health at Certificate and Diploma level in 2011 was approximately 888. The largest subgroups at this level were Human Movement and Sport Science (252 students), Nursing (202 students), and Public Health (200 students))4.
There are significant differences between students studying toward the Bachelor of Medicine and Bachelor of Surgery degrees offered at the University of Auckland and the University of Otago, and the Bachelor of Nursing degrees offered at a number of tertiary education organisations around New Zealand. Eighty-five percent of Pacific medical students are under the age of 25. Fifty-two percent of Pacific nursing students are over the age of 25.
The highest rates of nursing participation and completion are associated with the Wellington region, which may reflect the long commitment to the training of Pacific people by Whitireia Community Polytechnic through the Bachelor of Nursing (Pacific), and the proximity of the TEO to a significant Pacific community.
Smaller groups of students were studying toward postgraduate qualifications in other areas including Community Health (22 students), and Psychiatry (14 students). Consistent with the small numbers of Pacific people working in a range of the other health professions are very low enrolments, e.g no more than two individuals, in Midwifery, Nutrition and Dietetics, and Rehabilitation Therapies.
We have identified 191 Pacific health professionals who commenced clinical vocational training during the year ending 30 June 2012. There were 54 Pacific nurses and 21 Pacific doctors commencing their initial post-registration clinical training during that period. There were 70 Pacific nurses, 24 Pacific doctors and seven Allied Health professionals undertaking some other form of clinical training funded through Health Workforce New Zealand during that period.
There was insufficient data to draw a definitive conclusion about Pacific students working towards PhDs in Health fields although there are 212 students enrolled at that level overall.
There were 49 Pacific students studying at Masters level toward programmes related to Health. The largest group for whom field of study information is available is the 21 students enrolled in nursing-related studies. The number of Pacific people studying toward a Masters-level programme in Nursing suggests that there may be some opportunities to increase the small number (two out of 89) of Nurse Practitioners who are Pacific. This is because completion of a clinically-focussed Masters of Nursing degree is one of the requirements for registration as a Nurse Practitioner.
Of the 233 Pacific students enrolled in other postgraduate programmes, the largest group of those that were classified was Nursing with 108 students accounting for 46.4% of the total.
Forecasts to 2020 for the Pacific health workforce
The small numbers in the Pacific workforce meant that forecasts were completed for the doctors and registered nurses which form the largest groupings in the Pacific health workforce.
130 Pacific medical students by 2020 (up from 119 in 2011);
25 graduates in 2020 (up from 16 in 2011);
231 Pacific doctors (up from 180 in 2011); and
a ratio of 0.7 Pacific doctors per 1,000 Pacific people by 2020 (up from 0.6 in 2011).
Three scenarios for the Pacific registered nurse workforce based on the key factors in the workforce development model have been developed. The results of the scenarios suggest that significant change in the composition of the workforce in the short to medium term for nurses is relatively attainable. However, the per capita ratio of Pacific nurses to the Pacific population is lower than that for the general population, and even under relatively ambitious assumptions the numbers of Pacific registered nurses are not likely to increase to levels that reflect the share of the Pacific population between now and 2020.
By contrast, the development pathway for doctors takes much longer, and so the effects of any change in enrolment patterns, and decisions about the selection of specialities are not evident for several years. Nevertheless the effects of the recent increase in Pacific students enrolled in the Bachelor of Medicine and Bachelor of Surgery is an opportunity to encourage a higher proportion of the emerging generation of Pacific physicians to pursue careers in primary health care.
The scenarios for nurses and the medical workforce might provide some clues to the way in which the workforce for other health professions is formed, but further, and more detailed analysis is required.
Clinical Scenario Modelling
The Pacific Expert Group directed that the Pacific clinical scenarios should:
capture the complexity of Pacific health issues and the interplay with the current health workforce; and
take a family approach – an approach that focusses on the family as a whole rather than focusing on a clinical scenario for an individual.
Taking a family based approach (the Misi Family) as the clinical scenario differs significantly from other service reviews, which primarily focus on clinical scenarios for an individual.
The clinical scenario modelling highlighted that over a period of 12 months the Misi family engaged with approximately 30 separate health professionals to have their health needs met. Despite this, immunisation for the children was not up to date, a mother had not had her pregnancy monitored and there were five visits to hospital accident and emergency services. All visits were made by ambulance. Furthermore, two teenage members of the family, who are highly likely to have undiagnosed health issues, have had no visits to the doctor. It also highlighted significant socio-economic factors that impact on the family.
The scenario highlights the multi-morbidities affecting many members of the family. It is clear the family would benefit from access to health professionals operating in a primary care setting with a range of generalist medical skills such as diabetes management, immunisation, maternal health, oral health, mental health and rehabilitation.
Health professionals interacting with this family would also require the ability to provide a family based approach including ‘in home assessments’, supporting the family to address risk factors such as smoking, home economics, and living conditions. This is particularly important because of the collective nature of their living and cultural arrangements.
A culturally competent workforce that can transcend age and generational issues is also vitally important.