Iam Powell Speech On DHBs
District Health Boards Threaten Medical Workforce Development In New Zealand: The Folly Of A ‘Health System In One Country’ Approach
ASSSOCIATION OF SALARIED MEDICAL SPECIALISTS
WHANGAREI, 15 NOVEMBER 2006
ASSOCIATION OF SALARIED MEDICAL SPECIALISTS
New Zealand is always going to be in a vulnerable position for recruiting and retaining sufficient quality senior medical and dental staff (senior doctors) because of two critical defining factors beyond our control:
We are a small country with a small population base. This critical mass, low compared with many countries with more or less similar health and medical training systems that New Zealand has to compete with, has an obvious effect on our ability to provide staffing numbers that go such a long way to ensure comparable working conditions, particularly in the potentially more dangerous and stressful area of after-hours call rosters.
We are geographically isolated from most countries with similar health and medical training systems. This, in the absence of effective and transparent corrective measures, particularly disadvantages us in the critical area of professional development and education, so important in an innovative economy.
These factors pose significant challenges for our health system in recruiting and retaining senior doctors. It leaves New Zealand facing a constant battle to (a) retain our quality doctors who are highly valued overseas with their rich mix of generalist and specialist training and (b) recruit doctors from overseas in a very competitive and specialised labour market (the significance of this second part of the equation is that fact that around 35% of doctors working in New Zealand are overseas trained). In reference to the latter, New Zealand simply can’t recruit from the whole of the rest of the world because those countries with sufficient similarity in training systems are relatively small in number.
Even where it appears that we have reached a steady state of recruitment and retention this picture of stability disguises an underlying brittleness. It takes little, only a few set-backs, poor policy settings, or ‘left field’ developments around the margins, to upset the steady state and send us in the direction of difficulty, perhaps eventually crisis.
The ideological neglect and disparaging of medical workforce development in the 1990s did immense damage to New Zealand’s health system. However, the legislative framework has improved since then with the Public Health and Disability Act 2000 and the Employment Relations Act 2000 which together provide an overarching setting more conducive to workforce development.
A recruitment and retention strategy to be effective must form part of a wider approach to medical workforce development. We made a positive and important move towards the addressing of this challenge with the achievement of a national collective agreement (MECA) for senior doctors employed by district health boards which came into effect on 1 July 2003. This involved a merging and restructuring of 21 separate collective agreements into one national agreement which provided a more solid and robust basis for recruitment and retention. Its express emphasis on (a) senior doctor empowerment, (b) the ethos of professionalism, and (c) professional development and education were important components of an emerging workforce development strategy. It is a modern professional document which outlines an employment relationship between DHBs and senior doctors most appropriate for a system that produces a universal and essential public good.
Recent events, however, suggest a move in the opposite direction to that provided in our MECA and in doing so again exposes the brittleness of our international predicament.
Exposing the brittleness with an ice pick
The debate in the Soviet Union in the 1920s provides a limited analogy. Stalin argued in favour of ‘socialism in one country’ which was contrary to the internationalism of socialism and inconsistent with its ideal. In New Zealand we are presently faced with a stark choice over whether the recruitment and retention of health professionals should be seen as if the rest of the world did not exist through reality denial (a ‘health system in one country’) or whether it should be seen in the full real international context that faces it. The alternative of Stalin’s rival, Trotsky, of ‘permanent revolution’ may not be what our health system needs in the sense that this suggests constant qualitative change but if adapted to ‘permanent responsiveness’ to international and other challenges it has an appeal and applicability. For those with a sense and recollection of history the challenge confronting medical workforce development is, not to put too fine a point on it, whether this development is allowed to be the victim of a Stalinist ice pick mentality.
Senior doctors are critical to the performance of the most complex and integrated part of our health system, public hospitals. More than anything else, aside from realistic funding and sound policy settings, along with other health professionals senior doctors have the capacity and motivation to fix most of the key challenges facing public hospitals if they are allowed, encouraged and enabled with the necessary influence to make this happen. The health system is so fortunate in possessing the wonderful combination of intellectual wisdom, professional motivation and practical experience within its own walls to resolve its challenges. But the health system is equally so unfortunate not to have the leadership that sufficiently recognises this reality beyond a level of tokenism and rhetoric. The system’s continual capacity, regardless of the political flavour of the government of the day, to miss the obvious is extraordinary. To dump the latter in the dustbin of history and turn to the former requires an effective medical workforce development strategy.
But obstructing the utilisation of the most obvious resource available is the destructive and debilitating culture of managerialism which is one of the surviving legacies of the 1990s era. Managerialism is top-down and based on the premise that a mutated ostrich-like cult (senior management) within the system knows best. This still pervades, to one degree or another, today.
This descriptor should not be applied to the many operational and practical managers who work daily alongside and support health professionals doing good work. Rather it is more applicable to a number of those affected by the ‘tyranny of distance’ from operational practicality. Some of it is also driven by ideological zeal, again a carry-over from the 1990s. For others it is a default position that arises in times of fiscal and other pressures leading to short-term decision-making (without sufficient regard to longer term consequences) and without substantive and proactive consultation and engagement with health professionals.
The rubber usually hits the road between the cultures of managerialism and health professionals when financial pressures come into play, which is most of the time but particularly now in our public hospitals. Regrettably, while the government has a strategy for primary care, there is an absence of something comparable for secondary and tertiary care provided by public hospitals. DHBs are projected to be funded at less than the rate of inflation (3.5%) over the next three years through a process known as the ‘future funding track’—2.9% in 2006-07, 2.4% in 2007-08 and 2.1% in 2008-09. This is the government’s estimate of inflation over the three years minus 0.5% per annum which is a lever it is attempting to use to achieve ‘efficiencies’ (a tactic likely to produce adverse outcomes).
But these are indicative figures, especially the final two years, with two further budgets to come and the possibility of additional funding for specific initiatives (additional to the recent announcement of a permanent increase of $50 million per annum for electives which is also over and above the ‘future funding track’). The DHBs are basing their approach on the ‘future funding track’ which is then compounded by the requirement (unrealistic for several DHBs if the quality and range of services are to be maintained) of government, through the Ministry of Health, of running break-even budgets in the 2006-07 financial year.
In this environment DHBs are forced into short-term decision-making without regard to longer term consequences, including fiscal. This includes their approach to workforce development and involves ignoring New Zealand’s distinct and brittle vulnerability.
National RMO MECA Negotiations: A boomerang outcome
It is worth noting at this point how unsuccessful the strategy of the DHBs negotiating team in the resident medical officers MECA negotiations was. Their team was on a high, hyped on its own ‘success’ when it withstood the five day strike of RMOs back in June. Their success at that time can be measured by the fact that albeit a minority a significant number of RMOs continued to work for at least part of the strike and that the Resident Doctors’ Association was forced to abandon its follow-up industrial action strategy.
However, the DHBs negotiating team, and the more hard line chief executives who shaped its direction, committed the cardinal sin of being carried away with their hype and believing their own rhetoric. The objective of the DHBs was to significantly reduce the influence and control of the RDA over RMO rosters; emotive rhetoric of ‘reclaiming our rosters’ was used by DHB representatives in an effort to generate senior doctor empathy for their objective. However, their lack of clarity of objective led them to rigidly and obsessively lock themselves into one means only of achieving it rather than being sufficiently adept at considering other means of achieving it. Building up a relationship of mutual trust and confidence between DHBs and RMOs never formed part of their direction despite it being the most effective means available.
Consequently, over time the experience of a regrouped RDA, well placed to anticipate the effect of this bitter dispute on the RMO labour market and reported serious RMO shortages (some suggest a crisis) emerging in 2007, have now produced an outcome which at the very least sees the RDA’s influence maintained and arguably increased. The DHBs negotiating team’s post-strike strategy paper promoting taking advantage of the disappearing of the right of newly appointed RMOs to be covered by the expired MECA (12 months after its expiry date) further undermined the trust and confidence of RMOs in the DHBs and most likely intensified RMO shortages thereby increasing the RDA’s relative bargaining leverage.
The fact that the RDA did not achieve the quite different rostering changes it sought does not diminish the fact that the ‘non-negotiable’ position of the DHBs negotiating team was turned on its head. The fact that their negotiating team will provide an alternative spin, so important for one’s CV and subsequent career aspirations, does not diminish what the plain written word of the recent settlement actually says. To use a boxing analogy, inappropriate of course for medicine, while there were no knock-outs, the RDA scored a unanimous points victory.
But of three things there is no doubt, despite the DHBs negotiating team’s boomerang outcome. First, this acrimonious dispute has done serious longer-term damage to relationships between DHBs and the country’s younger doctors and has made New Zealand a less attractive place to recruit and retain them than before the negotiations commenced. Second, this detrimental effect will also damage for sometime the capacity for a trust and confidence relationship between RMOs and DHBs which is essential if the senior doctors concerns over RMO rostering arrangements are to be resolved. The legacy of the DHBs negotiating team’s approach to this negotiation is to set back medical workforce development for some time as well as failing miserably to achieve the objective they so assertively and publicly claimed was non-negotiable.
Third, exploiting the concerns of many senior doctors over aspects of RMO rostering arrangements, the DHBs negotiating team raised their expectations of resolving them in this negotiation, including the use of rhetoric such as ‘reclaiming our rosters’. This was used to foster a degree of empathy from a number of senior doctors towards the DHBs position in this dispute especially during the five day strike. But having raised expectations the DHBs’ negotiating team within their own description of success failed to deliver and have left a challenge that is now more difficult to resolve because of the bad will than before the negotiations commenced.
Senior Doctor National DHB MECA Negotiations: a lesson about turning on one’s most critical resource
In the case of our negotiations which commenced in late May (the current MECA expired on 30 June), we are experiencing considerable difficulties which also threaten medical workforce development. The two main problems are the DHBs negotiating team’s unrealistic insistence of limiting the fiscal increases to the government’s ‘future funding track’ discussed above and their inexplicable push to both increase managerial control, devalue professionalism, and furthering senior doctor disempowerment.
In the case of remuneration their position is that if everything was put into salaries and nothing else (eg, CME expenses), the average increase would be in the vicinity of 7% over three years (around 2.4% per annum). This compares with New South Wales with a compounded 29% over four years (averaging around 7% per annum). The Queensland enhanced rates (between 27-58% over three years) make New South Wales look modest leaving New Zealand even paler in comparison. Even Victoria’s more modest 9.3% over two years leaves New Zealand looking poorly.
Although the DHBs negotiating team is rigidly linking its position to the government’s ‘future funding track’, this is contradicted by the Minister of Health who perhaps unintentionally rebutted their argument when interviewed in Radio New Zealand’s Nine to Noon programme on 5 September. He made the following observation:
one part of the funding which is called FFT which is only 3%, is under the inflation rate, but when you add the various other streams of money that hospitals get, the increase in the year that we’re in at the moment ranges from DHB to DHB. The lowest I think is probably Otago which is my own DHB. That sits at 4%. The highest is probably around 7.5%, some would be touching 8%. None of those figures are well below inflation…
There are reports from within DHBs that despite this public statement the Minister has instructed chief executives to stick to the unrealistic limits of the ‘future funding track’ in collective agreement negotiations and not to make any settlements outside them. If this is correct, and we do not have collaborative evidence, then this would constitute blatant and unacceptable interference. Further, if correct, we would expect the Minister to front up to the negotiating table.
Given that in no small part the Australian increases are due to medical workforce shortages (Australia is fortunate to have much better undisputed data than New Zealand) and the similarity of our training schemes, it is of no surprise that New Zealand senior doctors are being actively and regularly targeted through systematic recruitment campaigns. But it is not only our currently employed medical labour market that is under threat. Around 35% of New Zealand’s senior doctors are overseas trained and it is from this overseas market that we will be endeavouring to compete against Australia. In addition to superior remuneration, by virtue of being a much larger country and, with a bigger critical mass the two largest states at least, New South Wales and Victoria, are also advantaged by superior staffing levels, greater registrar support and less frequent after-hours call obligations.
The DHBs Negotiating Team’s novel approach to medical workforce development
The response of the DHBs negotiating team, however, is to pretend that there is no serious challenge. There is an absence of the recognition of an effective recruitment and retention strategy even to the point of being oblivious to the high level of dependence on the greatly increased costs of senior doctor locums to fill vacancies. No consideration is given to other factors that might compensate for our comparative disadvantage such as a positive approach to promoting professional development and education, including sabbaticals and secondments, and the provision of sufficient time, consistent with professional standards, for non-clinical duties (largely professional activities). Instead the DHBs negotiating team is compounding their abysmal fiscal proposal with negative counter-claims that are largely about claw-backs, increasing managerial control, and senior doctor disempowerment.
No one in their team has ever adequately explained why such an approach would constitute an effective recruitment and retention strategy in a highly competitive international medical labour market and how it assists medical workforce development. These counter-claims from the DHBs negotiating team include:
1. Deletion of 30% Minimum Time for Non-Clinical Duties Professional Standard
They sought to delete the identification of the 30% minimum time for non-clinical duties as the appropriate professional standard for job sizing. The identification of this standard was an important gain of the current MECA although it had existed in previous forms in some of the predecessor single DHB collective agreements. The DHBs negotiating team advocated a disingenuous argument that they are merely providing clarification; but deletion of a professional standard is deletion, not clarification. Their position has subsequently shifted to other means of trying to water down the importance of this professional standard.
2. Cutting Salary While on Sabbatical
They attempted to cut senior doctors’ salaries while on sabbatical. The current MECA provides for full pay when on an approved sabbatical programme. Full pay includes the base salary, job sized hours above 40 per week and the availability allowance. Their proposal was to remove payment of the availability allowance. This is contrary to the express provision of the MECA for DHBs to actively encourage senior doctors to take sabbatical and other forms of professional development and education. They have now withdrawn this claim but the intention was alarming.
3. Reducing Eligibility for Sabbatical
They are endeavouring to make more restrictive the eligibility of senior doctors for sabbatical that have not undertaken it within the past six years (and have at least six years service). The means is the use of criteria which would make the ability for a senior doctor in this situation as difficult as if one was seeking approval of a fast-tracked proposal (within six years).
The current MECA clause differentiates between senior doctors with more and less than six years service; for all practical purposes the effect of the DHBs negotiating team’s counter-claim is to remove this differential and revert to the less than six years service threshold. This counter-claim still remains.
4. Joint Consultation Committees
They are seeking to prevent our Joint Consultation Committees in each DHB from discussing any matter covered by the MECA. Given that the scope of the MECA is so broad (eg, job sizing, resources to do one’s job, appointments processes), it would relegate the role of the JCCs to turgid discussion with human resource managers to matters of ‘high policy’ and ‘process’. It is an attempt to undercut and prevent SMO empowerment and they are still sticking with this position.
5. Consultation Rights
They have attempted to significantly minimise the current MECA clause on consultation (another hard won gain) to the point of being useless. This includes removing the requirement for DHBs to seek ASMS endorsement of terms of reference for reviews that affect the quality or delivery of clinical services and to expressly leave any final decision to the employer. This is a direct response to the ASMS’s successful application to the Employment Court for an interim injunction against a breach of MECA consultation obligations by two DHBs. This minimisation still remains their objective through different means.
6. SMO Accountability
They are seeking to introduce an additional explicit statement for senior doctors who have service management or clinical leadership roles that they are ‘accountable for the outcome of decisions made whilst performing duties’. But for accountability to be meaningful there needs to be a high level of empowerment and authority. Regrettably many DHBs do not have the necessary internal culture for this empowerment to continue.
7 ‘DHB Values’
As another indication of where the DHBs negotiating team is coming from another counter-claim, which has subsequently been withdrawn, was to seek to introduce into the MECA a requirement that senior doctors ‘execute their responsibilities in accordance with their DHBs values.’ This would have been part of Clause 40 of the MECA which covers professional responsibilities and accountabilities. Clause 40 is important because it covers the recognition of the parties (DHBs and ASMS) to the primacy of senior doctors’ personal responsibility to their patients; and to their role as a patient advocate; and their responsibility and accountability to the Medical (and Dental) Councils and to the ethical codes and standards of relevant colleges and professional associations.
If the ASMS had accepted this counter-claim the practical effect would have been to give a DHB’s unilaterally determined ‘values’ the same status as these matters discussed above.
A cry for leadership
These inexplicable and provocative short-sighted actions by the DHBs negotiating team which undermine medical workforce development highlights the cry for effective national leadership in the health system and for DHBs to play their part in providing this. This unacceptable behaviour along with their unrealistic fiscal position in our MECA negotiations led the Association’s Annual Conference on 2-3 November, attended by a record number of delegates, to adopt the following two resolutions. The first, adopted unanimously, stated:
That Annual Conference condemns the DHBs current approach to re-negotiating the national DHB collective agreement (MECA). This approach threatens the ability of the public health system to provide accessible high quality patient care, because of the DHBs’:
intransigence and refusal to negotiate genuinely;
devaluing of the critical and central contribution of senior doctors and dentists;
disregard for New Zealand’s vulnerability in the recruitment and retention of high quality senior doctors and dentists;
attempts to increase managerial control; and
devaluing of professionalism.
The second, adopted overwhelmingly, stated:
That, should the impasse in the re-negotiation of the national DHB collective agreement (MECA) continue, Annual Conference authorises the Association’s negotiating team to organise national stopwork meetings to consider appropriate means and forms of action for resolution.
It must be noted that stopwork meetings are not strike action. Instead they are an entitlement provided in the MECA for up to two paid 2-hour meetings per annum. There is no immediate analogy but they have more in common with special meetings that are called from time to time to discuss critical issues while emergency cover continues to be provided for the affected period. Although there have been the occasional stopwork meeting in the past, these were largely in the 1990s and over local issues. The national nature of these stopwork meetings and the context in which they are occurring make them unprecedented.
There is still some water to go under the bridge if and before they proceed with further negotiations scheduled for later this month and early December. Should there be a change of direction by the DHBs negotiating team involving preparedness to front up to the challenges facing us all which then leads to an end of the impasse, then the stopworks will not proceed (noting that ending an impasse does not necessarily mean a resolution of outstanding issues). If they do proceed the earliest will be next February.
As stated above stopworks are not strikes. But, as the second Conference resolution suggests, the stopworks are likely to discuss possible strike action. While it is impossible to imagine strikes affecting emergency care, discussion may focus on limited industrial action such as electives and clinics. But there is even more water to flow under this bridge before this form of action might occur. It would certainly require a membership ballot on the subject. Further, the MECA also sets out requirements before strike action (the opposite of which is lock-out action by DHBs) which include compulsory mediation (external facilitation) and voluntary adjudication (arbitration). Clause 57 states:
The parties are committed to negotiated outcomes. If a negotiated settlement for a claim for a collective agreement has not been arrived at, the parties agree that either party may refer disputed matters to the Mediation Services for mediation and that the parties agree to participate in the mediation process in a genuine attempt to reach a settlement.
If a dispute still remains which cannot be resolved by either negotiation or mediation, before considering strike or lock-out action, as applicable, the parties will meet to consider a possible adjudication process to resolve outstanding issues.
What’s driving the DHBs negotiating team?
It is unclear what is driving the DHBs negotiating team and why they would embark on a strategy which can only jeopardise and threaten medical workforce development which is contrary to the interests of DHBs, let alone the public whose interests they should be promoting. Their strategy, such as it is, is strikingly inconsistent with the approach of a number of DHBs which are in various ways and various degrees of success involved in efforts to encourage and develop cultures of engagement with and the empowerment of senior doctors.
One explanation is that when chief executives are corralled together a herd-like mentality subsumes them and some of their better instincts. Another, which has more currency within DHB conversational circles, is that hard line elements within the DHBs are calling the shots and driving this strategy. There is serious doubt over whether all chief executives are fully aware of what is being advocated in their name.
Whatever the explanation of one thing at least there is no doubt, however. The DHBs negotiating team, with or without mandate, is embarked upon a strategy that fails to recognise New Zealand’s brittle vulnerable position in the international medical labour market, undermines New Zealand’s ability to recruit and retain senior doctors and threatens medical workforce development. The narrow poorly thought-out Stalinist ice pick approach will collapse much more quickly, because of the immediacy of the ruptures it causes and crisis it threatens, than ‘Uncle Joe’s’ regime.