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Clinical Leadership & Medical Workforce in DHBs



Ian Powell
Executive Director


Thank you for the opportunity to address your leadership forum today. Owing to the nature of our membership the focus of my presentation is specialists in public hospitals. This is where clinical leadership is most difficult to achieve because much of public hospitals do is what the rest of the health system can’t do and refer to – electives, diagnostic, acutes, emergencies, chronic illnesses and population health. They are highly complex and integrated institutions that in my view should be regarded as national treasures.

There are two forms of clinical leadership. The first is formal leadership. These are formal positions from heads of department to clinical directors (large departments or clusters of departments) through to chief medical officers responsible for a whole DHB. Invariably they attract additional remuneration, usually still involve doing some level of clinical work, and are either permanent or fixed term appointments. In most cases holders of these positions have a parachute clause enabling them to return to their previous full clinical position.

They are important but not as important as the second form which is distributed clinical leadership. That is, leadership roles are distributed throughout much of the senior medical workforce including in their own service and organisation-wide. This might be a range of quality improvement initiatives or systems improvement projects.
This is obviously important for quality standards of patient care. But it is also important for fiscal responsibility. To put it in a nutshell what makes good clinical sense also makes good financial sense. If, for example, DHBs controlled the rate of acute admission increases and reduced the level of clinical variation, the patient gain and financial savings would be immense. But DHBs can’t do this effectively and sustainably without the clinical leadership of medical staff.

Driving innovation
To understand the importance of clinical leadership one first needs to understand what are the main factors that drive innovation in health. In summary, they are:
1. Workforce
2. Distributed clinical leadership.
3. Technology

Workforce is central because the health system is labour intensive. It is this labour that produces the value. This labour intensity provides an inexhaustible supply of creative intellectual capital, including potentially for systems improvement. This is not just specialists but given the highly specialised nature of their training and work reinforced by their cognitive attributes makes them central.

Distributed clinical leadership enables this to happen. It puts the wider senior medical workforce in the engine room of decision-making not simply for their patients but also for improving the way their services and their DHB functions. Specialists are experts in addressing the challenges of complexity. They are natural problem solvers. It does not take a large quantum leap to extend this skill from the complexity of patient care to the complexity of integrated systems between community and hospital, between hospitals and within hospitals. Putting workforce capacity (time linked to supply of positions) to one side for the moment, the extent to which happens depends on the extent to which there is an embedded culture of workforce engagement.

So, workforce is intellectual capacity and distributed clinical leadership is the engagement culture that provides the opportunity to unleash this capacity. The third driver is technology but perspective is required. Technology enables rather than drives improvement and innovation. Technology loses effectiveness without the intellectual capacity and culture to operationalise it.

Vulnerability of senior medical workforce
Realising the potential of distributed clinical leadership in public hospitals will never occur until DHBs address the vulnerability of their senior medical workforce. This workforce is increasingly stressed and strained, painting a worrying picture which the political and bureaucratic leaders are oblivious to.

The results of a survey by ASMS in 2015 and published in the NZMJ suggests that 88% of DHB-employed senior doctors routinely work through illness, with three-quarters suggesting they have turned up to work with an infectious illness. This is in the context of a workforce who have a negotiated entitlement in their collective agreement for largely open-ended sick leave. The average number of sick days reported by the survey respondents was less than three days per year.

Qualitative comments in the survey over why senior doctors felt pressured to work when they were sick provide several insightful observations, some of which are dramatic and distressing. They suggest that presenteeism is affected by workplace structural factors such as availability of cover, idealised and gendered norms about being part of the medical profession, and diverging views on what constitutes an acceptable threshold for taking sick leave.

Presenteeism is both a symptom and a consequence of an over-worked and over-stretched workforce.

A survey of burnout among DHB-employed senior doctors conducted by us last year and published in the BMJ Open revealed an alarming burnout rate of 50%. The results were severe everywhere (including gender, age and size of DHB). But they were particularly severe in middle-sized DHBs such as in Nelson Marlborough compared with smaller DHBs like West Coast and South Canterbury and larger DHBs like Canterbury and Southern. They were also more severe among younger rather than older specialists, especially younger females.

To express it graphically, if you require a cardiac operation the results suggest the chances are high (perhaps 50%) that the surgeon opening you up is burnt out, the specialist anaesthetising you and handling your pain management is burnt out, the cardiologist managing your care is burnt out, and the pathologist and/or radiologist providing the diagnosis essential for a successful operation is also burnt out. The chances are noticeably higher if any one of these five specialists are female. This is not scare-mongering. It is the reality of everyday working life.

The prospects of these specialists having the time to be engaged in achieving the benefits of distributed clinical leadership are severely impeded, if not near impossible.

Other research by the ASMS suggests that ocial DHB data on specialist vacancies is
misleading and signicantly understates the size of the problem. Ocial vacancies are only those positions DHBs elect to advertise. We know that the advertised roles are far fewer than that what is needed to sustain safe accessible services delivered through patient centred care, and the high rates of presenteeism further illuminate the pressures that the senior medical workforce is under to maintain service provision.
Yet-to-be published ASMS research into specialist workforce intentions reveals that around a quarter of respondents to another ASMS survey are either likely or extremely likely to leave the DHB workforce over the next ve years. This conclusion is consistent with the Ministry of Health’s own internal modelling of the vocationally registered medical workforce.

I have been attending meetings with senior management and our ASMS delegates in several DHBs over the past two months where this has been discussed. In these discussions, I identified two main reasons for this alarming discovery, largely beyond the control of DHBs.

The first is that like the rest of society the senior medical workforce is aging and many simply wish to retire. They have concluded that they are at an age where this is the right decision and DHBs can do little about this, if anything.

The second is the difficulty and reluctance of many to continue with providing acute after-hours care which is unavoidable in most public hospital branches of medicine. A little can be done about this but, because it involves taking them out of the after-hours’ roster or shift, realistically this option is confined to larger services such as anaesthesia in big hospitals such as Christchurch.

However, while I was correct with the first main reason (wanting to retire from medicine completely) I was wrong about the second. My designated second is important but it falls behind something else.

The something else is job dissatisfaction. This is the second main reason and it is avoidable. Excessive workloads and the lack of a sufficient engagement culture in DHBs are significant contributors.

Many of these doctors have employment options outside permanent DHB employment. Some can go overseas, some can work in the private sector, some can locum at their choice where the market heavily favours the supplier rather than purchaser of labour, and some can work for non-government organisations or agencies such as ACC.

Combined, the high rates of presenteeism and burnout, as well as the high level of intentions to leave DHB based employment, suggest a workforce under stress where senior doctors are torn between a high level of commitment to their patients, to their colleagues and to sustaining the New Zealand public health system. Sitting behind it is an undersupply of specialist positions in public hospitals worsened by the pending loss of specialists over the next five years at a higher rate than those coming into the system to replace them.

Through neglect, DHBs have allowed a situation to develop where entrenched hospital specialist shortages have become the norm. In the absence of sufficient insight and responsible leadership, this situation is trending in the wrong direction.

In late 2014 in its report, The Role of Health Workforce New Zealand, the government’s health workforce advisory body Health Workforce New Zealand identified public hospital specialists as vulnerable, and advised that the impact of prolonged labour market shortages of DHB-employed senior doctors on workloads, wellbeing and productivity was the most important issue for its medical taskforce to address.

Nothing has been done since to address this parlous state except improve the medical workforce database, despite the discovery of the extent of presenteeism and burnout along with specialist workforce intentions over the next five years.

A digression: funding vocational medical training
Instead, Health Workforce New Zealand appears intent on radically deconstructing our funding model for vocational training by seeking to replace our underfunded more professional college based (translate for clinically led) system with a still underfunded but highly bureaucratic, excessively transaction cost and expensive business-like edifice. The model would be based on a phased contestability process in which the college dimension is significantly diminished.
Contrary to the principles of clinical engagement, this proposal is being pushed through by a cabal of HWNZ and Ministry officials with selected DHB representatives, including their shared services agency DHBSS as support parrots. It appears that those DHB representatives involved in this process may not be representative of wider DHB views. Certainly, chief medical officers who should be at the centre of this piece of action are side-lined. The wider medical profession is marginalised in this process to the status of a frustrated bystander.

It is all about bureaucratic capture and empire building. This has all the hallmarks of a messy fiasco with significant unintended consequences and for a major stoush between the health bureaucracy and the medical profession but this is the subject of another presentation.

This is the kind of leadership you have when you are not having leadership.

Abandonment by political leadership
For over two decades Health Ministers have sent DHBs and their predecessors annual letters of expectations; what the Minister requires of them over the next 12 months. In the first half of the 2000s then Minister Annette King used this vehicle to emphasise the importance of clinical leadership in general. This was good but not good enough to drive the message home.
The last Labour Health Minister David Cunliffe made a significant difference in his brief 12 months in the portfolio until the election defeat in 2008. The outcome was a new relationship agreement titled Time for Quality between us and the DHBs. It took clinical leadership to a new level with the focus on the distributed nature of it.

Its engagement principles were also incorporated into our national collective agreement with the DHBs. One of these principles stated that in respect of service design, configuration and delivery the role of management was to support the lead role of senior doctors in each DHB.

In opposition Tony Ryall had picked up on ASMS’ advocacy of clinical leadership and pursued it with a passion. As Health Minister, he quickly assembled a working group to prepare policy advice on clinical leadership, which he endorsed. Titled In Good Hands, it was different in style to Time for Quality but was broadly consistent with a shared emphasis on the distributive side of clinical leadership. In Good Hands further deepened this emphasis.

However, many in DHB leadership gave lip service to this policy advice, watering it down to guideline status and then proceeding to file it. Tony Ryall continued to emphasise the importance of clinical leadership in his annual Letters of Expectation to DHBs. But he appeared to conclude that once his policy advice was sent to DHBs, his substantive job was done and he lost interest in the subject.

Current Minister Jonathan Coleman, in the role since late 2014, began with gusto and in his first address to the ASMS Annual Conference that same year strongly emphasised his commitment to promoting and adhering to clinical leadership. But that was as good as it got as he was overwhelmed by the rigour of disinterest and conked out.

For the first time since the initiative of Annette King in the early 2000s, Dr Coleman’s Letter of Expectations to DHBs for the current and previous years contain no reference to the importance of clinical leadership. The best he could do in his speech to our Annual Conference last year was to call for more specialists in management, minimalist in expectation and well short of the mark of what is required for improved quality and fiscal performance.

Ministry of health: ‘disruptive innovation’
Instead of addressing the vulnerability of its most highly trained and specialised workforce, the Ministry of Health has migrated to a different planet (some might say solar system) with its focus on disruptive innovation as a new lens and tool kit to approach the health system.

At a theoretical level, disruptive innovation attempts to understand and analyse why some commercial businesses have failed while others have thrived. The emphasis is on the disruptive power of unanticipated technological developments (eg, digital photography versus Kodak, Uber versus traditional taxi companies) that have transformed the way in which a business or service has been delivered.
At the heart of disruptive innovation theoretically is a fundamental belief in market forces. When applied to the ‘business of healthcare’, the view is that the health care industry simply need open its doors to these ‘high-tech’ market forces to raise the quality of health care for everyone. Existing powers need to ‘get out of the way’ to let market forces ‘play’. Once this ‘natural process’ of disruption can proceed, it will be possible to build a new health system.

But disruptive innovation is not a new law of nature, health care is generally assumed to be beyond for profit and not an economic ‘growth factory’. Further, given that people are not disk drives, it should be questioned whether this theoretical premise is appropriate as a discourse to frame a new direction for the New Zealand health system.

In March, I attended a two-day symposium on disruptive innovation organised by the Ministry of Health which in my view was disconnected to the challenges being faced by DHBs and where technology was seen as the driver rather than as an enabler of innovation. There were confusing messages. On the one hand, disrupted innovation was an international threat that would swamp our health system unless we adapted to it. On the other, disruptive innovation was wonderful and we should embrace it.

The net result of the Ministry of Health’s galactic journey is a massive distraction that relegates medical workforce vulnerability and clinical leadership to the giddy heights of unimportance.
I subscribe to an online facility called ‘Word of the Day’. Often the words are delightful, amusing and difficult to remember. But a recent word is unforgettable – Throttlebottom. Just reading the name in isolation suggested to me that it was either a medieval family name or a Shakespearean (perhaps Dickensian) character.

But this was not remotely close. Instead it means a harmless incompetent in public office.
For context, it was used in a 1984 biography of an American Vice President in the 1960s (Carl Solberg, Hubert Humphrey: A Biography) with the following quote:

If there was one function that any vice president, even a Throttlebottom, could be expected to perform it was to represent the president and the country at funerals of notables abroad.

To provide you with further irrelevant information, the term Throttlebottom was formed after the character Alexander Throttlebottom in the musical comedy Of Thee I Sing (1932).

So, the question arises, is the Health Ministry leadership a Throttlebottom? They are not incompetent. In fact, they are very competent, hardworking, committed and likeable. But while they are caught in this inter-planetary gaze, equally they are not harmless with their obsession with technology as the driver of innovation rather than as an enabler and focus on disruptive innovation. In other words, the leadership of our central government health organisation and much of our DHBs are hybrid Throttlebottoms.

I searched for further insight on health sector leadership where the disconnect with workforce reality is such that it manages to dodge one obstacle to fall into another. I could not see anything from those well know experts Blackadder and Mr Bean but I did find something from a younger Rowan Atkinson. Click here for video.

Advice from William Morris
This presentation risks being pessimistic in tone. But I’m optimistic that the day of distributed clinical leadership will come with persistent, strong, cogent and irritating advocacy. To understand where we need to go we also need to understand what are the obstacles preventing us, beginning with a serious undersupply of specialist positions in our DHBs. This is the role of ASMS but we would also welcome it becoming your role regardless of which branch of medicine you end up in, including general practice. After all, a high quality public hospital is a source of comfort for GPs.

In speaking to you today I am reminded of 19th century English activist William Morris. He was the ultimate multi-tasker – textile designer, novelist, architect, poet, translator and (when he had nothing else to do) socialist activist.

At a meeting in England Morris told his audience that “I’m here not to let you be contented with too little.”

Ian Powell

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