CYWHS CYWHS Workforce Workforce RoundtableRoundtable

Patrick CreganPatrick Cregan

29 Nov 200529 Nov 2005

Public Hospital ExpenditurePublic Hospital Expenditure

Nursing

Other PeoplePaymentsEverything Else

Nurse ratiosNurse ratios

Nurse / Physician Population Nurse / Physician Population RatiosRatios

Why now?Why now?

CYWHS RoundtableCYWHS Roundtable Productivity Productivity

CommissionCommission NSW IMETNSW IMET National Health National Health

Workforce Strategic Workforce Strategic FrameworkFramework

Workforce Challenges:Workforce Challenges:

• Global shortages of specialist doctors and of registered nurses

• Ageing of the health workforce• Increased in patient acuity• Ageing of the population• Increase in the complexity of care provided• Increased pressure on the workplace• Reduced access to patients for training• Increased numbers of overseas trained

HCPs (Health Care Professionals)

Political imperativesPolitical imperatives

Camden CampbelltownCamden Campbelltown Dr Patel / BundabergDr Patel / Bundaberg King EdwardKing Edward CostCost

National Health National Health Workforce Strategic Workforce Strategic

Framework:Framework:

1.1. Australia should focus on achieving, at a minimum, Australia should focus on achieving, at a minimum, national self sufficiency in health workforce supply, national self sufficiency in health workforce supply, whilst acknowledging it is part of a global market.whilst acknowledging it is part of a global market.

5. To make optimal use of workforce skills and ensure 5. To make optimal use of workforce skills and ensure best health outcomes, it is recognised that a best health outcomes, it is recognised that a complementary realignment of existing workforce complementary realignment of existing workforce roles or the creation of new roles may be necessary. roles or the creation of new roles may be necessary. Any workplace redesign will address health needs, Any workplace redesign will address health needs, the provision of sustainable quality care and the the provision of sustainable quality care and the required competencies to meet service needs.required competencies to meet service needs.

Productivity Commission Position Paper:

Australia’s Health Workforce

• Workplace innovation to better use skills available• Responsive education and training arrangements• National accreditation standards and processes to remove

inconsistencies• Workplace change to enhance delegation to “less highly

qualified, but more cost effective, health professionals”

• Workforce adaptation for special needs groups or areas such as rural and remote.

Three S’s of Best CareThree S’s of Best Care

Best SystemsProtocols

Team WorkHuman Factors

Appropriate CultureClinical Governance

Best SkillsTechnical

CommunicationEthics

Competence assessedSimulation

Best ScienceEvidence Based Care

Meta-analysesRandomized Controlled Trials

Guidelines

Best Care

Science – William OslerScience – William Osler Observe, apply Observe, apply

knowledge, knowledge, hypothesize, test, hypothesize, test, diagnose, treat, diagnose, treat, observe, adjust observe, adjust hypothesis or hypothesis or treatment etctreatment etc

Problem based Problem based learning is reflected learning is reflected in and used to in and used to teach this approachteach this approach

Skills – WS HalstedSkills – WS Halsted

Formalized the Formalized the apprenticeship apprenticeship system into the system into the American American Residency Training Residency Training Model Model

Systematic, Time Systematic, Time based graduated based graduated increase in increase in responsibilityresponsibility

Systems – Florence Systems – Florence NightingaleNightingale

Systems 2Systems 2 Florence Nightingale. Florence Nightingale. Introductory notes on lying-Introductory notes on lying-

in institutions.in institutions. London: Longmans, Green, and Co, London: Longmans, Green, and Co, 1871.[St. Thomas's Medical Collection S2 6.10.]1871.[St. Thomas's Medical Collection S2 6.10.]

Florence Nightingale.Florence Nightingale. Notes on Hospitals Notes on Hospitals. John W. . John W. London: Parker and Son, 1859. [St. Thomas's London: Parker and Son, 1859. [St. Thomas's Medical Collection S2 b.9.]Medical Collection S2 b.9.]

Florence Nightingale.Florence Nightingale. Notes on Nursing: what it is Notes on Nursing: what it is and what it is notand what it is not. London: Harrison, 1860.[St. . London: Harrison, 1860.[St. Thomas's Medical Collection S2 b.7.]Thomas's Medical Collection S2 b.7.]

Florence Nightingale.Florence Nightingale. A Contribution to the A Contribution to the Sanitary History of the British Army. London: Sanitary History of the British Army. London: Harrison and Sons, 1859. [St. Thomas's Medical Harrison and Sons, 1859. [St. Thomas's Medical Collection S2 c.11.]Collection S2 c.11.]

Training is a large part of the Training is a large part of the ProblemProblem

Osler / Science based – Osler / Science based – Undergraduate, FRACP part 1, PBLUndergraduate, FRACP part 1, PBL

Halsted / Skills – Postgraduate, Halsted / Skills – Postgraduate, Procedural practiceProcedural practice

Nightingale / Systems - NursingNightingale / Systems - Nursing

Problem SolvingProblem Solving

““when all you have is a when all you have is a hammer every problem looks hammer every problem looks

like a nail”like a nail”

TrainingTraining

Three distinct bases to the training of Three distinct bases to the training of the health workforce – the three S’sthe health workforce – the three S’s

ScienceScienceSkills Skills SystemsSystems

Three silos resultThree silos result

Currently addressing the Currently addressing the problem:problem:

Interdisciplinary educationInterdisciplinary education Emphasis on team workEmphasis on team work Role extension, particularly in rural areasRole extension, particularly in rural areas Skill mix changes, increased number of ENs Skill mix changes, increased number of ENs

and AINsand AINs Increased emphasis on quality and safety, Increased emphasis on quality and safety,

including performance appraisal / including performance appraisal / competence assessmentcompetence assessment

Evidence based practiceEvidence based practice

Is this enough?Is this enough?

Why can’t we train nurses to Why can’t we train nurses to prescribe antibiotics or supervise prescribe antibiotics or supervise anaesthetics?anaesthetics?

Why can’t EN’s scrub in the OR?Why can’t EN’s scrub in the OR? Why can’t EN’s give Narcotics?Why can’t EN’s give Narcotics? Why can’t Physiotherapists manage Why can’t Physiotherapists manage

simple fractures?simple fractures?

Is this enough ?Is this enough ?

Why does Medicine need to be a Why does Medicine need to be a postgraduate course? postgraduate course?

Why do we substitute length of training Why do we substitute length of training for demonstration of competence?for demonstration of competence?

Why do we not have career planning?Why do we not have career planning? Why is specialist training run by guild Why is specialist training run by guild

like organizations with less transparency like organizations with less transparency of process than golf clubs? of process than golf clubs?

Why? Could?Why? Could?

Why does it take a minimum of 13 years of Why does it take a minimum of 13 years of training after leaving school to become a training after leaving school to become a specialist? (When we get given the specialist? (When we get given the brightest, second most ethically driven brightest, second most ethically driven group with on the job assessment, group with on the job assessment, repeated examinations and a good long repeated examinations and a good long term reward system?)term reward system?)

Could another system or set of trainers do Could another system or set of trainers do it better?it better?

Are there other approaches?Are there other approaches?

Public Hospital ExpenditurePublic Hospital Expenditure

Nursing

Other PeoplePaymentsEverything Else

Why is there any human Why is there any human in the Operating Room in the Operating Room other than the Patient?other than the Patient?

Other approaches 1Other approaches 1 Penelope – a voice Penelope – a voice

activated, speech activated, speech recognizing robotic recognizing robotic tool changer tool changer

Penelope ( Surgical Penelope ( Surgical Instrument Server) – Instrument Server) – Dr Michael TreatDr Michael Treat

?Replacing scrub ?Replacing scrub nurses?nurses?

June 16 2005, Mercy June 16 2005, Mercy Medical Centre NY 1Medical Centre NY 1stst use in humans (Dr use in humans (Dr Spencer E Armory)Spencer E Armory)

http://global.med.cornell.edu/news/nyp/nyp_2005/06_16_05.shtml

Other Approaches 2Other Approaches 2

Other Approaches 3Other Approaches 3

Target Controlled Target Controlled Infusion in Infusion in AnaesthesiaAnaesthesia

Propofol, Propofol, RemifentanilRemifentanil

EthiconEthicon

1999;319;557-560 BMJ

Andrew J Fox and David J Rowbotham

Other Approaches 4Other Approaches 4

Virtual Critical Care Virtual Critical Care Unit – ViCCUUnit – ViCCU

CSIRO / Nepean CSIRO / Nepean HospitalHospital

Ultrabroadband Ultrabroadband Internet for Remote Internet for Remote TelepresenceTelepresence

Leverage off existing Leverage off existing workforceworkforce

Remote supervision of Remote supervision of a Cardiac Arresta Cardiac Arrest

Can we replace the Can we replace the Surgeon?Surgeon?

Can we replace the Can we replace the surgeon?surgeon?

(Gordon E) Moore’s (Gordon E) Moore’s founder of Intelfounder of Intel Law Law “computing power doubles every 18 “computing power doubles every 18 months and halves in price” months and halves in price”

Problem of complex pattern Problem of complex pattern recognition and strategy formation recognition and strategy formation and necessary computing power / and necessary computing power / floating point calculationsfloating point calculations

Should be right to 2030 ?????Should be right to 2030 ?????

Can we replace the surgeon – Can we replace the surgeon – yes!yes!

Growth in IT doubling every Growth in IT doubling every year = a factor of a billion year = a factor of a billion in 30 yearsin 30 years

2030 the non-biological 2030 the non-biological portion of our intelligence portion of our intelligence will dominatewill dominate

1988 John Gage “the 1988 John Gage “the network is the computer” network is the computer”

The net =1 kilohertz clock The net =1 kilohertz clock speed, 200 terabytes of speed, 200 terabytes of RAM, 10 terrabits per RAM, 10 terrabits per second transfer, 20 second transfer, 20 exabytes of data.exabytes of data.

ie the net is now about the ie the net is now about the size and complexity of a size and complexity of a human brainhuman brain

http://www.kurzweilai.net/brain/frame.html?startThought=Age%20of

%20Spiritual%20Machines

Public Hospital ExpenditurePublic Hospital Expenditure- 2030- 2030

ComputingPeople PaymentsEverything Else