Mid-Winter Dialogues: Medical Workforce Planning
Christchurch School Of Medicine
Medical Workforce Planning:
16 August 2002
Association Of Salaried Medical Specialists
Thank you for the opportunity to participate in this session today. The topic is most timely. I believe that there is a pending medical workforce crisis in this country, both in our public hospitals and general practice, due to several factors including:
- the loss of a whole decade, the 1990s, to plan for workforce development needs and anticipate future pressures because of the misplaced ideological belief that market forces would sort these things out and consequently denigrating “planning’ to a dirty word associated with a pre-1989 shipyard in the Polish city of Gdansk;
- widespread international shortages in the medical labour market across many branches of medicine forcing New Zealand to compete with larger countries in, for example, Europe and North America as well as across the Tasman;
- our relative geographic isolation; and
- the impact of medical debt due to high student fees forcing excessive reliance on student loans.
The overall effect of these and other factors is creating a serious medical workforce situation that is bordering on crisis or arguably is already here. When the Association was formed in 1989 there were two main areas of shortage among the, albeit most numerous, branches of medicine - anaesthesia and psychiatry. Now I struggle to think of a medical branch that is not vulnerable to either no applicants for vacancies or noticeably small fields of applicants.
To better understand the seriousness of this situation it is important to understand the nature of the Association’s membership. Unusually for many medical organisations our penetration is high with over 90% of our potential members having paid their way. Consequently we are a useful barometer. Predominantly but not exclusively our members are employed in secondary care, mainly as specialists, and mainly in a DHB provided public hospital setting.
By the time our members take up their first appointment they largely fall into two age categories - middle age and old age. Arguably we are the youth wing of Grey Power. Half our members can’t find their glasses when they need them while the other half when they have found them can’t remember what they wanted them for.
What this highlights is that the vulnerability of the senior medical workforce is more to recruitment than retention although the serious threat to the latter can’t easily be discounted. In the context of serious nursing, resident doctor and senior doctor shortages, our collective anecdotal experience is that many of our members are over-worked, under-resourced and working in increasing unsafe environments.
As vacancies occur through retirement and other factors the ability to fill them is becoming more difficult. It is misleading to focus on statistics that report national shortages or even those in a particular DHB or hospital. They must be seen as a proportion of a department. With many of our members on rosters ranging from 1:3 to 1:5, one vacancy represents a loss between 20-33%. The ability to recruit to this type of work environment compounded by less or no registrar support, for example, is very limited. Unless corrective action is taken I anticipate many of our provincial hospitals in centres the size of Gisborne, New Plymouth, Wanganui, Timaru and Invercargill having to withdraw from several key core services in the near future due to their inability to provide a safe working environment.
So how can this be fixed? There is an unrestricted menu of possibilities but it would be wrong to focus on salaries alone. While not diminishing the importance of continuing to negotiate salary increases, international comparisons are misleading because they do not account for comparative purchasing power. While, for example, salaries in the British National Health Service compare extremely well on paper with those in New Zealand, this is much less so when the fact that a dollar in New Zealand purchases about the same as a pound in Britain is considered.
I have the following suggestions to make as part of the menu of “fixes’, all of which are within this country’s capacity to address:
1. Aggressive Coordinated Promotion of New Zealand
Consistent with my earlier comments there needs to be an aggressive promotion of New Zealand as a country with comparatively higher domestic purchasing power and unique attractive life style opportunities. Turn the negative of lower remuneration into the positive of high relative discretionary spending power in a country in which most of the population live within 2-3 hours of both a beach and a mountain. This should be part of a nationally coordinated rather than individual DHB campaign.
2. Student Fees
Excessively high student tertiary fees, particularly for longer courses such as medicine and dentistry, can only be addressed by government. But its impact on student loans and consequently debt is significant and a major factor behind our serious workforce situation. Finding ways of reducing debt after it has been incurred is important but it is after the horse has bolted, inevitably ad hoc and prone to inequity. Furthermore it does not address the underlying problem of why the debt incurs in the first place. The government has a responsibility to ensure a coordinated and balanced strategy of reducing fees and increasing eligibility for allowances. This will take some years before it benefits the health sector but long-term problems require long-term solutions.
3. Professional Development and Education: Converting Rhetoric for Quality to Substance for Quality
New Zealand falls short in its support for the professional development and education of senior doctors despite the relentless calls for quality improvement. We are supposed to be an innovative economy but we lack the infrastructure support for the means to achieve quality improvement in a geographically isolated health system. In contrast senior doctors in Europe and North America can normally access the full range of quality improvement events within a 2-6 hour plane flight.
New Zealand lacks the critical mass and sufficient close neighbours to ensure access to the full range of continuing education conferences and various professional development activities. Senior doctors need from time to time to cross hemispheres to attend these important events in order to keep abreast of developments. While the leave entitlement (two weeks per annum) is competitive the expenses reimbursement ($6,000-7,000 per annum) fall short particularly given the limited international purchasing power of the New Zealand dollar, particularly in Europe and North America.
Further, although most DHBs have provisions in ASMS negotiated collective agreements for both shorter-term secondment and longer-term sabbatical, these are not actively encouraged and largely rest on a high level of managerial discretion. There is no sense of pro-activeness within DHBs to utilise these valuable provisions.
And, of course, what is most devalued is time for quality. Time is the biggest resource for a highly intelligent, specialised, innovative and cognitive workforce and is precisely the key resource that is devalued with the narrow focus on those tangible things that can be counted - operating lists, clinics and ward rounds. Time for patient related investigation, clinical audit, peer review, administration and other clinical and non-clinical duties is downplayed. The ASMS is raising the importance of “time for quality’ in our collective bargaining and other forums but is disappointing to see so many DHB managers run for cover or turn their nose up due to their inability to distinguish between price and value.
Critical to overcoming our medical workforce dilemma is for New Zealand to market itself as a country that actively promotes high quality and value by aggressively resourcing and implementing professional and education development through a strategy based on:
- better funding for continuing education conferences and activities;
- resourcing and facilitating secondments (around two weeks every three years) and sabbaticals (around three months every five years); and
- ensuring adequate time for non-patient contact activities that are both clinical and non-clinical.
4. Quality Time for Rest and Recreation
Employees who on a daily basis make decisions that affect whether other people have their life harmed or improvement, suffer or receive relief, live or die are subjected to intense routine pressure. The routine nature of this pressure often means that it is taken for granted. But it is highly stressful and dangerous work. The consequences of error are severe for patients and therefore emotionally devastating for senior doctors before we start to even contemplate the implications for professional careers and medico-legal liability. Few others in the workforce face this level of stress and danger on a daily routine basis. Those who work like this need quality time out for rest and recreation in the interests of their own well-being and that of their patients as well as their productivity and effectiveness.
Britain is a key competitor in the highly competitive medical labour movement and one of its most attractive features is quality time for rest and recreation, particularly through six weeks annual leave. In fact so do many of our other international competitors. The ASMS has negotiated many improvements in annual leave from the original entitlement of fours weeks. Now the 21 DHBs range between five and six weeks with one-third receiving the maximum. Six weeks is the international standard and an effective recruitment strategy requires that it be across-the-board.
5. National Terms and Conditions of Employment
In 1992 the ASMS was forced to abandon national collective negotiations and instead negotiate on a single employer basis. Although we thought the world would end we proved rather good at it achieving many significant enhancements. We ratcheted around the land on the premise that if we did not ratchet we would end up as “rat shit’.
But, despite our objective of national consistency, it encouraged differentiation of employment conditions in different parts of the country for no other reason than enhanced bargaining leverage at particular times and circumstances more often than not due to our opportunist taking advantage of good fortune. There was no particular logic or rhyme and reason for these variable outcomes.
National conditions based on national negotiations is the most effective way of achieving national consistency and this is best for a coordinated recruitment strategy. With the diminishing ability to ratchet entitlements from DHB to DHB and with greater opportunities created by the fairer and more responsible Employment Relations Act, the ASMS will be considering this important issue at our annual conference later this year. This is a decision that rests with the ASMS although its effectiveness will also be determined by the behaviour and attitude of DHBs in the event that we proceed with national negotiations.
6. Calibre of DHB Management
One of the most depressing features on the health landscape is the wide variety of managerial skills and attitudes. We have an oversupply of managers and an under-supply of managerial talent. We have four types of managers in DHBs - the good, the bad, the ugly and the “frigging’ ugly. Fortunately managers are not equally distributed among these four categories.
Despite what it often feels like only a minority of managers are distributed among the last three categories. But they punch well above their weight and unfairly tar the reputations of the majority. The ASMS has witnessed too many instances of short-sighted or aggressive managerial attitudes being the last straw in senior doctors packing their bags or deciding not to take up an appointment. In a labour-intensive people-orientated service we even have some human resource staff that do not even seem to like people let alone have an affinity for health professionals.
Managers need to understand what makes doctors tick and what irritates them. They need to differentiate between the woods and the trees. I have seen too many cases of poorly performing managers in one part of the country turning up as “bright new brooms’ in other parts of the country. Too many managers travel with two suitcases - one for their luggage and the other for their egos.
In my view poor managerial performance is a factor that contributes to our workforce problems and part of the obstacle to overcoming them. The effect of the “bush telegraph’ service in the medical professional should not be under-estimated including its capacity to communicate experiences of bad management both nationally and internationally. Management is an administrative overhead that of itself does not produce value. We need good managers and often we have them. But they need to appreciate that they do best when they focus on helping those that actually produce value, health professionals, improve their effectiveness and efficiency. Managers must completely abandon the pervasive seagull culture of flying over the health sector, crapping everywhere and flying off.
7. General Practice
I have largely focused on secondary care but we should not forget primary care which is also facing a pending crisis and where the ASMS also has a growing number of members. I suspect that general practice offers a key foundation stone in helping address the staffing needs of our rural and provincial hospitals. General practice coupled with supplementary special interests may provide good quality generalist care that many of our secondary care settings would benefit from. It is an attractive prospect that fits in well with current government support for workforce planning and development and primary and secondary care integration.
But we also need to look at general practice from the standpoint of primary care itself, much of which is provided and provided well by the self-employed small business model. But I believe that this model is coming to the end of its life span in terms of the predominant means of provision. Already roughly 15% of primary care is provided by other means, largely community based organisations.
Workforce shortages among GPs and the associated recruitment problems are already well-known in rural New Zealand but our cities are also not immune. Even in the cities we learn of GPs having difficulties selling their practices and some walking away from them. Studies confirm high stress levels among currently employed GPs.
It is increasingly evident that many younger and aspiring GPs do not wish to purchase a practice. They just want to practice medicine. It is not just their high debt that is behind this attitude. Other factors include changing gender composition, desire for a family friendly work environment, hassles of running a small business and the problems in business partner relationships. I also suspect that many currently employed GPs would welcome the opportunity to leave behind these frustrations and consider salaried employment.
It is in this context that the government would do well to create an alternative career path for GPs by providing as a voluntary option, salaried employment by DHBs. In addition to guaranteed predictable income, the non-salary benefits would also be invaluable (eg, CME, annual leave, sick leave). This should only be considered as an option. Compulsion would be detrimental. But by allowing two options for career development - the current small business model and salaried employee status - would provide flexibility in such a way as to better cater for today’s and tomorrow’s new GPs.
I appreciate the opportunity to participate in this mid-winter dialogue and thank you for the invitation.