How audible is nursing's voice at policy level in the Ministry of Health? As new Director-General Steve McKernan takes up the reins, it is timely to reflect on how well the Ministry of Health serves nurses and nursing.

It was a privilege to attend the powhiri welcoming new Director-General to the Ministry of Health, Steve McKernan, at the end of July. The ceremony itself was warm and embracing, showcasing the respect and fondness his former colleagues at Counties Manukau District Health Board hold for their departing chief executive. Karen Poutasi's successor is obviously a capable and treasured leader, known for being accessible to others.

What sort of government department will McKernan be running? The Ministry of Health is a complex organisation that aims to be knowledge-based, people-centered and systems-minded. It recognises eight key responsibilities that include having to "provide policy advice on improving health outcomes, reducing inequalities and increasing participation". (1) As nursing comprises over half the health workforce, it would be reasonable to assume it should be effectively represented at the Ministry's policy tables (not just committees), yet chief (and only) nursing adviser Mark Jones has to carry much of the responsibility on his own.

Looking back at history

The history of nursing representation at the Ministry and its preceding bodies is revealing. In 1984, the Department of Health had its own division of nursing, led by director Margaret Bazley. The division had 16 staff, including the director, three assistant directors, an executive officer, seven nurse advisers and four administrators. Staff worked closely with other staff in the department on a range of issues with implications for nursing. These included developing policy papers and revising legislation administered by the division; developing submissions on issues from other departments with implications for health and/or nursing; giving advice to hospital boards on all aspects of nursing administration; and providing advice on all matters affecting nursing education and planning nursing manpower. (2)

It is clear there have been radical changes since 1984 in the structures that give nursing a voice within the Ministry. With the appointment of a new Director-General, it is timely to ask what has contributed to the continued erosion of nursing representation at the health policy table since 1984? Where have these functions shifted to, and what have nurses gained or lost from this shift?

Invisibility of nursing

Since the health reforms of the late 1980s-90s, the visibility of nursing has steadily decreased. The common reasons cited for reform were the ever-increasing demand for health services (ie rising costs) as a result of an ageing population, new technologies and higher consumer expectations. (3) The State Sector Act 1988 and other measures for "reconsidering and redesigning the role of government" resulted in significant flow-on effects. (3) Sally Shaw was Director of Nursing from 1985-1987, then becoming acting assistant secretary within the workforce development division. In 1989 she left the Ministry with "no appropriate position being offered to her, apparently because her views had not always agreed with those of the Director-General and because of her commitment and advocacy for nursing." (4) This sounds like a sad obituary for nursing's effective voice in the Ministry's policy formation process.

Sheryl Smail was the chief nursing officer from 1988-1990. The devolution of responsibility of health policy decision-making continued. Small stated that "Now all boards [hospital] are in the process of putting general management principles into their board structure. They will do this with nurses or despite nurses. It is up to you to ensure that it is with nurses." (5) This statement resonates with today's primary health care sector, and with nurses being directed to involve themselves in primary health organisations and their governance structures, despite complex barriers.

The erosion of the nursing presence in the department continued. In 1992, principal professional adviser (nursing) Gillian Grew expressed concern that nursing had been a bit dispersed and, as a result, the impact of professional advice had suffered. (5) Grew continued as senior nursing adviser until 1997.

The passing of the Health and Disability Services Act in 1993 resulted in a split between purchasers and providers of health services. The Act meant that service provision was effectively separated from the policy end of the Ministry.

Over this extended period of health reform, the number of nursing issues emerging has been significant. Hospital restructuring alone has resulted in the loss of nursing leadership, with nursing management positions being disestablished (removing the nursing voice from senior management teams); senior nurses have been made redundant or transferred into general management positions; staffing reductions have been ongoing, with an associated weakening of the nursing skills mix. Increasing levels of job stress, dissatisfaction, and numbers leaving the profession all figure as major concerns. The increased casualisation of the nursing workforce has led to concern about the quality of patient care provided in hospitals. (6) This a worrying package of issues that lacks representation at the policy table, where seminal decisions are made and pathways determined. The primary health care sector has plenty of nursing issues, too, acknowledged by Health Minister Pete Hodgson, in July this year. (7)

Compromised representation

In 1998, Frances Hughes became one of ten generic ministry advisers. Her role was to "advise the Minister on strategic policy and to interpret and help implement government policy on health." (8) According to nurse researcher Jocelyn Keith, the office she assumed was "a pale shadow of its former self in terms of resourcing and staffing. She, like her fellow public servants, must be totally loyal to, and advocate for the position of whatever government is in power". (5) Being a solo nursing adviser advocating for nursing at the policy table--when other commitments allow you the time to be there--makes for compromised representation, especially when that person is heavily outflanked by other health professionals with their seemingly disproportionate representation. Medicine, of course, is represented well.

McKernan, who is only the second non-medical practitioner to hold the Director-General position, heads up a Ministry with firmly entrenched structures and processes. His equivalent, the first Chief Health Officer James Mason, appointed in 1900, was lauded in The Evening Post as "a practical and scholarly man, young enough to be energetic and not the type to be cowed by the 'cramping influences of official red-tape'." (9) It seems the same sentiments fit Steve McKernan over 100 years later. His vision and ability to effect changes will be more than welcome.

* References are listed on p10.

By professional nursing adviser Anne Brinkman

HOW AUDIBLES IS NURSING'S VOICE? REFERENCES FROM P22

1) www.moh.govt.nz/moh.nsf/wpg_index/About-moh. Retrieved 7/8/06.

2) The Division of Nursing, Department of Health. (1984) Kai Tiaki. The New Zealand Nursing Journal; 77: 7.

3) Bloom, A. L. (2000) Health Reform in Australia and New Zealand. Melbourne: Oxford University Press.

4) National Council report. (1990) New Zealand Nursing Journal Kai Tiaki; 83: 1, 28.

5) Keith, J. (2000) It takes two hands to make a sound. (2000) Kai Tiaki Nursing New Zealand; 6:10, 18 - 20.

6) Gower, S., Finlayson, M., and Turnbull, J. (2003) hospital restructuring: The impact on nursing, In Gauld, R. (2003) Continuity amid chaos: health care management and delivery in New Zealand. Dunedin: University of Otago Press.

7) Hodgson, P. (2006) http://www.nzno.org.nz/site/campaigns/parity.aspx. Retrieved 17/8/2006.

8) Manchester, A. (1998) In the forefront of change. Kai Tiaki Nursing New Zealand; 4: 2, 11.

9) Dow, D.A. (1995) Safeguarding the public health: a history of the New Zealand Department of Health. Wellington: Victoria University Press.