Publications
The Specialist
Issue 65 - December 2005
Proudly Sponsored by:
- Time for non-clinical duties: the next stage is up to members — think collective and collegial
- Simplifying the achievement of time for non-clinical duties
- The contractual status of non-clinical duties (30% minimum)
- Lifeguards and Lifesavers
- Patients before arrangements at your peril!
- We deserve better from Human Resource/Employment Relations managers
- ASMS Annual Conference highlights
- Medical Council elections: last chance for professionalism?
- BMJ Careers advertising campaign encouraging
- DHB league table: time for non-clinical duties
- A big thank you to our sponsors who make it easier
................................................................................................................
Time for non-clinical duties: the next stage is up to members — think collective and collegial
The seeking and application of time for non-clinical duties (i.e. professional and related activities) did not begin with the negotiation of the first national DHB collective agreement (MECA) and is now entering another stage in which the impetus rests with members themselves.
In this new stage there are two key words, collective and collegial, which sum up the most effective means of achieving the professional standard recognised in the MECA that at least 30% of one’s job size (excluding rostered after-hours call and clinical/managerial leadership duties) should be for non-clinical duties not directly related to the care of an individual patient.
In other words, if ASMS members pursue the achievement of the 30% minimum collectively with colleagues in the same service/department or on the same roster in a collegial manner rather than individually the prospects of success are greatly enhanced.
Creation of the Process
It is unfortunate that some short-sighted blinkered DHB managers behave as if time for non-clinical duties is a creation of the MECA. Rather it is a creation of the medical profession, in particular the colleges, and assertively pursued by the ASMS. The profession developed the 30% minimum as a positive response to the exigencies facing and standards expected of doctors.
The ASMS has picked up the profession’s ball and run with it. The MECA is the latest vehicle available to strengthen its implementation and provision. But no matter what the actual words of the MECA might be on this subject, the 30% minimum can’t be automatically implemented. It first requires the proactive collective and collegial initiative of senior medical staff in their departments/services in preparing a programme of scheduled non-clinical duties.
It is easy to under-estimate how many ASMS members have already achieved the 30% minimum for non-clinical duties prior to the settlement of the MECA. In fact, the ASMS had been actively pursuing this objective for several years prior to the MECA. This included a range of outcomes in our previous single DHB collective agreements and successful support and representation on behalf of groups of members.
The 30% minimum was already in place for many ASMS members in several DHBs before the ASMS and DHB chief executives signed the MECA. Much of it also has origins in the overlapping statement of the Committee of Presidents of the Australasian Colleges that one-third of a clinical department’s time should be spent on non-patient contact. This formed part of the foundation of much of the original job sizing of the early 1990s; non-patient contact time and time for non-clinical duties are not exactly the same but there is much in common.
The MECA marks a new stage in the implementation of the 30% minimum by providing a much stronger contractual framework (refer to contractual information at end of article). Those DHBs and managers who take a negative or obstructive attitude towards their responsibility to provide the necessary time for non-clinical duties deliberately focus on one aspect of the MECA (the reference to the Council of Medical Colleges’ endorsement of the 30% minimum) and try to pretend that the rest of the MECA does not exist. For these DHBs and managers the MECA is like a web trapping these blinkered and irresponsible spiders.
On the other hand, several other DHBs and managers appreciate the MECA in full context. They recognise their responsibility to adhere to professional standards, quality of patient care, and continuing quality improvement initiatives and requirements. They are demonstrating a positive attitude towards achieving the expected recognition of time for non-clinical duties.
The Next Stage: Members’ Initiative
To date the ASMS has promoted the importance of DHBs providing the 30% minimum time for non-clinical duties, has provided a contractual framework and process for achieving it in the MECA, and has produced our own practical guide, ASMS Standpoint, for understanding, simplifying and implementing it as part of a wider job size. In some DHBs we have also ‘fast-tracked’ a coordinated opportunity for members who wish to seek a review of their job size, including time for non-clinical duties.
It is now up to members working collectively and collegially with their colleagues to take the next step (many have already taken the initiative) with the active support and advice of the ASMS. If members believe they are being short-changed in their job size and/or time for non-clinical duties is not being sufficiently recognised (e.g. less than the 30% minimum) then they should work collectively and collegially by preparing their case for a review of their job size with ASMS support.
This includes a scheduled programme of specific non-clinical duties as part of a wider job size. A robust programme of non-clinical duties consistent with the 30% minimum standard as part of a wider job size is virtually unassailable even by the most backward managerial culture. By using ASMS Standpoint as the guide the exercise is much simplified. The advice and support of the ASMS national office is also available.
DHB Responses
Some DHBs are responding positively to the challenge of meeting the professional standard of the 30% minimum provided the MECA What is pleasing is that they see it as the responsible thing to do and do not resort to blinkered contractual misinterpretations. Though some of these positive DHBs might consider implementation of the 30% minimum as a contractual obligation, they do see it as an appropriate and important DHB responsibility. Even if the intent might take a little time to implement the ASMS has no hesitation in openly commending these DHBs for their responsible approach.
Others are ducking for cover or being obstructive. Ironically, in some of these ducking or obstructive DHBs the 30% minimum is already in place in a number of departments creating an additional internal inequity. The ‘duckers’ and ‘obstructers’ resort to two essential arguments—misrepresent and distort what the MECA states and try to fiscally ‘guilt trip’ SMOs through ‘immoral blackmail’ (e.g. if you want 30% then patients’ access to care will suffer, a false argument that could be just as easily used against any monetary entitlement such as a salary increase for doctors or nurses for that matter). In effect they are displaying a two-faced attitude towards quality improvement—supporting it in rhetoric but obstructing it in practice.
This sort of shameful behaviour should not be tolerated. Senior medical staff should ensure that they do not internalise and succumb to this tactic; those that do will simply allow the problem to continue to simmer until the pot boils over and it becomes more difficult and acrimonious to resolve.
It is these negative DHBs that the ASMS, without enthusiasm, is prepared to ‘name, shame and blame’ if there is no other way to persuade them to face up to their responsibilities. The first step in this direction is the comparative performance ‘league table’ published elsewhere in this issue of The Specialist.
It’s a ‘no brainer’
The reasons for achieving and the importance of the 30% minimum time for non-clinical duties are obvious, so obvious that the issue is a ‘no brainer’. One cannot provide the level of quality, standards of care and implement effective quality improvement initiatives required by statutory authorities, colleges, patients and DHBs themselves without meeting the professional standard of sufficient time (30% minimum) for non-clinical duties. The Health & Disability Commissioner will not let SMOs off the hook in the event of an upheld complaint over an adverse patient outcome that might have otherwise be prevented had their DHB allowed sufficient time for non-clinical duties (by comparison the DHB would receive at worst ‘once over lightly’ treatment). Nor for that matter will the media.
It should not be necessary to negotiate the provision of time for non-clinical duties in a contractual agreement such as the MECA but the experience of short-sighted and otherwise negative managerial cultures, including most recently, provides ample evidence and experience over why we have no option. The so-called ‘gentleman’s handshake’ is long gone if it ever truly existed.
The MECA strengthens the ability to achieve this but in the first instance members acting as teams have to take the first step and develop a new proposed job size including time for non-clinical duties that will then provide the basis of discussion with managers. The ASMS is ready and waiting to further assist, advise and support members in this process.
Ian Powell
Executive Director
Top of Page
................................................................................................................
Lifeguards and Lifesavers
Only when those who swim in the currents and rips of medical practice determine the dispersal of lifeguards can the public safely dive in.
These words resonated with some of the radio and print media reporting from the 2005 Annual Conference. Commentary and support ensued from specialists, active and retired, resident and abroad, and even a past Director-General of Health. Was this a call to arms, a signal for revolution? To overthrow the system?
No.
We have all seen the side effects of top-down reform after reform after reform. Merely catching up with terminology, ideology and idiocy has consumed emotional and intellectual energy better devoted to patient and systemic care.
Yet we are acutely aware that the corridors of Parliament and Treasury echo with claims of poor productivity, of profligacy and waste.
How can the dollar from the Treasurer translate into an outcome for the patient? How can the brilliant innovator be encouraged to risk a new system, a new style, for long term rather than monthly balance sheet benefit?
How can the best of clinical leadership and managerial encouragement be harnessed in the face of chief executive risk aversion and Board parochialism?
Health professional led networks
In a country of only four million with 21 DHBs and layers of administrative manipulation, the only rational way to direct the flow of the Treasury dollar to the care of the patient is to have health professional led networks. To strengthen the networks that clinicians have developed, to encourage clinician led change in regional rationalisation and national direction. Leadership has to be divested to those at the coalface. To those with feet firmly grounded in daily patient contact, not those with heads in the clouds of fondly remembered but distant past practice.
For we have a unique relationship with the patient. There is no-one else who has the same relationship. We cannot abrogate it. We may devolve bits of our practice to other health professionals. But there is none other as well equipped to lead the team, as well qualified to make the difficult decisions, as well trained to tailor the dollar to the demand. We, and only we, have the broad intelligent mix of skill and apprentice based training that equips us to constantly reshape our practice. To lead all health teams, not as mere members but as shapers and shifters.
We know the struggles of a parent whose expectations for their multiply handicapped child far outstrip the rational disbursement of health dollars. We know the unreal demands of patients seeking futile allopathic and alternative cures for unavoidable misery. We know the overbearing gratitude for the merest of ministrations when nature really took its course. We know the limits of predictability and precision of practice.
We know the waste of time and effort reinventing charts, protocols and guidelines in multiple DHBs. We know the special strengths of managers who work with us to examine, explain, exhort and exhume the best exemplars of experiment and excellence. And we suffer, with our patients, when perverse incentives drive unreal behaviour and bureaucratic bumbling.
It is only too easy to descend into that instant attraction of clinical expediency. To retreat to the training that encourages sublimation to the problems of the individual, not the rigours of rationing, to the patient in front of us, not the person who cannot get to us. And then complain that those making momentous decisions do so without our blessing.
But just getting on and seeing the patient is not good enough
We cannot stand aside. We can no longer leave it to others. We must, each and every one of us, demand of ourselves and of those around us the leadership of our workplace. In conjunction with the mangers who have the patient at heart, who have earned by their actions the trust of the health professionals they work with. These partnerships must demand and drive the clinical networks that put real leadership into the hands of those who can truly lead.
Leadership to those who know the entanglement with the patient – physical, emotional, ethical – that enriches and enhances the doctor-patient relationship on the shared path to healing.
When we have a health professional led health system we can truly get value from the best of the passionate, persuasive, perfectionist SMO workforce. Seize power, not for its own sake, but to effect change. To streamline, to strengthen, to support clinical networks.
So that the lifesavers will also be the lifeguards. Will determine the dispersal of flags and funding, of standards and safe practice, of innovation and incentive.
Then, and only then, can the public safely dive in.
Jeff Brown
National President
Top of Page
................................................................................................................
Patients before arrangements at your peril!
2006 is almost upon us and one wonders where 2005 went. For the ophthalmologists who have now run the Commerce Act gauntlet for over nine years the New Year can probably not start soon enough, so it would be remiss of me not to draw attention to this piece of legislation that sits waiting to strike the health sector again.
One can see the public good of having the oil companies not collude in the market place, although it is amazing how exactly similar the cost of a tank of 98 is, but there is a tension that we at MPS see between the need for doctors to co-operate not only for the patients good, but for the safe and personal well being of themselves.
For the 10 years or more of postgraduate training it is known what is paid for work done, but when moving beyond the protection of the hospital employment very different rules apply. Should a doctor wish to be involved in a collective provision of a service to another patient group, like a rest home, back up a service in another hospital, or provide 24/7 cover I would simply ask of that doctor, how was it negotiated, were you individually negotiated with, is it a joint venture, did you get written legal advice and were the lawyers Commerce Act experts? For me these are the questions to be answered before any discussions around ‘will the consumer benefit’ simply because the financial risks of getting it wrong are considerable.
To quote from an article by
- When entering into an arrangement with more than one person with agreed prices, advice should be sought to ensure that the provisions of the Commerce Act are not breached.’
So where to from here? To this my advice must be ‘we are unsure’ as at present there is no practical guidance from the Commerce Commission about what alternatives there are to the arrangement that was used by the ophthalmologists. We could of course amend the Act but that is beyond the brief of the MPS.
A Happy Christmas and a safe New Year.
Dr. Peter H Robinson
Medico-legal Advisor
Medical Protection Society
Top of Page
................................................................................................................
We deserve better from Human Resource/Employment Relations managers
In the beginning there were industrial relations managers (actually strictly speaking this is not true as even earlier they were called personnel managers but this was so long ago that the memory fades). What they did, their purpose, and how they earned their crust was much simpler and easier to understand in those days.
Then we had human resource (HR) managers who were to be everybody’s friend and to be, oh so, holistic acting in the interest of the greater good [In one part of the country this was taken to the nauseating extreme of the holder of an HR position succeeding in having it re-designated ‘human assets manager’, no shortage of salad bowls to vomit into in that neck of the woods!]
Eventually, but not surprisingly, these HR managers ignored sensible family planning advice and promiscuously procreated employment relations (ER) managers whose focus was more on the employer-employee relationship. In fact, some of them no longer are called managers; these little cuties are called ‘HR’ or ‘ER consultants’ if you please.
We now have this hive of verbal pollution and tree-killing within DHBs from an enthusiastic managerial broom of HR/ER managers/consultants busy-bodying around the place and talking to themselves about themselves in the most self-flattering tones imaginable. But what they do to earn their crust we simply don’t know.
The
To be fair some of these HR/ER types have failed to succeed because of reasons beyond their control. Some have not been given the opportunity to display their wares because their potential role and contribution is devalued or not understood by other senior managers, in the odd case by their chief executive.
But nevertheless the cynical introduction to this column is justified because in the main our DHBs are short-changed by the calibre of HR/ER managers. It is a much contestable view whether the calibre and performance of DHB management has improved since we had a change of government direction in health policy since late 1999. My own view is that overall (and despite several exceptions which can explode in my face) it has improved.
But the most obvious exception to this is in the HR/ER field where I believe on balance it has declined. It is not so much the aspiring bullies (searching for a training course to fulfil their aspirations), the bovver boys searching for bovver boots, or the otherwise adversarial inclined. They exist and they are destructive but they are a small number and can be dealt with or to. Nor is it so much the clots; they also exist, despairingly so, perhaps in somewhat greater numbers than we might be prepared to admit but still only a minority at best/worst.
The truth is that most HR/ER managers are intelligent, educated (if, in some of these cases, a law degree qualifies as education) and hard-working. They are not all otherwise unemployable psychologists or sociologists. But most also live in their own world divorced from much of the reality of the front-line of what happens and works at the core of a modern health service. They are excessively process driven, sometimes driven by embellished notions of managerial prerogative, with high policies here and high policies there. They are often out-of-touch or unappreciative of why collective agreements address various issues (such as the 30% minimum for non-clinical duties) in the way they do.
Their paradigms are not those of value adding health professionals. They struggle to accept the serious limitation in the health sector of narrow managerial prerogative and the importance of enhancing true health professional leadership. Much of the challenges facing those that add the real value to what DHBs do
(i.e. health professionals) instead require thoughtful planned practical solutions and support. The working worlds of health professionals as the value adders and HR/ER managers as administrative overheads could not be further apart.
If our HR/ER managers are to demonstrate their relevance to health professionals then many of them are going to have to pull their socks up and enter the brave new world outside their jargonistic cocoons. Alternatively they may need to find another solar system consistent with their own paradigm to work.
Ian Powell
Executive Director
Top of Page
................................................................................................................
ASMS Annual Conference highlights
The 17th ASMS Annual Conference was held in
Arguably the highlight of the Conference was a well crafted address by Dr
Other Features of the Conference:
- Life membership was awarded to
- Dr Jeff Brown’s Presidential Address which was previously electronically forwarded to members and is also avail
- Associate Professor
- Executive Director Ian Powell led two sessions on the performance of the joint DHB-ASMS consultation committees created by the national DHB collective agreement (MECA) and underway since May this year and preparing for the re-negotiation of the MECA next year (it expires on 30 June 2006).
- Dr
- Dr
Conference Decisions
- Conference voted to support the establishment of a national advisory and support network for doctors and recommended that the National Executive explore how to further this objective. This is expected to be pursued through the Pan Professional Medical Forum.
- Conference voted that we seek a bargaining fee for non-members in order that they might benefit from collective agreements negotiated by the ASMS. This will require membership ballots in each of the DHBs next year and, subject to the ballot outcome, agreement with the DHBs in next year’s negotiations. This is in accordance with Part 6B of the Employment Relations Act which came into force late in 2004.
- The National Executive was authorised to negotiate as part of the next national DHB MECA an hourly system for the pro rata calculation of remuneration provided that there are satisfactory transitional protection arrangements and the provision of flexible sessions of working time for both clinical and non-clinical duties.
- Consistent with the rate of inflation and actual costs facing the ASMS, Conference voted overwhelmingly to increase the annual membership subscription by $20.00 to $600.00 (GST inclusive) for the 2006-2007 financial year.
- The next Annual Conference will be held in
Top of Page
................................................................................................................
Medical Council elections: last chance for professionalism?
One of the major deficiencies of the Health Practitioners Competence Assurance Act was that it did not ensure that at least some of the positions representing doctors on the Medical Council were filled by doctors elected by doctors. The ASMS along with other medical organisations (and also the Medical Council itself) were very critical of this removal. In 2002 and 2003 when medical organisations including the Association were campaigning to address this deficiency in the Bill the then Minister of Health, Annette King, pointed out that as only 39.6% of doctors on the register voted in the previous Medical Council election, it did not appear to be an issue close to the hearts of doctors themselves. The HPCA Act does allow the Minister the discretion to introduce regulations allowing for elections (s120 (4)) but the previous Minister did not want to take this approach. The new Minister has not expressed a view on the issue to our knowledge but he is likely to take into account the level of participation in the “election for nominations” presently being run by the Medical Council when making a decision.
Since the passage of the HPCA Act, the Minister has, at the urging of the profession (including the Association), reappointed existing members of the Council. The plan is to hold an “election for nominations”. The names of the “elected nominees” will then be forwarded to the Minister in the expectation that he will appoint them to the vacancies. (The Minister is under no legal obligation to appoint the successful candidates.)
This approach has already been successfully utilised in dentistry where the Dental Association representing over 90% of dentists conducted elections for the Dental Council, forwarded the results to the Minister who duly appointed them.
The election will also hopefully demonstrate, by high participation in the vote, that doctors place a high value on the limited degree of self-regulation that is avail
The newly formed Pan Professional Medical Forum (Council of Medical Colleges, ASMS, RDA and NZMA) has set as one of its key goals the reinstatement of the right of election. The goal is to persuade the new Minister of Health to issue regulations under the HPCA Act allowing for the right of elections to the Medical Council which are not dependent on Ministerial discretion. (The ASMS also supports the Dental Association in advocating this for the Dental Council).
It is important that there is a good range of candidates. Candidates need to have been notified to the Medical Council by noon on Monday 23 January. This means that discussion within the profession as to who would be good candidates has to happen now.
You should all have received the newsletter from the Medical Council about the election and a nomination declaration. We also sent one out with a recent ASMS Direct.
Please read this material. You should consider either standing for the Council or supporting the nomination of a colleague. This material (together with further background) can also be found on the Council’s website at: http://www.mcnz.org.nz/Default.aspx?tabid=1158.
Ballot papers will be going out by Wednesday 22 February 2006 and the ballot will close on Friday 24 March 2006.
The Association will be exhorting members to vote in all our publications. Politically it is important that doctors demonstrate that the right to self–regulate is something that they value.
Angela Belich
Assistant Executive Director
Top of Page
................................................................................................................
BMJ Careers advertising campaign encouraging
The Association’s international advertising campaign to recruit senior doctors and dentists from overseas to fill vacant positions in
The main thrust of the advertising campaign is to focus on
Early signs are encouraging with over 200 recorded visits per month being referred directly from BMJ Careers.com to the ASMS website. The greater the take-up by DHBs of this new exciting venture the greater the chance of filling medical/dental vacancies; and at a much lower cost than DHBs advertising directly in BMJ Careers.
Top of Page
................................................................................................................
DHB league tab le: time for non-clinical duties
In the 1990s when the health system was required to function as competing ‘businesses’ the ASMS periodically published in The Specialist league t
With the ending of this ‘business model’ followed by the achievement of the national DHB collective agreement (MECA) the role of league t
The league t
Whether DHBs believe that they have a contractual obligation to implement the 30% minimum (as discussed separately in this issue of The Specialist subject to certain provisos they do) is not the key issue. Rather the key test for this t
DHB League table: Non-Clinical Duties
Waikato Tairawhiti
A-
Northland
Already had strong commitment to 30% minimum in local collective agreement prior to MECA.
B+
Bay of Plenty
Taranaki
Whanganui
Wairarapa
Hutt ValleyHas adopted a positive attitude consistent with the ASMS’s approach including an agreed process for implementation. [
B
Lakes
Initially negative comments from lower level management but Chief Executive and senior management have recently affirmed a positive approach consistent with the ASMS’s. An implementation process has also been agreed.
B
MidCentral
Positive promising approach consistent with ASMS’s although yet to confirm implementation process.
B
West Coast
Owing to recent change In chief executive, the opportunity to engage over this issue has been recent. But the signs are encouraging with this DHB expressing an approach consistent with the ASMS’s. There has been insufficient opportunity to agree upon an implementation process.
B-
Waitemata
First DHB to make a commitment in a collective agreement (set 30% minimum as a medium term objective in 2001; medium term is now up). But there are unfortunately some managerial pressures to renege on this commitment.
B-
Implementation is being pursued incrementally but no indication at any disagreement with the ASMS approach.
C
Southland
Position unclear due to high level of internal instability but no outward negativity expressed.
C
Nelson Marlborough
Struggling to understand why professional standards need to be made explicit and why there are advantages in an agreed implementation process. But it has accepted the importance of recognising time for non-clinical duties and is not demonstrating negativity or hostility.
C-
Canterbury
In the past, prior to the MECA, has taken a positive approach with the 30% minimum implemented in a number of departments. More recently other attitudes emerging from negative hostility and a narrow contractualist misrepresentation of its obligations under the MECA (employment relations section) to flakiness and uncertainty. Hopefully this DHB’s new Chief Executive will provide much needed positive leadership.
D+
Counties Manukau
Position unclear but negativity and confusing messages coming from some managerial personnel. Chief Executive known to respect importance of quality improvement and professional standards; it is important that he asserts leadership.
D
Auckland
Too blinded by deficit challenges to grasp importance of the issue. Needs to move out of crisis management mode and look ahead.
D
Capital and Coast
Ducking for cover by claiming that this is a national issue; utter nonsense and procrastination. But we are edging closer towards an agreed implementation process
E
Otago
Has adapted a negative attitude, quite hostile from its human resources section, based on a failure to appreciate the importance of meeting professional standards and a narrow contractual misrepresentation of its obligations under the MECA. The fact that it has nevertheless come close to agreeing upon an implementation process with ASMS mean that it is rated 20th rather than 21st.
F
Hawkes Bay
Although camouflaged in ‘warm and fuzzy’ rhetoric, this DHB has also displayed a thoroughly negative attitude which includes a narrow contractualist misrepresentation of its obligations under the MECA
Top of Page
................................................................................................................
A big thank you to our sponsors who make it easier
|
The Annual Conference was launched at a well-attended cocktail function on 2 November, generously funded by the Medical Assurance Society. | |
|
| |
|
The Conference Dinner, again generously supported by the | |
|
| |
|
Ricoh kindly provided the Conference programme and enclosures. | |
|
| |
Top of Page
................................................................................................................
