Letter Of Expectations To The Minister Of Health
Letter Of Expectations To The Minister Of Health
Address to the Hospital And Community Dentistry Conference
NAPIER, 27 JULY 2012
ASSOCIATION OF SALARIED MEDICAL SPECIALISTS
Thank you for the opportunity to address you again. As always my comments are personal observations although in broad terms at least I believe they are consistent with the Association’s view on the matters discussed. In this address I would like to do two things – discuss whether we still have a public hospital specialist workforce crisis and outline a variation to the Minister of Health’s letter of expectations to district health boards – that is, instead of a letter from him, a letter to him.
Before this I would like to tell an
amusing story about innovation in the American penal system.
The health system is riddled with one-off gains but we need
longer-term sustainable gains. This story is about the
An old Italian lived alone in New Jersey. He wanted to plant his annual tomato garden, but it was very difficult work as the ground was hard. His only son, Vincent, who used to help him, was in prison. The old man wrote a letter to his son and described his predicament:
I am feeling pretty sad, because it looks like I won't be able to plant my tomato garden this year. I'm just getting too old to be digging up a garden plot. I know if you were here my troubles would be over. I know you would be happy to dig the plot for me, like in the old days.
A few days later he received a letter from his son.
Don't dig up that garden. That's where the bodies are buried.
At 4 a.m. the next morning, FBI agents and local police arrived and dug up the entire area without finding any bodies. They apologized to the old man and left.
That same day the old man received another letter from his son.
Go ahead and plant the tomatoes now. That's the best I could do under the circumstances.
This was innovative, it worked but it would not work a second time. If Vinnie could pull something off like this each year for his Pop now that would be sustainable. But I don’t think so.
we have a public hospital specialist workforce
In opposition, Tony Ryall declared that there was a specialist workforce crisis in public hospitals. He reaffirmed this when, as Minister of Health, he met our National Executive in 2009. Then, on 3 October 2010, he reiterated this declaring that:
“We have a
workforce crisis in New Zealand because we need to maintain
more of our hospital specialists, I say yes we do, it’s
our number one priority.”
In November 2010 the blueprint document, ‘Securing a sustainable senior medical and dental officer workforce in New Zealand: The business case’, jointly developed by the DHBs and ASMS, reaffirmed that there was a specialist workforce crisis, that it was causing serious risks for the public health system (including standards of patient care and financial wastage), and set out actions to address the crisis.
Description of a crisis
The Business Case based its work on the best ‘health intelligence’ available and its observations included the following:
• New Zealand has the second-highest
emigration rate of doctors in the OECD. New Zealand has in
effect become a medical training ground for other countries,
• The New Zealand specialist workforce has the highest dependency on international medical graduates (IMGs - primary degree gained in a country other than New Zealand) in the OECD, averaging 41% across all specialties. Further, it is trending upwards. Over recent years IMGs have comprised approximately half of new specialist registrations.
• Employment of IMGs in both specialist and resident medical officer (RMO) positions is essential to the running of our health service, and the international “brain exchange” of hospital specialists facilitates the sharing of knowledge and experience. However, New Zealand’s excessive reliance on IMGs often adds further to specialists’ workloads and further worsens our systemic instability.
• Retention rates of IMG specialists are poorer than those of New Zealand-trained specialists. While Medical Council data show that around 16% of a cohort of New Zealand specialists are lost to New Zealand nine years-post vocational registration, about a third of vocationally registered IMGs are lost over the same period.
• The high turnover of IMGs contributes to the reduction of the capacity to develop strong clinical leadership, bring cohesiveness to medical services generally, and increases specialists’ supervisory load.
• Our high dependence on IMGs puts services in a vulnerable position in view of the increasing international competition to attract health professionals. Any change in migration flows outside the control of New Zealand authorities could have a dramatic impact on our health services.
• Our growing and ageing population requires a significantly larger specialist workforce to serve it. Currently about 13% of New Zealanders are aged 65 or over; by 2021 that figure is projected to increase to 17%.
• The Government requires specialists to play a greater role in RMO training and education. However, increasing clinical demands have meant that many specialists are not able to find adequate time for training and supervision on current workloads.
• There is a growing imbalance between specialists and RMOs which not only increases the inability of specialists to provide the necessary training and support for RMOs, but also is likely to worsen New Zealand’s already poor retention rates of specialists and RMOs. The substantial government investment in boosting the RMO workforce could continue to be lost offshore.
• A Ministerial Review Group report in 2009 estimated that up to $800 million is spent annually on potentially preventable adverse events in public hospitals. Research indicates the majority of these events are from subsequent admissions, not incurred in the original admission. While a range of factors contribute to this, there are many examples indicating specialist staffing levels are an important one (for example, an external review of clinical quality at Whanganui Hospital in 2007).
• Staff shortages and heavy workloads mean that quality improvement activities such as clinical audit are not sufficiently emphasised. But a key practical measure for reducing adverse events in hospitals is improving the supervision and support of RMOs.
• Shortages, combined with increasing clinical demands, are preventing many specialists from finding adequate time for training and supervision. This situation will worsen as the Government is requiring specialists to play a greater role in RMO training and education, and medical workforce data indicate the RMO workforce is increasing at a much more rapid rate than the specialist workforce.
• Specialists’ lack of adequate time to enable quality supervision of RMOs is contributing to job dissatisfaction and poor RMO retention rates.
• Specialist shortages and heavy dependence on short-term locum positions severely limits the ability to implement government policy to develop clinical leadership in our hospitals.
• DHBs spent more than $50 million in 2009-10 to employ short-term specialist locums (mostly to cover vacancies) the cost of whose services are significantly greater than those of permanent salaried specialists.
• Significant growth in the trainee doctor workforce is set to continue as the increases in medical school entrants flow on to the medical workforce. Intakes into medical schools increased in 2004 (from 285 to 325) for the first time since 1982. Intakes rose again, to 365, in 2007. The Government’s plan to increase the number of medical school places by a further 200 over the next five years will mean that between 2004 and 2015 the number of medical school entrants will double. Poor retention rates of RMOs means much of this financial and professional investment may be lost to New Zealand but the training they receive before they go must still be given by our stretched hospital specialist workforce.
• Implementation of the RMO Commission’s (2009) recommendations adopted by the Government requires specialists to both spend more time in RMO training and supervision and undertake more clinical duties in order to allow RMOs protected time to receive their training.
• Of the medical graduates that first registered in the year 2000, only 60% held a New Zealand practising certificate 10 years later. Allowing for fluctuations, the losses in each year’s graduation class are not improving. Further, around 13–15 years post-graduation, about only two-thirds of the original cohort of doctors hold a New Zealand annual practising certificate (and some of those may not necessarily be practising in New Zealand).
• The loss to New Zealand of a relatively small number of New Zealand-trained specialists represents a loss of tens of millions of dollars of government investment – and leads to even further costs of tens of millions of dollars each year. Those costs are incurred in recruiting specialists from overseas, who tend to have very poor retention rates (about two-thirds are gone in three years), which in turn creates further costs in recruitment. In the meantime many of the resulting service gaps are filled by employing locums on high-paying short-term contracts.
• Inability to secure a stable and cohesive specialist workforce inevitably leads to still further, less tangible, costs resulting from poor workforce satisfaction levels and the inability to develop effective clinical leadership to drive innovative changes in service delivery.
• A lack of mentoring, training, support, oversight, professional interest and recognition contributes to RMOs feeling unvalued and, in some cases, leaving the country or leaving the profession.
• A number of factors impacted adversely on the availability of specialists to teach RMOs, including an increasing clinical workload (reducing the time available to teach); changes to RMO working hours and rosters which reduce contact (and therefore teaching opportunities) between specialists and RMOs; and an increase in RMO numbers and the associated additional teaching and training workload.
• The specialist workforce must grow at a faster rate than the RMO workforce to develop the capacity to respond effectively to RMOs’ training and support needs.
• Large financial debts incurred by doctors during the course of their education played a part in “increasing the focus on future income”. In 2010 student debt influenced 36% of medical student surveyed in their choice of vocation, and 64% in their choice of locality of work in the world.
• An ASMS national survey and telephone interviews with training directors across four major specialties (psychiatry, anaesthesia, surgery, general medicine and intensive care), undertaken at the end of 2009, found that half of New Zealand’s registrars in their final year leave to take up their first specialist positions with overseas employers and that the most common reason for leaving, according to the training directors, was for better salaries and conditions.
• In order to keep our own graduates in New Zealand, measures must first be introduced to fix the specialist recruitment and retention crisis. Until that is done, a substantial part of the huge government investments going into specialist training each year will continue to be lost offshore.
If we continue as we are
The Business Case concluded that if we continue as we are:
will continue to lose many specialists and RMOs
• We will continue to rely heavily on IMGs and locums to maintain services, exacerbating the high medical staff turnover rates.
• Some services will not be clinically and financially viable.
• Some of the Government’s key health targets will not be achievable in the coming years.
• The ability to build a health service to meet future needs, including the development of clinical leadership, integration of services, regional and sub-regional service networks and integration, and improved efficiencies through innovative models of service will be seriously limited.
Do we still have a specialist workforce crisis
It is timely to consider what the word ‘crisis’ actually means as there is a temptation to throw it at every circumstance of uncertainty. In the passion and heat of the moment it risks being overused. Crisis is of Greek origin and means an event that is, or expected to lead to, an unstable and dangerous situation affecting an individual, group, community or whole society. It has also been described as a process of transformation where the old system can no longer be maintained.
Certainly the situation of the DHB-employed specialist workforce confirms the assessment of the Minister of Health, DHBs and ASMS in late 2010 that there was a specialist workforce crisis in DHBs.
This then begs the question of whether the situation between late 2010 and now has changed to the extent that the crisis has been averted. The government and some ideological hanger-ons and appendages are claiming it has. They point to three assertions – hospital doctor numbers have significantly increased; specialists will be flooding from England; and resident doctors will be flooding from Australia.
Before commenting on these assertions, two points should be noted. First, the assessment that there was a crisis by the DHBs and ASMS in the Business Case was not based on vacancy data. It was based on the points discussed earlier. Vacancy data was referred to but it was accepted, as it was by the SMO Commission in 2009, as being unreliable. Vacancies are a significant understatement of shortages. Based on DHB surveys of specific DHBs by the ASMS, we concluded that the official formal vacancies understate shortages by between one-half and two-thirds.
Second, there are signs that the situation in 2012 is a little better than 2010. Much of this is due to DHBs, through specialists, improving on ‘growing their own’ by smartly ‘shoulder tapping’ senior registrars to accept specialist appointments in their departments before they leave. This appears to have been assisted by the dropping off of the three bottom salary steps of the specialist salary scale in our last MECA negotiations. However, this does not change at all the underlying factors discussed above that provide the basis of the crisis assessment. It is a change of degree rather than kind.
So what about the claims of significant growth in public hospital doctor numbers over the past three years, what the ASMS has described as ‘spread-sheet doctors’. When we have drilled down into the data, despite the best obstructive efforts of the National Health Board to prevent this, what has emerged is that over the last three years if anything there has been a decline in the rate of specialist increases. The reported high figures are due to highly suspect resident doctor numbers.
What about a flood of specialists from England? With the destructive radical restructuring of the National Health Service in England, including the expected loss of consultant positions, some predict a flood. However, caution is required. There have been similar predictions over many years that have not materialised. As two experienced and pragmatic chief executives have said to the ASMS recently, we have heard this before and we will believe it when we see it. Those consultants who might leave England have to get past the greater financial temptations of North America and Australia first. A quick observation of a cohort analysis of medical graduates by the British Medical Association suggests a possible figure of 85 doctors (including GPs and RMOs) per annum considering coming to New Zealand permanently. It is also worth noting periods of reducing specialist numbers invariably leads to a need to increase them because of the consequences of the reduction. Depending on a flood of English specialists is speculative and also risks further increasing our excessive dependence on international medical graduates with its associated financial risks.
What about Australia? Again we need to drill down below the headlines. Through a flawed analysis in the 1990s that Australia had too many doctors, rather than too few, massive shortages developed. The consequential crisis that developed, including Bundaberg, led to the federal government significantly increasing the number of medical students and medical school. Unfortunately they did not make sufficient investment, despite advice from the Australian Medical Association, to the capacity of public hospitals to train these students once they became house surgeons and registrars.
But this does not automatically mean an ongoing flood of RMOs to New Zealand who then stay on to become specialists. First, efforts to improve this capacity problem will affect any possible flood. Second, the specialist shortages still remain and the temptation for any Australian RMOs who come across to return home to considerably higher remuneration and other conditions will be high.
A reality check is required. In The Business Case the ASMS and DHBs agreed that in order to secure a sustainable specialist workforce for New Zealand, we would need to match Australia’s projected specialist-to-population ratio by 2021, the average net growth for the next 10 years would need to be an estimated 232 specialists per year. According to DHB provided data we continue to perform considerably less than that. In the three years to 2008 the average annual specialist increase was 167. In the subsequent three years (to 2011) it reduced to 124 (a 25% decline). We are falling further and further behind in achieving this important objective.
Our decision-makers need to focus on addressing the underlying causes of the crisis and not get diverted by searching for magic bullets that they can then put in their CVs.
‘Letter of Expectations’ to the Minister of
Each year the Minister of Health sends DHBs an annual ‘Letter of Expectations’ about what he expects from them in the forthcoming financial year. I thought it appropriate to, for a change, pen an unofficial ‘Letter of Expectations’ to Mr Ryall. It would go like this:
Dear Minister (or Tony if you would prefer)
This letter outlines our expectations of you for the coming 12 months. We would first like to congratulate you for improvements that have been made under your ‘watch’ to date. These include the provision for some elected medical practitioners on the Medical Council (the Dental Council remains unchanged although there are some complications there which you have inherited); the In Good Hands policy statement on clinical leadership; the more operational focus of the Ministry of Health (through the National Health Board); the formation of the Health Quality & Safety Council; the increased recognition of the important positive role of public hospitals; and, with qualification, the targets.
In respect of targets they have the value of sharpening focus on important matters. But care is required. Much clinical work provided by DHBs is not covered by the targets, including chronic illnesses, intensive care, and mental health. Our caution is that the more the targets are over-emphasised, the more likely the risk is that performance of the targets is that’s all you will get.
We have several specific requirements below.
We appreciate the serious financial challenges faced by the government. But the continuing reduction in the level of increased funding to DHBs is now risking serious harms. You periodically compare health funding in New Zealand with other countries but unfortunately these are selective. Your comparisons are with poorer performing economies. Comparative work by Rand Europe on European health systems under the global economic recession suggest that many European countries would have been envious of New Zealand’s financial position in 2008 when the recession fully hit, with particular reference to debt levels and unemployment.
Public hospitals have not been well funded for some time, even during the period of significant funding increases in the 2000s. Greater priority was given to primary care, new initiatives and capital works. The situation has been made worse by increasing demands on what they are expected to do and the revision to the ‘efficiency adjuster’ which was changed to a ‘contribution’ towards cost pressures. The combined effect is increased demands and funding increases below the level of costs. It has been made worse by the failure to invest in distributive clinical leadership which provides the basis for significantly improved fiscal effectiveness.
We note that in the Budget advice recently released by the Ministry of Health major financial shortfalls are revealed (coded as ‘required efficiency and reprioritisation’) - $376 million in 2012-13; $719 million in 2013-14; $1,087 million in 2014-15; and $2,136 million in 2015-16.
The ‘rubber is now hitting the road’ as DHBs and health professionals struggle to cope. There are too many unproductive creaks and strains in the system and the workforce is being over-stretched. Without corrective action the situation will only further deteriorate and consequential risks to clinical and financial performance escalate.
One of the negative effects of these pressures is the adoption of petty short-sighted decision-making in some DHBs. The Auckland District Health Board is an example with what is now widely popularised as the ‘$5.47 stapler’. One of the largest departments required a stapler costing $5.47. The service manager ordered it in the normal manner only to unexpectedly be advised that she did not have the delegated authority to make this decision. The clinical director then ordered it but only to receive the same response (to someone who has the delegated authority to save lives). This then led to some blunt internal discussions including the obvious observation that the time taken to debate it cost well in excess of $5.47. The eventual outcome was the purchase of the stapler and a highly embarrassed DHB as more and more staff became aware of the fiasco. There are other stories on the subject of pens but there is not enough time to describe them.
Consequently we require you to review health funding in order to ensure that it is able to meet both cost pressures and increased government and demographic demands as well as invest in distributive clinical leadership.
Health Benefits Ltd
We welcome the initiative of utilising Health Benefits Ltd to improve efficiencies although we decry the derogatory connotation of the artificial divide between ‘back office’ and ‘front line’. They are in fact highly integrated and inter-dependent. The latter can’t function without the former. Try telling surgeons and anaesthetists working in Christchurch Hospital during and immediately after the devastating February 2011 earthquake that boilermakers are not integral to the front line.
Unfortunately there are serious problems with the expectations of HBL and its process. The required five-year cumulated savings of $700 million is an arbitrary figure not derived from any robust analysis. It was a plucked figure which, some might say, leads to a similar sounding word aptly describing the outcome. HBL is not resourced to meet its expectations. Instead it is forced to engage external consultants without sufficient experience in the issues they advise on, leading to advice based on tenuous assumptions.
While on paper there is a good change management framework agreed between HBL, DHBs and the health unions, it is likely to be rendered ineffective for three main reasons. First, the sheer volume of work risks overloading it. Particularly within the tight time framework the combination of procurement, finance & supply chain, facilities, and human resources is too much.
Second, almost inevitably, the consultation with the workforces represented by the health unions will be constrained to the application of what the DHBs and HBL agree to rather than the merits or otherwise of the proposals.
Third, it is disingenuous to say that it is for each DHB to decide whether to accept HBL’s recommended business case on ‘procurement, finance & supply chains’ due later this year and then to require each DHB to have the business plan approval linked to the Annual Plan that you require. This is setting up conflict between the DHBs and the health unions arising out of a process not of their making.
DHBs are forced to make a considerable financial payment of around $85 million, through the top-slicing mechanism, to fund HBL with the financial benefits arising out of this investment being both speculative and well down the track.
It is disappointing that the positive initiative of the alliance of the South Island DHBs appears to be side-lined. They have already made promising advances, including savings, in procurement through a virtual share services framework which does not require the same financial set-up costs that HBL requires. It is important to note that this initiative is based on collaborative clinical and financial/procurement expertise from within the five DHBs. What was HBL’s response? They used external consultants without comparable experience and expertise to evaluate the work of those with considerably more relevant experience and expertise. The net result was a report that had a ‘bob’ both ways. Unless something changes it is likely that the South Island DHBs will have to make further savings, without factoring in the savings they have already made through their own process.
Consequently we require you to slow down the time frame HBL and narrow its scope of work to what is realistic and manageable in order to avoid serious risks, ultimately to patient care. Further, we require you to ensure that HBL seconds relevant financial, procurement and clinical expertise to advise it rather than use external business consultants. Finally we require you to embrace the initiative of the South Island DHBs and ensure that HBL adopts a supportive attitude towards it.
Despite the excellent In Good Hands policy (2009) advice to DHBs distributive clinical leadership has not advanced in the manner outlined in that document or, for that matter, the Ministerial Review Group Report (2009). While there have been encouraging developments in some DHBs, others have barely progressed. Overall the situation has not advanced substantially since the publication of these two documents.
While cultural issues (prevalence of managerialism) are a factor behind the lack of progress, the main problem is the specialist workforce capacity in DHBs. In general because of shortages specialists do not have enough time to engage in distributive clinical leadership to the level envisaged by In Good Hands. As clinical pressures increase they are affected by what is known as ‘clinical creep’. This means that time for other activities including core process improvement is either non-existent or very limited.
This is a tragedy because the failure to utilise a workforce that is, by virtue of its training and experience, natural and effective problem-solvers is a wasted opportunity to achieve both enhanced quality improvement and fiscal effectiveness. Failing to invest in this workforce is a strategic failure.
The DHBs unprincipled U-turn and unprofessional behaviour over the Business Case last year was a major set-back for those proponents of distributive clinical leadership, including yourself. Subsequently the ASMS and DHBs did agree on a document called the Quality Improvement & Patient Safety Plan which was based on the Business Case but, aside from sharpening the focus a little, has made no substantive difference and is likely to wither away.
Earlier this week the ASMS sponsored with the MidCentral and Whanganui DHBs a successful engagement workshop focussed on clinical collaboration between the two DHBs. Had you been fortunate enough to have the opportunity to attend you would have been very excited with the positive attitudes. It would have made your shirts glow even brighter. However, it became clear that the current specialist workforce capacity was only likely to sustain much of the collaboration to the level of clinical standards and professional development rather than to the next step of service configuration which is what we all need.
Consequently we require you to ensure the right investment is made in specialist workforce capacity to achieve comprehensive distributive clinical leadership in and between DHBs consistent with In Good Hands.
Claims of Increased Hospital Doctor
You will be aware that the ASMS has been critical of your assertions of increased hospital doctor numbers since you became Minister (from 500 to 800 to 1,000). This first occurred from delegates at our Annual Conference when you addressed it last year and has continued in the public arena in response to your media releases. We have endeavoured to seek clarity from the National Health Board but this has proven to be very difficult.
However, it is clear that the NHB has been giving you very unreliable data despite them being emphatically advised of this. The data you have been using in respect of specialists is, in fact, consistent with what we have been saying. Given that the data to both the NHB and ASMS comes from the same source (DHBs) this is hardly surprising. The differences are because the former is full-time equivalents and the latter is headcount but the trends are very similar. Essentially the annual specialist increases from 2009 are averaging 25% less than what they were over the previous three years. They continue to be well short of the increases recommended by the Business Case.
The much higher figures quoted by you are explained by highly suspect and dodgy resident medical officer numbers due to changes in the locum market and the reclassification of several of them from casuals (coded no fte) to employees (actual ftes, usually coded 1.0).
It is also disappointing that the NHB has opted to report to you in a misleading manner. It advises you that senior medical and dental officers have had the greatest increase among the categories of hospital doctors. However, this is only achieved by dividing resident doctors and dentists into two – house surgeons and registrars.
We require you not to make public statements based on unreliable misleading information from the NHB. Giving NHB officials a jolly good spanking for giving poor quality advice would also not go astray.
The decision to require Canterbury DHB to explore a possible Private Public Partnership for the hospital redevelopment arising out of the earthquake damage was unwise. At best it is a serious distraction for very busy people. The only potential benefit is that it removes the cost of the rebuild from the government’s balance sheet. It is very risky to insert profit maximisation in the running of hospital and clinical support facilities which is so interwoven in the provision of patient care. It also creates confused accountabilities between the PPP consortium and the DHB for staff whose work directly or indirectly affects both. As reported in the British Medical Journal and Lancet the experience of PPPs in the United Kingdom has been alarming. After all the people of Canterbury have been through they don’t need to be exposed to this as well.
Consequently we require you to cease going down this PPP path because of the high level of risk, disruptive impact and resultant destabilisation. There would be more logic in asking a panel beater to design a traffic intersection.
Amendments to Employment Relations
While this is not your Ministerial portfolio proposed government changes to the Employment Relations Act are of serious concern in terms of the implications for the health system. The proposal to remove the application of the duty of good faith on the parties to a collective agreement to conclude a settlement will give health employers too much power and incentivise the potential for abusing this imbalance.
The proposal to remove the 30-day protection for new employees to be covered by the provisions of the applicable collective agreement incentivises health employers to try to impose inferior conditions on those at the most vulnerable part of their employment relationship and less aware of the implications.
National and other multi-employer collective agreements (MECAs) are particularly appropriate in the health system given its industry and vocational nature. They bring major benefits to all parties, including reduced transaction costs and the opportunity to focus on sector-wide issues. The proposal to allow employers to opt out of MECA negotiations is an incentive for poor disruptive behaviour and undermining the benefits MECAs can bring.
DHB chief executives rely on their human resources advisers for advice on these matters. Despite DHBs usually being the largest employer in their location this is not reflected in the calibre of human resource management. The standard is mixed and overall not strong.
Consequently we require you to recommend to the Minister of Labour that these and other proposals that introduce unfairness and increased imbalance into employment relations be withdrawn.
Trans Pacific Partnership
The secrecy, coupled with the inevitable leaks that arise as a consequence, associated with the Trans Pacific Partnership Agreement negotiations is raising major concerns. This includes the future effectiveness of Pharmac and the ability of overseas tobacco companies to take legal action against anti-smoking measures in New Zealand
We require you to persuade the Prime Minister and Minister of Foreign Affairs & Trade that these negotiations do not lead to a reduction of Pharmac’s effectiveness in negotiating with the international pharmaceutical companies and that public health initiatives (such as anti-smoking) are not able to be legally threatened by overseas companies. New Zealand’s sovereignty in these matters should be retained.
Workforce Development and
The achievement of improved workforce development and planning has been a major disappointment. The formation of Health Workforce New Zealand seemed like a good idea at the time. But it has failed to develop a strategic direction and get ‘runs on the board’. There is too much focus on looking for magic bullets instead of sustainable longer term solutions and too much of a scattergun approach.
We require you to improve the performance of health workforce development and planning through much more collaborative and practical engagement with the health sector.
Finally we are disappointed that you at times can be oversensitive to the issues raised by critics while having no apparent problem in listening to spivs. We require that you disregard the advice of Spiv-like elements and regard the advice of critics as coming from your best friends because they will tell you what you may not want to know but need to hear. Critics are critics, not opponents. Spivs are something else. They are like seagulls; they fly over, deposit everywhere and fly off leaving others to clean up the mess.
Thank you for the opportunity to make these observations. I will leave it to you to mail the letter. But I will put on my back shield to protect myself from the inevitable knives that will be thrown. Perhaps I should contact Vinnie somewhere in a New Jersey prison. He’s good at one-off innovations.