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Moving Forward Or Backwards In The Health System

1 August 2005

Moving Forward Or Backwards In The Health System; New And Old Stories

Speech By: Ian Powell Executive director of the Association of Salaried Medical Specialists

To: New Zealand Society Of
Hospital And Community Dentistry

Once again thank you for the opportunity to address your Conference. My comments are personal rather than official Association observations although I believe that they are broadly consistent. I was delighted to learn that you were honouring John Hawke yesterday with his presentation. John was a member of the Association¡¦s first National Executive and continued in that role for some years, including serving a two-year term as National President.

He is known for his devastating and at times absolutely wicked sense of humour. But, while invariably hilarious, he never uses humour to put people down but in fact in his own way as a means of treating them with respect. But more than his humour, John stands out for his absolute commitment and dedication to the provision of high quality dental and other health services to patients.

Underpinning this commitment and dedication are his strong sense of values and ethics centred on the principles of professionalism. In fact, it was John¡¦s professionalism that led the Association to award him with its first ever life membership.

In this address I wish to focus on four main areas¡Xcurrent difficulties and challenges arising out of the government¡¦s present direction, alternative directions from the opposition parties, general observations on the way forward, and the positive contribution the ASMS¡¦s recently negotiated national DHB collective agreement (commonly known as the MECA) can play in the way forward. One underlying theme of this address is the astute, somewhat dialectical, observation of Salman Rushdie that:

No story comes from nowhere; new stories are born from old¡Xit is the combinations that make them new.

Before proceeding further, however, I would like to reminisce over a gem I recently received from the Southland District Health Board which raises the question of after over seven years of a market approach to health followed by nearly six years of a non-market approach whether any lessons have been learnt and whether anything of substance has changed.

Repeating Fiscal Fiascos

In 1993 the then Waikato crown health enterprise engaged an international firm of consultants, Proudfoot Consulting, with a reputation as hatchet operators to review its operations. Its review included asking penetrating questions such as ¡¥Why were nurses spending so much time talking to patients and their relatives?¡¦ Once the rhetoric was stripped away its recommendations were nothing short of cost cutting, particularly nursing levels. The end result was that following concerted opposition from nurses, supported by the Association¡¦s members at Waikato, the recommendations were not implemented. Although the lack of commercial accountability inherent in the market era of our health system at that time meant that the full fiscal costs of the Proudfoot extravaganza were not revealed, the most conservative estimate was $4 million. This fiscal wastage does not take into account the detrimental effect the exercise had on staff morale and confidence.

The Proudfoot extravaganza was one of a number of cases of that 1990s era where external consultants received considerable health dollars for no or minimal benefit. For some years I dined out on these accounts including at your conferences. Since 2000 it appeared that the era of this type of fiscal wastage had largely ended. However, the Southland DHB has proved me wrong.

In its print communication to DHB employees on 7 July the DHB boldly declared that it had engaged Proudfoot to ¡¥look at and analyse the current operational state and look at how we can potentially improve.¡¦ It will ¡¥help bring about the necessary behavioural and cultural adaptation, without which no improvement programme can truly succeed.¡¦ During this review ¡¥six Proudfoot consultants will dig deep¡Xthrough observations, reviews and diagnostics at an operational level¡Xto build up a detailed picture for the board of underlying root causes that might be limiting current performance.¡¦ And what is the time frame for these boffins with their clipboards to complete this ambitious task? 18 days inclusive of a couple of weekends!

Proudfoot is described as a

global consultancy, which for the last 60 years across some 16,000 assignments, has focussed its efforts entirely on installing sustainable improvements in the operational effectiveness of organisations producing significant results (including satisfactory financial returns and quality gains) in less than 12 months.

It would be interesting to know whether the Waikato fiscal fiasco is among these 16,000 success stories! And will anyone be surprised if this review leads to further projects that just happen to require the expertise of Proudfoot to implement?

The least disadvantageous outcome of this exercise is that a considerable amount of taxpayers¡¦ dollars will be wasted. The more likely outcome is that, in additional to fiscal irresponsibility, many health professionals will be made anxious and uncertain about their futures and that there is a period of disruptive destabilisation. The advantage will be another good story to dine out on for some time.

Present Stories: Current Challenges and Difficulties

The cynic might then reasonably assert that little in fact has changed despite the quite different philosophic and directional underpinnings of the 1990s legislation and today¡¦s. However, a cynic¡¦s assessment takes us nowhere because its paradigm only comprehends information that reinforces rather than contradicts or challenges their assessment. The Southland decision to engage Proudfoot is an example of a short-sighted managerial style in one DHB and should be seen in that context. Much has changed under the current Public Health and Disability Act and much of this has been for the better.

Positive Achievements

In essence the problem with the 1990s was the underlying direction which was in conflict with the values and expectations of the public and the ethos of health professionals. In contrast, there is less contention over the direction of this decade; rather the problem rests more in the execution and pace of the direction and the performance of its leadership. Again there have been positive achievements that are over and above keeping the system going and meeting the ongoing challenges of patients coming through the doors. Even its political opposition recognises that the government has significantly increased health spending to record levels. The debate is much more on the effectiveness and utilisation of health spending rather than levels.

The government¡¦s announcements last year and this year over increased funding for additional orthopaedic and cataract operations have been welcome initiatives which arose out of extensive consultation and engagement with health professionals in both areas. Both announcements have recognised capacity issues both in terms of the importance of using and building the public system and practical realism. The first port of call for all DHBs in the utilisation of this increased funding is for the additional procedures to be provided in their own facilities. To the extent that this might not be achievable then the second port of call is other DHBs. And then to the extent that neither has the capacity, the private sector can be considered.

The government also has good reason to be pleased with its Cancer Control Strategy. It is an excellent example of effective engagement across a field that by its very nature covers the relative extremes of hospital and community care, and much in between, and one in which ¡¥consumer¡¦ interests are as important to engage with as health professionals.

The encouraging signs reported in the NZ Herald (26 July) of the benefits of focused improvements to improved access to primary care and public health measures in Counties Manukau which include reduced child hospital admissions is something that the government can reasonably be proud of along with those actively involved in implementing them.

And it is certainly the case that the performance of management in some DHBs at least has improved and has become more in sync with the culture of professionalism that is critical to the running of an effective health system. Taranaki and Lakes are two examples that immediately come to mind. Taranaki, of course, could only go one way given its rather thuggish past but it has advanced considerably and is almost unrecognisable to what it was a few years ago. Lakes¡¦ improvement has been more incremental. It may be that part of the reason why at least some Association members employed by that DHB hold the board chair in so much deference is the fact that he is also their dentist. Nothing like a power relationship to shape behaviour! But, while there is still room for further improvement both DHBs provide good examples of the willingness to make best efforts to establish a relationship of constructive and effective engagement with their workforce.

The achievement of national collective agreements for nurses and medical/dental practitioners is a positive means of helping address our recruitment and retention difficulties and synchronises well with the importance of encouraging a culture of constructive collaboration within and between DHBs.

But Below the Radar

But, although there is much to applaud on the direction and at least health professionals are on the same philosophic planet as their current political masters, there still remain serious problems in the execution and pace of the direction which would be derelict to disregard and which can undermine the achievement of the direction. Some of these problems relate to an under-appreciation of capacity issues and of the enduring legacy of the 1990s era in some managerial quarters. The Prime Minister has on more than one occasion commented that things seem to progressing well in the health system. Presumably this is because health professionals, unions and others are not frothing at the mouth and because she has a discernibly people-orientated health minister who invariably in her interactions with health professionals and community health activists establishes a positive connection.

However, the Prime Minister¡¦s observation misses a considerable amount of dissatisfaction and anxiety among health professionals and the public that it is occurring below the political radar. The consistent message of political opinion polls is that health is either the most important issue for New Zealanders or up there among the most important issues. Overwhelmingly New Zealanders appear to think well of their health system and value the care it provides. Both doctors and nurses in particular rate very highly in public estimation. However, there remain serious concerns over access.

There are several reasons for this bleaker assessment of what is happening beneath the political radar:

„h Health professionals know from their daily ¡¥hands-on¡¦ experience that too many patients are being denied access to elective services notwithstanding the solid hard work undertaken to reduce excessive waiting times and address the high level of unmet need in communities. It is this denial of access that forms much of the negative media reports. The government¡¦s recourse to the prioritisation system to defend the excessive number of patients being referred back to GPs (which in turn increases the pressures on both these patients and their GPs) and excessive waiting times at times comes across to health professionals and affected patients, both of whom are left to confront the practical realities of this denial, as cynical and offensive, at the very least frustrating. Prioritisation systems are not without merit but invariably in the realm of illness and diagnosis are subjective and arbitrary; in the present context they provide resource rather than clinical thresholds and have potential risks in an environment of resource constraint.
„h While the recognition of the importance of workforce development, including the formation of the Health Workforce Advisory Committee, is welcome it has proceeded at far too slow a pace and has been predominantly a scene-setter. This is most unfortunate given that the 1990s was a fatal decade of deliberate neglect in this respect. And yet much of the higher profile problems in the health system, such as delayed or denied access to elective services and cancelled operations, relate to workforce shortages¡Xspecialists, intensive care staff nurses, ward nurses¡Xthan any other factor. The recently released report of HWAC¡¦s Medical Reference Group is an excellent document full of many valuable insights and directions to follow. But it is a report that should have come out 2-3 years rather than six years after the election of this government in November 1999.

-Notwithstanding my earlier positive comments about the improved performance of managers in some DHBs, the report card is still mixed with the good performance of many managers often undermined or blurred by the poor performance of others.

Some of that poor performance relates to calibre or autocratic top-down styles but much of it relates to the short-term decision-making modes that external and other pressures appear to drive many managers towards; too many managers are overwhelmed by the tasks confronting them. Bad behaviour, such as bullying and dictatorial styles by ¡¥bovver boys¡¦ who have misplaced their ¡¥bovver¡¦ boots, is rare but, on the other hand, there is a predominance of those who assume that data is a plurality of anecdotes.

-One of the negative legacies of the 1990s, the ¡¥Chinese Wall¡¦ between funding and providing, remains in some DHBs despite the repeated warnings of the Minister of Health that such an artificial demarcation in today¡¦s health system is inappropriate and should be discontinued. This unnecessary rigidity elevates the tension between funding and providing to an ideological rather than pragmatic level and cuts across the importance of an integrated collaborative approach to capacity building and the effectiveness of delivery.

-We still do not have systematic comprehensive service planning in secondary care, particularly in the provision of resources and service organisation and delivery. The main examples of where it has occurred have been, as discussed earlier, in cataracts and orthopaedics, but there is so much more to be done. These areas are only a small part of the totality of secondary care and ignore the growing problem of health professionals struggling to meet the needs of, for example, patients suffering from chronic illnesses.

- There is still much work to be done in effective inter and regional DHB and regional collaboration. My sense of it is that overall it is more advanced in the Midlands area where I have, for example, in mental health received positive feed-back from our members.

The DHB system does lend itself towards this approach but it is difficult to turn around a culture that prevailed in the 1990s when the various parts of the health system were encouraged to compete against other. Now they are encouraged to cooperate but it is more difficult than might have been anticipated to quickly turn this around. Habits are difficult to break. It does not take long to destroy a system but it takes much longer to reconstruct it.

- We are still a long way from achieving the level of clinical leadership required to make a substantive difference in the performance of DHBs despite the advocacy of this by the Deputy Prime Minister and Minister of Finance at our Annual Conference in 2003 and the Minister of Health who in her last two annual letters of expectations to DHBs has required them to develop shared leadership arrangements with clinicians.

To be fair this is not an easy task and some DHBs have made good efforts. But we remain well short of what is required in order that the potential benefits of such an approach are realised. It highlights the point that positive declarations from ministers of the crown are insufficient to make this happen and that stronger additional drivers are required.

-There is a need for greater clarity in the relationship with the private sector in the provision of secondary care services. The Cabinet protocol that presently applies is not too bad but does require further elaboration particularly in the areas of ensuring that any private sector utilisation does not run contrary to public hospital capacity building and to inter and regional DHB collaboration.

In fact, earlier this year the ASMS, NZ Nurses Organisation and the Minister¡¦s own Principal Medical Adviser prepared a proposal recommending a refining of the protocol along these lines. Although the Minister has expressed interest to us it is disappointing that at least at this stage her Ministry officials have yet to engage with us and the Nurses Organisation over our recommendation. In light of the example I am about to discuss there is also merit in the protocol being amended to differentiate between shorter and longer term contractual arrangements with the private sector.

An Encapsulating Example

I dislike focusing on one DHB in a critical light in an address such as this but seeing I have already bagged Southland why stop when you are on a roll. I may as well move a little further up the road. The example I believe neatly encapsulates many of the above points. One of the consequences of the DHB system was that DHBs assumed responsibility from the Ministry of Health for the funding of community as well as their own hospital laboratories.

Community testing was largely undertaken by private providers, a duopoly about, subject to the deliberations of the Commerce Commission, to become a total private monopoly. One of the features of these time-limited community contracts was that they were demand or volume driven and therefore at risk of exceeding budgetary limits.

For example, the Minister of Health granted the Otago DHB an additional one-off increase of $3.2 million to its District Annual Plan for 2004-05, in part because of the fiscal impact of its contract with a private laboratory (the other part was inter-district flows).

DHBs then had to consider the future delivery of community testing as the expiry dates of these contracts loomed. The DHBs considered a range of options but in a combined approach Otago and Southland went down a path that most did not. Using the 1990s ¡¥Chinese Wall¡¦ between funding and providing they adopted a largely secretive non-transparent process of putting the entirety of both their own hospital laboratories and community testing contracts up for competitive bids in a ¡¥winner-takes-all¡¦ process.

The DHB hospital laboratories were left no practical option but to endeavour to take over all private community testing. There was also a competing combined bid from the two private laboratories (now in effect a private monopoly). The DHBs could not, of course, make the final decision but rather had the role of making a recommendation to the Minister of Health for approval.

By adopting an approach based on commercial sensitivity and no engagement between funding and providing, one practical effect was to exclude the DHBs¡¦ own pathologists from engagement over the implications of the private proposal and to severely minimise their involvement in the development of the hospital laboratories¡¦ proposal.

In a murky process the DHBs were about to recommend the hospital laboratories proposal when an 11th hour second or revised proposal was received from the private consortium which they then accepted for a 10-year contract. They generated considerable media fanfare with questionable claims over fiscal savings in what appears to be a tactic of making it difficult for the Minister to decline the privatisation recommendation in the lead up to the general election.

If she declines the recommendation, no matter how robust her grounds she risks being confronted by a public relations spin over alleged savings. Such is the confidence of its advocates in Otago-Southland that our members and other laboratory staff are being given the impression that the Minister¡¦s role is that of a rubber stamp. Time will tell.

I apologise for spending so much time on this issue but it is a useful case study because it highlights in several ways the way in which outdated approaches subvert or contradict the direction the health system is supposed to be going. Its relevance is more than the fact that it has turned upside down the professional career aspirations of our affected members and other staff who are committed to the public system, feel betrayed by their DHBs, and are overwhelmingly opposed to the proposal, and that there are also separate investigations by the Commerce Commission and Auditor-General (the former anticipated and the latter not). For example:

- The two DHBs have defied the Minister¡¦s advice about not having an artificial ¡¥Chinese Wall¡¦ between funding and providing.

-Their approach only provided for an ¡¥all-or-nothing¡¦ approach rather than other more flexible possibilities such as Waikato (retaining their hospital laboratories and allowing a private laboratory to do much of the community testing) and both Capital & Coast and Hutt Valley (retaining their own laboratories and next year seeking bids for community testing).

-This approach, inclusive of its commercial sensitivity, effectively precluded the laboratory staff, including pathologists, from being engaged in the decision-making process and providing their expertise for the process. This defies the expectations of the Minister for shared leadership arrangements and increased clinician involvement in decision-making.

-The approach taken by the DHBs endeavours in effect to subvert and breach their consultation obligations under our new national collective agreement.

-It is contrary to the emphasis the government has placed on public hospital capacity building (for example, the increased funding announcements for orthopaedics and cataracts).

-It rests uncomfortably with the government¡¦s expectations of increased inter and regional DHB collaboration. In particular, part of the rejected hospital laboratories¡¦ proposal involved collaboration with the Canterbury DHB¡¦s laboratories which, under the proposal, would become more complicated.

-If this proposal is approved by the Minister it will be the largest privatisation of secondary care since the former government¡¦s pro-privatisation health reforms were introduced in 1993. Further, it is likely to be irreversible because of both the length of the contract (10 years) and the fact that it would come under the control of a private monopoly. Ironically, if the privatisation proposal was to proceed and down the track things were to go to custard the ultimate fiscal and political responsibility will rest with the crown, as was the case with the privatised Air New Zealand a few years ago.

There are several other serious concerns about this proposal such as the effect on recruitment and retention of specialists and on resident medical officer training but the points highlighted above are salient to the way in which two DHBs are behaving in the context of contradicting the execution of the direction the public health system is supposed to be going.

Old Stories: Forward to the Past

However, in election year especially, it is not sufficient to simply analyse directions under the government of the day. The opposition parties offering significantly alternative directions also deserve some consideration, in particular, National and ACT. Although the former party has been less specific to date, some assumptions can be made. While they appear (National at least) not to be considering further formal restructuring, processes may change with a strong emphasis on the role of the private sector and a hankering for the ideology and approaches of the 1990s, both in the provision of services and private health insurance.

Weaknesses of a Market Approach

There are serious weaknesses with this approach not because the private health sector is bad or wrong (it is neither) but because the expectations of its capacity are unrealistic and consequences in some instances counter-productive. For example:

- It forgets why public health systems, such as New Zealand¡¦s, developed in the first place. If the objective is to produce a universally available and comprehensive public good then an integrated and coordinated system is necessary rather than reliance on a system more orientated towards niche markets and profits. It requires a high level of public funding and benefits from a high level of public provision. Private systems cannot do this because it is not their reason for being. This is why our system moved to its key principles in the reforms of the late 1930s and why it has been incrementally enhanced over subsequent decades notwithstanding the ideological blip of the 1990s.

- The private sector¡¦s main involvement in secondary care is electives but these are a relatively small part of its totality inclusive of chronic and acute care.

- If more elective work is siphoned off to the private sector then the consequence of public hospital work becoming more acute based than what it currently is will make public hospitals much less attractive for recruitment and retention of senior medical and dental staff because of the unsatisfactory job mix. For job satisfaction and associated recruitment and retention alone, let alone other factors, public hospitals should be doing more, not less elective work.

-If all true costs are taken into account it is a more expensive way of providing care than public hospitals.

-There are limitations in the capacity of private hospitals to provide necessary post-operative care such as intensive care.

-There is not a reserve army of unemployed specialists to undertake significantly increased volumes in the private sector while at the same time maintaining the present level of electives in public hospitals.
-The suggestion of vouchers will most likely become a superfluous transaction cost without any real gain for patients. Arguably it could make public hospital planning of electives more difficult.

- To the extent that competitive tendering is institutionalised into the system then this will increase transaction and bureaucratic costs, increase fragmentation between services, risk destabilising planning for service delivery in public hospitals, and work contrary to inter and regional DHB collaboration over service organisation and delivery.

-The main benefit of private hospitals is the provision of additional plant (eg, theatres) rather than additional labour which is the main difficulty facing public hospitals.

- Tax rebates for private health insurance may or may not have some merit but there should be no expectation that this will relieve pressure on public hospitals. Much is said of the Australian experience of significant tax rebates. While this has been beneficial for private health insurers in that their client base has discernibly increased (although it appears now to be tapering off) it has not had the claimed effect of reducing the pressure on public hospitals.

None of the above comments are intended to suggest that the private sector might not have a role. It certainly can in meeting shorter term capacity needs but this is most likely to be around the margins rather than at the core of public hospital activity.

This proposed return to the past reminds me of my father¡¦s story I recall telling the first of your Conferences that I addressed. It involved an American astronaut orbiting the earth in one of the early space travel projects of the 1960s. When asked what he was thinking about in his isolated environment, he replied that it was the fact that each part of his space vehicle had gone to the lowest bidder.

False Productivity Debate

Of major concern is the potential impact of their industrial relations policy which at the very least is likely to create serious obstacles for organisations such as the ASMS and NZNO to negotiate national collective agreements with DHBs. These agreements are important instruments for enhancing recruitment and retention in challenging international labour markets and, as discussed later, in facilitating positive change and constructive working relationships. Should the next government, of whatever persuasion, endeavour to undermine or prevent the ability to negotiate national health collective agreements then it will incur the opposition and wrath of those covered by them.

As an aside it is disappointing to witness some of the misuse of Treasury reports on public hospital productivity. This data is sometimes used by opposition parties to suggest that public hospitals are doing insufficient additional work to justify the increased health spending of recent years. This is most unfair. As Treasury itself acknowledges the data used is the only data available and is confined to hospital discharges. This reminds me of the skit I saw as a child attending a local scout gang show. A man was searching for a lost coin at night under a street light. When asked by a friend where he lost it he pointed to some distance away. When asked why he was looking under the street light, the reply was because the light was better.

A large amount of the work undertaken in secondary care (eg, chronic illnesses, outpatient clinics and community work) is not picked up in this data. The activities of ENT surgeons at the Counties Manukau DHB in working alongside GPs in order that the latter can do more procedures in a primary care setting is already producing encouraging results with reduced hospital admissions and more timely treatment of patients. However, not only will this initiative not be picked up in the productivity data but also would, under this political misinterpretation of the Treasury reports, lead to a reduction of productivity.

Perversely productivity would be increased if only public hospitals would ensure that more patients died immediately after admission so that more could be admitted and discharged, preferably dead; surely this is not what those who misuse the Treasury reports mean or am I wrong?

Future Stories: Bottom up Responses from MECA

So where do we go from here? The Association is, in the absence of consistent systematic and effective leadership from the sector, adopting a bottom up approach kick-started by our national DHB MECA. We are very proud of the MECA not just because of the ¡¥pay and rations¡¦ but also its other features. In part through the mechanism of joint Consultation Committees with us and each individual DHB, it provides a foundation, with some contractual grunt behind it, to pursue more effective execution and increase the pace of the direction we should be going in.

Themes of MECA

The MECA is based on underlying themes of the empowerment of our members over their working conditions and environment, at their workplaces and in their DHB. There are several reasons why this empowerment is so important including turning around low morale and confidence where it exists, improving job satisfaction and conditions, promoting professionalism and collegiality, and improving the quality of DHB decision-making, both macro and micro.

Other themes are the integration of the ethos of professionalism linked to the importance of quality into the core of the MECA and the importance of collectivism and collegiality in addressing challenges. In all cases these themes are expressly reflected in both the Preamble and Underlying Principles of the MECA and in specific clauses. For example, one of the underlying principles is that each DHB undertakes ¡¥to do what it reasonably can to ensure the workplace is well resourced, professionally supportive and conducive to a very high standard of individual clinical practice.¡¦

One of the more significant longer term provisions is the requirement of each DHB and us to form joint workforce development and education taskforces to endeavour to develop agreed staffing plans for each service/department to meet the ¡¥objective needs¡¦ facing each DHB. Linked to this is the requirement to develop agreed plans for the effective provision of and access to high quality professional development and education (inclusive of CME, secondment and sabbatical). This combined initiative has major beneficial implications for DHBs developing the right resource base to meet current and anticipated unmet health needs of the communities they serve and to address the workforce development and planning challenges that they presently are confronted with. The MECA also requires that a national conference be held to evaluate the extent to which DHBs have progressed down this path and to share and compare experiences.

Related to this is the MECA¡¦s strong emphasis on requiring DHBs to actively encourage their senior medical/dental staff to undertake good quality professional education and development (CME, secondment and sabbatical). The MECA creates the basis that with the right level of collegial and collective planning DHBs will reach the situation where, in addition to the two weeks annual CME leave, senior medical/dental staff can reasonably be expected to spend two weeks around every three years on a resourced and paid secondment and similarly three months sabbatical after every six years. This has important implications for the resourcing and staffing of public hospitals but is critical for the development of a longer term recruitment and retention strategy given New Zealand¡¦s disadvantage of geographic isolation in an internationally competitive market.

Another significant feature of the MECA is its emphasis on the involvement of senior medical/dental staff in decision-making. The Association and the DHBs are committed to ¡¥empowering¡¦ the role of senior medical/dental staff in DHB decision-making, inclusive of democratic and mandated processes for determining their representation and involvement. To help facilitate this on a national level we and the DHBs are expected to develop national guidelines and subsequently hold a national conference to consider progress and developments.

The MECA commits each DHB to providing ¡¥good quality, suitable and safe workplace conditions, resources and accommodation¡¦. To this end we and each DHB are to undertake through an agreed process an evaluation of the extent to which these conditions, resources and accommodation are provided and to agree upon an agreed plan for remedying any deficiencies.

Finally, but no less important than the other features discussed earlier, is the recognition and incorporation of professional standards into job descriptions. This includes the explicit recognition of the need for sufficient time in order to undertake non-clinical duties not directly related to the care of individual patients. The professional standard identified and recognised by the MECA is a minimum of 30% of the time for scheduled clinical activities. While it may not be 30% in every case the clear expectation when the MECA is read in full context is that there has to be a very good professional reason why it might not apply in some instances and that the 30% minimum is the norm.

Both its specific provisions and the MECA as a whole provide the foundation for addressing many of the disappointments and deficiencies in the pursuit of the current laudable direction. Whether they are Salman Rushdie¡¦s combined stories, I am not sure, but they do provide the plot for a good piece of non-fiction and do not require a large cheque to an external consultant such as Proudfoot to achieve them.

Ian Powell



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