The Specialist June 2021 - Issue 127 by AssociationofSalariedMedicalSpecialists

T H E M AG A Z I N E O F T H E A S S O C I AT I O N O F S A L A R I E D M E D I C A L S P E C I A L I S T S

127 | JUNE 2021

Inside this issue ISSUE 127 | JUNE 2021

Want to know more? Find our latest resources and information on the ASMS website www.asms.org.nz or follow us on Facebook and Twitter. Also look out for our ASMS Direct email updates. This magazine is published by the Association of Salaried Medical Specialists and distributed by post and email to union members. Executive Director: Sarah Dalton Magazine Editor: Eileen Goodwin Designer: Dink Design If you have any feedback on the magazine or contribution ideas, please get in touch at asms@asms.org.nz.

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The Specialist is produced with the generous support of MAS.

ISSN (Print) 1174-9261 ISSN (Online) 2324-2787

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Change brings opportunity as well as challenges “Thank you for your service” – the great decluttering of New Zealand health Solidarity with nurses MECA 2021 – Getting to the crunch Pay ‘freeze’ sparks anger and back-pedalling A new era dawns – what do members think? Restructuring the health system: what’s needed Doctors fighting for democracy in Myanmar Public ‘mandate’ for health reforms – expert view Surprise and delight at bold reforms Little for health in Budget 2021 Riding the e-bike wave Health equity – being part of the solution Rural health ready for reform A view from rural health Did you know? Cheers to the new Executive Feedback A life spent fighting for justice – Helen Kelly Five minutes with Dr Tim Ritchie Enduring powers of attorney – Providing consent for those who can no longer consent for themselves Noticeboard Art Exhibition

Change brings opportunity as well as challenges Julian Vyas | ASMS President

ia ora ta-tou, I am proud to be the new President of Toi Mata Hauora/Association of Salaried Medical Specialists. It is a privilege to serve, and I shall carry out my duties to the very best of my ability.

I know my job will be made considerably easier by the talent and diligence of the National Office teams. Our industrial officers, policy and research, communications, and support services staff are committed to helping members. This means helping those who encounter workplace difficulties, as well as working for a better public health system. The team is led by our very own (and very able) Sarah Dalton. Without this care and professionalism, ASMS would not have the mana it enjoys from both the health and union sectors.

“A huge challenge for all of us in the next few years will be how the industrial and employment landscape will change when Health NZ becomes the sole employer.”

I am extremely lucky to be part of a National Executive that brings enthusiasm, experience, perception (and good humour!) to the twin duties of governance and strategy for ASMS. I must acknowledge just how indebted we are for the work done over the last three years by the outgoing Executive Board members. Murray Barclay (President), Julian Fuller (Vice-President) and Paul Wilson (National Secretary) have 40 years of Executive experience between them. Their knowledge, together with the support of the rest of the previous Executive, was invaluable in guiding the massive organisational change of the last three years, not least when Ian Powell retired, and Sarah took over as Executive Director. And now more change is afoot. Health Minister Andrew Little has announced

root and branch changes to the New Zealand health system with a strong emphasis placed on strengthening primary and community care. Doubtless there will be much discussion about these changes in the coming months. However, the prioritisation of community care has given me cause to reflect on what ‘community’ means for us as a union of dentists and doctors. Our ASMS community continues to grow. Recent data shows we have 5,201 members: 4,937 working for DHBs, and 264 members working outside the DHB sector – in hospices, ACC, union health clinics, family planning, blood transfusion services, primary care, and the Ministry of Health. As a community, our interests are best served by cohesion and collaboration and by connection with one another, even though we work in different environments and clinical disciplines. A huge challenge for all of us in the next few years will be how the industrial and employment landscape will change when Health NZ becomes the sole employer. We must retain our union collectivism and community to ensure that dentists and doctors are able to practise effectively, safely, and equitably for all New Zealanders. Maintaining our community will not happen by magic. To guarantee this we must all share our thoughts, concerns, and also solutions, with one another, and with ASMS as an organisation. In this way, even as ASMS’ structure and function may evolve in response to health sector reforms, we can be confident we represent the best interests of all our members. Therefore, I wish to issue a series of challenges: • To our National Executive (including myself): To use our motivation and skills to help maintain ASMS’ strategic vision

while the new health structure takes shape over the next few years. • To the National Office: The creation of a single employer and commissioning organisations means the current ways we engage and advocate for members will need to adapt. We will need to harness your energy and innovation to ensure local voices and needs are not lost in the day-to-day function of these new Leviathan-like bodies. • To ASMS members: More than ever we need you to keep us informed of what is happening in your place of work. A community can only exist with communication and mutual understanding between its members. In the next few years, ASMS will need to know what members find useful and what we might do differently to better represent you. • To myself: To do my utmost to determine what is of most concern to members. To speak up for them whenever I can, and to remember the common goals that make us a community.

“Without this care and professionalism, ASMS would not have the mana it enjoys from both the health and union sectors.”

‘May you live in interesting times’ is an apocryphal curse. Our times have most certainly become ‘interesting’, but this should be seen as an opportunity for the ASMS community to coalesce and to strengthen; perhaps to an extent we have not needed to before. Kia kaha. WWW.ASMS.ORG.NZ | THE SPECIALIST

“Thank you for your service” – the great decluttering of New Zealand health Sarah Dalton | Executive Director

ack in the day, T.S. Eliot gloomily wrote “April is the cruellest month” – a weird thing to say about spring, and now, living on our heating planet, it belies our long, benign autumns.1 However, this year at least, several DHB leaders might be inclined to agree. In a surprising announcement, Health Minister Andrew Little told us Cabinet has decided to go the whole hog and do away with every DHB. Along with the 20 DHBs, another 30 PHOs are likely to go in a massive bureaucratic clear out aimed, we think, at streamlining and nationalising our health system, and getting much more bang for the Vote Health buck. The sector was caught offguard by the decision, which went much further than the recommendations in the health and disability review led by Heather Simpson. The minister has effectively said to the DHBs “You no longer spark joy, thank you for your service” and, in a masterful, Marie Kondo-esque stroke, swept them all away.

“The sector was caught offguard by the decision, which went much further than the recommendations in the health and disability review led by Heather Simpson.”

I can list lots of things about the current system I won’t miss – haggling

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over local interpretations of the CME clauses ad nauseum, lobbying for a proper health workforce census and work focused on SMO supply, trying to find out who’s really running MECA negotiations (it’s never the people in the room), negotiating equitable pay and conditions for those of our members working in the contracted-out sector – NGOs, trusts, iwi providers. It’s very much a multi-tiered system with, believe it or not, privileged conditions in DHBs. And I know that for many of you working in the DHBs, it doesn’t feel privileged at all. You are struggling with short-staffing, lack of succession planning, patchy recovery arrangements after hours, and massive clinical encroachment on non-clinical time. You feel as though your pay and conditions are not keeping pace with living costs – let’s not even start on housing – and you are probably right. Yet, your employers – even the ones who tell us they’re championing the rights of those who earn least – are not even committing to paying a living wage to all their staff, let alone those in contracted-out services. And one of the tactics used to deal with these shortfalls and disparities is to bolt a salary ceiling firmly in place, while arguing they’re

busy raising the floor. In our view, neither is the case, and there is no benefit to any working person when downward pressure is applied to salaries and conditions. We know that, despite Vote Health costing taxpayers a fair chunk of our contribution to the public good, we need that investment to increase. And the biggest resource we need to invest in is our people. It is you. Whether these arguments will carry any more weight with the streamlined Health NZ, due to open its doors in July next year, is moot. But at least it should be clearer to us who we’re dealing with – and that the people in the room are the people calling the shots. If we can’t achieve that, we can’t achieve much at all. In the meantime, we are pressing on with our full programme of research and advocacy, and with our ASMS–DHB MECA negotiations. We very much appreciate the feedback you’re sending us. It’s feisty, mostly well-informed, contradictory, and deeply held. Please keep talking to us. We are listening. REFERENCES 1.

Please, no emails explaining The Waste Land to me – just accept my apologies for a lazy metaphor!

Sarah Dalton (ASMS Executive Director) and Justin Barry-Walsh (CCDHB Branch President)

Solidarity with nurses Nurses went on strike on 9 June to fight for fair pay and safe staffing. About 30,000 members of the NZNO walked off the job for eight hours. In Wellington, more than 2000 nurses and supporters marched to Parliament on the day. ASMS was out with banners, flags and posters in support. Several union leaders, including ASMS Executive Director Sarah Dalton, addressed the crowd, along with MPs and the Health Minister Andrew Little.

WWW.ASMS.ORG.NZ | THE SPECIALIST

MECA 2021 – Getting to the crunch Lloyd Woods | Senior Industrial Officer and Lead MECA Negotiator

he MECA negotiating team met with DHB representatives in Wellington on 26 and 27 May for days nine and ten of face-to-face discussions.

The DHBs had been asked to bring their best offer to the table. We were disappointed to find that apparently your Chief Executives feel that your reward for coping with understaffing, overwork, and burnout, as well as your contribution throughout Covid-19, is a zero salary increase this year, unless in some way you pay for it yourselves. Prior to this meeting the government had made it clear there is no wage freeze, so DHBs can no longer use that as an excuse. We acknowledge that there is an offer of 1% on each step of the salary scales in year two of a two-year term, but this was taken by the team as adding insult to injury. The other components of the DHB offer presented no change to their previous response, being “no offer”. The ASMS team decided the best way forward was to grasp the nettle. We spent 6 THE SPECIALIST | JUNE 2021

many hours talking about how we might persuade the Chief Executives that their continued refusal to respond to our claims was disrespectful and unacceptable. This includes the use of stop-work meetings and the possibility of industrial action.

response. This includes careful planning of stop-work meetings across all DHBs, and negotiation of the Life Preserving Services agreements in the interim in case we are forced into industrial action.

On Thursday 27 May we tabled this claim.

We can finish with some good news: ten days of talks have not been completely without outcomes. Although compared to our substantive claims some are relatively minor, we do have 13 improvements to the conditions in the last MECA agreed, including strengthening of PPE, vaccination rights, flexible working hours, onerous duties leave, recognition of Te Tiriti o Waitangi and others.

Given the very fair and reasonable claim we tabled, we have some optimism that the Chief Executives will ‘come to the party’. While hoping for the right thing to happen, we will continue to prepare for a poor

At this stage we do not have further talks timetabled. Given our offer we hope that we may not need them but there is room to meet if the Chief Executives show good faith in calling us back to the table.

We decided we needed to refine our own claims to meet what the Government is saying about salary increases (CPI). We also decided to refine the tabled claims to those of most importance (as identified by the ASMS team of 22 through a ranking process).

Pay ‘freeze’ sparks anger and back-pedalling A

SMS and other public sector unions took an angry and strong message to Public Service Minister Chris Hipkins last month after what can only be described as a major misstep by the Government in its call for continuing public sector pay restraint.

The Minister had ruled out pay increases for the next three years for those earning over $100,000. Coming amid MECA negotiations, it raised serious issues around the principles of good faith bargaining. ASMS publicly described it as a “kick in the teeth”. Other unions, such as the Public Service Association, the Nurses Organisation, and the Police Association expressed shock and outrage. ASMS members responded with a flood of emails to us. Here is a taste of the reaction:

“As a result of this announcement I have already looked at ads for my specialty in Australia and will continue to do so.”

“I AGREE SOME PEOPLE MIGHT LEAVE FOR OTHER COUNTRIES, BUT A LARGE MAJORITY WILL STAY BUT WILL BE DEMORALISED, FEEL DEVALUED, AND DEMOTIVATED LEADING TO FURTHER BURNOUT AND DROP IN QUALITY OF SERVICES.”

“I and many colleagues I have spoken to who were contemplating moving more time out of public to private (but we’re not doing so at this stage) are now determined, this was just the push we needed.”

“I guess pay doesn’t fix burnout – maybe we should be gracious about the pay this round and focus on appropriate staffing levels (which will cost more but is not a ‘pay increase’).”

“Hurting the workforce that they have relied on and publicly acclaimed is deceitful and shows poor character even for politicians.”

“As inflation goes up, our taxes have increased and our superannuation employer contribution stays static – this is in effect a cumulative pay cut in an environment where workloads, acuity, staff shortages and resource constraints are increasing.”

“Of course, those on less than 60k deserve a pay rise but so does everyone even just to keep up with CPI otherwise it is effectively a wage drop.”

“I think – given the impact of COVID – that those of us on high incomes can take a pay freeze. I would qualify this with the opinion that this should be for one year not three years – three years is excessive.”

“ABSOLUTELY DISGUSTING. WAIT FOR THE EXODUS. THIS IS THE THANKS WE GET FOR WORKING THROUGH COVID.”

“POSTCOVID WE HAVE BEEN WORKED OFF OUR FEET AND STRESSED TO THE MAX TO GET THIS GOVERNMENT’S TARGETS BACK ON TRACK. I’M AFRAID THE LAST OUNCE OF GOODWILL HAS BEEN EXHAUSTED.”

“Actually, I think the pay freeze is fine from an SMO point of view. The government has done a fine job protecting us from Covid, but it cost money. Got to be saved somewhere.”

Following a crisis meeting with the affected unions, the Government performed some quick back-pedalling. Mr Hipkins gave an assurance there would be no pay freeze, and negotiations will take place in good faith. It was also agreed that the pay expectations for public sector workers would be reviewed next year, rather than in three years, and that cost-ofliving increases would remain on the table. Addressing wellbeing and workload issues were also stressed as priorities. The Council of Trade Unions said that although the meeting was constructive, the public sector unions had made it crystal clear how unhappy and angry their members were in response to the initial policy announcement.

WWW.ASMS.ORG.NZ | THE SPECIALIST

A new era dawns – what do members think? A

SMS members have a wide range of views about the upcoming health reforms. Senior communications advisor Eileen Goodwin spoke to some from different parts of the country.

It’s to be hoped the revamped health system replicates the successes of the better performing District Health Boards, rather than the poorest-performing, Wellington radiologist Arun George says. He’s speaking from the perspective of radiology, and, for Dr George, Canterbury stands out, both in IT and workforce planning. “Christchurch workforce planning has been exceptional for radiology.” “They are the only ones who have a surplus [of radiologists] now to send to the rest of the country.” But looked at in purely financial terms, Canterbury District Health Board is seen as a failure. It depends how success is measured, Dr George says. “Are we aiming to be like Canterbury, or are we aiming to bring down the Canterburys to where Wellington is?” “The one centre where they showed the rest of the country how to do it, their Board was punished. “It’s almost like a complete disconnect.”

and listen to the people on the front line. Don’t start a conversation saying there are no resources”. “That just means you are coming into some kind of conversation with conditions, so it’s not going to go anywhere.”

In practice, she points out, increased access to service could mean travelling to Auckland Hospital. Many patients cannot afford petrol or parking costs.

Dr George says he has fought many times for additional resources by demonstrating need with hard data, but “it just keeps going in circles”.

“Whether patients benefit from the . . . amalgamation of services is not certain, and traditionally Auckland has tended to ‘win’ when this has happened.”

In Auckland, at Waitemata- District Health Board, Dr Jonathan Casement is also wary, saying he’s “neither for nor against” the shake-up. Dr Casement worries a populous area like the North Shore may lose out within metropolitan Auckland in a regional health authority. “Waitemata- District Health Board does well as it has a big population. When that population doesn’t matter because you’re in a region, I’m not sure how the allocation of resources across that region will take place.”

Dr George knows his view is unlikely to find favour in certain quarters, given the longrunning funding row between the Ministry of Health and the South Island board.

Dr Casement hopes the new system ushers in a transparent ranking system for prioritising hospital builds. He says while any system can be “gamed”, there is realistic potential for improvement.

“Are we aiming to be like Canterbury, or are we aiming to bring down the Canterburys to where Wellington is?”

He is sceptical of claims the system will end the postcode lottery, saying rural and sparsely populated areas will likely remain disadvantaged. He adds the shortage of doctors in rural areas persuaded him of the need for a third medical school. It’s too hard to get into medical training.

He says health care resources are simply not sufficient for the clinical demand after “many years of chronic underfunding”. Asked what he would, given the chance, tell the Health Minister: “I’d say come 8 THE SPECIALIST | JUNE 2021

She is also concerned about how the reforms will take shape.

“You don’t need people who are massively bright, you need people who are reasonably bright and work hard.” At Middlemore Hospital, Emergency Medicine Specialist Sylvia Boys says the reform’s goals, such as improving Ma-ori health, are commendable.

“The fact we’re all going to be one big happy family won’t translate into more specialist surgical services operating on the West Coast.”

“South Auckland does have a different population than elsewhere in the country, we are a substantial Pacific community, losing the DHB structure means that the local knowledge of how to provide care to our unique communities may be lost.” “I am concerned that centralisation of services, while on paper cost saving and allowing equitable access, will in fact continue or worsen inequities.” She wants to see much more emphasis on addressing the drivers of health, such as poverty, housing, and food. There are industrial implications from having a single employer which will require strong union representation to ensure staff are not forced to accept substantial changes in renumeration, conditions or location of work. “There has possibly never been a more important time to be an ASMS member,” she says. On the West Coast, there are concerns about a change in the special relationship with the larger Canterbury DHB.

Dr Arun George

Dr Graham Roper, West Coast DHB’s chief medical officer, calls the reforms a “double-edged sword”, with the potential downside including losing some of the benefits of the Transalpine partnership with Canterbury. “We’ve established some really good links with Canterbury DHB, and if it devolves into being a broader provider, some of those links are not going to matter as much, and not be of benefit to our community.”

Dr Sylvia Boys

“The fact we’re all going to be one big happy family won’t translate into more specialist surgical services operating on the West Coast.” He muses that perhaps more West Coast patients will be funded to travel elsewhere for treatment, but capacity constraints in other centres made this uncertain.

The DHBs have a shared senior leadership team, and a handful of clinical services have merged and are working well between Canterbury and West Coast.

And in Canterbury, it is fair to say there is trepidation. Dr Emma Jackson, Clinical Director of Obstetrics and Gynaecology at Canterbury DHB, hopes the new system will see all patients able to access communitybased treatments and clinically effective pathways that operate in some parts of the country, but not others.

He would not like to see the isolated West Coast become a “forgotten outlier” in the new system.

As an example, she cites community insertion of long-term reversible contraceptives.

“Rural health is a pretty small part of 20 different DHBs. The difficulty in rural is you need fundamentally different models of health care delivery.”

On the flipside, there’s potential for developing a strong South Island-wide rural health network under the auspices of Health NZ. He says the DHB is developing a proposal for how the model could work to present to health officials. Dr Roper says he’s not sure what the Health Minister’s promise to do away with the so-called postcode lottery means in practice.

“Some DHBs, such as Canterbury, have been able to achieve high levels of funded community insertion, whilst other DHBs have not passed on the funding to provide subsidy for community insertion, relying on wahine to travel to a DHB-based clinic which limits many from attending.” DHBs also have differing policies about which women meet the funding criteria. “I would hope that the reforms standardise this and make the care and subsidy streamlined and nationally accessible for all, locally, in a culturally appropriate setting,” Dr Jackson says. Further south, in Dunedin, paediatrician Dr Liza Edmonds welcomes the reform as she says the current system is not meeting the needs of the community. “Although major change sounds daunting and a big job, sometimes to

Dr Jonathan Casement

get actual change a major reform is what is needed.” “If we do not have significant change the existing inequity that we see will be perpetuated, and this reform needs to hold the system to account for this and enable the advantages experienced by some to be experienced by all,” Dr Edmonds says. She says her patients – children – are more affected by inequity. It will be essential their voices are heard in the reform. “It is challenging for child health voices to be heard amongst the larger more dominant adult health needs, and strong advocating for children will be needed within this reform or there will be missed opportunities for us all.” She adds there will be a need to advocate strongly for Otago and Southland to ensure they are not overlooked by decision-makers in Wellington. In Central Otago, Dunstan Hospital Rural Hospital specialist Garry Nixon sees potential for improvements in rural health from the national scale offered by Health NZ. “Rural health is a pretty small part of 20 different DHBs. The difficulty in rural is you need fundamentally different models of health care delivery.” He hopes a centralised function overseeing rural health will lead to increased networking and improvements in best practice. ASMS is keen to hear from other members about their views on the reforms and how they need to take shape. Please contact Senior Communications Advisor Eileen Goodwin – eileen.goodwin@asms.org.nz

WWW.ASMS.ORG.NZ | THE SPECIALIST

Restructuring the health system: what’s needed Lyndon Keene | Health Policy Analyst

In summary • •

All DHBs will be replaced by one national organisation, Health New Zealand (HNZ), which will be responsible for running hospitals and commissioning primary and community health services. It will have four regional divisions. A new Ma-ori Health Authority (MHA) will have the power to commission health services, monitor the state of Ma-ori health, and develop policy.

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A new Public Health Agency will be created.

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A “strengthened” Ministry of Health will monitor performance and advise Government on policy.

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The emphasis will be “squarely on primary and community health care”.

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The changes will be phased in over three years.

The new structure is potentially a game changer. It could enable a closing of the shameful health status gap between Ma-ori and non-Ma-ori, facilitate more consistent access to services nationwide, see better integration between hospitals and community service providers, reduce unmet health needs, and go a long way to meeting the Government’s wellbeing goals. Or it could do none of those things.

“The Commission hoped to change the mindset of political leaders, policymakers and economists who view health employment as a burden on the economy (as it is considered to be inefficient, resistant to gains in productivity and an expense to be stringently controlled). The Commission wanted to shift the focus of health employment as ‘consumption’ to health employment as an ‘investment’.”

To ensure it does achieve its goals, there are at least five ‘musts’ to be included in the missing detail.

In New Zealand, evidently there is still a lot of shifting to do.

Responsible investment policy

DHBs have failed to respond well to their local communities because they are primarily accountable to the Minister of Health. The background papers on the restructuring outline the plans for national, regional, and local “consumer forums” that will connect with HNZ, MHA and Ministry of Health. The system will “work towards a single mechanism” for two-way communication, so communities can see how their voice is being heard and acted upon.

The bold and politically high-stakes ambition proclaimed for this new system will need equally bold investment. Current funding levels are not meeting the needs of many people, so divvying up current funding levels between the MHA and HNZ, no matter how it was done, would perpetuate high levels of unmet need. The essential goal of health equity between Ma-ori and non-Ma-ori must go hand-inhand with a goal to significantly reduce universal unmet need. The aim must be to improve the health of the whole population while improving the health of the most disadvantaged faster. Greater investment to address entrenched health workforce shortages must be a priority. As the Health Workforce Advisory Board has pointed out, the United Nations High-Level Commission on Health Employment and Economic Growth has sought to draw attention to the social and economic benefits of investing in the health workforce, locally and globally. 10 THE SPECIALIST | JUNE 2021

Community voice

So far so good, assuming the process is well implemented, including being resourced to provide high quality forum facilitation and coordination. But to have a meaningful say on how services are designed and delivered, communities will also need access to comprehensive and relevant information, including local measures of unmet need for hospital care, as well as primary care, and data to identify service pressure points and assess where improvements are needed. Having to rely on Official Information Act requests for such information, which is then

subject to political risk assessment and can take many months, won’t wash. Clinicians’ voice The planned channel for community voice is not replicated for clinical voice. Aside from some “engagement with the health sector” as the new system is established, there is no indication of a clear ongoing means for front-line health professionals to have a say in how services are planned and run. This is a significant oversight that must be corrected. Globally, health systems employ many of the highest achievers in the labour force, yet their skills and knowledge are so often overlooked by policymakers and management when attempting system improvements. One can only imagine what might be achieved if 95% of employeegenerated ideas were put to practical use, as reported by one of the world’s leading car manufacturers, instead of just 10%, as reported in a health system study that appears to be typical of systems around the world, including New Zealand. The evidence shows securing greater engagement is a cultural change too important to be left to chance. It requires deliberate government policy and strong commitment. Get it right, and the elusive goals of systemic clinical leadership and integrated care will become more achievable. Cultural competency and safety First and foremost, as the MCNZ comments: “It is hoped that Ma-ori specific cultural competencies will be developed in a framework of self-awareness so that doctors

[and all staff] will be able to recognise their own values and attitudes, as well as the impact of these on their practices.”

on preventing illness and promoting health reduce pressure on hospital services?” on the ASMS website).

Addressing the determinants of ill health

A more holistic approach is needed to reduce pressure on hospitals. Within the health system itself, well-functioning primary care services depend on wellfunctioning, accessible hospitals.

The Government has signalled the emphasis in the new structure will be “squarely on primary and community healthcare” to take pressure off our hospital services. The evidence from New Zealand and overseas shows good primary health care helps prevent illness and death, but its effectiveness in taking pressure off hospitals generally falls well short of expectations – or potential – for a whole range of reasons (see ASMS Research Brief “Does more access to primary care and a greater focus

And policies with the most potential to reduce the need for hospital care are those that address the well-known determinants of ill health, such as poverty and poor housing. The evidence indicates efforts to improve the effectiveness of health services will struggle to make headway in reducing the need for acute hospital care without also addressing these broader issues.

Removing the cost barriers to primary health care Health equity, a primary aim of the restructuring, cannot be achieved while those most in need – Ma-ori, Pasifika and the poorest – cannot access primary care services due to user charges. Nor does the cost barrier help in the aim of reducing pressure on hospitals: these are the same groups who have the highest primary care preventable hospitalisation rates. Finally, if there’s one over-arching ‘must’ to make the new structure work, it’s a lesson from the Covid-19 pandemic: Heed the evidence – even when it means spending money.

Doctors fighting for democracy in Myanmar Michael Naylor | Executive Officer UnionAID

he military coup in Myanmar on 1 February this year has shattered hopes for democracy, but workers, unions and youth in the country have been fighting back.

While major street demonstrations have been violently supressed by the military, hundreds of thousands of public sector workers are continuing a three-month civil disobedience movement, refusing to work for the military junta. This movement is seen as one of the most effective tools against the junta and was initiated by Myanmar’s doctors and nurses. Many doctors are now facing the wrath of the junta. Reports received from union partners show that in April, 120 doctors across Myanmar were charged with ‘shaming the state’ and could face more than two years in prison. Those who bravely continue their strike action have been offering free care through community hospitals or other means but have now gone months without pay. Many doctors joined the massive street protests that gripped Myanmar during March and April, often organising to provide emergency medical care to shot protestors. They did so at great personal risk. Two doctors were shot and killed by the military soldiers in Mandalay on 27 March. UnionAID has had a long relationship with Myanmar. We have supported the establishment of trade unions and run the Myanmar Young Leaders Programme to promote democracy and human rights.

Throughout this crisis UnionAID has worked to assist unions, journalists, and striking workers with resources to sustain their pro-democracy fight.

Many doctors joined the massive street protests that gripped Myanmar during March and April, often organising to provide emergency medical care to shot protestors.

The World Bank estimates 120 million people fell into extreme poverty last year – the first increase in poverty in a generation. UnionAID is holding a special appeal calling for donations from New Zealand union members so it can provide unions in developing countries with resources and tools to organise and provide education and training to build strong unions. The funds raised will go towards brave campaigns for human rights against authoritarian and military governments in Myanmar, Thailand and the Philippines. If you would like to make a donation, visit www.unionaid.org.nz/2021-appeal/

The coup and ensuing crisis in Myanmar os one example of rising authoritarianism in our Asia-Pacific region. Coupled with Covid-19, it is devastating for many working people, especially the poorest.

*UnionAID works to alleviate poverty and achieve social justice for working people in Asia and the Pacific. It is a registered New Zealand charity and is an accredited New Zealand Aid Programme partner.

Doctors are playing a leading role in Myanmar’s ongoing fight for democracy. Credit: Civicus

WWW.ASMS.ORG.NZ | THE SPECIALIST

Professor Robin Gauld

Professor Peter Crampton

Public ‘mandate’ for health reforms – expert view P

rofessor Peter Crampton, a public health researcher in Otago University’s Ko-hatu, Centre for Hauora Ma-ori, was a member of the Health and Disability System Review panel which suggested a more tepid set of changes. Senior Communications Advisor Eileen Goodwin spoke to Professor Crampton, and also Professor Robin Gauld. Professor Crampton is delighted the Government has gone further than what the panel recommended. “I’m excited by the possibilities that arise out of the Minister’s decision. I see huge potential here. I think this is the most remarkable point in time in my professional life from a health systems point of view,” he tells The Specialist. He says he had agreed with the panel’s consensus to recommend retaining, but reducing the number of, DHBs. The vexed question of striking a balance between centralisation and decentralisation led the panel to that view, but, essentially, it’s an “imponderable”, he says. He believes there is a mandate from both the public and the sector for wholesale change.

He is enthusiastic about the development of a Ma-ori Health Authority. “I am a very strong supporter of universalist principles. However, within our universalist system we need to take heed of the huge amount of research that shows Ma-ori needs, and other ethnicities, are not well catered for with a culturally monolithic approach.” The right to commission health care tailored for their people will, he believes, shift the dial on Ma-ori health outcomes. It is not a “magic bullet” – he does not believe in those – but is an essential step within the framework of Te Tiriti o Waitangi. “Tino rangatiratanga is an essential prerequisite for health for Ma-ori.” He believes that at some point in future the Pacific Island community may acquire its own mechanism to commission health services. 12 THE SPECIALIST | JUNE 2021

Asked about cancer services, he says the evidence shows that after diagnosis, Ma-ori sometimes face longer wait times and poorer outcomes than Pa-keha-. This is evidence that the system is sometimes “blind” to the needs of some patients – though he points out this is not the intention of the treating clinicians and managers. Professor Crampton, a former dean of Otago Medical School, says the new Health NZ will be able to deliver proper workforce planning. Health and education have never worked together closely, and that has been a major shortcoming, he says. Professor Robin Gauld, co-director of Otago University’s Centre for Health Systems and Technology, says the DHB system has failed “miserably” at putting patients at the centre of the system.

requiring the private system to support the public system at times of need should be examined. A social insurance model should probably be looked at too, he says.

“You would get a DHB chief and a PHO chief who just don’t see eye-to-eye, which is unacceptable. This is about patients and communities, and to have personality politics is absolutely unacceptable.”

The reforms will sweep away the DHBs and their tendency to become mired in local game-playing and petty politics.

He hopes the new Ma-ori Health Authority – an “exciting, progressive, and overdue” development – will raise some of these “thorny questions” he’s been asking about the system. He says a similar Ma-ori health body

“You would get a DHB chief and a PHO chief who just don’t see eye-to-eye, which is unacceptable.”

was mooted in the early 1990s but failed to get the support of the then National government.

“This is about patients and communities, and to have personality politics is absolutely unacceptable.”

He says Health NZ itself is something of a throwback to the Health Funding Authority of the late 1990s. This worked rather well at the time and had been a welcome change from the market-driven health reform of the late 1980s and early 1990s. It was scrapped in favour of locally elected DHBs in 2000. Even after being around for 20 years, the elected boards had not found ways to operate effectively at a governance level and the public was disengaged from them, he said.

While an enthusiastic proponent of scrapping the DHBs, Professor Gauld also believes the reforms will only go part of the way towards improving health outcomes. He is concerned too many resources are tied up in the private health care system, which cannot be accessed by all patients. He says a possible regulatory reform

Surprise and delight at bold reforms V

eteran ASMS member David Galler casts his mind back to when Auckland Hospital resembled “Italy before Garibaldi” in this Q & A with Senior Communications Advisor Eileen Goodwin.

What’s your reaction to the health reforms? I tuned into the announcement and found myself strangely moved by it – not just by its aspiration but more by the tone with which it was delivered. My immediate reaction was surprise and delight. Surprise because I didn’t expect the aspiration to be so bold, and delight from the clarity of the rationale for change and the intent expressed for what these reforms are in place to achieve. Do we risk over-centralising health? The question presumes that health is not over-centralised now, and that the status quo delivers for those populations covered by the existing district health boards. It clearly doesn’t, and there is unwarranted duplication and variation in every aspect of what district health boards do, which contributes to the distress felt by our workforce. The current approach is heavy on a lumbering over-centralisation, micromanagement and an intolerance of innovation. Any reform will be hard pressed to match that! I see the structures announced as enablers for services to be shaped and continually improved by the professions and the public to customise different solutions. What’s one good thing in the current system that you fear might be lost? In response to the constraints and problems that exist within the current model/approach (I hesitate to call it a system), a range of highly functional and successful clinical networks have arisen linking patients and clinical staff across the regions. It would be a tragedy if these were lost and not used as a basis for learning to achieve the aspirations of the current reform. What does this mean for a big urban area like Auckland? Don’t the Auckland DHBs already collaborate? What I hope for is change that sees the expertise of all staff working within the metro area networked across all the hospital sites to ensure an equity in access and service provision that doesn’t exist now. Often the past is a reliable predictor of the present, and what will repeat in the future without critical appraisal and change. When my specialist career began,

Middlemore, Auckland, Greenlane and National Women’s hospitals were part of the Auckland Area Health Board chaired by Papatoetoe GP Frank Rutter. In those days, Auckland Hospital was (and perhaps in some ways still is) like Italy before Garibaldi – not a unified country but a collection of city states each protected by high walls with professors in high heels patrolling the ramparts pouring burning oil on anyone who came near them. So, no surprise when I started as a specialist at Middlemore that every tile in the place was cracked and every loo leaked. There had been no investment into that place for a very long time. But despite it, I was amongst like-minded friends and we worked hard and we worked well together. Not long after came the deficit switch, which saw the Northern Regional Health Authority absorb Auckland Hospital’s massive debt, but not Middlemore’s, leading to a long period of austerity. The population we served missed out on many services available to a population 14 km up the motorway. For years we had no CT scanner whilst Auckland had two, one ultrasound machine when Auckland had many, and so it went, and so it still goes.

What is your advice for the Health Minister as he embarks on this reform? 1) Keep a focus on the end game. 2) Learn from our collective success in managing the Covid-19 pandemic – transparency, clear communication, embracing the views of experts and the public, not just those of the bureaucracy. These will build strong relationships and trust among the professions and public. 3) Establish a set of relevant metrics for improvement to measure key aspects of the reform process and outcomes. 4) Your portfolio traditionally concentrates on the provision of health care services, but these will never keep pace with demand without a more holistic approach to keeping people well. This can only be achieved by addressing more broadly the many societal determinants of health that are continually formed by policies from across all of government. Dr Galler recently retired as an ICU specialist from Middlemore Hospital after 31 years

It is remarkable that today a population of 650,000 people with the most complex health needs in the country has less access to services than populations in the more Pa-keha- cities of Te Whanganuia-Tara, Otautahi and Otepoti. In those days, as it still is today, there are no inpatient acute services in important specialty areas, and instead of addressing that directly, the tendency is for them to become increasingly centralised. A truly regional service means staff who have traditionally been bound to one institution liberated to work across other sites. What will this mean for the themes you have been outspoken about, particularly food and obesity? There are several potential benefits for communities like those in South Auckland who have been abandoned to the market, and in particular, fallen prey to the fast food, alcohol and tobacco moguls, to suffer high rates of preventable harm from obesity-related complications of diabetes. These include better access to a wider range of services, and a better coordinated approach to public health.

Dr David Galler

WWW.ASMS.ORG.NZ | THE SPECIALIST

Little for health in Budget 2021 Lyndon Keene | Health Policy Analyst

eyond the big budget items relating to Covid-19 and the system restructure, there are patches of improvement but little sign of progress towards revitalising the health system after many years of under-investment. For DHBs, it’s more of the same, writes health policy advisor Lyndon Keene. For all the big numbers headlining last month’s health budget, most frontline hospital staff are unlikely to see any relief from current workload pressures. This year’s boost for DHBs at first appears substantial ($914 million more than last year’s budget). However, after wage, demographic growth, and the cost of new initiatives, it falls well short of what’s needed to stand still, let alone make progress. And there is no explicit funding for additional nurses from the safer staffing initiative, and the New Zealand Nurses Organisation’s pending pay equity settlement, which will probably be in the hundreds of millions. In a letter to Finance Minister Grant Robertson in December last year, Health Minister Andrew Little argued: “Efforts to improve equity, coverage, service quality, and maintain safety could be undermined in an environment where providers are struggling to manage fiscal constraints, creating risks for the populations they serve.” Evidently Mr Robertson was not convinced. Services would be under even further pressure were it not for virtually all DHBs running deficits over multiple years – an indicator of structural under-funding – estimated to be around $650 million for 2020/21. Despite the Minister’s Letter of Expectations to DHBs emphasising they must “deliver break-even results by the end of 2021/22”, it is highly likely they will run up big deficits through to their final days. The line being run by the Government is that focusing more resources into primary care will take the pressure off hospital services (though the evidence does not support that assumption). Hence the primary health care strategy gets a $51 million boost (14 percent over 2020/21), though mostly to cover cost and volume pressures. Funding for National Mental Health Services, managed by the Ministry of Health, gains $42 million (21 percent increase) partly to fund the ongoing 2019 Budget initiative to expand access to mental health services in the community. Much of this, however, has been carried forward from “savings”

14 THE SPECIALIST | JUNE 2021

and under-spends from the two previous years. The vast bulk of mental health funding – a ring-fenced portion of DHB budgets for specialist services – is not separately itemised in the Budget. There is no indication it has been increased, other than for the usual demographic and cost pressures. Putting aside funding related to Covid-19, national Public Health Service Purchasing, also managed by the Ministry, received just $4 million more than the final budgeted figure of $503 million in 2020/21 (an increase of less than 1 percent). A range of new initiatives include additional funding for public health units ($9 million), cervical screening ($7 million), breast screening ($5 million) and bowel cancer screening ($3 million), which will be part-funded by unspent money from previous years and partly at the expense of other services. The total budget for Public Health Service Purchasing amounts to 2.3 percent of Vote Health. Public health groups have been calling for it to be lifted to at least 5 percent. Health Coalition Aotearoa Chair Professor Boyd Swinburn says the Budget does not address decades of under-funding public health to reduce preventable diseases. “A status quo of under-investment in prevention is setting up the health care system for even more pressure.” The biggest area of new spending is the Covid-19 vaccination programme, announced earlier this year. Funding for this $1.4 billion programme began with $673 million allocated in the current year to June 2021, with a further $714 million budgeted for 2021/22. There is also substantial funding for other Covid-19 related measures: $2.2 billion over two years, including more support for PPE, MIQ facilities, surveillance, and testing. For the health system restructuring, $486 million is allocated over four years, including setting up Health New Zealand, the Ma-ori Health Authority, Hauora Ma-ori and locality networks for primary and community healthcare. This will almost certainly require more. Pharmaceuticals get an additional $40 million in 2021/22. And a further $140

million is provided over this and next year for “continuity of supply of medicines and medical devices”. National Disability Support Services, mostly provided by NGOs, received an additional $171 million (a 10 percent increase), but this is largely accounted for by cost and volume pressures, ongoing pay equity costs for support workers, and in-between travel costs. Of that, $7 million is provided to increase the availability of cochlear implants. Capital is mainly provided through a multiyear funding allocation; $5 billion from 2020-2025, of which $1 billion is estimated to have been spent this financial year, and a further $1.5 billion estimated for next year, leaving $2.5 billion for the remaining years. To put this in context: in 2018 DHB capital spending needs were forecast to exceed $14 billion over the following 10 years. Key areas that urgently need more attention include: • Workforce shortages: Investment in the health workforce is needed to address shortages across a wide range of occupations. • Mental health services: These remain in crisis mode, despite additional funding initiated in 2019 for mostly communitybased services (much of which is under-spent). Specialist mental health services continue to be funded to cover 3 percent of the population when there is long-standing evidence it needs to be 5 percent. • Prevention and promotion: Nationally administered public health services receive just 2.1 percent of Vote Health while New Zealand is facing significant public health issues. A major aim of the restructuring is to take pressure off hospital services. Effective public health services will be vital. • User charges: Eliminating primary care practitioner fees would improve access to services, especially for those who most need them, a key aim of government policy. Such a move would require recompensing practitioners accordingly.

Dr John Chambers out riding his e-bike on the Otago Peninsula

Riding the e-bike wave Elizabeth Brown | Senior Communciations Advisor

he thing Dr John Chambers loves best about his new e-bike is that he doesn’t have to wear Lycra.

The long-serving Dunedin Emergency Medicine specialist and ASMS stalwart recently bought himself an e-bike using a discount available to all Southern DHB staff. “I live on the Otago Peninsula, and there is a new cycling/walking path all the way out to Portobello. An e-bike overcomes the wind resistance and makes getting up the steep slope to the scenic Highcliff Road very easy.” In 2019 the Government negotiated bulk-purchase discounts on e-bikes. They were to be made available to interested workers in public sector organisations, including DHBs, councils and state sector agencies. The discounts range anywhere from $300 to $1200 and are offered through certain retailers. The aim of the initiative was to reduce pressure on car parking in places like busy hospitals, relieve traffic congestion, and foster individual health benefits. Dr Chambers says staff at Southern DHB were informed by email when

the scheme was announced, and there have been ongoing flyers, along with publicised opportunities to jump on an e-bike and give it a go. To get his $1200 discount he simply had to go to a specific retailer and show his Southern DHB staff ID. However, while some DHBs around the country have joined the discount programme, it appears others have not. According to the Public Sector E-bike Scheme, run through Waka Kotahi NZ Transport Agency, it is up to individual organisations to sign up and create a scheme for staff to access. Any interested SMOs or SDOs should approach management (or sustainability managers in some DHBs) about whether a scheme is in place, or about getting the wheels moving to set one up. E-bike usage and popularity has soared in recent years, and while the drive for more sustainable transport should not

be discouraged, it has spawned a new set of problems. ASMS members increasingly raise concerns about a lack of bike storage and charging facilities. It is an issue that ASMS has been pushing DHBs to tackle and will continue to do so. “E-biking has become the primary mode of transport to work for me, but there are increasing numbers of e-bikes in the bike cage and it’s difficult to find a park after 7.50 am,” says Auckland City Hospital specialist Dr Simon Fu. Down south too, Dr Chambers says most of his colleagues now have e-bikes. “The big advantage of an e-bike is the ability to go pretty fast without the need for body-hugging Lycra. This suits me as an older doctor with modest proportions,” he says. To find out more about the e-bike discounts go to the Waka Kotahi website www.nzta.govt.nz and search for ‘Public sector e-bike scheme’.

WWW.ASMS.ORG.NZ | THE SPECIALIST

16 THE SPECIALIST | JUNE 2021

Health equity – being part of the solution

Dr Curtis Walker

Dame Sue Bagshaw

virtual conference co-hosted by ASMS and the Canterbury Charity Hospital Trust promises not to be just another ‘talk and chalk’ fest. Speakers and participants will be challenged to come up with tangible solutions and recommendations to take to the Government. The Creating Solutions – Towards Health Equity Outcomes for All conference is the brainchild of Canterbury Charity Hospital Trust founders Dame Sue Bagshaw and Dr Phil Bagshaw. It was born of frustration with what they consider the failure of successive governments to take action and deliver universal access to comprehensive health care. “When you live in a relatively first world country, which is supposedly providing the same services, but one group of people dies eight years sooner than the other – that is shocking,” Dame Sue says. As co-host, ASMS is delighted to be part of the conference, whose themes align with our values.

“When you live in a relatively first world country, which is supposedly providing the same services, but one group of people dies eight years sooner than the other – that is shocking.”

with a scale and intensity proportionate to levels of disadvantage in a population. Dame Sue believes it is an idea that needs to be put on the public radar. “We all know what the problems are, we all know that the pre-determinants of health aren’t working in terms of housing, income and healthy food.” “We also know 20% of New Zealanders can’t afford to go to their GP and if you can’t afford to go to your GP you can’t go to the hospital and see a specialist, and our emergency departments are bulging as a result.” The conference is targeting the health workforce and practising health professionals. Dame Sue makes the point that “we need to get our own house in order in terms of acknowledging our own inherent racism and making sure we are not providing a barrier to health care ourselves”. The new black Medical Council Chair and Palmerston North physician Dr Curtis Walker describes health equity as “the new black”, and believes all New Zealanders want to see fairness of health care and fairness in health outcomes. He will be speaking at the conference on strong clinical leadership.

One of the key areas of discussion will be the idea of proportionate universalism, with a keynote address by British health equity researcher Sir Michael Marmot, a well-known proponent of the concept.

“In each of our roles and organisations, whether it’s as frontline health practitioners or organisations like the Medical Council, we all need to show leadership over health equity and how we can progress it and achieve it,” he says.

Proportionate universalism argues that to reduce steep social inequalities in health, actions must be universal, but

“There are a lot of practical things we can do within our workplaces to make sure that our services are culturally

safe, examining our outcomes to make sure we’re delivering equitably within our services and population.” Dame Sue believes the conference is well timed with the Government about to launch an ambitious programme of health reforms. “We really need to look at how we fund health and ask do we see it as a cost to the nation and the taxpayer, or do we see it as an investment which pays off in the long-term because we have healthier people being employed, doing a better job and ensuring the country develops well?”

“There are a lot of practical things we can do within our workplaces to make sure that our services are culturally safe, examining our outcomes to make sure we’re delivering equitably within our services and population.” In her view the bottom line of the Creating Solutions conference is to increase public awareness of its themes. “We need buy in. It’s about getting people to join the debate, put in their point of view, and say I want to take this on board because it makes sense.” The conference is being held on 2–3 July. It is not too late to register. You can follow the QR code in the poster or go to our website www.asms.org.nz for a full programme and registration details.

WWW.ASMS.ORG.NZ | THE SPECIALIST

Rural health ready for reform Mary Harvey | ASMS Policy Advisor

he big health shake up could have profound effects in rural health care, ASMS Policy Advisor Mary Harvey writes.

A new ASMS Research Brief argues that people in rural areas should expect similar health outcomes to those in urban areas. Written just before Health Minister Andrew Little unveiled a sweeping reform of the sector – whose scope goes far beyond what most people expected – the Research Brief examines the impact of the postcode lottery in rural areas. People living in rural areas face significant barriers, including long travel distances to access health care. A particular difficulty is recruiting and retaining doctors and other health professionals.

Ma-ori, many of whom live in rural areas and experience poorer access to health services. We note that Health NZ will be charged with developing a New Zealand Health Plan. We expect to see the current difficulties accessing and delivering health care in rural areas to be addressed. While supportive of the direction of the reforms, ASMS is disappointed at the lack of focus on rural health in the announcement.

The proposed changes include replacing district health boards with one national organisation – Health NZ.

In many rural communities, the barriers to access are even higher for specialist services such as mental health, maternal health, and emergency care. Poor access to services is felt more keenly by vulnerable groups, particularly Ma-ori who live in rural areas with high levels of deprivation.

While supportive of the direction of the reforms, ASMS is disappointed at the lack of focus on rural health in the announcement.

ASMS argues that people in rural areas should expect similar health and disability outcomes for their communities as people living in urban areas. We believe the Government has an obligation to support rural hospitals with funding and staffing models to ensure access to safe, high quality health care services.

Under the new health system, hospital and specialist services will operate as a network and be managed regionally. There is a promise of greater clarity and consistency on which services rural communities can expect to be able to access, and where they will be delivered. ASMS welcomes these changes. We also support the decision to establish a fully empowered Ma-ori Health Authority. This development will strengthen the system’s ability to address health inequities for

18 THE SPECIALIST | JUNE 2021

The development of the Rural Hospital Medicine (RHM) scope of practice in New Zealand is helping to improve recruitment and retention of rural hospital doctors in some areas. There are good examples, such as in the Hokianga, where this workforce and the rural generalism model of care works well. Nevertheless, there is a severe shortage of doctors across rural hospitals and general practices, and a heavy reliance on locums to fill the gaps. The Research Brief notes the high rate of burnout experienced by RHM doctors. In addition, a large proportion of RHM doctors

and rural GPs are international medical graduates. Many do not stay in New Zealand for long periods. At the same time, we are aware of a continuing decline in rural GP numbers; the rural general practice workforce is under considerable strain.

We believe the Government has an obligation to support rural hospitals with funding and staffing models to ensure access to safe, high quality health care services.

ASMS recognises that rural communities are diverse, and have different needs, depending on their location and relative distance to large centres. Approaches to the provision of health care in rural areas must be tailored to local circumstances. However, there is an urgent need for an overall plan for rural health services in New Zealand. Successive governments have tended to overlook the problem of inequitable access to health services for rural populations. We believe the health sector reforms offer a once-in-alifetime opportunity. This will require a strong focus on developing and supporting a sustainable rural medical workforce, and a clear plan for achieving equitable health outcomes for rural populations. The ASMS Research Brief – “Rural health at a crossroads: tailoring local services for diverse communities” – is available on the ASMS website.

A view from rural health Eileen Goodwin | Senior Communications Advisor

ural health providers will still be operating at a distance from those holding the purse strings when health undergoes its big structural reform, says Dr Jennifer Keys, a Rural Hospital Medicine specialist at Lakes District Hospital in Queenstown.

“It probably doesn’t matter whether we’re mostly run from Dunedin, or mostly from Wellington. We are all run by organisations that are distant from us anyway, and I’m not sure how much difference it will make.” There are considerable communication difficulties between rural-based providers and their city-based funders.

more effective than others. She says the provision of specialist outpatient services in rural services is ad hoc. It’s possible this will improve under the planned reforms, which emphasises a national health system. “We are very dependent on individuals rather than systems at the moment,” Dr Keys says.

Along with the lack of a specifically rural undergraduate medical programme, it was proving difficult to get PGY1s and PGY2s into rural areas. “The DHBs seem to be hanging on to them in the cities,” she says.

Dr Keys says she hopes that dynamic will change, but it’s uncertain because of a lack of detail about how the new system will operate.

One of the biggest problems is a lack of doctors. Dr Keys says recruitment and retention of doctors for hard-to-staff areas is still not being adequately addressed. Many comparable countries have fully rural medical schools now; New Zealand does not.

“It probably doesn’t matter whether we’re mostly run from Dunedin or mostly from Wellington. We are all run by organisations that are distant from us anyway, and I’m not sure how much difference it will make.”

And she says the uncertain position of PHOs presents a “huge unknown”. She says some of the PHOs have “designed really innovative services”, and some are

Rural immersion as part of the existing medical school programme is valuable and useful, but temporary exposure is not enough, she says.

Dr Keys is presently on sabbatical from her clinical role.

“Sometimes they don’t seem to understand the service we provide, despite the fact they’ve had extensive interactions with us.”

About stop work meetings? Stop work meetings are covered both by legislation and by the DHB MECA. We are entitled to hold two stop work meetings up to two hours in duration on full pay every calendar year. We must give 14 days’ notice of a meeting, and we must make suitable arrangements to cover “essential activities” during the meeting time. We are currently arranging stop work meetings for August to discuss the DHBs’ latest MECA offer. All members, unless agreed otherwise, should attend. Meetings will be held at all major worksites to enable full participation, and zoom links will be provided for those who cannot easily attend. WWW.ASMS.ORG.NZ | THE SPECIALIST

Pat Hartung and Kiri Rikihana

Allister Williams and Kai Haidekker

Vanessa Beavis and Henry Stubbs

Andrew Robinson, Steve Hurring, Sylvia Boys Kirsty Farrant, Sarah Dalton, Katie Ben

Aaron Crawford and Julian Fuller

Sarah Dalton and Julian Vyas (toasting Murray Barclay)

George Collins and Kris Smith

Andrew Laurenson and Dr Ayesha Verrall

Lloyd Woods and Deborah Powell

Justin Barry-Walsh and Chris Wisely

Cheers to the new Executive ASMS hosted a celebration to welcome the new ASMS National Executive at the start of their three-year term. New ASMS President Dr Julian Vyas thanked immediate past president Professor Murray Barclay and former executive members for their service over the past three years. He told those gathered that ASMS performs an important role in the delivery of health care in New Zealand. He stressed the need for everyone present to work collaboratively towards a common goal of a fair, equitable, and high quality health care system for New Zealanders.

20 THE SPECIALIST | JUNE 2021

Feedback

ast September, The Specialist ran an opinion piece by Dr Rob Burrell and Dr Marty Minehan titled “Will we go back to our love affair with jet travel?” which asked some tough questions about the future of CME travel in the age of climate awareness. Respiratory medicine specialists at Auckland District Health Board took issue with aspects of the article. Their letter, along with a response from Dr Burrell and Dr Minehan, is published below. We write collectively to express our disappointment at the ASMS support of some of the opinions expressed in the article “Will we go back to our love affair with jet travel?” Our diverse respiratory department in a tertiary centre has national and international experts in a number of sub-specialty areas. We have developed that expertise over the years through fellowships, sabbaticals and invitations to international working parties and advisory groups. We have also worked hard to recruit young and talented SMOs who we hope will carry our services forward into the future. The senior members have built up connections over years of networking to create training pathways for the registrars we have recruited to join our service. None of this would have been possible had we been unable to travel overseas supported by MECA CME entitlements. We believe the people of Aotearoa New Zealand deserve and expect

The Response: Thank you for engaging in the debate. We are very pleased that SMOs have given our article some attention. It was certainly intended to get people thinking about their contribution to climate change. We cannot but agree with you. Overseas travel and our CME entitlements have created an environment where SMOs have flourished, knowledge was gained, and skills were honed. The contacts we made with our overseas colleagues benefited our careers, and our patients. Two decades or more of available and refundable travel within the ASMS MECA has been great for us all. Those two decades have not been kind to the planet, however. The only certain thing is that the future will not look like the past. We would like to see senior doctors leading this issue, not reacting to interrogation by media, nor fighting resentment and obstruction by management. The public expects doctors to

a high quality of specialised health care. As specialists in our fields, we receive frequent referrals and calls for advice from our colleagues around the country, and are able to call on our overseas friends and colleagues to provide support with some of our more challenging cases. The last year has provided challenges in terms of fostering and maintaining such networks, communication with all non-local colleagues, and ensuring ongoing education and CME. We have all also felt the stress of the repeated lockdowns, lack of leave, and time away from the workplace. Those SMOs privileged enough to be towards the end of their careers, and having already enjoyed all the benefits of travel and networking, may be happy to and be well placed to undertake CME at home. They may underestimate the challenges faced by their younger colleagues living in shared accommodation, with multigenerational families or

provide direction, not just health care. Publicly funded business class air travel is rapidly becoming a bad look, and there will be significant changes in the travel policies of DHBs. In December, the Government (perhaps optimistically) committed Aotearoa’s public sector to carbon neutrality by 2025. What will that look like? If doctors are not coming on this journey, what hope is there for us, the public, or even the planet? We disagree with the implication that this is a generational issue. In fact, younger doctors have probably travelled more at their stage of training than older doctors. Commercial air travel has shown an exponential rise since the 1950s, and doctors have been keen to purchase tickets. Younger doctors have the most to lose from unbridled carbon emissions, and will have to live with the consequences of climate change, while many older doctors will be gone before things become very uncomfortable. However, pitting

with children at home, attempting to undertake CME by Zoom either at home or by default in the workplace. Our department supports endeavours to reduce carbon emissions both at a personal and group level. We believe, however, that well-chosen and justified CME-funded travel provides a vital role in ensuring that the people of Aotearoa New Zealand get the highly educated and specialised medical workforce that they deserve and increasingly demand. Senior SMOs who have enjoyed all of the benefits of CME travel or who work in less specialised areas where the benefits are less apparent should not deprive our young specialists trying to build careers (often in conjunction with raising families) of the opportunity to educate themselves to the same high level and to build up the same international networks that we did to allow advancement of our careers. Respiratory medicine specialists, Auckland District Health Board

generation against generation is not constructive in this debate and will not bring about the required changes in our carbon emissions. We are not advocating a moratorium on CME air travel. We know that doctors will continue to want to travel to learn, teach, and connect. But we are suggesting that we will all have to be much more judicious in the where, why, and how. Constraint will come, before 2025, whether we like it or not. Better to create these checks than have them imposed on us. The opinions expressed in the article are our own. They are not mainstream ASMS thinking, as far as we know. We ask our colleagues to imagine a future where we have faced the realities of unrestrained carbon pollution. What does good medicine look like in that scenario? It is an uncomfortable question; it exposes a conflict between wants and needs. Dr Rob Burrell, Dr Marty Minehan

WWW.ASMS.ORG.NZ | THE SPECIALIST

A life spent fighting for justice – Helen Kelly A

new book celebrates the life and achievements of the remarkable union leader Helen Kelly.

Helen Kelly: Her Life, written by journalist Rebecca Macfie, relates the life and times of a leader who stood up for workers amid the fallout from the neoliberal shift, growing inequality, and slumping union membership. The book posits that had she lived, Ms Kelly might have gone on to become prime minister. As a young child, Ms Kelly fancied herself in the role. “Her high school friends saw her as so capable and reliable that this would likely come to pass,” Macfie writes. So did her mother, Cath Kelly, who labelled her towel rail in the family home ‘H.M. [Helen Margaret] Kelly, PM’. In 2007 Ms Kelly postponed her plan to enter parliament as MP for Wellington Central when she agreed to become head of the Council of Trade Unions (CTU), a job she had been encouraged to take on by then president Ross Wilson. Grant Robertson, who coveted the Wellington Central Labour nomination, recalls nervously meeting her for coffee. “I wasn’t a hundred percent certain that Helen wouldn’t say, ‘Actually I’m not going to be CTU president, I am going to go for Wellington Central’.” Mr Robertson won Wellington Central in the 2008 election and is today deputy prime minister. Ms Kelly went on to become an energetic and courageous champion of workers’ rights, battling against some of the country’s toughest adversaries, from Talley’s to Ports of Auckland. Ms Kelly was the daughter of Pat and Cath Kelly, long-time communists who in the 1970s switched their political loyalties to the Labour Party. Her father, Cleaners Union secretary Pat Kelly, mentored many young activists in the union movement. Her mother Cath Kelly was a Labour Party stalwart who became a tireless supporter of the people of Vietnam. In her role as CTU president, Ms Kelly believed all workers, whether in a union or not, deserved to be given a fair go. Her battles with famous people were the stuff of headlines. She took on film director Peter Jackson when he opposed demands from Actors’ Equity for an agreement over pay and conditions for workers on The 22 THE SPECIALIST | JUNE 2021

Hobbit. She was accused in parliament of doing “irreparable damage” to the union movement, and by employers of exploiting the bereaved families of dead workers when she exposed dangerous work practices in forestry companies. While many New Zealanders saw her as a hero, to others she was ‘that woman’, a bloody pain in the neck. After being diagnosed with cancer in February 2015, she fought for the

legalisation of medicinal cannabis and jousted on social media with the Associate Minister of Health, Peter Dunne, using the hashtag #apersoncoulddiewaiting. She died in 2016, at the age of 52. Macfie’s previous book, Tragedy at Pike River Mine, won three major awards. Helen Kelly: Her Life by Rebecca Macfie, published by Awa Press. Release date: 15 May 2021. RRP: $50.

MINUT

with Dinner by the Punakaiki River

Dr Tim Ritchie

Dr Tim Ritchie is an Emergency Medicine Specialist at Dunedin Hospital. What inspired you to get into your field of medicine? I had the interesting experience during medical school of finding myself in the opposite quadrant of the Myers-Briggs personality test to just about everyone else in my class. Which is probably why nowhere in the hospital felt right until I did my ED run as a trainee intern. Walking into the ED felt like putting on a comfortable old pair of jeans and I never looked back. Ten years later I repeated the Myers-Briggs test during an ACEM fellowship pre-exam course. Most of my fellow course attendees were clustered in the same quadrant as me and my study buddy’s personality type was exactly the same as mine. Inspired? More like self-selected. What are some of the more challenging aspects of the current health environment? In my opinion hospital flow is the biggest challenge faced by emergency medicine in Aotearoa. Without decent flow we can’t guarantee quality care for our patients. Unfortunately, many of the determinants of hospital flow are beyond the day-today control of emergency physicians. The spectre of burnout is another big challenge. Working in congested low quality environments undoubtedly contributes to the high levels of burn

out consistently measured in Emergency Physicians. The freely flowing hospital of my nirvana would be safe for patients and a great place to work. Let’s figure out how to get there. What’s your passion? I think the thing I love most about work is the storytelling. Maybe I should have been a poet. Every patient interaction involves some kind of story. Some are tragic, some are hilarious. You never know what you’re going to hear. I get to tell my own stories too. The best ones are where patients laugh at my own ridiculousness. I love the endless storytelling with colleagues. I have literally cried with laughter at some of the stories I have been told at work. Storytelling in the ED could be seen as a bit like leaning on a shovel, but I think it’s an essential part of how we connect and make things better for our patients and each other. What keeps you happy outside of work? The ocean and the mountains are the magic places for my mind. I’d surf all day long if I thought I could get away with it. My favourite places to surf are in the depths of South Westland or other similarly remote and splendid locales, which I dare not mention for fear of word getting out. Marine conservation spins my

wheels and I’ve just finished a tenure on a forum tasked with working out where to place a network of marine protected areas around the south-eastern coast of Te Wai Pounamu. Ski mountaineering and tramping are my means of communing with the mountains. Sometimes I just sit and look at them. I do a lot of this stuff with my kids now. Watching them get a buzz from the outdoors makes me happy. My old mate Cog keeps me happy too. He’s 77 and one of the most inspiring people I know. If you’re ever wondering where I’ve disappeared to on an office day, it’s usually for a coffee with Cog. Why did you become involved with ASMS? I think that by and large we have very good terms and conditions. Every now and again I get a bit excited though when common sense seems to have gone out the window. Two of my latest projects have involved getting paid for the work we do when we’re on call, and paid recovery time after shift work that finishes in the early hours of the morning. Fortunately, common sense is invariably backed up by a clause in the MECA, and I am ever grateful for the hard work and support of the ASMS. We have a hard and stressful job and it’s good to know that such a strong and professional organisation has got our backs. Cheers ASMS! WWW.ASMS.ORG.NZ | THE SPECIALIST

Enduring powers of attorney – Providing consent for those who can no longer consent for themselves L

ucy Gibberd, Medicolegal Consultant at Medical Protection, spells out the basics of the conditions under which an enduring power of attorney (EPOA) can be set up, the situations where it may be activated, and the limits of what can be consented to using an EPOA. A recent HDC case found a doctor in breach of the Code of Health and Disability Services Consumers’ Rights because they did not adequately assess their patient’s capacity with regard to setting up an enduring power of attorney (EPOA). In 2018, the doctor saw a patient and provided a certificate stating that the patient, who had been diagnosed with dementia, lacked the capacity to

24 THE SPECIALIST | JUNE 2021

make decisions regarding her financial and medical wellbeing. The doctor did not conduct a formal assessment of the patient’s capacity prior to issuing the certificate. The patient’s partner then contacted the doctor and explained that the certificate provided was not what the solicitor required. He explained that he required a certificate stating whether the doctor deemed the

woman to have the mental capacity to appoint him (the partner) EPOA. The doctor then provided a certificate stating the patient had capacity to appoint an EPOA, despite the lack of a formal assessment and the previous certificate stating the patient lacked capacity to make decisions about finances and health. The Commissioner found that by failing to perform a formal

assessment of mental capacity to appoint an EPOA and certifying the woman’s mental capacity to appoint an EPOA, contrary to the previous certificate, the doctor failed to provide services to the woman that complied with legal and professional standards. Over the past few years, Medical Protection has seen an increasing number of cases related to issues with setting up, activating, and using EPOAs. While the issues in the case above pertain to contradictory certificates provided without any formal assessment, the decisions in these cases can often be complex and difficult, and we encourage doctors to discuss such situations with Medical Protection or their medical defence organisation (MDO). Many people believe that their ‘next of kin’ would be able to provide consent on their behalf if they were no longer able to do so, but this is incorrect. In general, an EPOA (or guardianship order) is required to provide the legal basis on which a person can consent on another adult’s behalf. An EPOA can be set up by someone who has mental capacity to choose whom they wish to consent to act on their behalf in the future, should they lack capacity at some later date. When a person sets up an EPOA, they are known as the donor. At the time of setting up an EPOA, the donor must have the capacity to understand, retain, and reason through the information required to make a decision to appoint an EPOA. The person who is chosen is usually a family member or close friend, but can be a lawyer or a trustee company such as the Public Trust. The attorney must be at least 20 years old, not bankrupt, and mentally capable. Setting up an EPOA must be witnessed by a lawyer, or legal executive, or by the authorised representative of a trustee company. An EPOA ceases having effect as soon as the donor dies. At that point, the executor of the estate takes over as the legal representative of the deceased person. There are two separate forms of EPOAs: one that can be set up for use regarding personal care and welfare, and the other which covers financial and property decisions. These two separate EPOAs do have some unique features. Enduring power of attorney for property •

More than one individual can be named as the EPOA for property and can be mandated to act either jointly or separately.

•

The donor can choose that the EPOA for property comes into effect immediately (while the donor still

has mental capacity), or that it only becomes effective if and when the donor lacks capacity to manage their own affairs. •

A ‘successor’ attorney can be named to take over if the initial attorney dies, withdraws, or becomes incapacitated themselves.

Health practitioners may become involved with EPOAs at various points: •

They may be asked to perform an assessment to ensure a person has the mental capacity to set up an EPOA.

•

They may be asked to provide a certificate to say whether the patient now lacks capacity, thus allowing an EPOA to be activated.

•

When there is a legal conflict within a family, they may be asked to retrospectively describe a person’s mental capacity at a point in the past, when they were not asked to perform an assessment at the time. This situation contains a number of pitfalls, and we would suggest you contact Medical Protection (or your MDO) to discuss such requests before providing any response.

Enduring power of attorney for personal care and welfare •

An attorney for personal care and welfare will have the power to make decisions on medical treatment, where the donor lives, and whether they need to go into residential care. This is a very significant position, and people need to choose someone they trust completely to make the best decisions on their behalf.

•

Only one person can be named as the attorney, which means this position cannot be jointly held. A successor attorney can be named, as with an EPOA for property.

•

An EPOA for personal care and welfare cannot be activated while the donor still has capacity. Before the EPOA is formally activated, the appointed attorney can make a decision on the donor’s behalf if the decision which the attorney is making is minor, and they have a reasonable belief that the donor lacks capacity. If the decision is a major one (such as choosing where a person is going to live), a doctor’s certificate is required either to activate the EPOA or to confirm that the donor lacks the capacity to make that decision.

•

Even when an EPOA has been activated, the donor may still have the capacity to make some decisions for themselves, and they should be consulted about decisions to the extent that they are able to understand.

•

The attorney cannot consent to brain surgery or electro-convulsive treatment provided for the purposes of changing your behaviour. They also cannot consent to experimental treatment, unless it could save the donor’s life or prevent serious damage to their health.

•

The attorney is required to always act in the donor’s best interest, and cannot direct that lifesaving treatment, or treatment to prevent serious damage to health, should be withheld. This means if a patient wishes not to be resuscitated, they must set up an advance directive, rather than relying on their EPOA to be able to refuse consent on their behalf.

When performing a capacity assessment, the doctor needs to be clear what the decision is for which the patient’s capacity is being assessed. Capacity is decision specific; a person may have capacity to decide they wish to undergo a specific treatment but may not have the capacity to manage their financial affairs. When performing a capacity assessment, the decision in question should be clearly stated and the assessment should be directed towards clarifying the patient’s capacity to understand, retain, and reason through the information required to make that specific decision. Sometimes these assessments can be straightforward and can be performed by any clinician, and there are some good resources that can help with performing and documenting such assessments. In complex cases, or cases where the patient’s capacity is borderline and the consequences of the decision are significant, it may be best to refer the patient to a psychiatrist, neuropsychologist or psychogeriatrician. Medical Protection members who need more specific information about EPOAs can contact us on 0800 225 5677. REFERENCES 1.

Health and Disability Commissioner. 2021. Doctor’s failure to assess mental capacity of dementia patient. https://www.hdc.org.nz/decisions/ search-decisions/2021/20hdc00126/ 2. Hawke’s Bay District Health Board. nd. Performing Capacity Assessments: Information for GPs. http://hawkesbay. health.nz/assets/Publications/ Performing-Capacity-Assessmentselectronic-booklet.pdf Douglass A, Young G, McMillan J. 2016. A Toolkit for Assessing Capacity. http://www.aspenltd.co.nz/mc/assets/ Capacity%20Toolkit.pdf

WWW.ASMS.ORG.NZ | THE SPECIALIST

Sharing research and expertise

Noticeboard

ASMS is proud to have res earch it commissioned from Motu on the gender pay gap published in the renowned internation al journal BMJ Open. The article – The gender wage gap among medical specialists: a quantitative analysis of the hourly pay of publicly employed senior doctors in New Zealand – suggested a gender pay gap of 12.5%. You can search for it on the BMJ Open website. ASMS’ research has also featured prominently at two virtual internation al conferences. Dr Charlotte Chambers spo ke to the International Association on Workplac e Bullying and Harassment Conference in Dubai recently, and gave a presentation on spe cialist burnout to the joint BMA/AMA conferenc e on doctors’ health in London. She was also the keynote speaker at the recent RACS Conferen ce Women’s Breakfast where she spoke about gen der bias in medicine.

Smokefree 2025 submission ASMS has made a submission to the Ministry of Health on its discussion document, Proposals for a Smokefree Aotearoa 2025 Action Plan. It considers that proposed actions to reduce the appeal and addictiveness of tobacco products, reduce affordability, and reduce access to tobacco provide a strong basis for achieving the goal of less than 5% tobacco use prevalence in Aotearoa New Zealand by 2025.

Prevocational conference Registrations ha ve opened for th e virtual 2021 Aust ralian and New Zealand Prevoc ational Medical Education Forum on 18 and 19 October. The mai n themes of this year’s conference are transitions an d innovations; heal th equity and cu ltural safety; professio nalism and wellb eing. The keynote spea kers are Dr Jason Frank (Can ada), Dr Rhys Jones (Aotearoa) , and Professor Trudie Roberts (U K). For more information, inclu ding details of how to submit an abstract, visit: prevocationalfo rum2021.com

26 THE SPECIALIST | JUNE 2021

ss Sick leave succe

e Government ing a win after th Unions are claim mber days of nu the minimum g tin lif n w la a ed pass strong campaig 10. It followed a to e ly av le ng k ro sic st s id pa ich wa ature petition, wh r and 10,000-sign e importance fo th g in ht lig gh hi S, M AS w la by w d supporte ed. The ne sick leave they ne e th ve le ha op to pe le n peop d will mea ect in August an is due to take eff ys sick leave will da 10 an ng less th days, effective currently receivi t increased to 10 en m le tit en r ei have th ent. Under the of their employm y ar rs led ve ni an e on th ployees are entit A agreement, em s es illn of t en ev ASMS DHB MEC full pay in the on e” av le le ab to “reason exceeds five here an absence ee or an accident. W quire the employ re e employer may th , ys da g in rk wo ical certificate. to produce a med

Art Exhibition

ASMS staff

We are excited to let you know that the art exhibition featuring the work of senior doctors and dentists is now confirmed. It will coincide with ASMS’ Annual Conference in November.

Communications

The “Doctor and Dentist Artists” exhibition is being curated by the New Zealand Academy of Fine Arts in Wellington, where the artworks will go on display.

Senior Communications Advisor Eileen Goodwin

More than 50 doctors and dentists have already signed up to take part but there is room for more. The artwork can include ceramics, sculpture, paintings, photography, or jewellery. Decisions on whether individual works will be accepted will be made by Academy staff.

Industrial

If you are keen to submit something or want more details, please contact our industrial officer Lloyd Woods at lloyd.woods@asms.org.nz as soon as possible. We are looking forward to what promises to be a great event!

Executive Director Sarah Dalton Senior Communications Advisor Elizabeth Brown

Senior Industrial Officer Steve Hurring Senior Industrial Officer Lloyd Woods Senior Industrial Officer Henry Stubbs Industrial Officer Ian Weir-Smith Industrial Officer David Kettley

ASMS services to members

Other services

As a professional association, we promote:

ASMS job vacancies online

• the right of equal access for all New Zealanders to high quality health services

Check out jobs.asms.org.nz a comprehensive source of job vacancies for senior medical and dental specialists/ consultants within New Zealand hospitals and health services.

• professional interests of salaried doctors and dentists • policies sought in legislation and government by salaried doctors and dentists. As a union of professionals, we: • provide advice to salaried doctors and dentists who receive a job offer from a New Zealand employer • negotiate effective and enforceable collective employment agreements with employers. This includes the collective agreement (MECA) covering employment of senior medical and dental staff in DHBs, which ensures minimum terms and conditions for more than 5,000 doctors and dentists, nearly 90% of this workforce • advise and represent members when necessary • support workplace empowerment and clinical leadership.

Industrial Officer Miriam Long Industrial Officer George Collins Industrial Officer Kris Smith Industrial Officer Georgia Choveaux Industrial Officer Tina McIvor Policy & Research

Postal address: PO Box 10763, The Terrace, Wellington 6143

Director of Policy and Research Charlotte Chambers

P 04 499 1271 E asms@asms.org.nz W www.asms.org.nz

Support services

Policy Advisor Mary Harvey Manager Support Services Sharlene Lawrence Senior Support Officer Vanessa Wratt

Have you changed address or phone number recently?

Membership Officer Saasha Everiss

Please email any changes to your contact details to: asms@asms.org.nz

Support Services Administrator Cassey van Riel

If you have reason or need to seek a reduction or waiver to your annual subscription, please write to us. Our constitution allows for this in certain circumstances. Emails should be addressed to sarah.dalton@asms.org.nz

PO Box 10763, The Terrace Wellington 6143, New Zealand +64 4 499 1271 asms@asms.org.nz

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A century of trust.

The Specialist June 2021 - Issue 127

Articles inside

Art Exhibition

Noticeboard

Enduring powers of attorney – Providing consent for those who can no longer consent for themselves

Five minutes with Dr Tim Ritchie

A life spent fighting for justice – Helen Kelly

A view from rural health Did you know?

Feedback

Little for health in Budget 2021

Rural health ready for reform

Riding the e-bike wave

Health equity – being part of the solution

Surprise and delight at bold reforms

Public ‘mandate’ for health reforms – expert view

Doctors fighting for democracy in Myanmar

Restructuring the health system: what’s needed

A new era dawns – what do members think?

MECA 2021 – Getting to the crunch

Solidarity with nurses

Pay ‘freeze’ sparks anger and back-pedalling

Change brings opportunity as well as challenges

“Thank you for your service” – the great decluttering of New Zealand health