Healthcare whodunit has twists
Immigration debate drags on as nursing shortage bites
The Government wants to move on from the immigration debate, but it’s dragging on because the health system has a critical nursing shortage just as it’s approaching another peak in pandemic pressure.
On the first day of mega-agency Health NZ’S official existence, chief executive Margie Apa said it wanted the Government to add nurses to the fast-track tier of the new immigration green list.
That should be enough for any Government to sit up and take notice, but if it’s not, then the Association of General Surgeons, the NZ Nurses Organisation, Plunket, Family Planning, and the Home and Community Health Association are also calling on the Government to rethink the policy.
Whodunit?
At the heart of the problem is a fascinating policy “whodunit?” The Government defended the policy of putting nurses (and others such as midwives and lab technicians) on a two-year work to residency pathway, by saying it was the health sector that asked for it as they were worried about staff leaving their professions.
Like a gripping crime procedural, suspicion over the identity of the mystery requester fell on, and then was eliminated from, a list of likely candidates. Was it the (now defunct) district health boards (DHBS)?
Responding to a question from National Party MP Erica Stanford, Immigration Minister Michael Wood said the advice came from the Ministry of Health.
Health Minister Andrew Little, in turn, said the ministry didn’t get it from the DHBS.
Last week, the green list Cabinet paper was finally published. It said the Government consulted two stakeholders from the health sector.
One was the Home and Community Health Association, which you’ll note is on the above list and confirmed to Businessdesk that it had made it clear its preference was for nursing to be fast-tracked.
How much more attractive is being a resident from day one instead of waiting two
years to apply?
The big reveal
By this stage of a good whodunit, armchair detectives should have just enough clues to solve the mystery and keen observers will have noticed one name missing from my opening roll call of health-sector lobbyists — the Aged Care Association.
Yes, ACA was the other stakeholder consulted on the green list. But like all good stories, this one still has a few plot twists to go — so don’t blame ACA as Heather du Plessis-allan did in her interview with its chief executive, Simon Wallace.
Wallace said the industry has a big problem with DHBS poaching its nurses, so it asked for its migrant nurses to be required to work in aged care for at least two years. Note it did not express concern about nurses leaving the profession altogether.
Root cause
Policy people talk about the importance of defining the problem correctly so policy impacts are targeted as close to the root cause of the issue as possible.
The root cause here is the pay gap between DHB nurses (sorry “Health NZ nurses”) and those working in aged care.
How that gap came about (particularly when the Government also funds aged care) is an investigation for another day, but the point is that trying to fix the consequences through immigration settings will always be a second-best approach.
Another key idea in policy shops is “intervention logic”, which is an exercise in mapping out the potential impacts of various policy options.
I would love to see the analysis that shows the impact of a work-toresidence pathway on workforce retention in aged care, because while it might help get nurses into rest homes, it will do nothing to slow the revolving door that sees them exit.
Not the done thing
At Wood’s most recent select committee appearance, Act MP James Mcdowall raised the possibility of putting conditions on residency visas.
This approach has been used before for applicants who have committed to living outside the Auckland region. This way you could fast-track everyone, but make sure they worked in their specified roles for a minimum time period.
Wood sounded like he was caught off guard by this suggestion and offered that he didn’t like having a policy regime based on special interest groups lobbying for exceptions and carve-outs — fair enough, but hard to reconcile with the whole concept of a green list.
Following up with officials, Businessdesk was told the option had indeed been considered, but the reasons they offered for dismissing it were just as puzzling: If the new residents left their occupation they would be liable for deportation.
It is “undermining” and not “beneficial” to restrict the work rights that normally come with residency.
It is more appropriate to use settings on temporary work visas to require migrants to show a commitment to working in their profession.
The first reason is obviously silly as it would apply equally to a nurse on a temporary work visa.
As for the other two — I can almost hear the echo of some ancient Westminster mandarin uttering, “It simply isn’t done”, as that seems to be about the sum total of their argument.
Also if we want nurses to have shown a commitment to working in their profession then why not do as Australia does and make three years of work experience in the role a condition of access to the fast track?
Damn statistics
Another policy shop buzzword is “evidence”.
The Cabinet paper said nurses and midwives should be included in the work to residence requirement “because we see a higher exit rate of internationally qualified midwives and nurses relative to their domestically trained counterparts”, which for nurses in 2020 was 6 per cent vs 4 per cent. That’s based on Nursing Council data on numbers renewing their annual practising certificate.
The thing with evidence is that it is all in the interpretation.
I remember a senior official once saying the same evidence can be interpreted by different governments in different ways, which I heard as “we can come up with a justification for whatever policy the minister chooses”. My interpretation of the exit rates is that some of it will be migrant nurses on temporary work visas leaving the country, not the profession.
As Stanford tried to explain to Wood at the select committee, it doesn’t actually tell us anything specific about retention rates for nurses on residence visas.
Second, let’s just accept that there is an exit rate for nurses with residency of say 12 per cent over 2 years.
How many more would have been recruited on a residency fast track compared with a work-to-residence pathway? If it’s more than 12 per cent then you are still ahead. The Government appears not to have considered this other side of the equation.
So, the question is: “How much more attractive is being a resident from day one instead of waiting two years to apply?”
I put that to David Cooper, chief executive of immigration advisory firm Malcolm Pacific, who said the two-year wait is a big turn-off for three key reasons: You can’t buy a house. If your children enrol in tertiary education, they have to pay international student fees. If you or a family member develops a serious health issue your application could get rejected.
‘Exploitist’?
The Cabinet paper said the rationale for the green list having a work-toresidence tier was the “risk some migrants will leave the occupation after gaining residence owing to conditions . . . ” [emphasis added].
The key word there is “conditions”: Wood said recently migration has been running on a kind of “exploitist charter”. Are they saying migrant exploitation is actually okay as long as it is limited to two years and the country desperately needs them?
At least Wood and the Prime Minister have both said they’re open to reviewing the green list policy if it isn’t working. The thing about painting yourself into a corner is that you’re only stuck there until the paint dries.