The elements of whanaungatanga-Tapu, mana, Pono, Tiki and Aroha as described by Pa Henare Tate in his thesis, resonates deeply with the nursing philisophy of caring for self, respect, trust and restoration. If this basis of traditional Maori society was better understood and accepted by New Zealanders- not least politicians and funders and legislators, perhaps the growing inequality and inequity issues we are experiencing as a society may be arrested.

The benefits of utilising the triumverate of Pono- the reality, Tika- what is right, and Aroha- what is compassionate in all my connections with people in our mutual efforts to achieve Te Wa -the journey of life – appears to be self evident. The knowledge inherent in these concepts are simple and clear. Many of the values that our New Zealand society hold dear are expressed within the traditional Maori values system, within their definitions of roles and relationships.Perhaps if more Kiwis (including Maori) were to be open to learning and accepting these in a more overt formal way within our lives and our work, whanau/child poverty, whanau violence, alcoholism and other negative behaviours may be more readily rejected and eradicated.

Simple in purpose but rich in content. And deeply empowering.

In his efforts to examine the issues behind the reduced funding  of  PHC services, Professor Matheson describes the importance of distinquishing between higher order goals such as improved health outcomes and equity, and those that provide the more operational goals of how to provide the services within budget restraints.

Matheson has identified that the 40% of discretionary funding that a DHB had to fund PHC services has been chipped away by  increasingly tight budgets and the directive by the Ministry of Health (MoH) to focus funding to achieve targets that provide  little in terms of solutions to improving the health outcomes of people with complex health and social needs, or than narrow the ever widening inequity gap.

Targets such as ED waiting times and improved access to elective surgery are nonsensical in the face of burgeoning chronic conditions, increasing unemployment and all the social woes that follow a fiscally challenging time.

Better to identify targets that will truly measure how well we are providing the care, not how many surrogate markers we manage to collect from people who can barely afford prescriptions and medications as they struggle to pay higher power prices on minimum non livable wages. Providers and organisations are constantly distracted from providing quality evidence based care by having to reach targets that may not be at all relevant to the person sitting in front of them. To educate a patient on the benefits of having a low CVRA when they are struggling to breathe because of their emphysema or being diagnosed with a non curable illness is ludicrous, and yet if the box is not ticked, the ultimate penalty may be loss of income for the provider’s employer.

Best to have a system that rewards quality service by identifying improvement of quality markers such as patient satisfaction with a service, clinical competencies of providers, a multidisciplinary team approach and successful team components. Markers of a well functioning clinically integrated health system could also be utilised as targets to hasten the implementation of this throughout NZ.

Indeed this is what Cathy O’Malley – the Deputy Director of Health- has signalled will occur over time, as the PHO contracts are examined this year. DHBs and PHO will be asked to do more towards becoming  an integrated health system. Unfortunately whilst DHBs have so  little funding and influence over the PHC sector, with it’s privately owned and commercially driven business models, this work programme will be fraught with power struggles and political bargaining, with the biggest loser being the patient at the centre of a maelstrom rather than the calm epicentre of patient focused PHC!

And where are the nurses in this storm? At the bedsides in hospitals, and with people in their homes, but not at the top tables in any great numbers debating and developing the contracts and policies. It never ceases to amaze and frustrate that the largest  workforce in the health system, and thus potentially the  most affected by any structural, legislative or contractual changes is not included as of right, but must insist on being consulted.

I have no problem with business making a good profit, but not at the expense of New Zealand older adults, many of whom are vulnerable and yet must pay all their savings to live in supported care. And then there is the dispute about fair wages for Aged Care workers.

And to top it all off- these facilities get most of the funding from mine and your taxes! So essentially we are all shareholders in the business? Or at least we are all stakeholders in it as one day we may face the same dilemma- stay at home unsafe or relent and pay up to be cared for by the businesses who have been taking our taxes all along.

So who do you think in the winner on the day?

Doing a scan of the nursing landscape shows some changes but much still as it has been for the past decade for nurses:

The Health Promotion Forum of NZ put out an interesting read on the Challenges and Opportunities of Primary Care. The paper identifies 8 areas of change:(the italics are mine)

• A reduction in the number of PHOs (by about half)………………………………………………………mostly done

• ‘Better, sooner, more convenient’ primary care (emphasizing the devolution of services from hospitals into the primary care sector)                                                                   …………………………..……………………..in progress

• Increased clinical governance and leadership in decision making…………………………………..not evident yet!

• Changes in funding, generally less dollars but possibly greater local flexibility……………..…..certainly seen the “less dollars”- no sign of the “greater flexibility!”

• Establishment of ‘integrated family health centers’ (IFHCs) ……………………………………………activity visible around the country but variable and not always inclusive of clinical leaders

• The development of ‘Whānau Ora’ services ………………………………………………………………….little effort has been made to intergrate these services with existing provider services; until this is occuring the services may remain fragmented and ineffective

• Changing approaches to service contracting………………………………………………………………..this one may prove problematic for nursing services- without being able to influence planners and funders, nursing services contracts may be put out to tender to funders with little understanding of the PHC environment

• A reduced focus on public health services…………………………………………………………………...this is somewhat alarming considering the PHC Strategy’s focus on population health- how can we have a strong primary health care environment without good public health services?

This week the NZ Government has finally agreed to include delegated prescribing into the legislation.

More changes ahead with Danny Wu’s resignation from his position at the Ministry of Health as the national programme manager for the Primary Health Care implementation. His presence in the Ministry has spanned a decade, so much institutional  knowledge will be lost with his leaving. The part that concerns me is that within the statement from the MoH they said that “A decision is being made over the next month on the future management of the primary health care programme”. Guess we can only watch, wait and sharpen our lobbying tools.

The NZ College of Primary Health Care Nurses, NZNO have started a facebook page- check it out and contribute to the discussion on kiwi nursing.

Can anyone tell me why this is so?

Every smeartaker should be able to complete the second phase of a smear- the bi-manual exam. It is not rocket science. It is a technique like many others nurses do- invasive- yes but you are already down there anyway! But not dangerous.

Makes me wonder who designed the original smeartakers courses in the first place?

Is it because we need to justify and prove the value of nursing because the financial benefits to an organisation from nursing are so difficult to prove?

Is it because we, as women, need to describe what we do as nurses, to describe the complexities of nursing and how it relates to the patient/human experience of health and illness?

According to this article, the patient experience is so intrinsically involved in the quality of a service, that the nursing gets dissected within the evaluation of that service. So what happens when the evaluation doesn’t show a great outcome for the service? Where does that leave the nurses? Is it so intrinsically incorporated with the service outcomes that the nursing role gets thrown out with the bathwater?

Is this one reason why nursing is struggling for financial and professional respect/recognition in specialist roles, or why it is often the first service to face budget cuts? With all the research on the value of effective nursing and the positive effect it has on overall quality in an organisation (see Magnet hospital research for example), what other conclusion can we come to about poor funding decisions made for, and on behalf of, nursing?

And yes, once again, this article’s summary states that the study described “clearly demonstrated the complexity and multiplicity of components of the CNS role and its impact on patients”.

Humpph -dont see “health” anywhere in that statement!

Apparently they want a model that estimates the financial impact of task substitution between nurses and GPs. Now there is the first problem I have. This is suggesting that nursing and medicine is able to be “measured” by “tasks”. Have they not learnt anything from the massive amount of research done in the States around quality of health care services, health outcomes  and magnet hospitals. Every time a bean counter tries to measure health we end up in a morass of money saving cuts,and no proven benefits to patients or services.

Then if you read the limitations of the study it essentially makes the study rather pointless to my mind. Because it hasn’t been able to capture the complexity of the practice nurse and the team role in general practice. It doesn’t take into consideration the patient at all- older and high needs populations will change the picture markedly in terms of consultation times and team involvement costs etc. A scary implication is that if you make nurses more expensive and shorten their consultation times (see 6.5) they will make you more money- boom,there goes accessibility and quality out the door, right there!

What it does do is provide a good overview of literature around nursing-PN’ s and NPs in general practice and the issues therein. So I guess it is watch and wait time to see what sort of model gets spewed out. As we all should know- cheap does not necessarily= better! Penny wise, pound foolish….

“The published literature also shows that collaborative, team-based approaches to care—including teams led by nurse practitioners—should be actively promoted to reduce overall spending on health care.”

Because at the end of the day that is a big part of my role,and one that can make the most difference. I just fill the gaps where GPs can’t,not interested, dont have time to, reach. And there are plenty of gaps if you look differently at the wider picture, and at a different angle. It’s  more often that the funding that should follow the need isn’t there at the same gap at the right time, so that’s where innovation and funding flexibilty must happen.

At the end of the day, there is plenty of work to go around, so why can’t we all just pack away our prejudices and patch protection blinkers and just get along.