Publications

The Specialist

Issue 59 June 2004

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• The Path to MECA: Light at the end of the tunnel (or a train coming from the opposite direction)?
• National Executive Resolutions
• Growing Apart, or Growing Up Together
• Continuing Failure to Learn
• The Incompetency of Holmes
• New Holidays Act 2003 and Payment for Public Holidays
• Medical Misadventure to be Abolished
• The Public Finance (State Sector Management) Bill
• HPCA Act - Practices, Pathways and Political Change
• Medical Protection Society
• ASMS Membership Workshops: August
• Medical Assurance Sociey, in business over 80 years and still going strong
• ASMS Recruitment and Vacancy Report: MidCentral DHB
• ASMS 16th Annual Conference

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The Path to MECA: Light at the end of the tunnel (or a train coming from the opposite direction)?

The March issue of The Specialist reported extensively on the national DHB collective agreement negotiations that had commenced on 29 April 2003. Since then there have been two turns of events-an aggressive media attack on us by the DHBs that threatened to collapse the negotiations and a turnaround in the negotiation process leading to a considerable narrowing down of the issues that the two negotiating teams were apart over.

The DHBs' media attack, in the name of Counties Manukau chief executive Stephen McKernan, has been reported fully in our Bargaining Bulletin circulated to all DHB-employed ASMS members. In summary, the 'McKernan statement':

• Misrepresented badly the position of the ASMS in the negotiations and overstated the DHBs' own position.
• Was extraordinarily ignorant of the real pressures facing the medical/dental workforce in DHBs, including the true vacancy levels and recruitment difficulties.
• Erroneously raised private practice as a negative red-herring.

Attached to the DHBs' media statement was another brief paper asserting that if the ASMS did not accept their offer (ie, that which was rejected by 84% of respondents in our secret ballot paper in January), then it was
back to the beginning and starting afresh 21 times to negotiate 21 separate agreements.

The message could not have been clearer; do what we say or we will retreat to our own 'sandpit'! In response to membership feed-back that, in summary, (a) the ASMS should not allow DHBs to derail our attempt to achieve a national agreement and (b) to continue to strive to achieve reasonable terms and conditions of employment that would assist recruitment and retention needs, the ASMS negotiating team has pursued a two-fold objective:

1. Not give the DHBs any excuse to walk away from the negotiating table.
2. Pro-actively make new proposals which compel the DHBs to respond and which are also consistent with our assessment over what might comprise a good settlement able to be ratified by members.

This was the approach that the ASMS negotiating team took when returning to mediation on 28 April, 14 May and 2 June. Although there continue to be differences between the two negotiating teams, discussion has now become generally constructive and useful, including on possible scenario outcomes, and the differences between our respective positions have narrowed considerably.

If these are all resolved on 24 June when mediation resumes for a 16th day (28th day of negotiations since 29 April 2003), then it is likely that a proposal will be referred to the DHB chief executives. Subject to the outcome of that process (resolution between the teams on 24 June is still not possible), the proposal would then be forwarded to ASMS members for consideration in a postal ballot.

However, given the dramatic turns and shifts since the March issue of The Specialist, we can't rule out the possibility of another (third) turn and what presently appears to be light at the end of the tunnel transforming into a train coming from the opposite direction.

Ian Powell
Executive Director

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National Executive Resolutions

In response to the DHBs' media attack on the ASMS (29 March) including the threat to can the national MECA negotiations, the ASMS National Executive adopted the following resolutions on 1 April:

1. That the Association continues to pursue the negotiation of a national DHB (multi-employer) collective agreement.
2. That, due to the approach of the DHBs to the MECA negotiations, the National Executive notes that in some DHBs the collective wish of members may be to
   initiate single DHB collective bargaining and resolves that this will be supported. Further, the National Executive considers that initiation of single DHB collective bargaining in this context would be consistent with the Association's objective of endeavouring to achieve a national multi-DHB collective agreement.

These resolutions recognised that the ASMS will not be cowered or otherwise pressured into accepting a position that was rejected overwhelmingly by our members; we continue to recognise the considerable benefits of a MECA both to our members and to the wider health sector; and that we continue to be prepared to make reasonable compromises to achieve

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Growing Apart, or Growing Up Together

It has not been considered the core business of ASMS to concern itself with the affairs of resident doctors. Our colleagues in training have their own very effective union to represent them, to negotiate on their behalf. We were once them, and many of us resented the punitive conditions we worked under. We railed against the subservient nature of our jobs, only gilded by the potential promise of better times to come. Many of us were part of the moves to improve conditions, to improve training, to reduce the exhausting hours we were expected to endure.

Yet today I sense a growing disengagement between "senior" and "junior" doctors. And at a time when the medical profession believes itself under siege from those who would be doctors but do not want to train as such, and from those who expect infallibility but leap to blame when nature crumbles. At a time our profession depends on unity and growth together, we risk being driven apart.

Not only as a result of, but contributed to by restrictions of working hours, we see senior doctors (particularly when working in consultant roles) left as the only personal continuity in patient care. Not only as a result of, but contributed to by restrictions of working hours, we see residents struggling to gain sufficient experience to fulfil college training requirements. Procedure based specialties at first, and now other specialties, are grappling with conflicts of training expectations, and those of service rosters.

Growing apart?
Residents are showing senior doctors that life outside of medicine is important, that looking after oneself is not selfish, but essential to longevity, to service without dependency on alcohol or other nefarious supports. That a career of caring does not require complete sacrifice of self. Can their senior colleagues argue against a shift of focus to family and self, when many have either succumbed to the insatiable demands of public service, or elected the control of private practice, or attempted to balance both?

Some managers are starting to argue that resident doctors are "pricing" themselves out of the market; are looking for alternative ways of staffing hospitals; and are considering the costs of training as excessive contributors to deficits. However, without training-whether or not the true costs are reflected in balance sheets-there is no future health service. Avoiding the reality of the energy and expense of education only defers the deficit funding to a future manager's balance sheet.

Who then carries the can? Senior doctors-the doctors who work most with resident doctors; the professional colleagues who have "been there, done that", who know most how tough it can be to work the hours of tedium and turmoil; the mentors and teachers of the future senior doctors; who rely on and need to trust the honesty, dedication and skills of those in training; whose example must energise without envy of entitlements!

Who, some pay-masters have wagered, will "just pick up the pieces" to fill roster gaps, to be accountable for signings of MECAs with conditions that no smaller hospital can possibly adhere to! Whose lives and families count the cost of responsibility not only in name but also now in person! Who easily slip to criticise their junior colleagues for perceived failings of dedication or responsibility!

And, if these opinions become pervasive, then we have been driven apart. Not deliberately but insidiously. Not actively but as a falling apart; a division which can deteriorate so easily into derision.

Growing up
The affairs of resident doctors affect all ASMS members; more directly and in the longer term, than our affairs affect them. Their working conditions impinge on our daily lives, on our methods of care for our patients. Their expectations extend into future working lives as senior doctors-they will be us. We cannot ignore how they see their work and future-they are our future. For we are not them and us. We are we.

Only by talking together, walking together, working out together what we expect from each other, individually and collectively, can we learn from each other. Learn how to look after ourselves. Learn how to look after our profession. Learn how to look after our patients.
We must grow up together, or else we will surely grow apart.

Jeff Brown
National President

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Continuing Failure to Learn

If I had to nominate the most frustrating feature of our health system it would be the repetitive failure of our political and managerial masters to learn from bad processes, decisions and outcomes and the failure to appreciate that their most effective resource for sustainable improvements and efficiencies is right in front of their eyes.

In the 1990s lack of effective engagement between decision-makers and health professionals reached a high point. A new competitive business/market model was introduced without regard to practicality or effectiveness in a health system expected to produce a universal public good and in a country with a small population base.

Within this ideological context a series of blunders and fiscal shockers occurred. Millions of dollars were wasted on unsuccessful top-down consultancy-driven projects such as Proudfoot at Waikato and Deloitte at Taranaki. Both Waikato, in particular, and Capital & Coast had information technology fiascos with the ill-suited American Shared Medical Systems. In addition to more fiscal wastage, the endeavours of the then Third Sight consultancy had a destructive and corrosive effect on Wellington Hospital. Arguably the most devastating case was the Health & Disability Commissioner's enquiry and damming report into patient safety at Christchurch Hospital.

In all cases these were outcomes that arose out of autocratic managerial styles which largely precluded effective engagement with senior medical staff and the rest of the health professional workforce. In fact, in a number of instances these decisions were made despite the express opposition of health professionals. Aside from fiscal irresponsibility and wastage, the overall outcome was the failure to lead to changes which were beneficial, effective and sustainable. Had there been a culture of effective engagement with health professionals then, at the very least, these disasters would have been avoided.

These were among the higher profile cases of the 1990s but there were several others. While thankfully the market model was abandoned at the commencement of this decade and we do not have the same high profile cases as occurred in the 1990s, nevertheless within DHBs a new culture of engagement with health professionals has yet to occur in any comprehensive or systematic manner, despite some exceptions and occasional protestations to the contrary. The drivers of change today are similar to the drivers of the 1990s; political leaders, political advisers, DHB board chairs and senior managers. Although there have been many improvements during the early years of this decade, involving senior medical staff and other health professionals in the engine-room of decision-making has not been one of them. There have, of course, been notable and positive exceptions; the cancer strategy and the recently announced increased hip and knee surgery funding immediately come to mind. But the fact that they stand out exemplifies the problem; the engagement over these projects is not typical or prevalent in the sector as a whole.

One only needs to look at the new Auckland DHB hospital at Grafton as health professionals struggle to cope with a range of capacity issues, including staffing levels, staff skill mixes, theatre space, information technology and other resources. Again, had there been effective engagement with senior medical staff and had their expressed concerns been taken on board, then many of these frustrations might have been avoided; certainly they would have been minimised.

Looking across the Tasman offers a different view of what is possible. Over three years ago the New South Wales government established the Greater Metropolitan Transition Taskforce (GMTT) as a transitional vehicle for testing new processes for the planning of clinical services. It was driven by health professionals, including senior doctors, rather than the state health department or health managers. The GMTT was responsible for the coordination of service planning in metropolitan New South Wales. It made numerous recommendations to the Minister of Health over specific clinical resource expenditure, such as stroke units and trauma centres, which were adopted overwhelmingly as government policy.

That three-year project is now over and an independent audit of its effectiveness has been completed. The audit concluded that the GMTT process had led to 'engaging the clinicians in meaningful planning and decision making as opposed to the traditional "advisory" role in which clinicians are usually invited to be involved.' It had 'created a fundamental change in health service planning in New South Wales. This is being achieved by providing meaningful clinician engagement in planning and decision making and broadening the basis of this engagement…which includes all health professional groups, is fostering a high level of cooperation, and consideration of all aspects of care delivery.'

Further, the audit concluded that probably the 'most significant gains have been the acceleration of decision making and the implementation of new strategies and services and the development of clinical networks.'

While one country should not simply replicate what is happening in another country, the New South Wales experience is evidence that engaging with health professionals in the engine room of decision-making is much more likely to lead to effective and sustainable quality improvements and also to avoid the wastage, corrosiveness and frustrations that the alternative has provided to date.

Ian Powell
Executive Director

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The Incompetency of Holmes

On 14 April TVNZ's Holmes programme, presented by Susan Woods, ran an item that began as a report on an isolated incident involving a general surgeon and a registrar employed by the Southland District Health Board. That incident provided the background and apparent justification for the substance of the item which linked patient safety to the accountability, competence and standards of specialists in provincial hospitals; to the integrity and professionalism of specialists in general; tried to argue that general surgeons were not specialists; and misrepresented the role of the Health & Disability Commissioner. The programme was categorised by incompetence, inaccuracy, unfairness, lack of balance, ignorance and harsh damaging accusations.

In response to this appalling piece of journalism the ASMS has made a formal complaint to TVNZ which is currently under consideration. TVNZ appear concerned about the seriousness of the ASMS's complaint as it has advised that it requires additional time to consider it.

All of this could have been avoided if Holmes had (a) consulted the ASMS in advance about the background and/or substance of the matters it wished to canvas in the programme and (b) consulted TVNZ's own specialist health correspondent. Those responsible for the item were irresponsible for doing neither. Unfortunately TVNZ news is handled by separate competing fiefdoms (the official News, Holmes, Sunday and Breakfast), which largely operate in isolation from, and competition with, each other, including for headlines and 'scoops', even though some journalists from these programmes work in the same newsroom.

Holmes also introduced a Dr Pim Borren who was described as a 'health economist' into the discussion, presumably because the programme believed he was an 'expert' and would have something useful to add to the examination of the issues. The programme failed to indicate whether or not Dr Borren was a medical doctor and left open the strong possibility, given the nature of the questions put to him, that he was. Dr Borren's use of the word 'we' later in the programme also left the impression that he was part of the medical profession.

We understand Dr Borren is not medically qualified and his doctorate is in some other unrelated field. In this regard Holmes was misleading and left an inaccurate impression that Dr Borren was an expert or at least more competent than any other member of the public to comment on the serious issues raised by the programme. Dr Borren was fed a series of questions which simply invited him to endorse the extravagant and emotional propositions made by Susan Wood. There was not a single challenge to any of his responses from the interviewer. He was asked about matters of fact and his responses were simple allegations of facts that were frequently inaccurate or misleading. He was not an expert and came across as a 'stool pigeon' to support the presenter's misleading, inaccurate and emotional assumptions.

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New Holidays Act 2003 and Payment for Public Holidays

The old Holidays Act was a difficult piece of legislation: in some crucial areas it was difficult to interpret and therefore difficult for both employers and employees to apply. Moreover with the social and commercial changes that have transformed New Zealand society in recent decades, it had become a relic of a former age when, for many New Zealanders work stopped at 5.00 pm during the week and weekends and public holidays were reserved for families, rest and recreation. For many New Zealanders of course life was not really like that, but that was the myth and the old Holidays Act reflected that myth.

The new Act, for the most part, is easy to understand and is a long-overdue and welcome piece of legislation.

Public Holidays
The most significant changes of interest to our members are likely to be those affecting public holidays and include the following:
Employers must pay an employee time and a half for working on a public holiday [s.50];

Closedown Periods [sections 30-35]
A closedown period is defined as "a period during which an employer customarily closes the employer's operations or discontinues the work of 1 or more employees". In the public hospital service this might well occur over the Christmas/New Year period with the closure of some theatres, perhaps a ward and the stopping of some clinics. Provided this occurs "customarily" and the employer gives the affected employees not less than 14 days' notice, the employees may be required to take annual leave during the period of the closedown.
The term "customarily" will have to be defined but probably means each year with no (or few) exceptions.

Four Weeks' Annual Holiday
The other major change in the new Holidays Act is in s.41 and will increase the minimum annual leave entitlement from 3 to 4 weeks from 1 April 2007. This will not affect any of our members. All our members have at least four weeks annual leave anyway and, in DHBs, the range is currently between five and six weeks.

S.50 - Time-and-a-Half & "Relevant Daily Pay"
The commonly held belief is that the new Act requires employees who work on public holidays to be paid "time and a half" and to receive a paid holiday on a later date, as a day in lieu. Strictly speaking that is correct, but it's not as simple as that.

The matter of the day in lieu is not an issue. It is clear cut and there is unlikely to be any serious disagreement over that particular part of the entitlement. But the issue of time and a half is likely to be more contentious.

I have set out below the relevant part of section 50 in full:

50 Employer must pay employee time and a half for working on public holiday
(1) If an employee works (in accordance with his or her employment agreement) on any part of a public holiday, the employer must pay the employee at least the portion of the employee's relevant daily rate that relates to the time actually worked on the day plus half that sum again.

It would be a simple matter for our members if the section provided for time and a half of the employee's ordinary or basic hourly rate to be paid for all time worked on a public holiday. But it doesn't; it provides for time and a half of a new concept, referred to as the relevant daily rate to be paid.
Elsewhere, in s.9 the Act advises the parties how to calculate the relevant daily rate. Essentially, for our members, the relevant daily rate is your gross earnings for the previous two pay periods (i.e. 4 weeks) divided by the number of days or part days you worked during that period, including days on call.

Gross earnings includes the full job size and any other regular payments, including Clinical Director or other personal e.g. a full-time allowances or a recruitment & retention allowance. It will be apparent that the relevant daily rate is going to be significantly greater than 8 hours pay for a nominal day. Therefore the 50% loading will deliver a larger payment than 50% on the basic hourly rate, which is derived by dividing your nominal fulltime base salary by 2080 (being 52 weeks x 40 hours).

We have not yet reached agreement with the DHBs (through DHBNZ) on a practical and simple way of satisfying the requirements of s.50 and for the present, DHBs are simply paying 50% on top of your basic hourly rate. In our view that is too little, but it is a start and, until we have agreement on a different approach, it allows records to be kept of the hours that members have worked and claimed and how much they have been paid for working on the public holidays, to date. Payment adjustments will be made in due course when we have agreement.

But there are at least two other serious problems to deal with:

If you are a part-timer and have been called in on the public holiday but the holiday fell on a day that you would not otherwise have worked, you will not have a relevant daily rate for that particular day and an artificial relevant daily rate will need to be agreed.

The second problem is likely to be much more common.

In some DHBs our agreements provide for premium rates to be paid for after hours work (T x 1.25, T x 1.5 or in the case of Waitemata T x 2). In two others, namely Bay or Plenty & Hawkes Bay other special rates have been agreed and in particular departments and services elsewhere there are numerous other special arrangements for paying on-call at rates higher than those provided for in the relevant collective agreement.

In our view, the new law requires each of these rates to be increased by 50%, for the time actually worked on the public holiday. This is causing some anxiety amongst employers!

Section 51 of the new Act is an interesting provision: It appears to absolve employers of the requirements to pay the 50% loading under section 50 provided:

an amount for working on public holidays has been previously genuinely negotiated into the employee's regular pay

Despite the contention of at least one DHB (MidCentral) there has been no such genuine negotiation and agreement with any of our employers. The negotiations and agreements have all related expressly to after-hours' on-call arrangements and none were negotiated to provide for premium rates for working public holidays.

In Summary
We live in interesting times and the new Holidays Act 2003 may not have increased our members' annual leave entitlement but it most certainly appears to have paved the way for more than time and a half of your ordinary hourly rate to be paid for all work actually performed on public holidays.

The law does not change what you are paid for, only the rate at which you will be paid. If you are on-call on a public holiday but are not telephoned or otherwise required to work, you are not entitled to claim any additional payment but you will of course receive your standard salary for the fortnight and a day in lieu.

For the present, we do not have full agreement with DHBNZ on how the relevant daily rate will be calculated for all our members and it may be that we will have to take one or more claims to the Employment Relations Authority before our members' absolute entitlements are clarified.

However until we have that agreement or clarification, members should keep a record of the actual time they work on a particular public holiday i.e. hours spent working, including time spent on the telephone, travelling to and from their place of work (if called in) and time in the hospital or other location. Management will pay an additional 50% of your base rate for these hours but may well be required to pay a "top-up" in due course.

If you encounter difficulties with your employer in obtaining any additional payment for working on a public holiday, or your circumstances are not covered above and you would like further advice please call or email me hs@asms.org.zn for further advice.

Henry Stubbs
Industrial Officer

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Medical Misadventure to be Abolished

On 16 March ACC Minister, Ruth Dyson, (also Associate Health Minister) announced that legislation would be introduced later this year to replace medical misadventure (including medical error) with treatment injury and place it on the same no fault basis as the rest of the accident compensation scheme. This is the outcome of a review conducted by ACC and the Department of Labour that began two years ago.

The ASMS made a submission to the review. After the initial submissions the review team dropped the options that were not supported by submitters and undertook a further round of consultation with 'stakeholders', including the ASMS. The result was a textbook example of an impressive consultation process.

The current medical misadventure system provides ACC cover for two sorts of personal injury in the course of medical treatment: medical mishap and medical error.

Medical mishap is where the personal injury is rare, (occurring in 1% or less of cases where that treatment is given). Medical error requires finding fault on the part of a practitioner or (more recently) an organisation. ACC is required to report medical errors to the relevant statutory bodies. The result is a system that is not consistent with the no fault basis of the rest of ACC, that did not provide quick and certain cover for the injured and added yet another arm to the complaint culture against doctors and that confused doctors ,patients and politicians.

Interestingly most people consulted as part of the review had problems with it: 80% of respondents to the review supported introduction of new cover criteria.

The government has adopted the option that does away with the requirement to find fault. Both the medical error and mishap provisions will be repealed. Treatment injury will cover injuries whether they are serious or not. This makes it more consistent with the rest of the scheme.

One of the aspects of greatest interest to ASMS members is that ACC's reporting requirements will change so that it will only report to relevant statutory bodies where it sees a risk of public harm. Complaints about a health professional will be made through the Health and Disability Commissioner not ACC. When ACC identifies an adverse, trend it will report this to relevant bodies without identifying individuals involved.

Injuries that are a necessary part of treatment, such as a surgical incision, or injuries that result from the patient's underlying condition, will not be covered. There will also not be cover if the desired results were not achieved.

Neither will there be any requirement that an injury meets a 'seriousness' threshold. Most minor injuries will probably continue not to be reported, or will be resolved during the treatment process. This should simplify the claims process and reduce the bureaucracy in the system.

The results of this review have been one of the few unequivocally good results in recent health legislation. We look forward to seeing the legislation introduced in Parliament.

Angela Belich
Industrial & Policy Adviser

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The Public Finance (State Sector Management) Bill

The Public Finance (State Sector Management) Bill is a massive 348 pages. The Bill's first reading in Parliament started on 17 December 2003, the last day before Parliament adjourned for Christmas and concluded on 17 February. The Bill was then referred to the Finance and Expenditure Select Committee and submissions called for. The ASMS has made a submission.

The Bill will eventually be divided into four major pieces of legislation: a new Crown Entities Bill; amendments to the Public Finance Act, including integrating the Fiscal Responsibility Act 1994 into the Public Finance Act; amendments to the State Sector Act; and amendments to the State-Owned Enterprises Act. This is in addition to many amendments to other legislation.

Implications for ASMS members?
At least some of these provisions have implications for ASMS members. Under the Crown Entities Bill, district health boards will become crown agents (in contrast to the other categories, which are autonomous crown entities and independent crown entities).

This will mean that the State Services Commissioner will have the power under Clause 57 to set minimum standards of integrity and conduct in the same way he or she can presently for public servants. How this will mesh with professional codes of conduct, the provisions of the Health Practitioners Competence Assurance Act and present rights set out in collective agreements (for instance, the right to participate in public debate and dialogue) is unclear.

Intent of Bill
The overall intent of Bill is stated to be to 'build a strong state sector, including enhanced capability and strong leadership on values and standards'. It is, at least partially, the outcome of an earlier consultation process known as the 'Review of the Centre' which appeared initially as intended to reverse some of the fragmentation that had resulted from the contractualist policies pursued in the 1980s and 1990s.

It contains some provisions that indicate movement in that direction (for instance, Clause 152 allows the Cabinet to issue 'whole of government' directives on a curiously limited list of matters). However, overall the initiatives in this area are limited and the government has opted for a 'no big change' approach to the quasi-market foundations of the State Sector Act and Public Finance Act.

The financial management model implemented through the Public Finance Act 1989, State Sector Act 1988 and other state sector legislation (retained and extended in this Bill) is designed around a contracting model. It has been suggested that this legislation is structurally biased toward extracting money from state organisations and setting them up to fail despite the intentions and policy of the current government.

Clauses 205 and 206 in Part 5 of the Bill, outline the procedures for net surpluses and capital charges to be paid by state organisations. This includes DHBs. The extension of the interpretation of surplus to include accumulated surpluses (as well as any annual profit) carries with it the danger of asset-stripping. Some crown entities, (tertiary education institutions), are not to be covered by these provisions. It may be desirable that DHBs should also be exempted. The Council of Trade Unions and the ASMS have proposed that the select committee take a cautionary approach and does not extend these provisions to areas where they do not currently apply.

Impact on Health Sector?
It is hard to assess the full impact of the Bill on the health sector. Schedule 8 contains 15 pages of amendments to the New Zealand Public Health and Disability Act 2000. In contrast to the core public service and to a lesser extent the tertiary education sector, the health sector unions have not been briefed on the full implications of the Bill (despite efforts made to obtain a briefing).

In addition, we understand that tertiary education sector employers and officials have prepared a supplementary order paper which will exempt the universities from some of the provisions of the Bill. It is possible that similar exemptions should be made for district health boards. Health sector unions are simply not in a position to know.

Openness, transparency and accountability for the use of public money are important principles. Such transparency should be extended to cover all delegated rule-making powers proposed in the Bill and presently wielded under the Public Finance Act. The rules proposed in the Bill as well as those presently wielded by Treasury and other government departments should become subject to parliamentary and public scrutiny.

The ASMS has a long-standing commitment to a strong co-ordinated public health service that is able to take strategic decisions that benefit the health of New Zealanders in the long-term. This commitment has most recently taken the form of an attempt to negotiate a multi-employer collective agreement (MECA) covering all senior doctors and dentists employed by DHBs. During this process there has been evidence that the existing structures and accountabilities of the DHBs are not set up to facilitate a strategic approach across the public health service. DHBs have difficulty responding to anything other than financial indicators from the government. The government becomes merely a purchaser, a customer or an investor.

The mechanisms of contractualism are not sufficient to actuate either the need for co-ordination in the public health service or to implement many of the government's non-financial goals and policies. An example is the existence of DHBNZ, an organisation set up by the DHBs themselves and not subject to any of the accountabilities in this legislation. DHBNZ exists because of the failure of any existing government structure to provide a co-ordinating role. Health professionals have also pointed out the failures of the contractualist model for tertiary services which need to be organised on a national rather than DHB basis. 'Whole of government', or 'whole of health service', initiatives are too important to be left to the blunt fictions of the quasi-market of provider and funder.

Angela Belich
Industrial & Policy Adviser

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HPCA Act - Practices, Pathways and Political Change

The ASMS invited Professor John Campbell, President of the Medical Council, to write an article for ASMS members on the Council's approach to the implementation of the new Health Practitioners Competence Assurance Act, which was adopted by Parliament last year but which takes effect for the medical profession this year. It is already largely applicable to the dental profession. While the ASMS has major concerns with the new legislation, including the risk of narrow scopes of practice and politically appointed Medical and Dental Councils, we are reassured by the pragmatic approach of the Medical Council in preparing for its implementation.

In September this year, the Health Practitioners Competence Assurance Act 2003 (HPCAA) takes effect. Much of the HPCAA was modelled on the current Medical Practitioners Act 1995 so that the medical profession will be the least affected of the 14 health professions included in the Act. ASMS has concerns about a number of the changes, particularly scopes of practice, registration pathways and the independence of the Medical Council of New Zealand (MCNZ) and I shall address these issues.

Scopes of Practice
The HPCAA requires Council to register doctors within scopes of practice-a scope of practice is defined as a service that forms part of the profession which a doctor is permitted to perform, subject to any conditions imposed by Council. Council has defined high level, broad scopes of practice:

• General scope-is intended for all doctors who have completed their internship and who have not completed vocational training. The doctor must work within a collegial relationship to ensure appropriate continuing professional development, peer review and audit takes place.
• Vocational scope-a vocational scope has been defined in consultation with the branch advisory bodies for each of the 34 branches of medicine specified in the Medical Practitioners (Vocational Registration) Order 1999, and will be defined for new branches as they are approved. A doctor may work independently within the vocational scope in which he or she is registered.

The doctor must participate in an approved branch advisory body MOPS or recertification programme to maintain registration within a vocational scope.

• Special purpose scope-this scope is for doctors undertaking research, sponsored training, a locum tenens for up to six months or for an emergency
  or other defined purpose.

The Medical Council will also grant vocational registration limited to certain areas of work to some specialists trained overseas who have qualifications and experience in areas of practice which are narrower than our scopes of practice. This will be infrequent and determined by Council on a case by case basis. For example, a doctor, after initial qualification and overseas training, may have worked exclusively with patients who have had strokes and in stroke research. The doctor would not be suitable for vocational registration as a neurologist but may well have expertise of considerable value to patients and the profession when registered to work within a narrow scope of stroke medicine.

Council has always been quite clear that all doctors practising in NZ should have initial broad clinical experience. For this reason we do not recognise graduates with Canadian degrees in the same way as we do UK graduates. Recent Canadian graduates do not have to have a general intern year but may enter specialist training immediately on graduation.

Registration
There will no longer be a temporary form of registration as there will be no statutory restriction on the length of time registration is granted. Doctors will be first registered in a provisional scope and expected to satisfy requirements for registration within a general or vocational scope within two years. Doctors unable to do this will have their registration reviewed by Council.

Annual practising certificates issued under the MPA will continue until the certificate expires. When a new Annual Practising Certificate is issued it will contain details about a doctor's scope of practice under the HPCAA.

Doctors currently on temporary registration will continue to be able to practise until their temporary registration certificate expires. They may apply for registration under the Council's new policies.

Full details of the transitional arrangements may be found on the Council's website (www.mcnz.org.nz) under News and Issues.
In August the Council will write to all registered doctors with details of their registration status and explain each doctor's scope of practice under the HCPAA.

Appointment of Council
The Minister of Health is responsible for the appointment of the 10 members of Council, three public members and seven medical practitioners. There is no requirement for elected members under the HPCAA. Although health professional councils under the HPCAA may hold an election, and the current MCNZ sees this as very important to do, the Minister is not bound by the results. The current Council has nominated existing members, for the balance of their terms, as the initial members of the first Council under the HPCAA. Under the Medical Practitioners Act the next elections would have been held in 2005. The new Council will need to advise the profession of its election policy and arrangements soon after taking office.

I consider changes under the HPCAA will have little effect on the great majority of practising doctors. Work in the areas of competence, health and education will continue largely unchanged.

A Medical Council newsletter will give general details on the HPCAA and detail areas of Council policies that will change under the HPCAA. Additional information can be found on the Ministry of Health website at www.moh.govt.nz/hpca.

Professor John Campbell
President MCNZ

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Medical Protection Society

Dr Paul Nisselle, a medical indemnity expert from Australia and formerly employed by the Medical Protection Society in Australasia, makes the following comments about the implications for New Zealand doctors considering working in Australia in light of the most recent developments that country to resolve its medical indemnity crisis.

Under the just introduced 'Run Off Cover Scheme' (ROCS) legislation, a doctor who comes to Australia to work on a temporary visa will have 'free' run off cover after he or she leaves Australia. This is being introduced because now all the medical defence organisations (MDOs) offer only claims-made insurance, and neither the Medical Protection Society nor the Medical Defence Union (no longer involved in Australasia) will insure work in Australia, doctors coming here on short-term visas to have working holidays faced having to but claims-made cover for whilst they are here and run-off cover when they left.

Responding to the Crisis
As most 'After Hours Deputising Services' rely heavily in recruiting such doctors to work for them, and as such doctors found the existing run-off arrangements unsatisfactory, the federal government was pressured to provide the run-off for such doctors 'free'.

In fact, it will be funded by an 8.5% levy on all medical insureds (collected through their MDO). That money will also fund the fun off on deceased or disabled doctors plus doctors who retired at or over 65 years, or doctors who retired at a younger age and paid their own run off for three years.

So, New Zealand doctors can come here, take out claims-made insurance from an insurer here for the time they are in Australia, and then to back to New Zealand and resume their MPS membership knowing their Australian tail will be covered. The legislation has not yet been introduced to Parliament but it is intended to apply from 1 July this year!

The 'Run-off Cover Scheme' (ROCS)
As announced by the federal government in March 2004, the (ROCS) ensures that selected groups of doctors effectively have free medical indemnity cover when they leave the medical workforce. ROCS will apply to doctors who:

• are 65 years of age or more who have declared that they have retired permanently from medical practice;
• are permanently disabled;
• are under 65 years of age and have left the private medical workforce for three years and have declared their intention to retire (this group includes those who have retired before the age of 65; those working solely in the private sector and those no longer practicing medicine);
• are on maternity leave; or
• are dead (provided that a claim can still be made against a doctor's estate).

This means that some doctors will enter the ROCS permanently and others will leave when they are no longer eligible.
Subsequently, in the last few weeks, the government also decided to extend ROCS to cover overseas trained doctors working in Australia for a short time.

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ASMS Membership Workshops: August

In response to our growing membership and the challenges facing us, the ASMS is holding seven regional half-day workshops during August in order to help increase membership empowerment by providing an opportunity for ASMS members to learn more about some of the key issues affecting members and becoming involved, or more involved, in the ASMS. They are targeted at interested ASMS members who work both for DHBs and for other non-DHB employers such as community trusts.
The schedule for the workshops is:
Date Where DHB Areas
Monday 9 August Palmerston North MidCentral, Whanganui, Taranaki
Tuesday 10 August Hastings/Napier Hawkes Bay, Tairawhiti
Thursday 12 August Wellington Capital & Coast, Hutt Valley, Wairarapa, Nelson Marlborough
Monday 16 August Auckland Northland, Waitemata, Auckland, Counties Manukau
Tuesday 17 August Hamilton Waikato, Bay of Plenty, Lakes
Monday 23 August Dunedin Otago, Southland
Tuesday 24 August Christchurch Canterbury, South Canterbury, West Coast
At this stage the specific venues and times have yet to be confirmed except that they are likely to commence around mid-day.
The workshops will be led by the ASMS's Industrial Officer Henry Stubbs and the programme will include:
" The ASMS's membership empowerment approach.
" Issues arising out of hours of work and job sizing.
" Other key issues including the new Holidays Act, dealing with managers, and problem-solving at workplaces.
" The Employment Relations Act including its broad principles, the code of good faith and employment relationship problems.
" The Health and Safety in Employment Act including the role of health and safety delegates.
" Local DHB bipartite (management-union) processes.
" Role and purpose of ASMS delegates.
If you are interested in participating in these workshops please advise our Membership Support Officer Kathy Eaden ke@asms.org.nz. Further information about the workshop will be forwarded to members at a later date.

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Medical Assurance Sociey, in business over 80 years and still going strong

Over recent years the Medical Assurance Society and the ASMS have forged a close collaborative working relationship. The ASMS recognises that the Society is part of a wider 'medical family'. The article below has been provided by the Society. It provides a broad historical outline and context of the Society's formation, development and reason for being.

Mention Medical Assurance Society in health professional circles and you are bound to come across someone who's a member of the Society. It's not surprising the Society is so well known to health professionals-for over 80 years, it has been providing specialist insurance services and, more recently, financial services such as loans and investment products, to health professionals all over New Zealand.
The Society currently has nearly 19,000 members and its membership base is still growing. With over $500 million in assets, the Society has come a long way since its humble beginnings, founded at a residential address in Napier back in 1921.
The Society was born out of the determination of a group of Napier doctors who felt insurance companies of the day were not meeting doctors' needs to protect their incomes during illness. They wanted insurance designed to meet the needs of medical practitioners-and their top priority was a policy for sickness and accident that had no restrictions on the diseases covered, and that would be easy to deal with when making claims.
On 12 April 1921, four doctors met at Dr Frank Harvey's Tennyson Street home and approved the formation of the New Zealand Medical Assurance Society Co-operative. They decided to offer insurance covering all accident and sickness, motor cars and fire to members of the medical profession. The four became the Society's first directors and nominated Dr Harvey (in his words) "unpaid chairman, treasurer and bottle-washer".

The Society reached the end of its first year with a membership of 336. It had appointed an experienced manager, shifted its administration to Wellington, and achieved a net profit of £879.
By the time the Napier earthquake struck in 1931, the Society was well placed to face its first major test, and to set an early precedent of going beyond the call of duty for members. The earthquake caused massive damage to houses, commercial buildings, roads, water and electricity supplies-and none of the Hawkes Bay members were covered for earthquake damage. The total loss to these members was more than £12,000.
The Government offered ex-gratia payments for fire damage caused by the earthquake, but not for damage directly caused by it. The Society felt that more could be done and a ballot of members voted overwhelmingly to compensate those affected a total of £4,000 from the Society's reserves, which despite its infancy, had grown to £15,000.
Over the next 30 years the Society grew to add new policies and broaden membership to include other health professionals. This led to a 65 per cent increase in membership, from 1,962 to 4,340 members in 1970, and a three-fold increase in assets to $1.2 million over the same period.
But in 1972 members became increasingly uneasy about aspects of the way in which the Society was run. They considered the constitution outdated, and were shocked to discover that the liability of members in the event of the Society collapsing was unlimited-a well-known fact in the 1920s but unknown to virtually all members in 1972. The outcome was a drawn-out, and ultimately successful, take-over bid. The members had spoken again.

An intense period of change followed as the new directors swung into action. A new constitution was drawn up and the Society's name was changed to Medical Assurance Society New Zealand Ltd. The new directors did their best to create a larger, more accommodating Society with a wider range of services, and to improve communication between themselves and members.
That approach, which continues today, has seen the Society take a place in New Zealand's top 20 financial institutions, providing a range of financial, insurance, investment and financial planning services to members.
Through all the change, the Society has remained relevant to members by retaining and developing its niche. The unique qualities that keep it going strong continue to be its understanding of the demands on health professionals and a philosophy of bending over backwards to make members' lives easier. It's all about going that extra mile, with personal service and good old-fashioned values.

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ASMS Recruitment and Vacancy Report: MidCentral DHB

The ASMS has prepared a report on specialist recruitment and vacancies at the MidCentral DHB on 20 April. In part this was in response to claims made by DHBs nationally (although not by the MidCentral DHB itself) in the MECA negotiations that there was no serious recruitment or shortage problem. MidCentral was chosen because of its accessibility to the national office and because it is a middle-size DHB.
The results confirm the ASMS's concerns over recruitment. The investigation revealed a minimum actual vacancy rate of at least 19%. When recognised professional standards are taken into account then the 'professional vacancy rate' increases to 43%. This is a resource intensive activity but over time we hope to undertake this activity in other DHBs.
When asked to comment by the local newspaper, the MidCentral DHB chief executive stated that eight of the reported vacancies had subsequently been filled. What he neglected to add, however, was that these were all locum appointments, precisely the ASMS's point about the additional costs caused by the inability to make permanent appointments.
The report, which received coverage on TV1 News (26 April) is available on the ASMS website www.asms.org.nz or from Administration Officer, Angelina Hachey ah@asms.org.nz.

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ASMS 16th Annual Conference

• The Specialist
• Standpoint
• Health Dialogue
• Addresses and Papers
• Surveys and Submissions
• Parliamentary Briefings
• In Depth Reports
• Archives
• Annual Conference Reports
• Conference 2010 Presenters Addresses