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What we want for health

Pre-budget2

The Government’s 2016 Budget will be announced in a couple of weeks so we thought we’d set out now what NZNO wants for health. Here’s hoping that is what the Government delivers.

What we want is a health system where everybody can access the health care they need, where and when they need it.

It’s not an outrageous ask, and we’ve never met anyone who disagrees. So, let’s unpick it and see what lies beneath the words.

  • We want a health system that is funded to provide equitable and universal health care.
  • We need the right people to make it happen; nurses, doctors, kaimahi hauora, kaiāwhina, administrators, cooks, cleaners and clinical leaders.
  • Those people must be trained and paid appropriately and be provided with safe work environments.

Last years’ Budget does not provide enough funding to meet the health needs of New Zealanders. Nor did the Budget the year before, or the year before that… In fact economist Bill Rosenberg estimated last year that the funding allocated for health was at least $260 million short. This year will be worse. Rosenberg says that in the eight months to February 2016, District Health Boards were already $27.9 million in deficit.

Funding for the primary health services we so desperately need are being squeezed and cut and services are closing. It just doesn’t make sense – primary care is the way to make our vision for a healthy New Zealand happen. Attacking small services as they begin to make headway into our communities is completely counter-intuitive.

Pre-budget

The Minister of Health is famous for saying “We must live within our means” – implying that health funding is a finite pool. It’s not. This Government could prioritise health if it wanted to.

The Government could say, for example, it’s worth spending more on health for the next 10 years until the massive benefits of focusing on primary care start showing in the system. It could say, more spending now means spending less in future.

If there was a plan, we would know how many nurses to train and we’d be able to support and mentor them after graduation appropriately.

It would be recognised that short term “savings” often don’t yield long term rewards, for people or for budgets.

Nurses, midwives, caregivers and other health care workers tell us they are stretched to the limit. Some are having to sacrifice tea and lunch breaks and working unpaid overtime just to keep up with the care they need to give to ensure needs of patients are met. Support for training and development is decreasing. Stress levels are rising and morale is low.

Pre-budget3

A healthy health system would train and employ the right number and skill mix of staff so that people aren’t burning out and/or making mistakes and/or rationing care.

So, that’s what we want in the Budget. New Zealanders deserve it and, as the largest health workforce, we expect to be heard. We are putting it out there that we will fight for it, for all New Zealanders.

A healthy health system should be a top priority for any Government. We want a health system where everybody can access the health care they need, where and when they need it.


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Mask up or ship out?!

maskThe issue of vaccinations and the flu vaccination in particular has been on our agenda over the past few months, as it has been for the sector.  In 2015, despite improved uptake of the flu vaccination amongst DHB employees, one DHB (Waikato) has still taken a punitive approach to non vaccinated staff, insisting they wear masks when in direct patient contact or risk suspension and disciplinary procedures.

We felt at this time it might be appropriate to discuss the role of NZNO in this matter. Amongst our membership we have the full spectrum from those passionately in favor of vaccinations, to those equally against.  So should the union even have a view and if so on what basis?

So starting with the right not to be vaccinated – we all have that right.  Being injected against our will is assault, pure and simple.  In addition, when in receipt of healthcare, everyone is covered by the HDC Code of (patient) Rights.  This provides for the right to informed consent and the right to say “no”.  It also provides for the right to be treated with respect.  Given one role of NZNO is the legal protection of member’s rights, enforcing the right not to be vaccinated goes without question.

The issue of vaccination largely comes down to an individual view (I do or do not wish to be vaccinated because I…) or a collective one.  On the latter, there is both a public health good derived from vaccinations and an employment one. The former relates to the reduced spread of disease and therefore harm, especially amongst those in our communities who are most vulnerable, and the latter, lack of staff to treat the sick due to staff themselves being sick. And yes for the DHBs fewer sick days and so less cost, is attractive.

Evidence confirms that whilst not a perfect remedy, vaccination is the best mechanism we have to prevent the spread of disease and the human toll that disease represents. Herd immunity, where vaccination rates are high enough to stem the spread of disease and therefore protect a community, is the goal.

The flu vaccine is not 100% effective. Each year the vaccine must be reconstituted to capture the new strains of flu that emerge.  The flu virus is a nasty little beast that genetically morphs from year to year, hence its success as an organism!  As impressive as this may be, lets not forget, it also kills. Regardless of your view on vaccination, this virus is not the common cold we can all expect to suffer most years.  It is a serious and life threatening virus that has caused millions to die.

When the unions and DHBs (in the forum known as NBAG) collectively came together to investigate the issue what became clear was that a positive, educative and supportive approach to the issue of vaccinations was far more successful than punitive, threatening or negative.  If the overall motivation is community good through protection from disease, having people “on board” is going to more effective than the resistance a negative approach inevitably engenders.  This is not so much about vaccinations per se, but about how we approach the issue.

Acknowledging that employees can’t be required to be vaccinated, what about the DHBs ability to decide what to do with the non vaccinated staff?  In fairness NBAG didn’t even go there (at that time).  We agreed a positive and constructive approach was better and looked (amongst other things) to whether the unions had a role in leadership on this issue, thereby in effect avoiding a negative reaction that some DHBs might have in the face of non vaccination. The answer was yes: better to keep members out of trouble whilst recognising everyone has rights.

NBAG put out guidelines to the DHBs supporting a positive and educative approach, rather than punitive. And the unions agreed to support engagement with members on this issue.

So far so good. Unions avoided the punitive and inevitably adversarial approach DHBs might take against members: DHBs got our support on the vaccination process.

Interestingly, for all the concerns expressed by the DHBs, the uptake of vaccination by management was no different from the rest of the staff, confirming that we are dealing with a wider and more intrinsic issue than superficial review might suggest.

So why did Waikato DHB ignore NBAG advice and fail to engage with us on the issue?

Well Waikato DHB has an already evidenced poor culture when it comes to employee engagement, so probably no surprises there. It is sad, but this DHB continues to have a poor attitude towards their own employees on a number of fronts, including bullying.  And again, regardless of their personal views about vaccination, members have been almost universally concerned at how Waikato DHB is handling this matter.

We have made an application to the Employment Relations Authority to test the DHB’s policy on the basis of a failure to adequately consult prior to implementation. Not only is the issue of ignoring considered national advice on the matter concerning, a whole lot of other issues have arisen that, had proper consultation occurred, would probably have been worked through.  And these issues do need to be resolved, including:

  • What is “direct patient contact”?
  • How effective is mask wearing, including how often we need to change masks to be effective?
  • What of the effect on patient – staff communication through a mask?
  • Distribution of personal health information (vaccination status is health information).
  • What of patient and visitor vaccination status? Visitors can equally spread the virus (remembering the flu is communicable up to 14 days prior to symptoms emerging) so what is the point of just concentrating on staff?
  • If the patient is vaccinated, should the staff member have to wear a mask?
  • If such a public health issue, consistent application of measures are surely required? If that means short staffed areas being left without staff and services interrupted as a result, what is the balance between non vaccinated staff on duty and no service?

We could go on….  Waikato DHB’s approach is also causing resistance amongst staff, and could be self defeating. It is also exacerbating a prevalent negative culture in this DHB which is corrosive, damaging to staff and in need of change all issues of concern to us and our members.

So in summary:  Why are we involved?

  • Because members have rights and we are tasked legally with preserving those rights.
  • Because we also have a role to play in avoiding conflict and progressing matters on an evidence based and reasonable basis.
  • Because Union leadership is evidenced as being instrumental in assisting with positive change on issues such as this (and our own experience supports this).
  • Because at the end of the day our members want what is in the interests of not just themselves but their patients and communities. However as with most things in health, this is a more complex issue than a superficial glance might suggest, and we need to do the best we can to get it right.


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The greatest threat to human health

personal protective equipmentNew campaigns adviser, Jenn Lawless and I were talking about NZNO’s recent submission on climate change and some of the many ways climate change will affect health in New Zealand/Aotearoa and the world. Jenn then went and wrote this scenario – she calls it a best case scenario; some of us are more hopeful. I hope you’ll love it as much as I do.

You have woken up in the future. The year is 2115, and you are getting ready to go to your nursing job at Auckland Central Island hospital.

5:00am Rise out of your sleeping pod you share with 25 other Critical Core Workers (CCW) so that you can catch the circular ferry as it stops in at the Southern Auckland Islands that used to be known as Mangere before the great Greenland Ice sheet collapse. You’re lucky you’re a CCW so you can stay in on the Southern Auckland Island so close to Central Island; if you were an unskilled worker or climate refugee you’d be stuck on the far Western Islands where there’s no daily ferry if there’s energy shortages.

7:00am Arrive at work and receive your morning food portion. Because of all the salt water getting into the soil and the summer cyclones there is never enough food for everyone. CCW’s get a basic nutrition package as part of their job. A regular part of your day is treating a variety of difficult health problems because of malnutrition, especially in children.

7:15am You are sent down to Refugee Arrivals for your first shift and jump on the medical barge. There isn’t space to dock all of the rickety ships from climate refugees or unload the undocumented families without land-passes or citizenship, so it’s a case of providing emergency relief on the water. Dehydration from months of dangerous travel at sea is the most common problem, but you can’t get onto the refugee ships- despite your full-body suit, the risk of unknown epidemic diseases to an already fragile population is too great.

12:30pm You recycle your haz-suit and get a few minutes of delicious cool in the air-conditioned Central Island staff lounge. At the same time you take your regular scan for skin cancer and cataracts– a real problem now with depleted ozone.

1:pm You get a call for overload help from General Population Medical. Lots of Land-Pass holders there have been waiting all morning and they are angry that refugees are getting any medical treatment at all when there is such a shortage of medicine and basic supplies. Because of the Oceanic Fresh-Water Wars, getting any medicine we can’t produce in New Zealand can take months by boat, to get around the no-sail and heavily pirated areas. You spend the afternoon doing what you can to treat the malaria, dengue fever, heat-stress and other tropical diseases with basic symptom management until the next medical supply ship gets through. Education about mosquito nets and natural repellent is just as important as treatment, but there is not much you can do about the malnutrition transfers from Northland. Expensive treatments like dialysis are out of the question; but patients might be lucky enough to win the 3D printed kidney lottery granted twice a year.

6:pm Passing back through the armed exit to Medical and Nutrition, you feel so lucky to be a CCW, but also sad about what more you could do for your patients if you had the resources that the Global-Pass holders have hoarded. It’s true they seem to keep everything running for the Land-Pass holders like yourself but you’re sure it didn’t used to be this unequal in the past…back in the Democracy. They were so lucky. But nobody saw this coming then. Did they?

The World Health Organisation has described climate change as ‘the greatest threat to human health this century’ and that 250,000 more people will die every year between 2030 and 2050. This imagined future is based on risks outlined in the recent New Zealand Nurses Organisation submission to ‘Setting New Zealand’s post-2020 climate change target’ run by the Ministry for the Environment.

 


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Unmasking the evidence

Coughs_and_Sneezes_Spread_Diseases_Art.IWMPST14133Many DHBs have been talking about forcing staff who don’t get the flu vaccination to wear masks.

It’s one of those things that on first glance might seem like a good idea, but peel back a few layers and you’re left with the bitter taste of a purely punitive measure.

NZNO acknowledges the right of every person to vaccinate or not. We encourage it, of course; to the extent that we pay for our own staff to get the flu vaccination if they choose to. Healthy workplaces are a priority. We believe education and access are key to improving uptake but we do not think mandatory vaccination is the way forward.

DHBs want safe environments for their staff and patients too and we applaud that. What we’re saying is the DHBs are grabbing onto a “solution” that’s not evidence-based and seems to be designed to shame individuals rather than keep staff and patients safe from the flu.

We do not support the use of face masks to protect patients from unimmunised nurses.

For one thing, masks don’t work. Evidence shows masks are ineffective in protecting healthcare workers from patients with flu; so why do DHBs think the opposite would be different?

For another – a nurse with the flu would only be able to pass it on to a patient or colleague if he or she was at work. Nurses should not be working, or be made to feel that they should have to be at work, when they are sick. DHBs need to make sure enough staff are available to cover the inevitable rise in sick leave during “flu season”.

And it’s not just nurses. There must be clear information for patients, staff, contractors and visitors that sick people should stay away.

DHBs should also be promoting good hand washing and the use of tissues for coughs and sneezes.

Our motto is “Freed to care, proud to nurse” and we want that for every single NZNO member. Please don’t hesitate to give us a call if you are being treated unfairly 0800 28 38 48.

Here is NZNO principal researcher, Dr Léonie Walker’s analysis of the evidence for and against masks to protect against flu.

Health care workers have long relied heavily on surgical masks to provide protection against influenza and other infections. Yet there are no convincing scientific data that support the effectiveness of masks for respiratory protection. The masks we use are not designed for such purposes, and when tested, they have proved to vary widely in filtration capability, allowing penetration of aerosol particles ranging from 4 to 90%1.

The efficacy of any respiratory device depends on user compliance. Workers’ tolerance for wearing most types of respiratory protective devices is poor and often declines over the course of a work shift; in one study, no more than 30% of workers tolerated these devices consistently throughout an 8-hour workday, citing difficulties with speaking and communication, discomfort, and other physical problems2.

The Institute of Medicine committee has recommended that current Centers for Disease Control and Prevention guidelines for respiratory protection be maintained3. Until more data are available, the Institute of Medicine committee recommended the use of personally fitted, N95 respirator when confronting patients with influenza-like illnesses, particularly in enclosed spaces4.

1Oberg T, Brosseau LM. Surgical mask filter and fit performance. Am J Infect Control (2008);36:276-282

2Radonovich LJ Jr, Cheng J, Shenal BV,Hodgson M, Bender BS. (2009) Respirator tolerance in health care workers. JAMA ;301:36-38

3www.cdc.gov/h1n1flu/guidelines_infection_control.htm.

4Kenneth I. Shine, M.D., Bonnie Rogers, Dr.P.H., R.N., and Lewis R. Goldfrank, M.D (2009) Novel H1N1 Influenza and Respiratory Protection for Health Care Workers N Engl J Med 361:1823-1825”

 


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Who’s in charge here?

2007-08-02-UncleSam-thumbNZNO senior policy analyst Marilyn Head asks why we would want to let the United States dictate New Zealand’s laws.

I’ve been following the progress of the Trans Pacific Partnership (TPP) negotiations right from the beginning. It’s a scary process, being negotiated in secret. The leaked documents I have seen show that if signed, New Zealand would lose out in all sorts of ways – from a loss of sovereignty to adversely affected public health outcomes.

What I didn’t fully appreciate until now was that, if we go ahead with the agreement, the United States’ (US) heavy handed approach to enforcement could extend as far as directing New Zealand’s laws. Judging by information released on a new website which  identifies the legislative changes the US might expect of  TPP partners, it appears I was overly optimistic.

The US has a ‘certification’ process which involves consultation with and monitoring of trading partners to ensure that their regulatory environment in consistent with treaty/partnership obligations. While that sounds fair – we all want to be sure that we are operating from a level playing field – in practice it is more ominous, amounting  to direct interference in the democratic processes of sovereign nations.

The certification process would come after the TPP agreement is signed! It is another opportunity for the US to tell us what laws and regulations we must change before they implement the agreement. It is like having another bite at the cherry. It enables the US to exert huge pressure on countries which may not want to risk the ‘good deal’ they’ve signed up to with 11 other countries if the US pulls out.

The website exposé shows the areas they will be looking for ‘compliance’ with US regulations and the sort of pressure they’ve exerted on countries such as Peru where, as part of the certification process for the Peru-US free trade agreement, the Office of the United States Trade Representative actually drafted Peru’s legislation and demanded that it be accepted without change, with quite disastrous consequences for Peruvians.

The ‘barriers’ the US wants removed according to the website,  will require changes to our domestic copyright and patent laws and Pharmac’s operating processes –  changes that NZNO and many in the health sector have repeatedly pointed out present a risk of  increasing the cost of medicines and limiting  government’s ability to regulate for public good. The New Zealand Climate and Health Council OraTaiao says (pdf) that losing our sovereign right to create and strengthen the laws that form the building blocks for fair and healthy lives – access to medicines, clean water, food and air – will make it extremely difficult for New Zealand to maintain and improve our quality of life.

I agree. New Zealand laws must be made by New Zealanders.

Ahakoa, he iti he pounamu.

 

 


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Referrals from ED to primary care

B7_emergencyIn a bid to reduce patient numbers Southern DHB announced this week that it would implement a new system in its Emergency department, where patients not deemed in need of urgent medical attention would be asked to see their GP instead.

Those unable to afford to see their GP would be issued with a voucher. Southern PHO would be the partnering community provider of GP services.

Southern PHO head, Ian Macara wasn’t keen to publicise the vouchers though:

”We don’t want to set up a free service – that all you’ve got to do is trot down to your local ED and get a voucher and away you go.” 

The new Southern DHB system proposes that a triage nurse (if comfortable to do so) would have a conversation with a patient and ‘encourage’ them to see a GP instead. If cost was a barrier a voucher could be issued.

Southern DHB says they are not turning patients away, merely “offering the patient the choice of an alternative treatment provider.”

NZNO was asked our view of the new system. Our answer is – it must comply with Ministry of Health guidelines on the interface with primary care.

Making sure every single New Zealander has access to Emergency Departments is a fundamental part of our public health system.

The decision to treat someone in ED or redirect them is a clinical decision with clinical and professional accountabilities for the health practitioner.  We all know what happens when something goes wrong!

According to the plan, the burden of this work will fall on registered nurses.  Our members were not part of the design of this local system and we fear they may be pressured to reach targets, either of acuity or numbers of patients seen in ED.

Not only that, but the system is counter to the Ministry of Health NZ guidelines on the interface with primary care, which includes the important proviso that ‘encouragement’ to leave ED and make an appointment with a GP instead should not occur at the triage stage of the process. Triage does not accurately determine the appropriateness of a patient’s condition for presentation at either the ED or primary health care.

The Ministry of Health guidelines also state that the NZ public will not be declined care in emergency departments.

If the system does not change at Southern DHB, patients will not receive the assessment/diagnosis that must happen before a decision is made, triage nurses will be at risk and their workload will increase greatly.  This is not good for patient safety.

Nurses should have been part of the planning for this process and now need to have education on the redirection process, including the understanding of professional accountabilities.

NZNO will be working with Southern and other DHBs to ensure patients and staff receive high quality care, where and when they need it. The College of Emergency Nurses NZ -NZNO is drafting a position paper to detail responsibilities. We’ll link to that when it is finalised.

Below are the relevant sections of Ministry of Health’s 2011 guidelines on the Interface with primary health care.

2. Referring patients from ED to primary health care for ongoing care

2.4  The extent of ED care prior to referral to primary health care will vary, but the guiding principles should be that sufficient assessment/care is undertaken so that ED staff are satisfied that the patient is clinically:

  • safe (a need for alternative or more urgent care does not appear to be needed);
  • comfortable (distressing symptoms are addressed); and
  • appropriate (sufficient diagnostic work-up has been done so that there is reasonable certainty that primary health care is best suited to continue the patient’s management).

4. Identifying and referring patients for whom primary health care is better suited to meet their needs

4.4  However, referral to primary health care may occur if further clinical assessment determines that primary health care is better suited to meet the patient’s needs. This clinical assessment must be over and above the usual triage process and should ensure that the criteria in paragraph 2.4 are met. In addition, referral to primary health care in this context must:

  • be facilitatory and not against the patient’s wishes (ED care should not be denied);
  • be based on a high level of comfort from the assessing clinician that referral is best for the patient (the assessing clinician must not feel any institutional pressure to ‘refer’ patients to primary health care and must be protected from any undue risk associated with the referral of patients); and
  • occur in the context of a responsive primary health care service (the patient must be able to be seen in primary health care in an appropriate timeframe for their condition).