The Magazine of the Association of Salaried Medical Specialists | I S S U E # 1 3 7 | D E C E M B E R 2 0 2 3
T H E Y S A W R E D STRIKE COVERAGE FROM THE PICKET LINES P. 4 – 1 5 M O T H E R H O O D T A X A N D C M E THE GROWING GENDER GAP BETWEEN MALE AND FEMALE CME CLAIMS P. 2 2 Q U E S T I O N S O F R E F O R M Q&A WITH NATIONAL DIRECTOR OF HOSPITAL AND SPECIALIST SERVICES P. 3 2
ISSUE #137 DECEMBER 2023 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: Andrew Chick Journalist: Matt Shand Designer: Twofold Cover Image: Shutterstock (edited) The Specialist is produced with the generous support of MAS.
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UPFRONT 02 We have their number 03 An executive summary ON THE PICKET LINE 04 Combating outdated austerity 09 They saw red 12 A numbers game 14 A striking distraction PROFILE: DR HIRAN THABREW Shrinking numbers
16
Royal Australian and New Zealand College of Psychiatrists Chair Dr Hiran Thabrew speaks about the shortages plaguing the mental health sector and what they hope the incoming government can do.
18
Unions call for stronger stance on government failures
FEATURES 22 Motherhood tax and CME 26 Clashing cultures 28 A sea of difference 32 Questions of reform 34 The times they are constraining 36 Doctors make the judgement call IN BRIEF 39 Health and Disability Commissioner launches video on respecting rights
39 40 40 40
Te Whatu Ora hears from ASMS about health and safety Consultation to regulate physician associates is extended New industrial officer for Northern region Rapid growth in private surgery a threat to the public system
DECEMBER 2023 PAGE 1
WE HAVE THEIR NUMBER
It seems perverse to adopt rhetoric that will antagonise a crucial workforce.”
PAGE 2 THE SPECIALIST
JULIAN VYAS, ASMS PRESIDENT
The specious numbers published by Te Whatu Ora during negotiations have only further eroded members’ goodwill. And our strike action has put this erosion in a new light. Since my last article we have reached a draft settlement for our Te Whatu Ora negotiations. By the time you read this – hopefully – everything will be signed and sealed. These negotiations have been historic for ASMS. The failure of Te Whatu Ora to come to the table with anything like a meaningful offer meant we had no choice but to take industrial action for the first time ever. The tenets upon which we based our initial claim were fair and cogent. Te Whatu Ora’s paltry offer (no doubt shaped in part by the Government) fell well below that. Unsurprisingly, given the longstanding crisis of workforce numbers and morale in the public health sector, Te Whatu Ora’s ‘tone deaf’ approach resulted in members voting overwhelmingly to go out on strike. Te Whatu Ora’s public ‘counter argument’ to our claims was to conjure up specious figures for the average pay that an SMO gets. This merely served to galvanise members’ resolve even further, and we had excellent turnout on all three strike days. I don’t think the powers that be expected us to go through with them. Despite the brief duration of each strike, I sincerely believe that they had a significant ‘wake-up’ effect on our employer and the Government, and resulted in them noticeably improving their offer. But, in trying to portray us as greedy, I fear Te Whatu Ora has made a further significant error. It seems perverse in the extreme to adopt rhetoric that will antagonise a workforce that is crucial for the success of the health system reforms. Assuming there is not another threemonth delay while the employer finds a bargaining team, we will be in bargaining again from mid-July next year. It is most likely we will still be facing a senior medical workforce crisis of recruitment and retention. Emollient words about the workforce ‘doing it tough’ without significantly addressing the underlying problems will look completely hollow.
Members will quite rightly expect those who have accepted positions of leadership – within the health sector and government – to find solutions to the problems of the public health system they are responsible for. The recent performance review data shows that, whilst some of the most extreme delays have been overcome, the health system is still failing an increasing number of Kiwis. I would also question the reliability of the data Te Whatu Ora is using – in my own hospital I am still aware of some patients waiting more than a year for non-surgical treatment to be initiated. Without a workable solution in place, and assuming an incoming Government might be even less inclined to pay public sector workers more, the system needs huge goodwill from all its workforce just to keep things ticking over. Memories of specious data about doctors’ pay could well finish off any vestiges of that goodwill. I think an important facet of the strikes that might be overlooked is the way it has changed how we view ourselves. We made our paymasters understand that recruitment and retention is ignored at the risk of the whole system. And we showed the public how important their health and wellbeing is to us. In doing both these things, we showed that when we stand alongside one another to fight for our health system, we see ourselves in a new light of self-empowerment and connectedness with our peers. I genuinely hope that, when we start bargaining, ASMS members will not have to resort to industrial action again. After this September, I also know that if we are left with no alternative but to strike, we’ll be prepared to do this – as yet another battle in our ongoing fight for a properly functioning, properly staffed and properly resourced public health system.
AN EXECUTIVE SUMMARY
THIS JOB QUICKLY BRINGS YOU FACE-TO-FACE WITH THE MANY PROBLEMS CONFRONTING OUR HEALTH SYSTEM.
SARAH DALTON, EXECUTIVE DIRECTOR
Thinking about what to write this issue, I realised many of you may have little idea what I do on any given day. So I thought today I’d paint a picture of a day in the life of an executive director. It started with a coffee meeting with one of Te Whatu Ora’s senior workforce people. We hadn’t met previously. It was a chance to understand a bit about them and what they’ve been tasked with. Encouragingly, they completely agreed with our key analysis – that the DHBs (and now Te Whatu Ora) see overstaffing as riskier than understaffing. It’s a polite way to say we deliberately understaff our hospitals. The bigger and more important question is, what will Te Whatu Ora do about it – and when? Next, I responded to a member email detailing chronic understaffing of an ICU. It has been ongoing for years, and we’re at the point of imminent implosion. We had a discussion, agreed some steps, and I put in a call to one of the regional directors. Today is Mary Potter Hospice’s annual fundraiser. It involves atrocious music from the park next door, but also strawberries! It turns out a strawberry sundae at 10am is immensely good for the spirit – and I warmly recommend. It also brings me to recall the time I supported some hospice staff with a job sizing. They had to include ‘dressing as strawberries’ at their annual fundraiser as one of their required work activities. When will we fund core health services – including ambulances and palliative care – so that clinicians don’t have to include dress-ups and fundraising as part of their workload?
Next, I had to abandon a phone call with a concerned citizen who wanted to test their reckons about the health system, in favour of an internal strategy meeting about Kenepuru Hospital. Satisfied we had a good set of plans, I left the building in search of lunch. I have a lunch break most days (I’m better when fed – and a horror when hangry). I know many of you don’t. Maybe if you make one New Year’s resolution you make it that. The many, many facets of unmet health need will still be there when you get back – but you’ll be fed and watered, and slightly rested to go again. During lunch the regional director called me back about the ICU and I got an undertaking to be copied into the draft decision. There seems to be national engagement (through the network) and regional collaboration – so I’m hopeful that something tangible and positive might be about to happen. Then I got very late notice of an ‘information meeting’ about a decision on after-hours services at Kenepuru. This district has breached our consultation clause – so I explained to the Group Director Operations (GDO) they have to stop the current process and start over. If they don’t, we’ll injunct. By the time The Specialist lands in your letter box I guess we’ll know what happened. That brings me to three o’clock. Then it’s a couple of columns to write and, barring accidents, time to head home. Tomorrow, I’m talking to some psychiatry registrars about becoming SMOs and how ASMS can help. Then I’m heading to Auckland for the Waitematā JCC. It will be great to see some of you there in person – similarly at Annual Conference the week after. Again, I thank you all for your hard work, for your solidarity and courage, and for hanging in there, in our under-funded health system. We have so much to do and a tough environment in which to do it. And if you need a conversation starter (or finisher) at Christmas parties or dinners, try this: In 2020 Treasury estimated the economic cost of people living with ill health to be between $10 billion and $27 billion per year. This exceeded the $21 billion spent on health by the government in that same year!
I thought I’d paint a picture of a day in the life of an executive director.” DECEMBER 2023 PAGE 3
ON THE PICKET LINE
COMBATING OUTDATED AUSTERITY
PAGE 4 THE SPECIALIST
DECEMBER 2023 PAGE 5
ON THE PICKET LINE
THE PUBLIC SERVICE PAY ADJUSTMENT (PSPA) HAS BEEN A MAJOR HURDLE AND A CATALYST TO STRIKE ACTIONS FROM MAJOR UNIONS, INCLUDING ASMS THIS YEAR. HOW DID ASMS COMBAT THIS AUSTERITY MEASURE AROUND THE TABLE AS IT BARGAINED WITH TE WHATU ORA TO RENEW OUR COLLECTIVE AGREEMENT, AND HOW WILL IT AFFECT NEXT YEAR?
Nurses, teachers and senior doctors all had to be prepared to strike this year to combat a lack of recognition of the cost-of-living crisis from their employer. Each met with varying degrees of success. But all had to do so in the shadow of the Government’s Public Service Pay Adjustment (PSPA). The PSPA was initially heralded as a $2.3 billion additional pay bump to soften the impact of high inflation. Thousands of public service workers would receive a lump sum payment of $4,000 and an up to 3 per cent increase on their annual income the following year. There was one slight problem with the PSPA: rather than an additional pay offer, it became the only pay offer. “Right from the beginning we had a horrible, sinking feeling that the PSPA was not going to result in a cost-of-living adjustment and that the real outcome would be to potentially bind unions to the unofficial bar in public service negotiations,” ASMS Executive Director Sarah Dalton says. “Certainly, the PSPA formed the basis of Te Whatu Ora’s initial offer, which we rejected outright.” The final settlement of ASMS’ single employer collective agreement (SECA) seems like a
PAGE 6 THE SPECIALIST
success, given it occurred at a bargaining table dominated by a PSPA mindset. Essentially any request over the 3 per cent plus lump sum threshold would be an uphill battle. For this reason ASMS’ opening claim centred around the consumers price index (CPI). “The PSPA terms would have only delivered a 1.8 to 2.5 per cent salary rise for senior doctors and dentists,” ASMS lead advocate Steve Hurring said. “Through our bargaining efforts we have secured a nominal 7 to 8.8 per cent increase in salary rates and a weighted average across all salary bands of 5.73 per cent. “This means we achieved a better result than CPI overall for this year and a much better deal than the PSPA would have allowed us. “The increase is higher than that achieved by the Post Primary Teachers’ Association and the New Zealand Nurses Organisation this year. In comparison, judges were only awarded a 3.1 per cent salary increase.” Hurring says the bargaining had to be centred around what was achievable within a PSPA environment, and asking for a much higher sum initially would likely have resulted in the other side walking away from the table.
LEFT: HEADING OUT IN TAIRĀWHITI. BELOW: MEMBERS VISIT TE WHATU ORA HQ. BOTTOM: CROSS-UNION SOLIDARITY IN WELLINGTON.
“It is, however, a strong step in the right direction and one we will be building on when bargaining resumes next year,” he said. “We achieved much in this round of bargaining outside of the base salary, including improvements to the use of CME accumulation (essentially becoming four years instead of three) and the 20 per cent loading for shift workers in emergency departments. “We would not have got where we got without the strike action, that much is also clear. We will have to continue being vocal over the next year and continue to bring the pressure in 2024.” The pressure saw the negotiations taken to facilitated bargaining with the Employment Relations Authority. The final settlement was basically the recommendations of the facilitators and supported most of ASMS’ intended claims. This could signal a change in the tide when it comes to adherence to the PSPA in future, and ASMS receiving a larger than prescribed settlement could spell its death knell.
Learning for next year The new Te Whatu Ora agreement expires at the end of August 2024, meaning there will be another round of bargaining next year. It is possible that industrial action, in some shape or form, will be part of future bargaining too, and ASMS says it has learned much from this year’s action. ASMS members showed there was appetite to send a strong message to Te Whatu Ora about the state of the workplace. The strikes also showed doctors had a sense of unity. ASMS also reported an almost 7 per cent increase in membership through the period of industrial action. Based on the success of paid union meetings during this bargaining, ASMS is also planning to ensure it makes fuller use of the legal right to hold them in 2024 to bolster communication and feedback from members.
DECEMBER 2023 PAGE 7
ON THE PICKET LINE
THE SETTLEMENT The ASMS settlement delivers the following to members: •
The settlement will run until 31 August 2024. This means 8 months has passed since the previous MECA expired and leaves only 9 months before negotiations begin again.
•
There will be a 3 per cent plus $4,000 lump sum adjustment to all salary steps straight away.
•
There will be a second increase to salary steps from 1 January 2024. The increases are part of a smoothing process and vary at each step but see an average adjustment of $8,142 (with a minimum of $5,900) to all specialist steps and an average of $6,631 (with a minimum of $5,250) to all officer steps.
The following benefits have also been obtained through the negotiation process: •
A minimum shift allowance for emergency department of 20 per cent of base salary.
•
Revised CME accumulation rules so members can effectively accrue up to four years’ entitlement.
•
“Under the SECA, ASMS can hold two paid union meetings each year, and we intend to hold at least one of those next year leading up to bargaining.”
Going forward, doctors will be placed on the appropriate salary step from the time they meet the requirements of vocational registration, not the actual date of registration.
•
With MECA bargaining taking longer and including three separate strikes, the cost of the bargaining process exceeded its initial budget. With the 2024 MECA bargaining set to be even more protracted, and potentially include further forms of industrial action, ASMS has indicated it will increase its bargaining budget line four-fold up to $200,000.
Provisions to ensure leave balances, CME and retiring gratuities transfer when moving between Te Whatu Ora workplaces.
•
Technology is added to the list of resources the employer is expected to provide.
The meetings were held in 2023 to communicate the parameters of the initial Te Whatu Ora offer and allow members to discuss what strike action would look like. “We learned much from listening to our members and found the paid union meetings extremely valuable,” Dalton said.
This additional budget gives more flexibility to cover extended negotiations and collateral for any strike action that may occur. Further, ASMS will hold Te Whatu Ora to greater account over its preparedness to negotiate. The bargaining in 2023 was hampered by the lack of an advocate from Te Whatu Ora, which resulted in bargaining only starting after the formal term of the MECA had expired. “We will not be tolerating any delays or delaying tactics next year,” Dalton says. “We have generated a good result this year, but there is much more to achieve and we are motivated to get that result. “The strength of the strike action, the power of our collective voice, was heard throughout New Zealand and we need to build on that to ensure our health care work force is invested in so we can all enjoy a robust health care system.”
PAGE 8 THE SPECIALIST
To see the revised collective with changes marked up, visit https://asms.org.nz/wp-content/ uploads/2023/11/ASMS-TWO-SECA2023-Changes-Highlighted.pdf The see the additional terms of settlement agreed between the parties, visit https://asms.org.nz/wp-content/ uploads/2023/11/ASMS-TWO-SECAAdditional-terms-of-settlement.pdf
THEY SAW RED IN SEPTEMBER ASMS MEMBERS TOOK TO THE PICKET LINE IN THE UNION’S FIRST-EVER NATIONAL STRIKES.
DECEMBER 2023 PAGE 9
ON THE PICKET LINE Doctors turned up in red shirts, surgical scrubs and grim reaper outfits. However they dressed, their effort made a big difference as part of our first-ever national strike of senior doctors in New Zealand. At hospitals across the country, over three separate strikes, thousands of members turned out to voice their concerns about working conditions and pay issues that they knew have been present in the public health system for years. Collectively it was time to say it wasn’t good enough and it is time to invest in health. That message was proudly displayed on t-shirts and placards alike. From there it successfully made its way onto mainstream and social media. Media monitoring showed the September strikes received over 300 separate media mentions over print, radio and TV. The country at large clearly accepted the proposition that senior doctors and dentists should not have to shoulder another real-terms pay cut, especially in the current pressured environment. The breadth of coverage and public support gave Te Whatu Ora clear pause for thought.
levels of overtime to dangerous underresourcing and cracks in the system where patients all too often fell through. Each picket line had its own flavour. Auckland’s first strike drew a large crowd despite the rain. Coffee kept spirits and hands warm, and placards transformed into makeshift umbrellas for those caught short. In Wellington, members took impromptu action to bring their message into Te Whatu Ora’s headquarters in the CBD – for those decisionsmakers who chose to avoid the picket lines at the hospitals. Northland brought a touch of the macabre with a Halloween theme – including a coffin and a gorilla decrying the state of the health care system and funding for doctors. But every district saw some activity.
So too did the range of local issues that bubbled up with local media coverage. Across the country doctors spoke to media about the issues in their part of the health system and why the lack of investment contributed to those woes.
Perhaps most poignantly, Kapiti’s lone psychiatrist, Dr Marie Bismark, captured the attention of the community and the nation through her powerful message of being the ‘last one standing’ (see ’A Striking Distraction’ p15) at a one-person picket in Paraparaumu.
This ranged from short-staffed emergency departments, lack of colleagues, and crushing
Each effort added to the pressure, and that pressure had a real impact on the negotiations.
PAGE 10 THE SPECIALIST
The constant flood of headlines, showcasing the same fundamental issues at different hospitals, presented Te Whatu Ora with an undeniable narrative. The ongoing risk of reputational damage having their senior workforce on strike – and doing so in such a vocal way – gave ASMS important leverage it needed to continue to push for its core claims at the bargaining table. ASMS largely won out on those claims thanks to the pressure mounted by members on the picket lines, supported by the members who maintained life-preserving services during the strikes.
When Te Whatu Ora agreed to facilitated bargaining and it became clear some progress was possible, ASMS called off two longer strikes – scheduled before and after the General Election in October. In the employer’s mind those strikes were a much larger logistical challenge and a very real prospect given the earlier industrial action. With the term of this new collective agreement set to run out in August next year, and with more to do, this year’s industrial action has sent an important message that the senior medical and dental workforce will stand up for itself and make its voice very loud and clear.
DECEMBER 2023 PAGE 11
ON THE PICKET LINE
A NUMBERS GAME FACTCHECKING THE CLAIMS MADE BY TE WHATU ORA
Official Information Act requests have revealed some questionable data and tactics used by Te Whatu Ora when it decided to publicly release figures about the average salary levels of senior doctors and dentists during bargaining.
In the midst of ASMS’ negotiations for a new collective agreement with Te Whatu Ora, its Chief People Officer, Andrew Slater, who is paid between $372,800 and $657,600 a year, made a public statement in which he claimed the average salary for a senior doctor employed by Te Whatu Ora was $318,000 per annum. It was a claim that upset many ASMS members. It did not reflect the reality of their payslip and felt like a stunt – to provoke resentment from other working people amid protracted bargaining and undermine support for industrial action amongst the general public. The statement immediately drew ire from ASMS members, who raised it with ASMS staff and challenged it on social media. The ASMS bargaining team raised it across the negotiation table. A media statement from ASMS on August 22 challenged Te Whatu Ora to explain its figures and pointed to the MECA with printed rates for salaries between $170,000 and $250,000. The Specialist also asked Andrew Slater directly to explain how the numbers were calculated. When Te Whatu Ora did not provide an adequate response, we made an Official Information Act request. The emails released by that request reveal a chain of communication between Te Whatu Ora senior leadership. Slater emailed his team in response to the ASMS release stating, “Ummm we probably need to get prepared to defend our numbers.” In another email Te Whatu Ora bargaining advocate Mick Prior states, “The numbers are defensible and have been tabled in bargaining (without question of rejection by the union).” ASMS says this never occurred.
PAGE 12 THE SPECIALIST
Slater also said, “We will share our detailed calculation data at discussion planned later this week with the union.” Again, ASMS says this did not happen. Following these emails suggesting Te Whatu Ora was prepared to be transparent, the communications show a change in approach. First, Mick Prior requested that media enquiries from The Specialist about Slater’s statement be “deflected to the advocates (me) for response”. However, when The Specialist did direct its questions to Prior, as requested, he advised they “should be directed through its [ASMS’] advocate” first. When ASMS was informed via the Te Whatu Ora media team to do so and asked the question further, ASMS was deflected again and told the question “should be directed through its advocate”. In another email Te Whatu Ora Director Employment Relations Gretchen Dean emailed the leadership team defending the data and stated, “No other data should be provided publicly in response to the ASMS media release…” “We do not need to defend salaries only the accuracy of publicly release [sic] information. The table below has been established on payroll data dated September 2023.” A staffer who collated that data admitted in an email to senior leadership, “The data has a few wrinkles!” One unintended ‘wrinkle’ is the year that the data is being taken from. Dean says the data is from the September 2023 payroll. However, the data released under the Official Information Act is from September 2022. Using that 2022 data, the average salary figure of $318,000 was achieved by adding in overtime, additional duties, superannuation and KiwiSaver
It was a claim that upset many ASMS members. It did not reflect the reality of their payslip and felt like a stunt.”
contributions and dividing by the total FTE employees, not the actual head count. Another ‘wrinkle’ is that the figures are different from a second set of payroll data released to The Specialist via the Official Information Act process. These second figures show the average salary package, including overtime, additional duties and superannuation commitments, for an idealised FTE was $287,147 in 2022 and $304,702 in 2023 (again including all overtime and additional benefits). This second data set also showed the validity of the claim from ASMS that doctors are fed up with the amount of overtime and additional duties they are being expected to shoulder. The payroll data showed Te Whatu Ora’s overtime and additional duties costs have increased 284 per cent over the past 10 years whereas salary totals increased just 17 per cent. ASMS executive director Sarah Dalton says doctors are becoming fed up with having the plug gaps in the workforce and would much rather have rest and recovery time. “Doctors want quality time, not overtime,” she said. In 2014 the amount paid to SMOs for overtime or additional duties was $32 million, but by June 2023 this figure had ballooned to $123 million per annum.
Further, using the amount of overtime a person is asked to work as a reason to not justify a cost-of-living increase to salary is a strange logic.” Chief People Officer Andrew Slater stands by his statement. In a release to The Specialist he wrote: “Te Whatu Ora stands by the information provided to media during pay negotiations with ASMS about average Te Whatu Ora employed specialist remuneration. This information was shared openly with union representatives during bargaining and in response to information requests, and was prepared by our data team. “There will be some members who looked at the average total remuneration figure and said ‘I don’t earn that much’. There will be some who would’ve said ‘I earn more than that’. “That is the crux of one of the issues Te Whatu Ora brought to bargaining, and both parties have committed to work on as part of the settlement. “We have undertaken to do further work on the pay disparity and inequity issues we have inherited during the term of this collective agreement and into the next bargaining. We look forward to working with ASMS to that end.”
“These figures show the extent Te Whatu Ora is relying on overtime and goodwill to fill gaps.
PAY SCALES FOR TE WHATU ORA EXECUTIVE LEADERSHIP Delivery roles, focused on frontline service delivery – Banding $438,400–$774,000
Enabling roles, focused on key enablers of delivery – Banding $372,800–$657,600
Support roles, focused on providing wider support – Banding $280,000–$475,000
National Director Hospital and Specialist Services
Chief People Officer
Chief of Staff
National Director National Public Health Service
Chief Financial Officer
Head of Assurance Audit and Risk
National Director Commissioning
Chief of Data and Digital
Maiaka Whakaruruhau Tikanga (Chief of Tikanga)
National Director Innovation and improvement
Chief of Infrastructure and Investment Officer
National Director Pacific Health
Chief Clinical Officer
DECEMBER 2023 PAGE 13
ON THE PICKET LINE
A STRIKING DISTRACTION MATT SHAND, JOURNALIST
Te Whatu Ora’s failure to recruit and retain staff for mental health services is leaving the community short, as a champion of the recent strikes soon discovered – her help came at others’ loss. In September the solo strike of Kapiti consultant psychiatrist Dr Marie Bismark captured the attention of the community and journalists – but Te Whatu Ora simply labelled her a “distraction”.
Bismark says this only shows how short the community mental health teams are and that vast numbers of people are unaware the service is even available.
Bismark’s picket sign said she was “all by herself” as her colleagues had all “burnt-out, retired, gone private or moved overseas”.
“We were inundated,” she says.
As a result, she was left to manage a population of 60,000 and a case load of 300 people, worrying each day someone was going to die as a result of a system stretched too thin for too long. “All I heard from Te Whatu Ora was that I was being ‘a distraction’,” she says. “I like to think if an Air New Zealand pilot was on the news warning about people dying in plane crashes it would be treated as more than a distraction.” Ironically, the end result of the publicity around Bismark’s strike action was that her office was flooded with calls from new patients wanting to join her service.
“People were calling and seeking medical attention. The point of the article was that there are not enough psychiatrists, but it revealed that many people never knew there was a community mental health facility in Kapiti. “Some had severe mental health issues that needed to be treated right away.” Following the strikes, Bismark was pleased to hear she would finally have some help in the form of another 0.7 FTE psychiatrist and a psychiatrist registrar at 0.5 FTE. But there was a catch. The extra staff comes at the cost of staff in Wellington’s community mental health team, who now just have 1.2 FTE and soon will have 0 FTE with one resigning and the other going on maternity leave. “It [having additional FTE] means someone else does not have them,” says Bismark. “Part of the problem is that we are just short everywhere. In Wellington we need 60 FTE and I know we have about 38 over the entire region. We need locums but struggle to attract them as we do not pay them market rates.” Bismark says the money ‘saved’ by Te Whatu Ora through missing FTE needs to be invested to assist the services. This could be locums, administration assistants or anything that will alleviate the workload. “There is a lot of money sitting there as vacancies that could assist people,” she says.
PAGE 14 THE SPECIALIST
“There must be millions ringfenced for specialists who are not in the system.” Bismark is correct. Data obtained by The Specialist via the Official Information Act reveals Te Whatu Ora has 739.8 FTE vacancies for SMOs as of October 2023. The data is not broken down into departments, but assuming an average salary based on Step 11 of the MECA, the vacancies represent approximately $165 million to $170 million worth of unassigned salaries. “I know it can be difficult to assign SMO salaries to other jobs as what happens when you recruit? But we are in dire straits now and need the help,” says Bismark. Te Whatu Ora Chief People Officer Andrew Slater says underspends in salary budgets do not mean they can be regarded as a surplus. “Vacancies do not necessarily translate to underspends or surpluses, including because vacancies often require that we pay overtime or allowance rates to continue delivering services,” he said.
Having additional FTE means someone else does not have them.” – DR MARIE BISMARK
Mental health whack-a-mole Wellington Community Mental Health psychiatrist Helen Cassidy says Te Whatu Ora is playing ‘whack-a-mole’ with its mental health staff.
“We model staffing levels on the basis of 0.8 FTE per 10,000 people over 65 years old,” he says. “I cover 35,000 people, so in reality there should be three of me.”
Bismark’s gain comes at the loss of staff in the Wellington Community Mental Health team. The move is not decried by Cassidy, but the lack of recruitment and retention from Te Whatu Ora is.
Regarding understaffing, Beverley says, “It’s been going on a long time. The DHBs were not very proactive in replacing everyone and I begin to think it’s a long-term financial strategy.”
“We fill one gap and create another,” she says.
The effect of this is his speciality service does not always get to those that need it. Patients miss out and those waiting for diagnosis may require additional hospital treatment.
“We are running at 45 per cent of our SMO allotment and there is no help in sight. We have 1.3 FTE and we should have 3.5.” Cassidy will soon be taking maternity leave and the remaining 0.3 FTE will be retiring about the same time. If a strike were to occur again, it would be a strike of none in Wellington. “Soon there will be no one left,” says Cassidy.
“I can only spread myself so far,” says Beverley. “I have noticed quite a few emails about my lack of availability in the Wairarapa, but I am only there for 8 hours a week. We need someone there for 40 hours a week.”
“We are disillusioned and there is not even any locum cover. There seems to be a lack of advertising for locums for our team and we desperately need them.
Beverley says any investment in his department would be a boost and make a real difference.
“Te Whatu Ora says they are advertising for more, but I do not see any evidence of it. Nothing ever happens.”
“A junior or a nurse practitioner would be really great. Adequate nursing staff would go a long way. Even a medical student would be a huge boost. The sad thing is it usually takes a coroner’s report to make a change in the system.
Cassidy says the long-term effect of being shortstaffed, aside from patients going without, is that a lack of trust starts to build up between staff and management. “We suspect they are more focused on acute issues, and acute services are understaffed as well. The system is beyond breaking point,” she says.
Help needed for all ages Psychiatrist geriatrician Dr. Patrick Beverley says his department’s statistics for staffing make for grim reading.
LEFT: MENTAL HEALTH, ADDICTION AND INTELLECTUAL DISABILITY SERVICE (MHAIDS) EXECUTIVE CLINICAL DIRECTOR PAUL OXNAM. RIGHT: TE WHATU ORA CHIEF PEOPLE OFFICER ANDREW SLATER .
“There are all sorts of people who could assist me without being a specialist,” he says.
“The shortages feed into each other, and when they occur everything wobbles. Everything is straining. I can be ruthless and work to my contract only, but it does not feel great to know there is a person I could have seen now suffering as a result.”
Te Whatu Ora responds Mental Health, Addiction and Intellectual Disability Service (MHAIDS) Executive Clinical Director Paul Oxnam acknowledges the service has workforce challenges.
“Like other providers, MHAIDS faces ongoing workforce challenges due to a local and national shortage of appropriately qualified mental health professionals,” he said. “This means New Zealand competes internationally for prospective employees who must consider factors such as housing affordability, cost of living, and immigration processes. “Our Adult Community Mental Health teams – including mainstream and cultural-specific teams in Wellington, the Hutt Valley, Porirua and Kāpiti – are among those experiencing these challenges and we acknowledge the strain on our highly-valued staff.” Oxnam disputes the severity of the vacancy issue and says the community mental health teams have only had a 15 per cent vacancy rate over the last 12 months. “MHAIDS actively recruits to fill all vacancies and, in the extremely unlikely event that a service faced the prospect of having no FTE available in a particular profession, we would ensure appropriate service coverage was provided,” he said.
DECEMBER 2023 PAGE 15
“We’ve been asking the incoming Government to understand that there is unspent committed mental health funding.” – DR HIRAN THABREW
SHRINKING NUMBERS MATT SHAND, JOURNALIST
Royal Australian and New Zealand College of Psychiatrists Chair Dr Hiran Thabrew speaks about the shortages plaguing the mental health sector and what they hope the incoming government can do.
A constant sense of failure and moral injury is overshadowing the work of doctors in mental health in New Zealand says Dr Hiran Thabrew.
“One of the things that was highlighted to us immediately was the lack of data to support the perceptions of people in the field,” Thabrew said.
A survey conducted by the Royal Australian and New Zealand College of Psychiatrists revealed 94 per cent of psychiatrists said the resourcing of inpatient and specialist mental health and addiction services is not fit for purpose.
“We are partnering with Te Whatu Ora to do a deep dive into the data regarding the psychiatry workforce around the country, see where the gaps are and make some recommendations for future recruitment.”
In addition, 90 per cent reported increased demand, increased complexity of patients’ needs, and increased after-hours work.
New Zealand has the lowest rate of psychiatrists per capita in the OECD, with just 15 per 100,000 of population.
“Amongst all of us there is a sense of moral injury,” says Thabrew. “Essentially people are trying to do their best for people. You are trained to do a job and you are not able to do that, so you constantly feel like you are failing.” In response to growing concerns, the College has been advocating and lobbying governments for change and increased investment into mental health services. A major hurdle to overcome is the lack of accurate, and robust, data from Te Whatu Ora about the state of the mental health workforce.
PAGE 16 THE SPECIALIST
In comparison, Australia has 20 per 100,000, and countries like Germany have 30. Psychiatry for the aged and very young is even more short staffed, with only one psychiatrist for every 100,000 children. “We’ve under-invested in training and as a result we have particularly high shortages of Māori psychiatrists and psychiatrists in rural areas, so there are increased inequities as a result of that. “Ahead of the election we asked an incoming Government to address the workforce shortages by investing $60 million over six years to support 60 new psychiatry trainees through the system and into practice.”
PROFILE
DR HIRAN THABREW.
The average age of the current workforce is 55, and in a decade they will be looking to retire. This will create shortages around supervisory positions to train the additional workforce needed to cover demand. “It is important we train New Zealand psychiatrists as research shows they are more likely to stay and practise in New Zealand,” Thabrew said. “Addressing the workforce shortage has to be the number one priority for the new Government, and the second will be supporting the 260,000 New Zealanders who suffer from moderate to severe mental illness, who have the greatest need. “We’ve been asking the incoming Government to understand that there is unspent committed mental health funding, and we are asking for that to be fully spent and for future mental health budgets to increase to meet population growth and the rising cost of existing services.
“Attract, train and retain are the three keywords.” Why is New Zealand suffering from such severe shortages of psychiatrists in the public system, and why does New Zealand struggle to keep its mental health workforce here? “There are multiple answers, and they all interact with each other,” says Thabrew. “Historically, we have not had enough people, which makes the workload untenable. This leads to burnout, which leads to more people leaving. “Also, if there are other options which seem more attractive, either overseas or in private practice, people will start to vote with their feet.
“The last thing is to commit to making evidence-based decisions. The sad fact of our system is the last mental health survey was done in 2006, so it is almost two decades old at this point.”
“We’ve seen massive recruitment drives from Australia in particular. We’re getting emails on a daily basis advertising work in Australia for exorbitant rates. The converse of that is, the people who stay in the system are passionate about what they do, and they try their best with the resources they have.
Thabrew says we need to stop treating mental health as a ‘luxury item’ and recognise it as the significant health issue it is for many New Zealanders.
“They also want to see change occur to validate their reasons for staying in New Zealand.
“There are many drivers of mental health. Covid-19 and the current costof-living crisis have definitely been very stressful and increased rates of mental health conditions here and elsewhere,” he says.
“There is a good case for why we have to improve things. What we do know is when people cannot see psychiatrists and access of care is delayed, their condition will worsen and become more complex. This in turn makes it more costly to treat and has more consequences for the patient.
“We know mental health conditions are increasing across the world. There is more demand for our services of all kinds, and that means we are struggling to meet demand and patients are struggling to access services.
“Te Whatu Ora and the Government ensuring that people get healthy access to mental health is a smart economic decision as well as a smart health one.”
DECEMBER 2023 PAGE 17
UNIONS CALL FOR STRONGER STANCE ON GOVERNMENT FAILURES MATT SHAND, JOURNALIST
The theme of ASMS’ 35th Annual Conference – held in Wellington on the 23rd and 24th of November – was “resetting the agenda”. The new environment created by the Te Whatu Ora and the even newer coalition Government presented Conference with plenty of challenges.
PAGE 18 THE SPECIALIST
A call to arms from across the health sector became the theme of the 2023 ASMS conference on November 23-24, as senior doctors put Te Whatu Ora senior leadership on notice about their dissatisfaction and lack of faith in the transformation. The conference tagline was “resetting the agenda” and, based on the speeches given, that reset will be much more aggressive in response to the recent inaction improving the healthcare system.
The questioned echoed the sentiment of ASMS President Julian Vyas who said ASMS will have to “become more mongrel” in the coming years. “We have finally cut our political teeth and went out on strike,” he said. “We have suffered years of platitudes from those leading the health service. We showed ourselves that, having been pushed too far, we were prepared to stand up for ourselves.
In a question-and-answer session with Te Whatu Ora’s Chief People Officer Andrew Slater, clinicians attacked the lack of awareness of frontline issues such as health and safety, infrastructure and lack of workforce.
“ASMS should be more mongrel. If ASMS is going to become this we have to face the ethical dilemas that come from striking and taking this stance.”
“There are far too few junior doctors, and we are frequently working as the registrar,” said one member. “At times we are supposed to have five registrars and we only have two. We have signalled that this is unsafe for ourselves and our patients and the only response we get from Te Whatu Ora is, ‘thank you for your mahi’.
Chief Executive of the New Zealand Nurses Organisation Paul Goulter spoke to Conference and said nurses are focusing on direct action, as talk is no longer effective.
“My question to you is what should we do when we feel we work in an unsafe environment - as I feel many of us are - and how can we be assured the people up high at Te Whatu Ora know what is going on? Because I have no confidence you do.” Slater replied the lack of workforce is his number one priority and he measures his success on his ability to improve the situation. “In terms of that health and safety element, you know, what’s really important is that incidences of unsafe workplaces are reported and logged because that enables us to look at them and that information goes to a Board level,” he said. The member replied unsafe work practices are occurring daily and there is no time to put in data to show that. “I’m sorry but that [filling in forms] is just not an answer.” Another ED doctor told Slater “faith is gone” with Te Whatu Ora. “Our new record tally for the day is 400 per cent capacity. When are we going to get to the systemic root of the problem that we have had underinvestment for a long time? No one wants to front up and say we’re going to start to invest long term to get things going. How are we going to keep anybody coming back to work?”
More mongrel Many doctors questioned the public comments made by Slater during the strikes that doctors earned on average $318,000 [see page 12 for more details], with many saying if that were true, we would not lose so many to Australia and other countries.
United front
“The workforce is in an abysmal state… not one official, elected or paid, has said ‘I got that wrong’. How can we have such a lack of accountability in the health system?” he said. “We, as NZNO, are going to take more direct action as nothing else will work. We need to be a united force. Nurses need to be fluent about the shortages of doctors and doctors need to be fluent about the shortage of nurses.”
Financials National Secretary Nathalie de Vries reported on ASMS’ strong financial position, which showed a surplus and growing reserves. For 2023/2024 de Vries presented a revised projected surplus of $946,523. This is higher than expected due to the increase in membership, which rose 6.2 per cent over the year. The current cash reserve is also above target with an additional $2.4 million in reserves. Both of these things could prove very useful, with the possibility of greater legal action against Te Whatu Ora around non-compliance issues in the coming year, and the prospect of a difficult SECA bargaining round when the new agreement expires in August 2024.
Remits Several constitutional remits were passed at the Conference. These included the extension of coverage to clinical academics employed by universities and the addition of two Maori executive members, which means the National Executive increases to 13 members. A more controversial member remit that ASMS should request private health insurance as part
of its next bargaining with Te Whatu Ora was opposed by the National Executive and did not pass. However, following a presentation from UnionAID Chief Executive Tim Sutton, a remit from the floor of the Conference was passed, agreeing to donate $1 per member to the charity – approximately $6,000 in total. The Conference also passed a statement on Gaza addressing “the loss of life and injuries inflicted on civilians and healthcare workers in the Middle East from 7 October 2023.”
DECEMBER 2023 PAGE 19
PAGE 20 THE SPECIALIST
22
26
28
32
34
36
Motherhood tax and CME
Clashing cultures
A sea of difference
Questions of reform
The times they are constraining
Doctors make the judgement call
DECEMBER 2023 PAGE 21
MOTHERHOOD TAX AND CME MATT SHAND, JOURNALIST
The gap between male and female CME use is at least $35.8 million and growing every day. Senior Medical Officers and mothers are calling for childcare to be included in CME applications to level the playing field.
PAGE 22 THE SPECIALIST
Since the arrival of her children, single mother by choice Dr Rebecca Ayers has had her access to vital conferences shut down by those who approve her continuing medical education (CME) leave. Over the past two years her entitlement has reached its maximum amount. She feels locked out and left behind by her male, or childless, colleagues. “I have been unable to attend an overseas conference in two years,” she said. “In life, there are increased costs of being a solo parent, but having to pay out of pocket [rather than be allowed to use CME] to get the equivalent education as my non-solo parent colleagues or those with childcare options feels unfair to me. “If a person has dependent children, then travel allowances should include them. “I enquired about using CME for childcare or bringing a carer with me and I received a flat ‘no’ from Southern DHB. I never addressed the issue again.” Instead, Ayers makes do with online conferences or other education opportunities not reliant on travel. It means she misses out on many education options along with the networking and after-lecture discussions that come with attending conferences in person. “I have an interest in hand surgery and especially congenital hand surgery. This is a real issue for me in maintaining my level of knowledge,” she said. “It is inequitable.”
career development given the trend for women to work predominantly in the public sector. She asked if this should be discussed during the next round of MECA bargaining. “I want something written on the contract rather than being at the mercy of a clinical director or manager. “I refuse to accept the current situation of having to negotiate with the clinical director and higher powers and involve ASMS every time women with children want to undertake face-to-face CME with childcare expenses,” she said. “Especially when we use our own CME allocation, which is essentially part of our salary package, to do so. Some clinical directors are supportive, but I know more clinical directors who really are not.” Clause 36.2(b) of the MECA states that “employees shall be reimbursed actual and reasonable expenses of up to $16,000 per annum” for CME. The term ‘reasonable’ is the nexus of the issue. Questions of what is reasonable and who decides are often being raised. Solo parents and parents with children with special needs have a different experience of that word.
Data obtained by The Specialist shows Ayers’ case is not an isolated one. A gulf exists between the amount of CME used by male and female SMOs, despite ASMS’ membership being split 45 per cent female to 55 per cent male.
Each year there is a $5 million to $6 million difference between the CME expenses claimed by male SMOs and female SMOs. When international travel dried up during the pandemic, the gulf between women and men dropped to just $1.6 million per year. As international departure gates reopened, so did the gulf. Ayers is not alone. A post on the New Zealand Women in Medicine Facebook group revealed widespread issues for parents trying to use CME to get childcare for their children. Dr Serena Park asked via the New Zealand Women in Medicine Facebook page if women should have more provision for their
ANNUAL TREND IN TOTAL TE WHATU ORA CME 80,000,000
60,000,000
Total CME Spend
From the eight districts able to separate CME payments by gender, male doctors received $115.4 million worth of CME over the past seven years while female doctors received $79.6 million.
40,000,000
20,000,000
0
2015
2016
2017
2018
2019
2020
2021
2022
Year
DECEMBER 2023 PAGE 23
FAR LEFT: DR FIONA BOWLES. LEFT: PRESIDENT OF THE NATIONAL COUNCIL OF WOMEN NEW ZEALAND SUZANNE MANNING.
Park argues doctors should have more flexibility and more certainty about when and how they can use their CME when they are the primary caregiver for a child, or women will continue to be left behind. “So long as it is not being abused for taking families on holidays, carers should be able to access it to cater for their individual care needs up to its limit,” she says. Park would also like to see parental leave changes included in MECA bargaining. “There are a number of things we can consider, including in our MECA, that don’t cost Te Whatu Ora any extra money but make a difference for women working in the public sector,” she says. In Victoria, Australia, use of CME for caregivers is spelled out as a $250 per day justifiable expense. Doctors just need to demonstrate they are the primary caregiver once to be able to access the additional funds. Doctor Fiona Bowles is a mother to a child with autism and agrees the Victoria model would be of great help. She says the experience of applying for CME leaves her feeling disillusioned and disenfranchised. “There are only three people in the world who can care for my child,” she says. “When I applied for CME to take my child and carer with me, I was asked by a nameless bureaucrat why he couldn’t just stay at home. “That is a very personal thing to reveal to a stranger. Eventually, they agreed to pay for my child but would not pay for a carer, which made the whole exercise [going to conference] pointless. “I think so long as you are not being cheeky you should be allowed to use your CME for your dependent children. “I watch my male, and childless, colleagues going off to conferences and I just can’t do that. It is a huge equity issue. I do most of my CME online, but it is just not the
PAGE 24 THE SPECIALIST
same. It is a complex issue as we don’t want people taking whole families away when they do not need to.” Doctor Katrina Gibson says, as a mother of two with one child requiring special care, she has had to stick to online courses or courses available during school time. “This is not just an issue for people with small children,” she says. “My child with special needs is 10 years old and I do not see my circumstances changing perhaps until he is an adult. “I do not want to take advantage of the funds but, clearly, I cannot take the same CME opportunities as a colleague who does not have those commitments. “It would be mind-blowing if I could use CME funds to enable me to take my child and support person with me, or even some proportion of that cost.” President of the National Council of Women New Zealand Suzanne Manning says the fact there are gaps in the education accessed by women “is unfortunate but not surprising”. “One thing that comes up often when it comes to inequities in the workplace is childcare. “There is a motherhood tax. From a wider point of view, what we would like to see are more systems in place to make access easier for mothers with children.” Manning says the inequities in receiving education and training on the job can lead to further the inequities in pay between women and men in the workplace. “We have to ask these questions from time to time and see what systems changes we can make to decrease inequities,” she says. ASMS Industrial Officer Iain Weir-Smith says childcare requirements for primary carers are an important aspect of CME, and it is particularly relevant for doctors coming from overseas.
MALE VS FEMALE – NUMBER OF CME APPLICATIONS
Male Female
MALE VS FEMALE – SUM OF CME VALUE 75,000,000
40,000
Sum of CME Value ($)
Number of CME Applications
50,000
Male Female
30,000 20,000
50,000,000
25,000,000
10,000 0
Auckland
Counties Manakau
Hutt Valley
Mid Central
0
Waitemata
Auckland
Counties Manakau
Hutt Valley
District
Mid Central
Waitemata
District
MALE VS FEMALE – NUMBER OF CME APPLICATIONS TOTAL
MALE VS FEMALE – SUM OF CME VALUE TOTAL
Sum of CME Applications Male TOTAL
58932
Sum of CME Value Male TOTAL
$98,293,492
Sum of CME Applications Female TOTAL
31688
Sum of CME Value Female TOTAL
$69,396,938
“IMGs are not likely to have the same networks of family and friends to rely on when it comes to childcare, especially if here solo,” he says. “This is part of the package to recruit IMGs, and it needs to be allowed for, providing the costs are reasonable. “We have had many cases where childcare was initially denied. But we argued with the employer about the reasonability of the claim and won. The challenge is determining what is reasonable, and the word reasonable means different things to different people.”
Dalton says the development of a national CME policy is irrelevant as CME policy already allows for doctors with children to use their allowance for childcare where needed. “It is a matter of following the rules instead of creating new ones,” says Dalton.
COMPARISON OF CME SPEND BY DISTRICT Auckland
ASMS Executive Director Sarah Dalton says this issue is about a fundamental right.
Bay of Plenty Canterbury
“We consider it an absolute right of the primary caregiver to have childcare included in the cost of CME leave,” she says. “If that is the cost of them attending a conference, and the only way a person can attend a conference, then it is a reasonable expense.
Cap Coast Counties Manakau Hawke’s Bay Hutt Valley
District
“If members are facing difficulty getting access to CME for childcare, we encourage you to make contact with your local industrial officer with more details.
Lakes MidCentral
“The MECA already allows for this. But we are becoming more and more aware of bad practices and of management putting up road blocks.”
Nelson Marlborough
Te Whatu Ora’s Chief People Officer Andrew Slater was asked whether CME should be used for childcare.
Tairawhiti
“Where there are specific concerns around accessing continuing medical education, we’d encourage SMOs to discuss these directly with their employer,” he said.
Waikato
“Te Whatu Ora and ASMS have previously discussed jointly developing a national CME policy, and we continue to be open to progressing this once bargaining is concluded and the parties can focus on this work.”
2020 2022
Southern
Taranaki
Waitemata Whanganui 0
1
2
3
4
5
6
7
8
9
10
11
12
$ (m) NOTE: Northland, Wairarapa, West Coast and South Canterbury were unable to provide data full data for this table.
DECEMBER 2023 PAGE 25
PALMERSTON NORTH HOSPITAL.
CLASHING CULTURES MATT SHAND, JOURNALIST
A review of Te Whatu Ora MidCentral’s workplace culture has revealed a widespread negativity that is causing professional and personal harm to SMOs. The Specialist looks into the report and what has been done to address the issues it raises. A damning report into the workplace culture at Palmerston North Hospital in July revealed most SMOs have experienced ‘frequent’ impacts of negative culture that produced substantial discomfort, stress and harm. The report, authored by organisational psychologist Jonathan Black, was commissioned in late 2022 and finalised in July 2023 after concerns were raised about the interpersonal incivility between medical staff. Instances of negative workplace culture – including siege mentality, fear of disagreement, tribalism, passive-aggressive habits and narrow concentrations of perceived power and influence – were found to be occurring. In the report’s own words, “The purpose of the proposed process was to identify patterns of thought and action impacting current medical staff regarding team culture and climate.”
PAGE 26 THE SPECIALIST
Interviews with clinical teams revealed a number of ‘external influences’ that were shaping culture, including the evolving health social contract, physical space limitations at the hospital, recruitment and retention issues, and ongoing chronic resource challenges. The report also notes the impact of demographic changes. “An increasingly aging population – anticipated and known within social planning – generates higher demands on public health service delivery and available resources.” Black recognises these factors lead to frustration. But it is when these frustrations are combined with people’s fear for their psychological and career safety that the impact is most harmful. According to Black, the chronic challenges in the workplace regarding workload have led many staff at MidCentral to feel “unsupported, under-
They are not turning up to clinicians’ meetings and hearing from their staff. It appears to be just more of the same. Zero change.” – ASMS MEMBER
valued and illustrative of a health system unwilling or unable to support and retain motivated, skilled and knowledgeable staff”. “This impact culminated for many interviewed – to varying degrees – in at times extreme exhaustion, compromised patient care, decreased clinical performance, increased clinical risk and dissatisfaction with MidCentral as a long-term career option.” In terms of practical recommendations, Black’s report recommended urgent consideration of funding for a dedicated high dependency unit and increased resourcing for the intensive care unit. It also recommended that:
ASMS Industrial Officer Greg Lloyd says addressing the ongoing issues at MidCentral is a priority for ASMS. The union will be conducting its own interviews and seeing what process changes members can make themselves. “It is important staff work in an environment where they feel safe and supported, and where they can work to the best of their ability. “The issues at MidCentral have been widespread. The report will have been pointless, unless the recommendations are actioned. “The best gauge of whether those recommendations have made a difference will be if the affected staff feel the situation has improved.” MidCentral acting director Dr Jeff Brown says there have been “internal culture challenges” but management is committed to addressing them.
•
a dedicated programme of confidential professional supervision be developed
•
a professional committee to provide a means to raise, address and resolve workplace relationships at the SMO level, separate from the existing hospital-wide Speaking Up For Safety programme, be established
“A safe and welcoming work environment which has patient safety and staff wellbeing at its centre is a priority for Te Whatu Ora and we will continue to strengthen the culture and shift practices towards the values, aspirations and behaviours outlined by Te Mauri o Rongo, our New Zealand Health Charter,” he said.
•
senior leadership acknowledge the importance of feedback and ensure ongoing communication with progress updates, suggestions, ideas and initiatives
“Changing culture takes time and MidCentral is working with peers across the country to shift the practices identified as part of recent reviews.
•
patient care pathways regarding referrals across departments and specialties be clarified
•
urgent consideration be given to funding a dedicated, appropriately resourced and accessible common area for both SMOs and RMOs.
What has been done?
“Other hospitals around the country have their own intensive care, high dependency units or critical care units and associated services aligned to local need, and common areas are likewise configured based on the needs of staff. We work to continually evaluate service sufficiency and whether we can make better use of our facilities for the benefit of patients and our people.
Sadly, staff at MidCentral report there has been limited, if any, change to the workplace culture since the report was published.
“Te Whatu Ora is committed to building a sufficient and well supported workforce – which is why our Health Workforce Plan 2023/24 has a focus on growing and strengthening our workforce.
“There is some on-the-ground change, where groups of people are trying to be nicer to each other, but there has been zero process change,” says one ASMS member. “As a result, we have lost some of the advocates for change, and the wider view is that changes have not been addressed.”
“We wouldn’t expect the Plan’s impact to be seen already in our latest available workforce data (June 2023), but we are confident it will begin to have a visible impact on workforce supply over the coming year and beyond.”
Management did establish a governance committee, but staff say it lacks power, adequate terms of reference and the follow-through to hold people to account. “They [management] say they want to do this,” says another ASMS member, “but they are not actually doing anything to enact that. They are not turning up to clinicians’ meetings and hearing from their staff. It appears to be just more of the same. Zero change.”
MIDCENTRAL ACTING DIRECTOR DR JEFF BROWN.
DECEMBER 2023 PAGE 27
“Our ophthalmology clinic will see between 40 and 50 patients every day it is docked in port over its 10-month stay in each city.” – ELLA HAWTHORNE
THE AFRICA MERCY AND GLOBAL MERCY MOORED IN DAKAR
PAGE 28 THE SPECIALIST
A SEA OF DIFFERENCE MATT SHAND, JOURNALIST
A New Zealand optometrist is currently working on board one of two volunteer-run hospital ships that provide vital medical services in Africa.
DECEMBER 2023 PAGE 29
“I don’t know how to explain it other than to say I feel like I am in the right place.” – ELLA HAWTHORNE
The days start early in Sierra Leone for New Plymouth optometrist Ella Hawthorne. But each day she takes solace in the difference she makes to those facing a life of blindness. For the past six months Hawthorne has been volunteering aboard the Global Mercy hospital ship currently docked in Sierra Leone, where she acts as Ophthalmic Team Manager. Initially taking a six-month sabbatical, Hawthorne has now signed up to complete two more years aboard the vessel – seeing the difference her work makes while seeing a different part of the world. “I don’t know how to explain it other than to say I feel like I am in the right place,” she says. The Global Mercy is a floating hospital that travels around Africa. It docks in locations for up to 10 months essentially ‘plugging in’ a hospital to regions that need additional care. The vessel is funded from charitable donations and grants. NEW PLYMOUTH OPTOMETRIST ELLA HAWTHORNE.
Every member of the crew, from captain to cleaner to orderly to surgeon, is a volunteer with a drive to improve the lives of others through accessible health care. “I wanted to use my privilege, in the form of education I received, and talents I was born with to help people in less fortunate situations,” she says. “Both sides of my family have stories of going above and beyond to help others, and that inspired me to volunteer.”
PAGE 30 THE SPECIALIST
Most of her days are geared towards maximising the impact of their ophthalmology clinic. This requires extensive groundwork, which sees Hawthorne travelling to remote communities in Sierra Leone, screening patients, assessing need, and planning to have the patients brought to the Global Mercy for procedures. Most of her days involve screening patients in the field – community health centres, community housing facilities, halls and anywhere that is free – assessing the severity of illness and recommending treatment options as well as conducting optometry work. Patients will then travel to the Global Mercy for surgery and other treatment within her department. “Our ophthalmology clinic will see between 40 and 50 patients every day it is docked in port over its 10-month stay in each city,” she says. “You just keep going. Some days you won’t be home until 7pm or later. The next person keeps coming in and you think, beautiful, how can I help this person. “We’re here to identify people who are blind or will soon be blind from the World Health Organization’s standard and remove them from that blindness list or prevent them from getting onto it. “There is a little give and take as our presence can cause a little bit of disruption in everybody’s
ELLA HELPS WITH PROCEDURES ON BOARD THE GLOBAL MERCY.
day-to-day lives but, in the end, they understand that we really are just there to help as many people as we can.” The pre-screening and patient logistic management mean when ophthalmology surgeons volunteer aboard the Global Mercy they are treating patients all day. “We run the eye clinic in such a way that when the volunteer surgeons come in, they can get as much surgery done as possible then head home,” she says. “The optometrists maximise the ophthalmologist’s surgical time. In our team we have an optometrist and ophthalmic technician alongside a scheduling
nurse, clinical coordinator, nurse and the day surgery unit lead. “It is a lot of professionals all coming together to build a team that can serve in a high functioning way. We have high volumes of patients, so it means everything needs to be coordinated. “The severity of some of our cases surprises you. The cataracts that we see are incredibly dense and it is a surprise people can even still walk around. “It is tough work, but it is worth it. Even if you only get a few hours sleep, you know, people can see now because of your work.” The tight unit complements the tight-run nature
of the ship. There is a strong sense that every role in the medical treatment process is important, and the value of the volunteers is respected. “The atmosphere on board is very supportive and collaborative,” Hawthorne says. “We’re all here and we’re all volunteering and that is the heart of the ship. You are always meeting new people.” Once the ship’s mission in Sierra Leone is complete, Hawthorne will be travelling on with it towards Madagascar. Hawthorne is looking forward to sailing aboard the vessel on open waters as she has never been on it whilst it is at sea.
Mercy Ships began in 1978 and has always had a strong connection with New Zealand. One of its earliest captains was a New Zealander. The ships have focused their efforts on Africa over the last 30 years. Nine out of 10 people in Africa are unable to access safe and affordable surgery when they need it. Mercy Ships recently added a second, larger hospital ship to their fleet. The older vessel, Africa Mercy, is about the size of the Interislander ferry and has a crew of 460. The newer vessel, Global Mercy, has a crew of 640. The intensive care unit, which includes 7 ICU/isolation beds, was paid for by a charitable contribution of $1 million from New Zealanders. The 174-metre Global Mercy provides the same level of care provision as a regional hospital and includes 6 operating theatres, 102 acute care beds and an additional 90 self-care beds along with auxiliary services. The hospital component of the ship is about 7,000 square metres, and the ship even has a school for volunteers travelling with families, so children do not miss out on their education. Over the 50-year lifespan of the ship it is expected to conduct more than 150,000 surgeries. More than 1,300 people volunteer aboard every year. More information is available at mercyships.org.nz
DECEMBER 2023 PAGE 31
QUESTIONS OF REFORM NATIONAL DIRECTOR HOSPITAL AND SPECIALIST SERVICES FIONNAGH DOUGAN FIELDS QUESTIONS ABOUT THE DIRECTION OF TE WHATU ORA, WHAT HAS BEEN LEARNED, AND WHAT THE ORGANISATION HOPES TO IMPROVE ON.
How has the centralisation of the health system helped things, are there any examples where it has hindered things, and what is being done to correct those hinderances? I have seen outstanding collaboration between our regions and districts as part of our drive to get waitlists down and to accommodate workforce shortages. More clinicians are travelling to other regions to deliver treatment, and more hospitals are opening their doors to treat patients from other areas. We are pulling together national-level data to give us a better view of gaps and opportunities – for example, we have done a nationwide theatre utilisation stocktake so we can start to maximise the productivity of our operating theatres. We are also increasingly well-positioned to hold national conversations with unions and other key health sector partners, which will support us all to problem-solve. Working through what the ‘new world’ looks like is a transitional issue, but it has caused some frustrations for our people, which must be acknowledged.
Staff shortages have been a major issue for senior medical officers, and they are voicing frustration. Data released by Te Whatu Ora revealed there are currently 740 unfilled FTE vacancies at present. Do you think this criticism is fair? SMOs typically take at least 14 years to train – so the current state of our SMO workforce has been building for some time. It will take time to fundamentally change that picture. What we’ve done is focused on international recruitment to try to alleviate the sharpest pressures and target areas where we most need more specialists. Increases to medical school places already announced will help increase the number of doctors graduating from our medical schools. We are also working to improve the pathway for our junior doctors to become SMOs, by increasing the number of training and fellowship roles available and by establishing a national RMO support service. It’s worth noting that we’ve got more doctors per head of population than ever before: one for every 275 people at July this year, compared to one for every 450 in 2000. This is all doctors, not just SMOs. We are continually growing our SMO workforce and added 100 more in the year to June 2023 – but demand for care also keeps rising.
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Based on immigration data, 811 Accredited Employer Work Visas (AEWVs) have been approved for doctors with Te Whatu Ora as of 30 October 2023. The AEWV was fully introduced in August 2022, and further changes to immigration settings in December 2022 made migration to New Zealand more attractive still for many health workers. So we suspect that we have not yet seen the full impact of those settings on our health workforce.
How many years will it be before New Zealand can rectify its SMO shortage? That is not something we can currently predict, because it depends on a range of decisions – not all of which are in our control. We know that growing our domestic medical cohorts and strengthening international recruitment is needed to make work more sustainable for our SMOs.
approach to reduce waitlists. Our immediate focus is on urgent patients and those who have been waiting the longest for treatment. We know this is making a difference. Long term, our goal remains that all patients accepted for surgery receive that treatment within four months. In the year to June 2023, we delivered nearly 20,000 more planned care interventions than the previous year – a 6.4 per cent increase, so that is a positive step.
How can New Zealand compete with Australia and global markets to ensure we get the specialists we need for our patients?
What are the key measures, you feel, that let New Zealand fall behind when it comes to recruiting and retaining SMOs?
Offering attractive terms and conditions and salary is important. Our real advantage is our commitment to growing our own and encouraging health workers from the rest of the world to recognise the unique context in which they can work. We can also capitalise on our reputation as one of the best nations in which to live. From Cape Reinga to Bluff there is something for everyone, and travel is easy.
We are not falling behind. We are in a global race for health talent. We are far from the only country where doctors are in high demand, and we need to keep making the case that New Zealand is the place to be.
What has been the biggest challenge for Te Whatu Ora during this time?
Growing domestic supply of doctors will make a big difference – New Zealanders are more likely to want to stay and work here than doctors who come here having grown up and trained overseas.
Some SMOs have said to management – ‘what is the plan’ when we run out of capacity to treat patients? Has this been discussed? Is there a plan when patient demand overruns staff supply? Our 2023/24 workforce plan is just the start of our more national, more coordinated action to grow our workforce. We are confident that by building on the plan we will not wind up in that situation. We are not going to plan for failing to address workforce pressures – we are going to focus on addressing them.
Te Whatu Ora data showed about 20–30 per cent of an average SMO’s salary was made up of overtime and additional duties. Is this an acceptable situation? Having a lot of allowances, as is common for SMOs, makes SMO pay nontransparent, and leads to people being paid different amounts to do the same job in different places. That is a result of how DHBs used to compete for senior medical talent. We want to focus on growing our workforce as a whole. We want to work with senior doctors over time on how we can improve transparency so that salary packages are fairer and more consistent.
A progress report from Te Whatu Ora showed only 3 of 101 moves recommended to improve planned care have been completed. What is causing the delays, what needs to happen, and what is the flow-on effect for patients? As of 1 November 2023, most of the recommendations (70) have been implemented or have planning underway. The majority of these will be ongoing – they do not have an end date as there will always be data and service improvements to be made. Three more have been completed and 28 are yet to be actioned. We acknowledge the impact waiting longer for surgery and treatment has on patients and their families and are taking a nationally coordinated
The reforms represent the biggest changes across the public sector in decades, and implementation began when we were still dealing with the pandemic and experiencing the impact of a global health workforce shortage. Change is always hard, but we hear these factors mean the transformation has been more disruptive for our kaimahi. This has been one of our biggest challenges, and I am very grateful for their patience and resilience.
What has been the biggest ‘win’ in your role so far? We have made progress in the area of planned care and know exactly who is on our waiting list and what their needs are. Working nationally and regionally we have been able to optimise use of our capacity and infrastructure to provide access and care for patients across what were previously specific boundaries. I am also very excited by the development of a much more integrated clinical voice as evidenced in the establishment of the national clinical networks. The priorities for each network will be clear and underpinned by our aspiration to deliver on the five system shifts outlined in Te Pae Tata.
What message do you want to pass on to specialists working at the front lines? We are listening and we really want to work with you on creating workplaces and operating models which support your engagement, empowerment and satisfaction. We know your work lives are busy and we want to alleviate the pressure as much as possible. I thank you for what you do every day.
What are you most excited to see occur in the next 6–12 months at Te Whatu Ora? The reorganisation of functions and roles across Hospital and Specialist Services has been a big challenge, and now people need certainty about their future as quicky as possible. Addressing our workforce shortages is critical to progressing our priorities, which are driving equity, implementing national and regional clinical networks, aligning daily operating models and optimising our capacity and productivity to improve flow and get planned care waitlists down.
DECEMBER 2023 PAGE 33
THE TIMES THEY ARE CONSTRAINING Health and Disability Commissioner Morag McDowell talks about the increased levels of HDC complaints post-Covid, the former Southern DHB Code breach, and informed consent issues.
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It is important that we guard against tolerance for a reduced standard of care and the potential for patient harm due to resourcing pressures.” – MORAG MCDOWELL
The current pressure the health and disability sector is under is evident in the increasing volume of complaints the Health and Disability Commissioner (HDC) is receiving – around 300 complaints a month. Complaint volumes are currently 36 per cent above pre-COVID levels. A number of these complaints reflect consumers’ concerns about current delays in care, staffing shortages impacting on the standard of care provided, constrained access to services and inadequate communication in the context of these delays. These issues are seen in many areas of the system, including specialist services, primary care, emergency services, mental health care, disability care and aged care services.
Resource constraints When the HDC sees areas of systemic concern, we raise these with the relevant agencies who can take action to address the issues. In this way we take a timely, collaborative approach to raising issues of shared concern. We have been engaging with Te Whatu Ora’s national office on the current issues seen in complaints about the pressure on specialist and emergency care, and the actions they are taking in this regard. The Code of Health and Disability Services Consumers’ Rights does not give people the right to access services. However, providers do owe people waiting for services a duty of care. Under the Code all people have the right to an appropriate standard of care that optimises their quality of life and minimises potential harm to them. This includes minimising delays where possible, particularly for care that is time-dependent, and ensuring that care is appropriately prioritised. It also means taking all practicable steps to ensure that staffing levels are adequate to provide an appropriate standard of care. The Code states that a provider is not in breach of the Code if the provider took reasonable actions in the circumstances to give effect to the rights and comply with the duties in the Code. Circumstances in this context include the consumer’s clinical circumstances and the provider’s resource constraints. The onus is on the provider to prove that it took reasonable actions. The HDC invariably takes the systemic context into account when assessing complaints, including staffing constraints and other resourcing issues. A recent example of the HDC’s consideration of delays in care is a commissioner-initiated investigation where I found the former Southern DHB (now Te Whatu Ora – Southern) in breach of the Code for delays in non-surgical cancer care. In this case, poor clinical governance systems (including inadequacies in quality measures and indicators) and poor relationships between clinicians and executive leadership led to the provider failing to adequately recognise and respond to the clinical risk associated with lack of capacity and consequent delays within its cancer service. As a result, people with cancer were harmed.
I acknowledge the work currently being undertaken in the sector to respond to the identified pressures, including a significant amount of work to reduce planned care backlogs. The constraints on the system are complex and will take time to address. The health reforms, while not yet fully realised, show us a potential way forward to address many long-standing issues in the sector, including geographical inequities in care, the poor outcomes experienced by some population groups and inconsistencies in quality of care. However, notwithstanding the current pressures, there is no room for complacency in terms of providing rights-based care, and the Code of Health and Disability Services Consumers’ Rights sets the benchmark for consumer-centred care in Aotearoa New Zealand. It is important that we guard against tolerance for a reduced standard of care and the potential for patient harm due to resourcing pressures. Reasonable actions must continue to be taken to give effect to people’s rights.
Informed consent Inadequate informed consent processes and information provision continue to be raised by complainants in around 18 per cent of complaints to the HDC. This is of concern, and continued focus is needed across the sector to improve informed consent processes. We launched online learning modules in November to support providers’ understanding of the Code, including informed consent and complaints management. These modules have been positively received by the sector, and they have currently been accessed by over 7,000 providers. In September I was very pleased to launch an animated video on the Code. This video was designed in consultation with consumers and provides a significant opportunity to lift the general public’s awareness and understanding of their rights under the Code. Ongoing increases in complaint volumes and complex and novel issues being raised in complaints, as well as having to respond to changes in the health and disability system, have posed significant challenges as well as opportunities. We have worked hard to respond to these challenges, focusing on peoplecentred and early resolution where possible and closing 16 per cent more complaints than the previous year. However, in the constrained environment within which we operate, there continues to be a gap between the number of complaints we receive and the number we can conceivably close. Regrettably, this is leading to delays in the assessment of many complaints. The HDC will continue to place a focus on reducing delays where possible in 2024, and re-designing our process to be more people-centred and culturally safe. In 2024 we will also be consulting publicly on a review of the HDC Act and Code. This review is a significant piece of work and will ensure the Act and Code remain effective and modern mechanisms for the promotion and protection of people’s rights.
DECEMBER 2023 PAGE 35
DOCTORS MAKE THE JUDGEMENT CALL JAYDE MEAD AND ADAM HOLLOWAY
A recent High Court case sends a message to the medical profession that courts discourage applications in cases where orders are sought that would require the court to make clinical decisions. Alvin Maharaj suffered a heart attack on 20 July 2023. He was placed on a life support system known as Veno-arterial Extra Corporeal Membrane Oxygenation (VA ECMO) at Auckland Hospital as a ‘bridge to a decision’ to allow his clinicians time to assess whether there were any interventional options available for him. From 20 July until 2 August 2023, Alvin’s family understood he was stable and the VA ECMO was working to preserve his life until a decision could be made by clinicians about the appropriate surgical intervention. On 3 August, Mr Maharaj’s family were advised there were no surgical remedies available, and the clinical team proposed taking Mr Maharaj off life support on 4 August 2023. This came as a shock to his family, resulting in distress and causing them to lose confidence in the clinical team’s medical advice. On 4 August, the lawyer for Mr Maharaj’s family wrote to Te Whatu Ora confirming the family did not consent to removing Mr Maharaj’s life
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support and asking for at least five days to allow them to obtain independent medical advice. Later that same day, applications were filed in the High Court by both parties. Te Whatu Ora sought an order that it was lawful for Mr Maharaj’s VA ECMO machine to be turned off, which would cause his death. Mr Maharaj’s family sought an order that Te Whatu Ora refrain from turning off the VA ECMO and continue to provide Mr Maharaj medical care until the family had obtained an independent medical opinion and had carried out religious duties. Te Whatu Ora obtained medical opinions from four clinicians involved in Mr Maharaj’s care, stating that there was no reasonable possibility of Mr Maharaj ever recovering and there was no further therapeutic benefit to continuing life support. Mr Maharaj’s family were unable to obtain an opinion from an overseas expert and sought further time to allow them to seek independent advice.
The Court considered that, ultimately, any declaration as to the lawfulness of the decision to withdraw life support will always turn on the specific facts of each case.” The High Court’s decision The Court dismissed both applications. It held this was not an appropriate situation for the Court to make orders, given the narrow nature of any potential unlawfulness and the serious and life-threatening consequences for other patients who might miss out on treatment as a result of decisions made about Mr Maharaj’s treatment. In making this ruling, the Court referred to a past Court of Appeal decision called Shortland v Northland Health Ltd, which held that “it is not for the courts to be the arbiters of the merits in cases of this kind”.i In reaching this point the Court had regard to two factors: •
•
Whether the doctors responsible for the patient, taking into account a responsible body of medical opinion, conclude there is no reasonable possibility of the patient ever recovering from their present clinical condition; and Whether there is any therapeutic or medical benefit to be gained by continuing to maintain the patient on support, and whether withdrawing such support accords with good medical practice, as recognised and approved within the medical profession.
The decision further recognised it is only in rare cases that a court might see fit to make a declaration of the nature sought by Te Whatu Ora.
The existing law The Crimes Act 1961 includes several duties that sometimes require the provision of lifeprolonging measures. These include section 151, which, applied to the hospital setting, imposes a legal duty on a doctor “who has actual care or charge of” a patient to supply them with the “necessaries” of life. While a doctor will only be criminally responsible for an omission to provide the necessaries of life if there is no lawful excuse for that omission (and the omission caused death, permanent injury to health, or endangered life), this duty is the key reason why doctors can be concerned about their legal obligations to patients on life support, ventilation, feeding tubes or other life-saving devices. Examples of past case law considering doctors’ obligations under the Crimes Act include: •
The Court considered that, ultimately, any declaration as to the lawfulness of the decision to withdraw life support will always turn on the specific facts of each case. The Court also accepted that a highly relevant consideration was the ongoing risk to the lives of other patients while Mr Maharaj remained on the VA ECMO, which is a limited resource. The Court stated: “The balance of convenience does not favour placing other patients’ lives at risk in circumstances where there is unanimous clinical opinion that Mr Maharaj will not survive, in the hope that an expert outside of New Zealand might take a contrary view.”
•
•
Hutt District Health Board v B:ii An order was sought declaring that the health professionals involved in the care of a 7-year-old boy with a terminal genetic condition, acting on the decision of the mother not to reinsert his PEG tube, would have a lawful excuseiii for that course of action – and such an “omission” would not constitute culpable homicide for the purposes of the Crimes Act. The Court held it was not in the child’s best interests to have the operation to reinsert the tube and that it would not be in accordance with good medical practice for this to occur. Auckland Area Health Board v AttorneyGeneral:iv The Court held there would be a “lawful excuse” to discontinue ventilation when there is no medical justification for continuing that form of medical assistance, and that this would not constitute culpable homicide for the purposes of the Crimes Act.
Shortland v Northland Health Ltd:v The Court applied the “good medical practice” test to determine that, by not providing dialysis treatment to a patient in the facts arising in that case, there would be no breach of the duty under section 151 of the Crimes Act.
Implications for clinicians In the context of the Crimes Act, it is understandable that clinicians have sometimes been concerned about and/or hesitant to proceed with withdrawing life support or similar life-saving tools without the Court’s confirmation that the proposed course of action will not have legal consequences. However, the Maharaj decision makes it clear that the merits of these decisions should not usually concern the courts. Clinicians should seek legal advice from their medical defence organisation in situations where they are unsure of their legal duties in a medical environment. There may still be situations more complex than the Maharaj case, where the factors involved are more nuanced, that would justify involving the Court. However, in cases like Mr Maharaj’s, where the patient’s clinicians say there is no other treatment that can be provided and no reasonable possibility of the patient ever recovering, the Court says that the law is clear, and clinicians should not be concerned so long as they are acting reasonably. i
Shortland v Northland Health Ltd [1998] 1 NZLR 433 (CA) at 134. ii Hutt District Health Board v B [2011] NZFLR 873. iii For the purposes of sections 151 and 164 of the Crimes Act 1961, Section 164 of the Crimes Act provides that accelerating a person’s death (for example, by removing a terminally ill patient’s feeding tube) can still be homicide (homicide is the killing of a human being by another, directly or indirectly, by any means whatsoever). This issue then becomes whether the homicide is “culpable” or not. iv Auckland Area Health Board v Attorney-General [1993] 1 NZLR 235. v Shortland v Northland Health Ltd [1998] 1 NZLR 433 (CA).
DECEMBER 2023 PAGE 37
Health and Disability Commissioner launches video on respecting rights Te Whatu Ora hears from ASMS about health and safety Consultation to regulate physician associates is extended New industrial officer for Northern region Rapid growth in private surgery a threat to the public system
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IN BRIEF NEWS FROM AROUND THE MOTU
HEALTH AND DISABILITY COMMISSIONER LAUNCHES VIDEO ON RESPECTING RIGHTS The Health and Disability Commissioner (HDC) has launched an animated video, titled Respecting your Rights!, aimed at empowering people to understand and exercise their rights when using health and disability services in Aotearoa New Zealand. “Everyone should be treated as a partner in their care,” says Health and Disability Commissioner Morag McDowell. “However, some communities continue to face challenges with health and disability services and may not understand their rights or feel empowered to exercise them. This video will strengthen people’s knowledge of their rights when receiving health and disability care and help promote person-centred care. “The Code [of Health and Disability Service Consumers’ Rights] gives everyone using health and disability services the right to an appropriate standard of care that meets their needs and upholds their dignity and mana.”
TE WHATU ORA HEARS FROM ASMS ABOUT HEALTH AND SAFETY Unsafe staffing conditions and a lack of contractual compliance – particularly around SMO accommodation and emergency department violence – were on the agenda when ASMS met with the health safety subcommittee of Te Whatu Ora’s Board on 17 November. The meeting was an opportunity to bring members’ issues directly to the people responsible for the governance of Te Whatu Ora. “We believe unsafe staffing has been normalised across our health system and we don’t see meaningful inroads into those shortages,” ASMS Executive Director Sarah Dalton told the subcommittee. “A story was told to me by an ED doctor about the day she was assaulted. She was punched by a patient and she talked about how she was so traumatised she couldn’t finish her shift and had to leave two hours early. But then she went back to work because we have normalised being assaulted as well as normalised short staffing.”
The video is aimed at everyone and covers what people’s rights look like in practice and the actions people can take if they are concerned about the care provided to them, or someone they know. These actions could include talking to the provider, having a support person on hand, using the Advocacy Service, or lodging a complaint with the HDC. McDowell says feedback from consumer hui was vital to the development of the animation. The launch of the animated video complements the recently developed online learning modules for providers about the Code. Over 7,000 providers have registered for the modules since they were developed late last year. The video is available in English and Te Reo Māori at www.hdc.org.nz.
Dalton also expressed displeasure at the “failure to provide standard and agreed facilities and conditions” as laid out by the collective employment agreement covering Te Whatu Ora, in terms of SMO accommodation, breastfeeding facilities and recovery time. “Our MECA provides for recovery time. It was introduced in 2017, to be in place by 2020, and it is still not the case. “In terms of sleeping accommodation for SMOs – many districts have no sleeping accommodation for SMOs let alone to the standard set out in the MECA. “We do a lot of talk about putting people at the centre of our health system, but we don’t. You are the Board and you are the people who have to have those conversations about Vote Health and how we continue to underfund our health system.” The chair of the health and safety subcommittee, Vanessa Stoddart, said it seemed there was a lot they could work on. “We are taking note of the workforce conditions… so heard,” she said, “but we’re trying to turn the Titanic after decades and decades of underinvestment.”
DECEMBER 2023 PAGE 39
NEW INDUSTRIAL OFFICER FOR NORTHERN REGION
CONSULTATION TO REGULATE PHYSICIAN ASSOCIATES IS EXTENDED
Sarah Thompson has joined ASMS as our latest industrial officer based in the Auckland region.
The Ministry of Health has been required to extend its consultation on a proposal to regulate Physician Associates (PAs) under the Health Practitioners Competence Assurance (HPCA) Act 2003
Sarah brings extensive campaigning and advocacy experience from her time at E tū union, where she most recently worked as their Campaign Director, and FIRST union as an organiser. Sarah also worked as the coordinator for Auckland Action Against Poverty.
The Ministry released a consultation document in June 2023 to a select group of stakeholders, including ASMS. In September, the Ministry paused the consultation process following a legal challenge from the New Zealand Resident Doctors’ Association (NZRDA), ASMS and the College of Nurses Aotearoa, under s116(b) of the HPCA Act. The challenge contended that the consultation had failed to meet the requirements established in this section of the Act, and that necessary detail was absent from the consultation documents. The Act requires that “providers of the health services concerned are generally agreed” on the qualifications of providers of those health services, the standards that providers of those health services are expected to meet and the competencies for scopes of practice for those health services. In November, the Ministry of Health released an addendum to their proposal, which included the education, training, competencies and scopes of practice required of physician associates in the United States, Canada and the United Kingdom. The consultation process has been re-started and will now run to 21 December 2023. The ASMS Policy and Research team is still interested in hearing from members about PAs, especially if you have experience working alongside or providing supervision for PAs. Please email virginia.mills@asms.org.nz. ASMS’ final submission will be available on our website following the December deadline.
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She has a masters in sociology with a focus on making social change. “I’m really looking forward to working with members to improve the health system,” says Sarah, “for doctors and dentists, and all of us who rely on it for our wellbeing.”
RAPID GROWTH IN PRIVATE SURGERY A THREAT TO THE PUBLIC SYSTEM Public money funnelled into private health care is undermining the public health care system, according to a new report from ASMS.
Creeping Privatisation reveals between 2014 and 2020 the number of elective private hospital discharges increased by 38 per cent, while public hospital non-acute discharges dropped 4 per cent. Over the same period the number of adults who saw a specialist at a private hospital (other than as an inpatient) jumped 32 per cent. “The public system is undermining itself with 46 per cent of private hospital discharges already funded from the public purse,” says ASMS Director of Policy and Research Harriet Wild. “Lack of investment in the public hospital workforce and infrastructure is rapidly increasing our dependency on private services to provide what public services cannot. “Further expansion of private health services means an expansion of private health staff. In a world desperately short of health workers, Aotearoa New Zealand’s private health sector is inevitably poaching from an already over-stretched public hospital workforce – and it’s easy pickings, given the poorer working conditions in public practice.” The report also addresses the equity issues that arise from an increase in private healthcare provision. “Private hospitals benefit those who can ‘pay to play’,” says Wild. “Those who have the money – or health insurance – to fund their surgery will get a health outcome those without simply cannot afford.” SEE WWW.ASMS.ORG.NZ/CREEPING-PRIVATISATION TO READ THE FULL REPORT.
ASMS SERVICES TO MEMBERS As a professional association, we promote: •
the right of equal access for all New Zealanders to high quality 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 at Te Whatu Ora, 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.
ASMS JOB VACANCIES ONLINE 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.
ASMS STAFF Executive Director
Sarah Dalton
COMMUNICATIONS Senior Communications Advisor
Andrew Chick Journalist/Communications Advisor
Matt Shand
INDUSTRIAL Senior Industrial Officers
Steve Hurring Ian Weir-Smith Industrial Officers
David Kettley Chan Dixon Adam Craigie Jenny Chapman Sarah Thompson Greg Lloyd Kirsty Macnab Kris Smith
POLICY & RESEARCH CONTACT US Association of Salaried Medical Specialists Level 9, The Bayleys Building, 36 Brandon St, Wellington Postal address: PO Box 10763, The Terrace, Wellington 6140 P 04 499 1271 E asms@asms.org.nz W www.asms.org.nz
FOLLOW US /asms.nz /ASMSNZ Have you changed address or phone number recently? Please email any changes to your contact details to: asms@asms.org.nz 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
Director of Policy and Research
Harriet Wild Principal Policy Advisor
Virginia Mills Health Policy Analyst
Lyndon Keene Industrial Research Advisor
Louie Hancock
SUPPORT SERVICES Manager Support Services
Sharlene Lawrence Finance and Technical Support Advisor
Vanessa Wratt Membership Officer
Saasha Manson Support Services Administrator
Danni Mackay
DECEMBER 2023 PAGE 41
MAS is a membership-based insurance and investment company for New Zealand professionals. We offer a range of general insurance, life insurance, income protection and KiwiSaver options to protect everything that’s important to you and your family. The MAS Retirement Savings Scheme is recognised by Te Whatu Ora Health New Zealand and the Royal New Zealand College of General Practitioners as a workplace savings option. The MAS Retirement Savings Scheme is also a recognised Overseas Pension Scheme for UK pension transfers.
Find out more at mas.co.nz or call us on 0800 800 627.