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Foot And Mouth By Health Unions Not Smart

Health systems are labour intensive which makes workforce critical to their performance. The fact that New Zealand’s public system is highly unionised, especially health professionals, is a systemic strength. Health unions have proven to be essential to protecting and enhancing the public health system.

I’m particularly proud of the work I was able to do for over 30 years as the Executive Director of the Association of Salaried Medical Specialists (ASMS) in both protecting and promoting the enhancement of the public health system. This included fighting against fragmentation (such as through privatisation) and under-resourcing (including workforce) through underfunding.

This pride also included advocating distributive clinical leadership which, if fully implemented according to its tenor, would substantially enhance the accessibility, quality and cost effectiveness of our public hospitals and other health services.

The NZ Nurses Organisation (NZNO) can also be proud of its health system role including its safe staffing campaigning to protect both nurses and patients.

But occasionally (fortunately rarely) feet can get stuck in union leadership mouths. This became evident in a headline grabbing Christchurch Press and Stuff online article published on 16 November.

Article flaws

The article implied a linkage between management salary increases and the high operating costs deficit at Canterbury District Health Board (CDHB). The deficit is largely due to the aftermath of the 2010 earthquake devastation and delayed commencement of a new hospital block in Christchurch.

Drawing upon annual reports it writes that over nine financial years from 2009-10 to 2019-20, the number of “management and administration” staff with salaries over $100,000 or more increased by 351% from 56 to 253. Superficially this is mindboggling until one drills down further. An immediate fault in the article is the absence of any comparison with other DHBs, particularly more comparable larger ones. There is no comparing apples with apples.

Overwhelmingly, and rightfully, these management staff (as with other CDHB staff) would have received annual salary increases of some form (for example, percentage increases or step advancements where scales existed). Let’s assume an average annual increase of 2%. In this scenario anyone earning $85,000 or more would now be earning over $100,000. Reasonable salary increases of $15,000 or a bit more spread over nine years go a long way to explain this growth.

In addition (which the article does acknowledge) there have been significant expansions in CDHB since 2009-10 around bringing back into the DHB previously privatised non-clinical services (commendable) and regional support for other South Island DHBs, particularly West Coast and Nelson Marlborough (collaborative).

However, what the article fails to mention is that some of this management growth also includes senior nursing leaders many of whom would deserve such salaries. Further, the staff employed under the shared services agency that services the five South Island DHBs are for administrative convenience technically counted as CDHB staff.

The article then goes on to contrast management and medical staff salaries. This is really where it gets it badly wrong with apples and mushy oranges coming into play. It claimed that the number of medical staff earning $100,000 or more increased during the same nine year period by 140% from 618 to 1,502.

This was an illogical comparison because medical staff includes both resident (junior) and senior doctors. More so, the bottom step on the specialist salary scale (40-hour week) was above $100,000 at the start of the nine years and is well above today. The whole comparison is nonsense and the data misunderstood.

Union responses

The responses of three unions were reported in the article. The Public Service Association made no judgemental comment about managerial salaries but made the legitimate point that many mainly female administration (rather than management) staff were underpaid.

NZNO, on the other hand, while raising valid safety concerns about nurse staffing levels, appeared to buy into the insinuation that high management salaries were at the expense of frontline staffing. It is worth adding that many DHB managers were previously experienced nurses and, with the occasional exception, the health system has benefited as a consequence. It was also unfortunate given that many senior nursing leaders are NZNO members.

Sadly, from my personal perspective, ASMS’s response was knee-jerk and unwise. By stating that it would be concerning if management staffing was increasing at the expense of medical staffing, it was perpetuating an incorrect insinuation in the article. Many of these management salaries would have increased by around $15,000-$20,000 over nine years; not excessive compared with specialist salaries over this time (I should know; I negotiated them).

Furthermore, CDHB is a huge employer – not only the biggest in the Canterbury province and South Island but the seventh biggest in the country employing a similar number to the Police and Defence Force. Of the DHBs only Auckland employs more staff.

CDHB employs over 10,700 staff of which 1,708 (around 16%) are in management and administration combined. The 253 managers on salaries $100,000 or higher comprise around 3% of total CDHB employees and around 15% of the total management and administration staff. There is nothing disproportionate about this given the size and high complexity responsibilities of CDHB.

Ironically ASMS as a union is one of the highest remunerator of staff for which I take ultimate responsibility (and endorse) with a higher proportion justifiably on salaries that ASMS questioned for CDHB senior managers. Words like stones and glass houses come to mind.

Get the focus right

There was an absence of nous in the response of ASMS and NZNO. I’m reminded of words of wisdom of the now deceased prominent militant union leader Bill Anderson: the first question to ask about some idea or proposal is who benefits. This article inadvertently served the interests of those responsible for the attacks on and scapegoating of the former senior leadership at CDHB (ie, Health Ministry, Treasury, Crown Monitor and Board Chair). Both unions took a principled position of criticising these attacks and scapegoating but now have inadvertently assisted them.

Rather than focus on the number of managers or their remuneration, a bigger issue is capability. Virtually all managers are conscientious and largely skilled but there are still some capability deficits for such a complex sector as health.

But much bigger than capability is leadership culture. Managerialism in which management leads systems improvement and operational work is pervasive. It erodes the ability of DHBs to perform better and in the process is much more financially expensive than how many managers DHBs have and how much they are paid. Changing the culture to distributive clinical leadership is what advocacy around management’s role should be.

It may seem odd for a former union leader of three decades to criticise unions. But it isn’t for one who has always believed that advocacy has to be based on strong empirical foundations and that ultimately unionism is more important than its structures that happen to be called unions. Mistakes are there to be learnt from, not shied away from.

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