Allied Health Professional Associations Forum

Submissions

Submissions by the Allied Health Professional Associations' Forum (AHPAF) to government on issues of common interest to allied health professions.

The Allied Health Professional Associations' Forum (AHPAF)

Submission to the National Advisory Committee on health and Disability: People with Chronic Conditions, a discussion paper.

Preamble
The Allied Health Professional Associations'Forum (AHPAF) is the peak body for allied health professional associations. AHPAF provides a forum for representatives of allied health professional associations to work together to:
• Promote the value of allied health professional services
• Make representations and submissions on issues of common interest to allied health professions
• Develop effective working relationships with government and other key stakeholders
• Take an active approach and be involved in development, implementation and monitoring of relevant health policies

The following associations are members:
• Aotearoa/NZ Association of Social Workers
• NZ Association of Occupational Therapists
• NZ Association of Optometrists
• NZ Association of Psychotherapists (Te Roopu Whakaora Hinengaro)
• NZ Audiological Society
• NZ College of Clinical Psychology
• NZ Dental Therapists Association
• NZ Dietetic Association
• NZ Institute of Medical Radiation Technology
• NZ Psychological Society
• NZ Society of Physiotherapists
• NZ Society of Podiatrists
• NZ Speech-Language Therapists Association
• NZ Public Service Association:Te Pūkenga Here Tikanga Mahi

AHPAF welcomes the publication of the discussion document People with Chronic Conditions. The ongoing treatment of people with chronic conditions forms an important component of the work load for members of AHPAF.

Introduction 
AHPAF supports the holistic view shown in this document regarding the ongoing support of people with chronic conditions, especially the recognition of the relationship between a person's spiritual well being and their physical and mental health. The use of multi-disciplinary assessments that are multifactorial is very important in the management of people with chronic conditions.

Points for discussion
Section 1
I. Definition of people with chronic conditions (p. 5-6)
Generally we agree with the range of conditions included but are concerned with the admission of obesity. The number of people suffering form morbid obesity is increasing and morbid obesity is definitely a chronic condition. We also strongly support interventions aimed at preventing the development of chronic conditions including increasing physical activity and dietary advice.

2. Who needs to be involved in supporting people with chronic conditions? (p.11)
AHPAF strongly supports the Primary Health Care Strategy of broadening the primary health teams to include allied health professionals such as social workers, pharmacists, physiotherapists, occupational therapists and podiatrists.
Section 2
Approach to chronic conditions (p.15)
1.  AHPAF recognises the importance of cultural competence in the management of people with chronic conditions. It also supports a policy of early identification and continuous rather than episodic care with an emphasis on community engagement and self management. All the examples given of the elements of chronic condition models are worthy of further exploration within the New Zealand health environment.

Self management (p.18)
1.  Self management is a strong tool in the treatment of chronic conditions. Beneficial effects in health behaviours and decreased hospital stay can be achieved in people involved in self management programmes which include allied health professionals. The promotion of self management is an essential part of the philosophy behind most allied health interventions and this includes helping people to reengage in activities on an individual or group basis. Greater involvement of allied health professionals in Primary Health Care teams would therefore support and encourage the philosophy of self management

Complimentary Health (p. 19)
1.  AHPAF recognises the importance of complementary and alternative health care to many people suffering from chronic conditions. However feel that health practices funded by government health funding must follow best practice guidelines and be evidence based.

Section 3
Suggestions to help improve the way people with chronic conditions are supported (p. 21)
1. AHPAF supports the comments made by people with chronic diseases in this section, regarding the problems they experience accessing allied health interventions. Allied health professionals need to be a recognised component of primary health teams and funded appropriately. The discrepancy that exists in access to funding services for chronic conditions, including personal health and disability funding, and those receiving ACC must be resolved.

Section 4
Interactions between people and professionals (p.27)
1. AHPAF strongly supports the importance of a caring relationship and good communication between the professional and patient and recognises the importance of culturally appropriate behaviour. The role of the extended family is also recognised.

Funding
1. Programmes for supporting people with chronic conditions need to be adequately funded. Adequate funding for early intervention programmes, such as activity based programmes can often delay or prevent the development of a chronic condition. It must also be recognised that every person with a chronic condition is an individual and there must be adequate time and funding for a full assessment of their needs.
2 .The special needs of people with complex and chronic conditions need to be recognised.
3. Long term funding must be guaranteed as it takes time to set up and develop an effective management programme for people with chronic conditions.
4. The problem of long waiting lists for access to allied health services needs to be addressed. The increased involvement of allied health professionals in the primary health sector including PHO's and NGO's may help address this issue.

Work force planning (p.32)
1.  AHPAF strongly supports the role of multi-disciplinary teams in the management of people with chronic conditions and recognises that the health work force needs to be increasingly flexible. AHPAF recognises that each professional group comes with its own set of skills and knowledge. It is important that this is acknowledged to ensure the health professional involved has the knowledge and appropriate set of skills for the job.
2.  There is definitely a role for trained community health workers in supporting people with chronic conditions.

Partnerships between health and community (p.37)
1. A major recommendation in this document is the need for allied health professionals to be more involved in primary health care especially as part of PHO's  and NGO's. More financial knowledge incentives may be needed for that to happen 

Submission on
New Professions under the Health Practitioners Competence Assurance Act 2003
Criteria for assessing applications for inclusion in the Act

This submission is made on behalf of members of the Allied Health Professional Associations' Forum (AHPAF) as listed above.

AHPAF supports the Protocol for the Content and Assessment of Applications from health professions for inclusion in the Health Practitioners Competence Assurance (HPCA) Act 2003 with the exception of the requirement for set up and operational costs of new authorities to be borne by the registrants.

The proposed requirement for new professions, which otherwise meet the criteria for inclusion in the HPCA Act, to have financial viability to support a proposed new authority is likely to place unrealistic financial requirements on the individual members of that profession.  Some health professional groups which will be applying for inclusion in the HPCA Act are small.  For example, current numbers for three of AHPAF's member associations who may make applications for inclusion in the Act are: New Zealand Audiological Society – 126;  New Zealand Association of Psychotherapists – 284;  New Zealand Speech-Language Therapists Association -  approximately 500.

A new authority will be faced with initial establishment costs including implementation of an electronic database and processes for registration and ongoing competency.  In addition, a new authority will expect to register all currently practicing members of the profession in the first year.  Once the authority is fully established and operational, the ongoing costs would be met from the fees gathered from new registrants and issue of annual practicing certificates.  It is considered to be too great a financial burden for health professions which are not generally well paid to have to meet a new authority's establishment costs.

It is noted that the discussion document also suggests that the financial viability of any proposed authority may have a bearing on the decision as to which of the section 115 options is the better mechanism.  It may not be appropriate, feasible or acceptable for a profession to be added to the existing authority of another health profession.   This could lead to a health profession which meets all other criteria for inclusion in the HPCA Act being turned down thus posing a risk of harm to the public.

AHPAF strongly recommends that grants be made available by Government for the establishment of required new authorities.

An example of such a grant is described in the Social Workers Registration Board (SWRB) Statement of Intent 2004/05.  The newly established SWRB expects to receive applications for registration from between 1,500 and 2,500 social workers in the first year

and thereafter in the range of 150-250 each year.  A Government Grant of $400,000 has been allocated for year one.  A further grant of $267,000 has been forecast for year two, subject to Government acceptance of the Board's business case regarding the need for such funding.

AHPAF fully supports the method used for the establishment of the SWRB by allocation of a Government Grant and recommends that the same method be used for the establishment of new authorities under the HPCA Act 2003.

Submission on

Fit for Purpose and Practice: A Review of the Medical Workforce in New Zealand

A Consultation Document from the Health Workforce Advisory Committee

Preamble
The Allied Health Professional Associations'forum (AHPAF) is a forum for representatives of allied health professional associations to work together to:
• Promote the value of allied health professional services
• Make representations and submissions on issues of common interest to allied health professions
• Develop effective working relationships with government and other key stakeholders
• Take an active approach and be involved in development, implementation and monitoring of relevant health policies

Member associations as at 7 July 2005 are:
• Aotearoa/NZ Association of Social Workers
• NZ Association of Counsellors
• NZ Association of Occupational Therapists
• NZ Association of Optometrists
• NZ Association of Psychotherapists (Te Roopu Whakaora Hinengaro)
• NZ Audiological Society
• NZ College of Clinical Psychologists
• NZ Dental Therapists Association
• NZ Dietetic Association
• NZ Institute of Medical Radiation Technology
•NZ Psychological Society
• NZ Society of Physiotherapists
• NZ Society of Podiatrists
• NZ Speech-Language Therapists Association
• NZ Public Service Association:Te Pūkenga Here Tikanga Mahi
(Associate Member)

Introduction
This discussion document is in many ways an enlightened look at the medical workforce and its relationship to the wider workforce and health sector. There is a strong emphasis on a systemic, sector wide approach and the need to show leadership in health workforce development as a whole, which AHPAF strongly supports. The main issue that allied health professions have is that because of the brief for the Medical Reference Group, this discussion takes place within a medical paradigm, rather than within a whole of health sector context. Inevitably the document focuses on the needs of the medical profession rather than the system as a whole.

The general debate, which should have preceded this discussion document, has been initiated outside of the Health Workforce Advisory Committee processes by the Ministry of Health. The Ministry's recently commissioned report Ageing New Zealand Health and Disability Services: Demand projections and workforce implications, 2002 – 2021 (NZIER 2004) looked at the increasing demand for health services as the population ages, the risk of labour shortages, particularly after 2011 and the need to focus attention on how the health and disability services workforce should be educated, trained, developed and deployed. The results of this consultation process should lead to a full systemic, sector wide approach to health workforce issues, putting the needs of the patient/client/consumer at the centre. This will flow naturally into a look at the roles of all those involved in the health workforce and how they contribute to the wellbeing of those they are employed to serve.

It is the view of AHPAF that this very positive discussion document has come at the wrong place in the cycle. The Ministry document should have been undertaken earlier, and probably by HWAC. This is an example of the lack of co-ordination in health workforce development and there needs to be clarity established on who is providing leadership in this very important area.

We do not want to hold back any positive developments for medicine that might come out of the Fit for Purpose and for Practice process, but HWAC, and the MRG, should be open to change as the sector decides where it wants to go in the wake of the Ministry of Health consultation process.

However, we wish to stress the many positive aspects to this report, including the points raised above, the emphasis on the new professionalism, the need to work in new ways, particularly in such areas as primary health care.

Comment on the discussion document is organised around the Chapter headings.

Key Issues Affecting Health Workforce Development
This chapter accurately sums up the major pressures on the health system and the implications for the health workforce. The definition of workforce development provided offers plenty of scope for engagement with other workers and professions in the health sector, including its emphasis on partnership.

The implications for the health workforce are accurately summarised on page 19. AHPAF agrees that “simply increasing workforce numbers is not a sustainable answer to New Zealand's health and medical workforce problems. It is also true that the “efficiency and effectiveness of the whole health workforce must improve.” Skill transfer and enhancement, and collaboration between all disciplines must occur, but AHPAF believes that we need to go beyond what doctors can delegate to nursing or allied health, but on how all the health workers in the system can best support patient/client/consumer focused care. This is a challenge for the allied health professions as much as it is for the medical professions.

The Medical Workforce in New Zealand – A Stocktake
The data outlined here is accurate and interesting. AHPAF notes the concern about the decline in GP numbers, the ageing GP workforce and the particular issues for rural GPs. We agree that these are major issues for primary health care provision for both GPs and allied health professionals, and need to be addressed. However we also think that the Primary Health Care Strategy represents an opportunity to rethink how primary and community services are delivered which may deal, at least in part, with the issues arising out of this shortage.

AHPAF sees the key attributes of a primary/community health care system as being:
• Lifelong care
• Evidence based health management
• It is cognisant of risk factors for disease
• A focus on population health objectives
• An effective targeting of services
• Assured access through networks of providers in local communities with integrated management of patient data

Such a system would see the medical, allied health and other professions delivering quality services through core locations (e.g. health centres staffed by doctors, nurses, and others such as health promotion officers,  and dietitians), satellite locations (e.g. community departments of the local DHB staffed by a range of allied health professionals) and partnership arrangements with independent practitioners (such as optometrists, occupational therapists, physiotherapists and others). While the GP would remain very important to this model, she/he would not necessarily be at the centre.

The Health Professions in a Changing Landscape
AHPAF agrees with the MRG that we need an environment that enables all health professionals to realise their full potential and that this necessitates career structures that “support lifelong professional development, build competency and align work with New Zealanders health service requirements.” We would go further and suggest that there could be some value in exploring an approach similar to Agenda for Change in the U.K., which establishes fair relativities between and within professions based on a gender neutral job evaluation tool, and which puts in place a knowledge and skills framework to enable health workers to progress and plan careers.

The New Professionalism
AHPAF welcomes the emphasis on the new professionalism in the report. We agree that a new social contract is required, although it should be one that involves all health professionals (not just doctors), users and society. This is consistent with a ‘personalisation approach in which service users …should not be utterly dependent upon the judgement of professionals; they should be able to question, challenge and deliberate with them. Nor are users merely consumers, choosing between different packages offered to them; they should be more intimately involved in shaping and even co-producing the service they want. Through participation users have greater voice in shaping the service, but this is exercised where it counts, where services are designed and delivered.

This represents a challenge for all health professionals, but particularly for the medical profession which has historically assumed a leadership role and the status that goes with that. While advocating new ways of working the MRG appears to still be influenced by the traditional assumptions about leadership and the report contains some mixed messages.

Under Leadership and Governance the MRG states that “leadership is an implicit requirement for many of the CanMEDS 2000 competencies. It is a set of behaviours and skills that many doctors are called upon to display in their clinical and governance roles within organisations and the wider health system.”

However, the CanMEDS 2000 'essential roles and key competencies for specialist physicians' don't actually name 'leader' as a role. Its true that the 'medical expert' and 'collaborator' roles could be interpreted as having some implicit assumptions about leadership in planning treatment, although the word isn't used. The only place it is used is in one of the objectives for the 'collaborator' role: "Effectively communicate with the members of an interdisciplinary team in the resolution of conflicts, provision of feedback, and where appropriate, be able to assume a leadership role(our italics).

Under the role of 'manager' there is an objective "Be open to working effectively as a member of a team or a partnership and to accomplish tasks whether one is a team leader or a team member." (our italics).

Rather than concentrating on 'leadership' in this context, it would be more accurate to say that 'Teamwork, communication and collaboration are explicit and implicit requirements for many of the CanMEDS 2000 competencies'. The MRG refer to 'health professionals' as well as 'doctors' as having leadership roles but really only seem to be thinking of doctors, and emphasise this at the expense of team member roles.

On page 40 the MRG state that health sector “politicians, managers and other health professionals look to doctors for leadership.”

This rather bald statement conflicts with statements elsewhere (e.g. see p.50) about recognising that team leadership is not automatically the role of the doctor. Many of our members experience of multi-disciplinary teams suggest that doctors assume this leadership even where it hasnt been explicitly granted to them. All health professionals need to learn leadership skills. For some it will include becoming more confident about their contribution and their own ability to lead, for others it will include learning to recognise the contribution of others, including their ability to lead. For all health professionals the reference to democratic and servant models of leadership are appropriate. What needs to be emphasised is leadership in the context of the team – a context in which leadership is shared.

We also note the comment on page 40 that 'Medical culture tends to view ill health, psychological ill health and addictive behaviour as personal weakness.' This has implications for doctors attitudes to service users as well as their reluctance to acknowledge their own health problems. The report seems to suggest that this attitude should change but on p.60 it raises objections to reducing the hours of rostered work by RMOs. This suggests that the MRG don't really believe that the current work/life balance is potentially unhealthy and reinforces the view of medical culture described on p.40.

Medical Work in a Changing Workplace Environment
There are many issues raised in this section of the report. AHPAF wishes to highlight just a few.

There is a need for service and workforce redesign, and a need for a systems based approach to drive that. Because the report starts with the medical workforce it cannot have a fully fledged systems based approach. For example, on p. 43, the report does not ask the right questions. The appropriate question should not be What services is it most appropriate for doctors to provide in the future?, but rather What services will users require in the future? and then Which health workers are most appropriately qualified to deliver those services?We do acknowledge the statement that services will be further redesigned in the future, with more responsibility for care being taken on by other trained health professionals.However, the next sentence reflects that the MRGconcern is to free doctors up by delegating roles to nurses and other health professionals rather than altering what doctors do in the light of service user need.

If this fundamental question is the starting point then the development of projects that engage front-line practitioners (as suggested on p. 44) is the appropriate way to proceed. As stated earlier, this approach is a challenge for all health professionals, not just doctors.

AHPAF supports the comments made about PHO development, the primary/secondary interface, the involvement of the NGO and private sector workforces and the further development of health care networks. Comments above highlight our support for a systems based approach to workforce development, but on a slightly different basis from that flagged in the report.

Information support is vital. Our vision for a primary/community health care system (see p.2 above) is predicated on effective information sharing. We are also strongly supportive of the comments on  communication and teamwork, although, as we have already noted, they appear to contradict earlier comments about leadership.

AHPAF notes the reference to accountability and the shame and blame culture. We agree that such a culture can be counterproductive but think that this goes beyond creating trust between managers and clinicians, important though that is. The new professionalism and the development of a system based on has the potential to reduce the need for the levels of accountability required under the HPCA. If managers and health professionals can build trust in the workplace, and with service users by involving them fully in their own care, then we may be able to move beyond the culture of complaint.

Human resource management is one of the issues that employers are taking an increased interest in but although most DHBs have human resource management systems, and a national human resource network co-ordinated by DHBNZ, we would note that compared with most government departments of a similar size, they are under resourced in this area.

The reference to the magnet hospital principles is noted, but this also a good example of an outmoded single profession approach to human resources and workforce development. It leaves our members out, other than as an afterthought, and inevitably focuses on the needs of nurses.

Education, Training and Career Development
Much of the focus of this section is specific to the medical profession. AHPAF wishes to comment only on the issues of role diversity and interprofessional learning and practice.

It is worth noting that role change for all health professionals is being driven by the factors identified on p. 59, but also on the changing demographics of both the wider society and the health workforce. This point is picked up earlier in the report, but needs to be repeated here.

The conclusions that MRG draws from that are mostly sound but we would suggest a slight change of emphasis. The central role of doctors will continue to be the diagnosis of clinical problems but it is possible that the provision and co-ordination of patient-centred care could be equally the responsibility of others. However, there will be new professional roles, probably through the development of population-based health programmes.

AHPAF is fully supportive of efforts to develop formal interprofessional learning and practice in New Zealand and notes with interest the developments in the U.K. There is great potential for some projects around this and it is our expectation that allied health professional associations will be involvement in assisting with the development of such programmes.

Recruiting and Retaining Doctors in a Global Market
AHPAF notes the points made in this section, many of which also apply to allied health professionals. We are supportive of any moves to reduce student debt as a means reducing the incentive to repay it by going overseas to work.

Working Together  A Systemic, Sector-wide Approach to Health Workforce Development
As stated earlier, AHPAF is supportive of developing a systemic, sector wide approach to health workforce development, but we think that the starting point for this report stops short of achieving that.

Notwithstanding this, we support the approach taken in this chapter, with its emphasis on networks and working together.

We note the comments on leadership, which serve to underline the point made in the introduction to this submission i.e. that there needs to be a single point of leadership to co-ordinate health workforce matters within the government and public service. We do, however, support the development of other points of leadership under this umbrella such as professional associations and unions, and the recognition of these contributions.

Conclusion Immediate Priorities for Action
Our comments of the immediate priorities for action are shaped by our analysis of the substance of the report as set out in this submission.
The primary healthcare/general practice workforce in primary health (as elsewhere) the emphasis should be on the whole workforce and not just GPs, although GP numbers do need to be addressed urgently.
– we support the comment that there needs to be major changes and innovations in the structure and process of both undergraduate and postgraduate education, and would extend the sentiment out to include allied health education and training. Better integration between medical education and the education of other health professionals needs to happen.
Service and training arrangements  there needs to be a better balance between service and training arrangements for medical practitioners in hospitals, but also for allied health. Allied health professionals have the added burden of inadequate budgets for professional development.
Recruitment and retention  there are similar issues for allied health professionals.
Information, innovation and research these comments are strongly supported, so long as the information, innovation and research treats the health workforce as an interrelated whole.
A systemic, sector-wide approach once again this needs to be a genuine systemic approach that starts with the needs of service users, moving out to an examination of the health workforce that is required to meet those needs.
Leadership is required at all levels of the health system. At a national level the responsibilities of the various agencies involved in health workforce development needs to be clarified to make it clear who is meant to be leading the debate.

References
AHPAF, Welcome to the Community Health System of the Future: A presentation by the Allied Health Professional AssociationsForum  (2004)
Leadbeater, C. Personalisation Through Participation: A new script for public services (Demos, 2004), available at www.demos.co.uk
Lissauer, R. Future Health Worker British Medical Journal, (29 April 2002)
O’Neill, O. A Question of Trust: Called to Account (Reith Lecture 3) (BBC, 2002), available on www.bbc.co.uk/print/radio4/reith2002/lecture3.shtml?print