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Executives of the former DHBs were responsible to the Ministry of Health and answerable to the director-general of health, so for Mr Fleming - who held the lead role for the combined DHBs covering health of older people - opting to write directly to Mr Little was an irregular decision.
"I have never been compelled to write directly to a minister to express my significant concerns," the June 3 letter said.
"However, I feel it is my duty to be very clear with you as I believe all of the signs are present indicating imminent system failure unless some meaningful and tangible actions are taken.
"I appreciate that you may dismiss my letter as being from someone about to exit the system ... However, I believe the time for action to tangibly address the recruitment and retention of nursing workforce across the entire sector is now.
"If not taken up, I am sure we will see more bed closures and this will ultimately clog up acute hospital settings."
Mr Fleming’s time with the SDHB ended on June 30, and he now runs two PaperPlus stores in the North Island.
His letter to Mr Little was the second such letter he wrote in his final months in the chief executive role; he wrote a similar letter to then director-general of health Ashley Bloomfield in December 2021, but obviously felt the need to escalate his concerns higher.
Mr Fleming also made several strong comments at SDHB board meetings in his final months with the board on the issue, warning staff were suffering burnout and leaving the industry, which would inevitably affect the quality of care given to residents.
He also called for aged-care nurses to receive equal pay to that of DHB nurses, a point he repeated in his letter to Mr Little.
"The time to act and address the inequity in remuneration to the aged-care sector is now - closure of facilities or beds are biting and this will have a direct flow-on impact as DHB hospitals become the default where access is bottlenecked.
"This will have significant flow-on impacts to the entire health sector."
Mr Fleming’s letters were released to National health spokesman Shane Reti under the Official Information Act and he made the letters public on Friday.
"He really laid it on the line to the minister, but he was boxing from the sector’s corner," Dr Reti said.
"He warned that facilities will be forced to close unless urgent action is taken to address nursing shortages."
Mr Little said Te Whatu Ora Health New Zealand and the Ministry of Health were working intently on addressing workforce and labour issues, including pay parity.
"There’s a lot of things going on to support the aged residential care sector, and part of immigration reset is about making sure that it’s easier for that sector and other funded or partially funded health sectors to recruit offshore, as well as to boost the onshore recruitment efforts."
Since the new settings came into effect last month, 27 residential aged-care nurses had applied for residency, Mr Little said.
"Eight have been approved and 19 are in progress."