1. 1 Australian College of Health Service Executives Responding to health labour issues: Locum doctors in NSW vs Nurse Patient Ratios in Victoria John Buchanan Director, Workplace Research Centre, The University of Sydney Claire Skinner former Project Officer, Locums Working Group, Greater Metropolitan Clinicians Taskforce Overheads used at Australian College of Health Service Executives Annual Meeting, May 2007

2. 2 Questions: What are the key workforce realities?: What can be done about them? Method: Comparative analysis NSW Emergency Department doctor shortage and rise of locum workforces Victoria Public Hospital Nurse Shortage and Agency workforces Analysis: Problem Definition Proposed policy responses Changes actually implemented Sources: Locum Doctors – MJA September 2006 Nurse Ratios – Labour and Industry, December 2005

3. 3 Doctor shortage and Locum Problem 900 junior and middle level vacancies (NSW 2004-05) – notably in ED – largely filled by OTD and locums Additional cost of locums - to locums: $30M - to agencies: $5.2M

4. 4 Causes Rising demands on Health system Push factors - Pressure on health system - Metropolitan hospitals lack of critical mass - Under staffing – Hours of work – Locum dependent nexus Pull factors - Pay and flexible hours dynamics of growing dependence on locum labour

5. 5 Consequences Higher Costs Quality and Safety compromised Legal and administrative ambiguities Medical workforce sustainability

6. 6 a) Traditional Pathway:  RMOs + college training program Registrars (PGY 2-8) Jnr changing work/ life preferences  Ex Registrars Drs +falling voc.ed.quality Locums Unstreamed b) Doctors not interested in  Drifters Drs traditional specialisation  Career Locums  CMOs/ MMOs The critical issue: occupational fragmentation

7. 7 Recommended Solution 1.Prevocations and Vocational Trainees 2.CMOs and unscreened doctors 3.Locums – centralise info 4.Revitalising goodwill amongst public hospital clinicians

8. 8 Action to date (2005 & 2006) NSW Health Working party Elements of change Incremental improvements to date (more details being supplied by NSW Health)

9. 9 Nurse Shortages and Agency Dependency Impact of new management strategies on nursing -“commercial” / “managerial” model of care -Changing :Nature of nursing work :Experience of nursing work -Undermined intrinsic rewards :care for patients :care for each other Legacy of stress Shortage of decent jobs nurses prepared to work in

10. 10 ANF(Vic) Response Develop industrial discipline - 1986 stoppages - early 1990’s – new retrenchments - late 1990’s EB campaign – wages - turn of new century – expanded the agenda for campaigning “Nursing the System Back to Health”

11. 11 Nursing the System Back to Health Objective: - A sustainable public health system Preparation: research and organisation - Outlaw agencies  “Nurse Bank” - Formulate Nurse-patient ratios

12. 12 Getting the ratios adopted and agencies banned Claim researched Claim endorsed by members Negotiations : stalled Industrial action : closed one bed in four : at militant sites, mattresses hidden Independent, promote arbitration - Union rates adopted (no management alternative: “state of denial”)

13. 13 Impact of the Ratios Context: changes continued Incidence: uneven Implementation: NUMs prime enforcers : Beds closed 48% of time Impact : improved patient care and working conditions problems remain: - “condition stable but critical”

14. 14 Lessons Evidence Claims Negotiation Action Third party intervention Necessary but not sufficient for change Vital for changing managerial priorities