Publications
The Specialist
Issue 68 - September 2006
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- How does 7.6% over 3 years compare with 29% over 4 years as a recruitment and retention strategy?
- A bedside story
- To arbitrate or not to arbitrate
- A national employment agreement for hospice doctors
- KiwiSaver initiative
- Support service for doctors
- Politicisation of the Medical Council
- ‘No more Mr/Ms Nice-Guy'
- An open letter from Canterbury DHB surgeons
- Negotiations outside the district health boards: an update
- New Industrial Officer
- BMJ Careers advertising campaign continues...
- ASMS 18th Annual Conference Thursday 2 - Friday 3 November
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How does 7.6% over 3 years compare with 29% over 4 years as a recruitment and retention strategy?
Rhetorical questions can be useful introductions to issues. How does offering a salary increase of around 7% over three years compare with offering 29% over four years as a recruitment and retention strategy? This is the question posed by the position taken by the DHBs’ negotiating team in our national DHB MECA negotiations.
Two recently concluded negotiation and arbitration processes for senior doctors in Australia have major repercussions for New Zealand given that (a) they were largely in response to workforce shortages, (b) the physical proximity of the two countries, (c) the similarities in training, and (d) the new remuneration rates will be actively used to compete against New Zealand to both retain our existing senior medical workforce and in the very tight international medical labour market upon which both countries are dependent.
Tale of two Australian States
One state is
The second state is
Further, perhaps more than
One of the features of both these outcomes is the relative willingness of both state governments to address the issue and to increase senior doctor remuneration. In
Sorry tale of
Well; how does
The DHBs are influenced by a government insufficiently sympathetic to the pressures on publicly provided secondary and tertiary health services. The government’s “future funding track” increases of 2.93%, 2.4% and 2.1% in the context of the pressures on the sector and inflation are simply unrealistic. This lack of realism is compounded by the government’s insistence that all DHBs now have balanced budgets which reduces flexible options. But DHB leaders, acting like World War I generals passing on and compounding the pressures on the soldiers in the trenches is no solution.
Remuneration is not everything although it certainly helps. The ASMS’s claim in these negotiations would only narrow the salary gap with
But there are also other ways. DHBs should be actively promoting sabbatical as part of a professional development package; DHBs should be actively promoting the fact that the MECA recognises the 30% minimum as the appropriate standard for time for non-clinical duties; and DHBs should be actively promoting the many features of the MECA which encourage SMO empowerment. It is not necessary to change the MECA to do this; one simply needs to do it.
But in the first around 13 weeks of the negotiations, at least, the DHBs have done the opposite. In addition to their unrealistic and visionless attitude towards remuneration, they have resorted to the strategy of some of the former crown health enterprises in the 1990s to claw-back on existing terms and conditions of employment and to enhance managerial control with the corollary of professional disempowerment.
If
Ian Powell
Executive Director
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A bedside story
At the bedside of one of the dozens on a late winter ward round. Wondering whether the mistakes I will have already made today will be picked up before they cause harm. Whether I am surrounded and protected by a culture of challenge and striven standards. By those who will salve emotional wounds when the mental stretch marks of tiredness threaten to trip me, the team, and the patient we focus on.
Remembering that I have to get around to filling in the workforce questions on my APC application before it expires, and send off the authority to deduct my credit card.
Recalling the ethical standards and pronouncements that shore up my profession, espoused by a Council whose deliberations protect the public from the few rogue versions of me, and whose determinations rehabilitate the few more who fall off the track temporarily.
Rude reality recalls that this august Council is no longer elected by the profession that pays for its functioning. No longer representative, rather comprised of the factotums of political favour. The Minister has chosen to ignore the advice of doctors and instead appointed other than the top four polling candidates in recent elections. He has shown that future Medical Councils may be mere mouthpieces for the party of the hour. And even if they are not, and the integrity of the individual members prevents favour, the perception that it may be so influenced is dangerous indeed.
Once the confidence of the profession in its own regulatory body is shaken, the safety of the public cannot remain unstirred. How can patients be confident their doctors are confirmed and constrained if the licensing authority and the source of ethical evaluation is open to political favour and fancy?
I resolve to assuage my concerns as soon as I finish our ward round. I recollect the Minister stating he has never been asked to use his powers to regulate that the top polling candidates in a Medical Council election be automatically appointed to the Council – with the other places appointed by the Minister. I recall that I have personally asked him to do exactly that. I recall that I have written to him asking him to do exactly that.
Yes Minister? Well, no. Not really.
Grabbing a coffee to keep us both awake, the registrar I am privileged to work with quizzes me not only on my management of winter’s ailments, but also attempts she perceives to claw back the working conditions of both RMOs and SMOs. She mentions the same single figure at negotiations and author of myopic muddling missives. She has also read the literature on bad bosses. She quotes Stanford professor Robert Sutton, an organizational psychologist, who has developed a philosophy, presented in a book to be published next year, on bosses who are jerks.
A difficult personality can be a status symbol. It can even be "a badge of honour" to be a domineering boss, "somebody who makes you constantly feel demeaned and lessened." There are scary, capricious bosses in every field. They are a drain on society. But what rewards them and encourages them in their pursuits and behaviour? Could it be a lifetime of selective bias? A career made of mining data selectively to bolster an argument? Of surrounding oneself with like-minded mediocrats – rather than rewarding colleagues for being sceptical. Or acclaiming opponents – for they may very well be right.
Studies of selective bias using neuroimaging with fMRI shows quiescent reasoning parts of the brain, and active emotional, reward and pleasure areas. “These partisans twirl the cognitive kaleidoscope until they get the conclusions they want, and then they get massively reinforced for it, with the elimination of negative emotional states and activation of positive ones.”
Four hundred years ago Francis Bacon observed “the human understanding when it has once adopted an opinion … draws all things else to support and agree with it. And though there be a greater number and weight of instances to be found on the other side, yet these it either neglects and despises … in order that by this great and pernicious predetermination the authority of its former conclusions may remain inviolate.”
As we returned to the bedsides of the ill and infirm, I shared a concern voiced eloquently by one so young. That two men could so undermine the fabric of doctoring in
When an ask, becomes a shout. Becomes a demand. Becomes a rallying cry. Becomes a unifying flag of conflict. Becomes the confirmatory bias for all future dealings. On behalf of the patients in the beds, on whose side we serve.
Jeff Brown
National President
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To arbitrate or not to arbitrate
One of the many calls during the five day RMO strike was for arbitration to be mandatory in such circumstances. Under our industrial law, the Employment Relations Act, there is no right to mandatory arbitration (the noticeable exception is the police who have their own Police Act) although a union and an employer could voluntarily agree to abide by an arbitration process in any particular collective agreement negotiation.
The ASMS had sought to get mandatory arbitration when we first negotiated the national DHB MECA but this was firmly rejected at that time by the DHBs. Instead we now have, in the current MECA, an obligation for both parties (ASMS and DHBs) to consider arbitration in the event that strike action (or lock-outs by DHBs) might be used to overcome an impasse in negotiations that independent mediation has failed to resolve.
But a word of caution on arbitration. In albeit rather unusual circumstances the ASMS’s past limited experiences of arbitration were largely unsuccessful. In general, arbitration lends itself towards the status quo and tends to accept uncritically employer claims on affordability.
On the other hand, however, it is unlikely that the DHBs’ proposed Memorandum of Understanding that has driven the DHBs and Resident Doctors’ Association so far apart in the RMO MECA negotiations would succeed because it is too far from the status quo. This supposition assumes that in an arbitrated process the controversial memorandum was the key issue of determination. It is noteworthy that the DHBs do not want arbitration for these negotiations.
ASMS members have taken legal strike action over a collective agreement negotiation. In 2003 our
One does not want to have a doomsday approach but the way our present MECA negotiations are proceeding and with the hard-line position being adopted to date by DHB leaders, this is something we might have to consider at some point. Fortunately we are not at that point now and hopefully we will not reach it.
Ian Powell
Executive Director
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A national employment agreement for hospice doctors
It has been a long standing aim of the Association to get an employment agreement covering Association members employed by hospices. A ballot of members working in the sector last year authorised the Association to begin bargaining and after some early hiccups negotiations started in March. There were real difficulties in the path of settlement. Hospices had funding difficulties; there were different conditions and different circumstances and we were dealing with a small number of doctors widely dispersed around the country. The Nurses Organisation had reached agreement with many of the same employers on a potential settlement of a hospice nurses MECA but the agreement was dependant on the government making additional money avail
The last negotiating session for the Hospice Doctors MECA was held on 25 August and it appears possible that ASMS has reached a provisional settlement with the employers potentially party to the agreement. This is subject to agreement on the terms of settlement and ratification by employers and ASMS members.
The term is for one year as the agreement needs to remain synchronised with the DHB MECA presently under negotiation. CME expenses, annual leave, sick leave, and redundancy payments are less than that in the DHB MECA. Payments for call are at a flat rate. Superannuation will be subject to a working party.
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KiwiSaver initiative
The following information has been provided for The Specialist by the Medical Assurance Society.
KiwiSaver is a subject most people have heard of - but know little about. However, come 1 July next year, KiwiSaver will affect ALL employees and employers, so it is worth having a broad overview of the salient features.
What is KiwiSaver?
KiwiSaver is one of a number of Government initiatives that focus on saving for the future. Other initiatives include the introduction of the State Sector Employee Scheme, and the NZ Super Fund - designed to save now to pay for state funded superannuation in the future.
From 1 July next year, all new employees will be automatically enrolled into KiwiSaver. They then must decide whether to remain enrolled, or whether to ‘opt-out’. However this decision will need to be made within 8 weeks of starting employment. Conversely, existing employees will have the opportunity to ‘opt-in’.
There will be a number of privately run KiwiSaver schemes, offered by financial services companies. These schemes are in essence superannuation schemes, with certain rules. For example, savings will be ‘locked-in’ until the age of NZ Super (65), and contributions must be a minimum of 4% of gross base pay.
A number of tax changes have also been proposed, aimed at making savings through such schemes more attractive to investors. These include removing capital gains on Australasian shares, and using personal tax rates, capped at 33%.
The Government is proposing incentives for individuals through a $1,000 contribution, a fee subsidy, and a (capped) tax break on employer contributions. IRD will be used as a centralised source to ease the administration burden for employers and coordinate the smooth running of the initiative as a whole.
So what does it mean for you?
- Employees are automatically enrolled when they begin a new job and have eight weeks in which to opt out
- Existing employees can choose to opt in to KiwiSaver
- Contributions are deducted from wages at a rate of 4% of gross base salary and wages, or 8% if you choose, with tax paid out of remaining income.
- Employer-matching contributions are exempt from tax (up to a capped amount)
- Employees can select which KiwiSaver scheme they wish to invest in. You may only have one scheme at a time. Changing employers does not mean you have to transfer schemes, though you can if you wish
- Those who do not specify a KiwiSaver scheme are randomly allocated to a default scheme provider (by IRD)
- The Government will pay $1,000 to ‘kick-start’ new accounts, and a (yet to be determined) fee subsidy each year
- Savings are locked in until the latter of 65, or 5 years after the first contribution.
What is happening now?
The KiwiSaver Bill is currently before Parliament and is yet to be finalised, so the rules may change. However, it is still likely to come into force 1 July next year. Medical Assurance Society is monitoring progress closely to make sure they are well positioned to provide continuity for current investors and allow investors to take maximum advantage of the incentives on offer.
Daniel Callaghan
Investment Products Manager
Medical Assurance Society
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Politicisation of the Medical Council
Published below is an open letter to the medical profession (21 July) from the Pan Professional Medical Forum which comprises the Council of Medical Colleges, ASMS, NZMA and the Resident Doctors' Association. It outlines serious concerns over the politicisation of the Medical Council following the Minister of Health's decision not to appoint all the successful candidates in the Medical Council conducted elections.
PAN PROFESSIONAL MEDICAL FORUM Dear Member We write to advise you of an important threat to the governance of the practice of medicine in You will be aware that earlier this year the Medical Council held an election for four places on the Council. You may not have realised that these were “informal” elections. There is now no provision in law for the election of members of the Council. The Medical Council now operates under the Health Practitioners Competence Assurance Act (2003) which provides for the appointment of all of the members of the Council by the Minister of Health. While the Minister may pass regulations to allow the Medical Council to hold elections for a minority of four places on the ten member Council, he has chosen not to do so. In the absence of such regulations, the Council has run “informal” elections, but both the former and the current Minister have agreed only to be “guided by” those elections and have refused to undertake to appoint automatically those who are so elected. In the view of many doctors, this amounts to taxation without representation. The Council of Medical Colleges in New Zealand, the New Zealand Medical Association, the Association of Salaried Medical Specialists and the Resident Doctors' Association, both before and since the passage of the Act, advocated on the question of elected members of the Medical Council with the former and present Ministers of Health. Our combined view is that while the HPCA Act specifies that the members of the Council are appointed by the Minister, it is open to the Minister to accept that a number (currently four) of appointments will be made of members elected by the profession. Both Ministers have refused to give such an assurance. The only possible reason for such a refusal is that the Minister reserves the right not to appoint individuals who have been successful in such an election, for reasons known only to himself or his unknown advisors. In his reply to us dated 15 February this year, Mr Hodgson said: “I do not believe that it would be appropriate for me to automatically This process is different to that used for appointments to District Health Boards. There, the elected members are automatically accepted and Government then appoints others to balance any perceived deficiencies in skill and knowledge. We believe the Government should utilise that model for appointments to the MCNZ also. In a letter we received from the Ministry of Health dated 7 July, we were notified of the appointment of four doctors to the Medical Council. Whilst all four were candidates in the Council election, not all of them were among the four highest-polling candidates. It is apparent that the Minister has not accepted the verdict of the medical electorate. We believe that the refusal of the Government to allow the members of the medical profession to have genuine participation in its own governance has grave consequences for the profession, for the practice of medicine, and for our patients, the people of Dr Phil Bagshaw Dr Ross Boswell
appoint those members who have been elected by the profession in
the Council's internal process. While I would certainly take account
of the results of the election, I would need to consider the overall
balance of skills on [sic] the Council members before making new
appointments to ensure that there is an appropriate mix of skills and
knowledge to carry out the purpose of the Act.”
President President
Association of Salaried Medical Specialists
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‘No more Mr/Ms Nice-Guy'
On 31 August the National Executive resolved that the ASMS should become more openly forthright and critical over health policy and related issues. This was in response to growing frustration with unsatisfactory government and DHB performance over a range of issues. It was also a reminder of the importance of the ASMS’s longstanding role as an advocate for an accessible high quality and comprehensive health service. One of the descriptions of the Executive’s decision was ‘no more Mr/Ms nice guy’.
Consequently, on 1 September, the ASMS made the following media statement:
Senior doctors intend to be more forthright and critical over their concerns about government and district health board performance in the health system.
It has become clear to us that we have much less in common with the government over objectives and direction than we previously thought. This has become evident in several areas including:
- Political indifference to patients being denied access to first specialist assessments and public hospital treatments. Instead of trying to address this unmet need the government appears more preoccupied with data cleansing.
- Deliberate under-funding of public hospitals with projected increases well below inflation and the real operational costs. Public hospitals are being financially squeezed and unable to be confident about the maintenance of quality care.
- Cynical and arrogant political interference in the selection of doctors on the Medical Council with the refusal of the Health Minister to accept the outcome of an election for some Council positions. This is undermining the confidence of doctors in the integrity and political independence of their registration body.
- Denying the existence of serious medical workforce shortages despite the evidence to the contrary.
- The government’s willingness to approve privatisation of core health services despite the serious risks and the existence of more robust alternatives.
- The government’s condoning of the culture of managerialism (management knows best) in district health boards instead of promoting more active engagement with health professionals in decision-making.
We will always continue to recognise when the government or district health boards make good decisions but we will be more consistently critical on those increasing occasions when they don’t.
This led to extensive media coverage on Saturday 2 September featuring prominently on the front page of both the Dominion Post and Christchurch Press along with other newspaper coverage, TV1 News and radio.
Then, on 5 September, ASMS National President Dr Jeff Brown and National Executive member Dr Torben Iversen were interviewed on Radio New
PRESENTER: The gloves are off between hospital doctors and the Government. Senior
doctors have launched a campaign against the Government over funding and
health policy. According to their union, the Association of Salaried Medical
Specialists, many hospital doctors are fed up with working in what they say is
a chronically under-funded system. They are accusing the Government of
political indifference, of deliberate under-funding, and a practice they call data
cleansing. Before we came on air, I spoke to two doctors who work in the
front line daily, Dr Torben Iversen who’s an obstetrician and gynaecologist at
Medical Specialists, which has all but declared war on the Government over
these under-funding and waiting list issues. I began by speaking with him and
asking him what this campaign is all about.
BROWN: Well, it’s an accumulation of things, Kathryn, and increasingly senior doctors
are feeling they’re not being listened to, they’re being disempowered and
decisions are being made under pressure by hospital managers under the
pressure of what’s called a future funding stream, which is less than even the
rate of inflation, and these decisions are basically being made without much
input from senior doctors around the country, and these decisions are starting
to affect the way senior doctors work in their day-to-day work and are
harming patients.
PRESENTER: What sort of decisions specifically are you talking about?
BROWN: Well, decisions to dump people from waiting lists to which
management responds by sending a directive around that GPs worried about
their patient who has been dumped from a waiting list cannot even ring a
specialist to discuss the patient, they have to go through a demand manager.
PRESENTER: What is that directive about?
BROWN: Well, that directive is trying to prevent doctors talking to doctors about their
patients and it’s a way of acting under pressure and trying to manage the
dumping of patients from waiting lists.
PRESENTER: But what does it achieve for the hospital? Why is directing them through a
demand manager a useful thing to do?
BROWN: I don’t believe it is a useful thing to do.
PRESENTER: What is a demand manager?
BROWN: Oh, I would like to know. It’s certainly not a doctor, it’s not a specialist and
it’s not a GP.
PRESENTER: This is a case of what, if you talk to a doctor, somehow this person can’t be
on the list that we’ve put them on or taken them off or whatever?
BROWN: Well, you could argue that it’s a way of trying to stop doctors making
decisions and trying to stop doctors having an influence on doctors about
priority of patients. This is the sort of response that you see when managers
are put under pressure to dump patients and where the only way to do it is to
get the decision-making away from doctors.
PRESENTER: So you’re saying that because they’ve got to make the numbers fit, they’re
using a non-clinician to decide who gets to talk to who and therefore
technically, what happens to a patient?
BROWN: That seems to be the response, yes, and that seems counter-productive when
you could argue that the very way to sort out the issues, particularly of
rationing of care, of distributing of scarce resources, is actually to involve the
very doctors who are making those decisions in the first place. And what
we’re seeing is individuals acting under stress and what they revert to is what
they do normally and if they are managers looking at the bottom line of a
budget or a spreadsheet, that is what they are good at doing and that is what
they revert to. And we see doctors also reverting. They’re saying I don’t
care about management; I will just get down, put my head down and look
after the patient. That is not the solution. We have to involve those doctors.
PRESENTER: This business about the doctors and the specialists not being able to
communicate, I mean, can that be enforced somehow?
BROWN: In reality, a GP is going to ring a specialist and say Mrs Smith or Mr Jones has
got a problem, can we discuss it, and in reality the doctors are going to go
ahead and do it anyway, and the problem with that is you are then separating
the managers and the doctors who need to provide and sort out solutions
together.
PRESENTER: The boards have been told to get their waiting times - their booking lists down
to the six month limit that they’re supposed to be at or they’re going to be
financially penalised?
BROWN: Exactly, so you have data cleansing to try and prove that they are getting
there, or else, yes, they lose millions by getting funding at the end of the
month instead of the beginning of the month. What a perverse incentive.
PRESENTER: Well, the thing is this, if they have got to comply with that requirement to get
the booking lists or booking system to stick within the six month limit, what
options do they have to do that? If you’ve got doctors involved all the way
and arguing over who goes where, they’re going to struggle to meet those
deadlines, aren’t they?
BROWN: So come back to the very beginning Kathryn, is who is making the decisions
about the six month limit and what is the validity of that six month limit?
PRESENTER: No, it’s government policy.
BROWN: And where does the Government policy come from and why is it there? Is it
there to give better care for patients?
PRESENTER: Their argument has always been that on the old waiting lists you could sit
there forever - never get your operation. At least with this booking system
you had certainty. If you were on it you would get your operation within six
months?
BROWN: Only if you managed to get on the list in the first place.
PRESENTER: And that’s really the nub of this isn’t it, because you talk about data cleansing.
What do you mean when you say that?
BROWN: Because the numbers and the rankings and the way of rationing is not
consistent across the country and the Minister of Health has shown that
himself so your access to varying operations, access to varying specialists is
vastly different across the whole country.
PRESENTER: It’s also a case isn’t it, that the booking system, the waiting list for the
booking system is not really the total number of people waiting, is it?
BROWN: Of course not, no.
PRESENTER: And I’m interested then in what you see the solution being to this issue of
whether the data reflects reality. If the government wants a booking system
that gives certainty to people that says you’ve got six months, no more, to
wait, what else is needed to bring more transparency into the actual number
of people waiting?
BROWN: Well, you need to know what the requirements for that particular procedure,
that particular health condition are in
understanding of the demand or the unmet need.
PRESENTER: The fact is, as other doctors have called for, there’s almost a second invisible
list that is simply not recorded. Is it recorded in any way? When people are
sent back to their GPs either because they’ve been taken off the booking
system or because they can’t get on it, is that recorded and available to you
in any way?
BROWN: It’s not available to me. Perhaps if you ask Dr Iversen about a surgical
opinion on that as to whether it’s recorded, whether he’s aware of who’s on
his list or not on his list or who’s been dumped off his list?
PRESENTER: Well, can I bring you in please Dr Torben Iversen because for a start you’ve
been here about four years. What do you make of the way we operate this
system, the waiting lists here if you like?
IVERSEN: Well, I think for a doctor it’s very disheartening to see the number of patients
that you have prioritised, those needing care and not being able to get care
anyway. It becomes extremely frustrating and disheartening for the doctors
and certainly not to speak of what it is for the patients.
PRESENTER: Does the booking system work in at least providing certainty to those people
who get themselves on the list and wait… and manage to stay on the list?
Does it work in providing them their operation within approximately six
months?
IVERSEN: No it doesn’t, because first of all you have to get into the system in the first
place where you actually get your first specialist assessment, and that by
itself is a hurdle to get over. But once you’ve got the first specialist
assessment and the specialist has decided that you need an operation, it is by
no means guaranteed that you will actually get that operation. There’s a
second black box that you have to get through before you actually make it to
the operating theatre and you could either linger or you could simply be
dumped off that surgical waiting list.
PRESENTER: This is the fact that the culls are taking place periodically, various boards are
simply removing people off the booking list because they’re not going to make
the six months?
IVERSEN: That is correct.
PRESENTER: What happens to those? How are they monitored? How are they recorded?
People who either come off the booking system or who can’t get on it despite
their doctors, their specialists wanting them on it?
IVERSEN: Well, there’s no way for the specialists certainly to monitor them. Once they
are out of the system the specialist has no contact or influence over how…
over what happens to them so they go back to the GP. The GP who knew
from the very beginning that this patient needs specialist treatment is then
stuck with the patient again and probably can’t do any more for them than he
or she has already done, because if he or she could do more for them he
would have done so already in the first place.
PRESENTER: Again are they being recorded in any way that is accessible to you or to
anyone else for that matter, on any sort of a waiting list? Are they in any sort
of a waiting system that is recorded?
IVERSEN: I am not aware of any system that records that. It’s certainly not accessible
to me.
PRESENTER: Do you believe that there should be a second waiting list, as some doctors
have called for, that reflects people trying to get on the booking system?
IVERSEN: Well, I believe there should be adequate resources so that we would be able
to see the people who actually need to be seen and operate on the people
who need to be operated on, and not having to dump people and not having
to ration care the way that we have now.
PRESENTER: What do you make of New Zealand’s performance, public health system
performance, and we’re talking primarily elective surgery, aren’t we, when
we’re talking about this system. What do you make of it in comparison to
other countries as best you can assess?
IVERSEN: Well, as best as I can assess, unfortunately we are falling far behind. Indeed
it is really sad to see a country like New Zealand that is such a wonderful
country, and my family and I love New Zealand and have decided to make
this our home, but it is really disheartening to see the huge problems that are
being faced in the public health system and see how many people are not
getting the care that they need.
PRESENTER: What is your own experience at your hospital?
IVERSEN: I’m in
small towns and centres have with under-staffing. It is very, very difficult for
us to recruit an adequate number of consultants to the smaller places for
many reasons, for lack of junior staff involvement so that the consultant is
always first line, because of increased roster availability for the consultant.
You are on call much, much more often than you would be in bigger centres.
Because the income that you can make in smaller centres is far below what
you can make in bigger centres, so for many of those reasons we seem to be
chronically under-staffed in most departments, and that adds to the
complexity and that adds to the waiting list. In my department for instance,
we have two consultants, we should be four, and try as hard as we can, two of
us cannot do the work of four people, so the waiting list in our specialty, in
obstetrics and gynaecology, is even worse because we are under-staffed.
PRESENTER: Are you seeing cases where people clinically are being compromised even
despite the booking system which is supposed to give them certainty about
getting their operation?
IVERSEN: I think if you have an acute problem, if you have cancer or if you have a
broken bone or something like that, you will be cared for immediately and you
will get very good care. If you have more of a chronic disabling problem, so
again in my field a woman who has chronic pelvic pain or chronic or horrible
menstrual periods, she may not get seen at all and it is disabling for her
although it is not dangerous to her health, but in terms of quality of life it is
disabling what happens to her, and she can go on for years without ever
making it into the system.
PRESENTER: Jeff Brown, if I could come back to you, you’ve accused the government of
deliberate under-funding. What does that mean?
BROWN: Well, the so-called future funding track, the percentage increase for DHB
funding projected over the next three years is less than the rate of inflation so
the DHBs are going to have to do more with less money. And when that
happens, managers start to focus on next month’s bottom line, the end of the
year budgets, they’re under threat of review and that produces the sort of
behaviour we’ve been seeing. Since the end of last year we have given the
minister a proposal to actually have a health professional-led taskforce, to
actually get top health professionals as part of looking at the distribution of
the expensive care, the sort of stuff that can’t be done for everyone in every
place but the expensive secondary and tertiary care around the country, look
at how to rationally use that and that’s been sitting with him. We would
welcome some dialogue, we would welcome some actual work with you know,
senior doctors, senior health professionals as to how we can use these limited
resources, the reduced funding, better.
PRESENTER: You know that the Government has poured masses of extra money into health
and in fact will say that more operations than ever before are being done. If
when there aren’t complete lists of those waiting if
behind, why is it happening?
BROWN: It’s a very good question. There is a perception that more and more money
has been poured in. There is also a public perception and a doctor perception
that less is being done and more is being rationed and more people are being
dumped. Somehow we have to work out why those two things are happening.
PRESENTER: Well, can you argue with the fact that more operations than ever before are
being done?
BROWN: In some places more operations are being done, in some places far fewer. In
from over 1,500 to just over 300. One argues why…Where are they being
done? Are they all being done in private now? This sort of data needs to be
found.
PRESENTER: And is the data a large chunk of the problem as far as professionals are
concerned? Since there has been a shift from one admittedly great big long
waiting list that for some people went on for years, but since the shift to this
concise booking system or else we don’t record you as waiting at all, is that
part of the problem as far as you’re concerned?
BROWN: It is part of the problem because then how can we compare ourselves say
with
we are doing better or worse?
PRESENTER: This campaign if you like, against the government, is it hot air, is it going to
have some teeth in it?
BROWN: I would hope that it causes the Minister and others to truly want to engage, to
truly want to talk, to sit down and have some action together.
PRESENTER: Well, you know that the Minister will say he’s happy to do that?
BROWN: Well, the Minister has had a number of opportunities. He’s had opportunities
with the Medical Council appointments, he’s had opportunities with a health
professional-led taskforce paper that he’s been given; he’s described as a gift.
The gift remains wrapped. He’s had a number of opportunities. He’s had
communication from, for example, ASMS to try and help him with a way
forward and at the moment we are still waiting so if you like, the door is open,
yes, but we would like to see some action and some true dialogue.
PRESENTER: Or else what?
BROWN: Well, it’s not or else what. I suppose that we will continue to be critical of
decisions and actions which we see harmful to the public health system.
This was immediately followed by an interview with Health Minister Pete Hodgson. The transcript, slightly edited, is below beginning by asking him for his reaction to the stand by the senior doctors.
HODGSON: The problem with this press statement is that I agree with bits of it and I
disagree with bits of it so on the issue of under-funding of hospitals, what’s
happened I think is that the union, if I might say, has made a straight-forward
mistake in assuming that one part of the funding which is called FFT which is
only 3%, is under the inflation rate, but when you add the various other
streams of money that hospitals get, the increase in the year that we’re in at
the moment ranges from DHB to DHB. The lowest I think is probably Otago
which is my own DHB. That sits at 4%. The highest is probably around 7.5%,
some would be touching 8%. None of those figures are well below inflation as
the union suggests.
PRESENTER: Yes, but if you are talking about when you add up total budgets, if they are
focusing on their turf I guess, and particularly this argument over elective
surgery, bits of budget that are committed to other things, administration or
whatever, are of no use to them?
HODGSON: Look, in general hospitals are each year struggling to make ends meet, there
is no doubt about that, and they manage very difficult operations generally
very well. It’s a matter of fact that their deficits are dropping year by year,
they’re now somewhere under one percent of their total budget, so they
clearly are doing things rather well, and also they are delivering more elective
services than ever before. But that’s not to say that they are delivering
enough and that’s the point of agreement I have with the union that you could
always argue, and I think they do and I think not inappropriately.
PRESENTER: Well, they will contest actually that. It’s easy to say more operations are
being done than ever before. If more people than ever before are going on
the lists, that doesn’t necessarily tell us anything. The question is whether or
not you are keeping up with the pace of demand and I want to get straight to
that issue because you have been accused of data cleansing and this is a
matter that won’t go away. There is an inbuilt dishonesty in the elective
waiting list system, in the booking system because you are quick to boast that
that guarantees people their operation within six months, if they manage to
stay on it, but that’s really only the tip of the iceberg of those truly waiting for
elective surgery and that is an inbuilt dishonesty isn’t it?
HODGSON: What happened was that we used to put people on a waiting list, this is back
in the 1990s and they used to wait. I know a person who was waiting for a
knee operation for 12 years. Now, you tell me whether that’s good service or
not. These days we are moving towards, and it started under National, a
booking system and we’ve said if you can’t treat someone within six months
then you shouldn’t admit them for treatment at all. Now, your question is all
fine and dandy but that just backs people up at the front door who need
surgery and who can’t get in because there isn’t enough capacity to deal with
them. If that’s the case, and from time to time then it does fall on the
Government to increase elective services. That’s where the orthopaedic
initiative came from where we doubled the number of hips and knee surgery
that’s being done in
PRESENTER: You can keep the booking system with its six months guarantee but why don’t
you establish a truly transparent system, a second list of those returned to
GPs from specialists that reveals the total numbers of people waiting for
elective surgery?
HODGSON: There is such a second list, it’s called active review, and it’s released publicly
every month. I do not know of a more transparent health system in the
western world.
PRESENTER: Well, none of the professionals we speak to would agree with that.
HODGSON: Some of the health professionals that you have spoken to don’t agree with it,
a large number do I can assure you, but the point they make and I think they
have some validity, is that if you do have a nice transparent system where
everybody gets treated and those who are put on active review are also made
transparent and that is the case that we have, you still haven’t answered the
question yes, but how much is enough, and I think that’s a valid question, and
that’s why there have been interventions by the government in the past and
there may well be further interventions in the future.
PRESENTER: How much is enough may well be measured by things like comparisons with
performances a decade ago and I don’t know really what figures you’re
referring to, Minister, because any search or inquiries we’ve made in recent
days over this have revealed utterly unintelligible information from the Health
Ministry. We’ve had the President of the Association of Salaried Medical
Specialists saying he has no knowledge of any list that sensibly measures
those waiting who aren’t on the booking system.
HODGSON: Well, the active review list is designed to do precisely that. He should know
that. But I do agree with you that going back in history is difficult, that you
end up with fairly confused data. In the case of the orthopaedics initiative
where we do have good international data, and we don’t have good
international data for many surgical specialities but we do have for
orthopaedics, we know that we were well below the western average when we
said that we needed to double hips and knees, and we do know that when we
have fully rolled out the increase, we will be well above the western average
though still as it happens, below Sweden. We will be as far as I’m aware,
running second.
PRESENTER: Doctors tell us that this country is slipping further behind comparable OECD
countries including
struggling to do so. Can you measure it? Can you tell me now that we are
not slipping further behind?
HODGSON: Only in some specialties and those specialities that I have information for,
I’ve already made that… put that information into the public arena. So, for
example, if you go to coronary artery bypass grafts and add to that the sort
of sister intervention called angioplasty, compare us internationally, we
compare better than some countries and not as good as others. In that
particular area we’re slightly better than average but not hugely.
PRESENTER: There have been high profile culls of the waiting lists recently. Are you
satisfied with the current performance on elective surgery across the board?
HODGSON: No I am not.
PRESENTER: The DHBs are rife with rumours of an injection of new funding for elective
surgery. Are you about to announce such a funding boost?
HODGSON: Maybe, but I think I should talk to my cabinet colleagues before I talk to Nine
to Noon.
PRESENTER: Will you be talking to them for a figure of around $60 million?
HODGSON: I will be talking to them first.
PRESENTER: Is any work underway within government at any level into a new means of
funding long-term health costs in this country?
HODGSON: What do you mean by long-term health costs?
PRESENTER: Well, as with the Super Fund which was planning long-term Super coverage.
HODGSON: Oh yes, I understand, yes I understand. No, there is no pre-saving in the
government’s fiscal policy for health. What there is instead is a very
significant attention going on primary health care and in fact that’s one of the
beefs I suppose that the Association of Salaried Medical Specialists have.
They do appreciate that primary healthcare is important but they say that you
shouldn’t do that at the expense of tertiary care.
PRESENTER: Looking at the total health budge hitting a crunch say in 20 years’ time as we
know it’s going to, is there any work currently underway on the concept of a
dedicated health tax or is that now completely dumped?
HODGSON: Well that was looked at by my predecessor, Annette King and Michael Cullen
some four or five years ago and the idea of a hypothecated health tax was
certainly in the arena. The findings from that study some years ago were that
it didn’t add or subtract anything; it didn’t have any additional value.
PRESENTER: The concept of compulsory contributions of any form similar to the Australian
system, is that being considered or to be considered in any work at any level?
HODGSON: No, we have compulsory contributions to our health system at the moment,
its called taxation. Taxation is a thoroughly legitimate way to fund a health
system as
form as we fund ACC in this country. Generally speaking, if you go to those
countries who use social insurance, they have a health system that’s no better
or worse than ours. They might be sometimes slightly more expensive.
PRESENTER: A couple of issues that pertain specifically back to where the specialists are
coming from. They’ve given us an example, in relation to culling of the
booking system, of a directive in Christchurch that GPs cannot phone the
specialist of a patient who’s been taken off the list, been dumped off the list.
They have to go through a demand manager, a non-clinical demand manager
and what we are being told is, the people making decisions about these lists
are not the clinicians, they are managers?
HODGSON: Could you please talk to the Canterbury District Health Board about any of
those matters. I don’t have anything to add to them but I would say this,
Canterbury and Canterbury alone has decided in years gone by that they
didn’t like the idea of a six month waiting list, they preferred a 12 months one.
This was contrary to the policy of successive governments. In December
2004 the Ministry of Health told the Canterbury DHB that they did need to
move by June of this year to a six month process. I then extended that to
September of this year to give them more time and the truth of the matter is
that the Canterbury DHB did not respond in a timely manner. The Canterbury
DHB is now under new management and the new manager, the new chief
executive, has committed himself to ensuring that Canterbury DHB, like the
other 20 DHBs, does follow Government policy. That for 5000 people has
been really, really bad news but the truth of the matter is, that Canterbury
DHB if you will, honoured government policy in the breach for years prior and
that’s the original problem.
PRESENTER: Should managers, non-clinical managers be making leading decisions about
clinical matters and blocking doctors from talking to specialists?
HODGSON: Without knowing any detail, my initial response is that that is absolutely
counter-intuitive and that actually one of the secrets to making a health
system work better is for GPs and specialists to be talking more often
together, not less often.
PRESENTER: There’s also been an offer to you of a health professionals’ taskforce
involving senior health professionals in better managing, better prioritising
resources, and we are told that as yet there is, apart from a positive verbal
response, no action on that front?
HODGSON: I’ve had a number of meetings with the Association of Salaried Medical
Specialists on that to try and identify a project which we both agree would be
an excellent way to give effect to this offer which I regard as a gift. So far we
have not been able to but I remain optimistic that we can continue to explore
that, and in the meantime I’m working with a range of senior doctors through
different agencies, for example the Royal Australasian College of Surgeons
and the Royal Australasian College of Anaesthetists, are both assisting me
now in a project to improve theatre efficiency. Although their work isn’t yet
done, the early signs are that they are making some really good progress and
I am grateful to them for it.
PRESENTER: Why have you not been able to make any progress on the gift from the
Association of Salaried Medical Specialists?
HODGSON: We have between us simply not been able to identify a way forward or if you
will, an identifiable project. I have put a number of projects on the table and
so far we haven’t been able to develop one of those.
PRESENTER: Well you simply can’t agree on what to do is that what you’re saying?
HODGSON: It’s not a matter of disagreeing with it actually it’s a matter of just finding a
way forward and I would say very clearly I’m wide open to that offer, I think
it’s a really good one. We now need to give it some detail and some
particularity. The original letter, whilst, you know, I warmly received it
publicly and privately, doesn’t yet have any detail to it.
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An open letter from Canterbury DHB surgeons
|
On 7 September 74 out of a total of 80 surgeons employed by the We, the undersigned surgeons from the Canterbury District Health Board, wish to make the following statement by way of publicly stating our concerns with this policy: The Ministry of Health Policy can be summarised as follows: 1. Patients booked for first specialist surgical (outpatient) appointments must be 2. Patients for whom a surgical procedure/operation has been recommended and We have no objections to Item 1 and indeed the CDHB surgical specialties are generally resourced and able to see all new and non urgent referrals well within this 6 month time frame. We do however, have significant issues with Item 2, of this Ministry of Health Policy Directive and these are: 1. The 6 month cut off of this directive has no clinical basis and is leading to more 2. Some patients who have been waiting longer than 6 months have been removed 3. The plan to return patients removed from waiting lists for GP review/managed 4. There are significant problems with the Clinical Priority Assessment Criteria 5. Many of the surgical specialties have examples of patients that have just been We well appreciate that there are limits in the funding of health care. As surgeons, we have a duty and accept responsibility for, the careful and appropriate use of this funding for the management of our patients. However the relative level of funding for the provision of health care for patients in our community and who require surgical care in particular is not adequate. Currently we are working under considerable constraints both in terms of our diagnostic facilities and our surgical treatment facilities. Compliance with this directive from the Ministry of Health will deny many of our surgical patients the benefits of modern surgery and force them to continue to live with worsening disabilities and in some cases undiagnosed and untreated conditions including tumours that will lead to premature death. It is the unanimous opinion of all the Surgical Clinical Directors and the large majority of their surgical colleagues whose names are appended that: 1. This policy and the directive from the Ministry of Health presents us surgeons 2. The Government and therefore the Canterbury District Health Board is not The public need to be honestly informed of all these issues and we surgeons feel that we have a responsibility to do so for the patients we have seen and will see in the future. If patients or their relatives wish to take this issue further then they certainly need to communicate their concerns to the Canterbury District Health Board, their local Member of Parliament and/or directly to the Minister of Health – as any change can only come about by change of government policy and therefore in the Ministry of Health. As surgeons we also wish to make an apology to all patients whose surgical investigations and/or care has been unable to be delivered, as we and they rightly expected it would, and to those patients whose care may be compromised in the future as a result of this policy. |
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Negotiations outside the district health boards: an update
Many of the collectives which were negotiated in the aftermath of the first DHB MECA are now expiring without a DHB settlement with which to claim relativity. This includes collectives at
Family Planning Association
Negotiations on 17 August resulted in a recommended settlement. The ballot on the settlement closes on 8 September. These doctors remain the lowest paid among our membership.
Doctors on the FPA scale will get a 5.5% increase and doctors on the vocational registrants scale will get a 6.5% increase. This will mean some movement towards our aim of providing additional incentives for vocational registration by increasing the differential between the two scales.
The settlement proposal includes increasing the amount available for reimbursement of annual practicing certificates etc to $2,000 and decreasing the number of hours from 24 to 20 entitling doctors to reimbursement if they have no other medical practice. For the first time doctors working less than 20 hours a week will get reimbursed up to $1000 if they have no other medical practice. In each case doctors with other medical practice will have their entitlements pro rated.
Continuing medical education will now be available on the basis of 40 hours leave a year (pro rata for part-timers) plus agreed reasonable travel time. Actual and reasonable expenses of $1,000 will be available for all doctors on a pro rata basis. The mileage rate increases from 60 cents to 63 a kilometre.
New Zealand Blood Service
NZ Blood Service members voted to join the DHB MECA so we have issued a notice joining the Blood Service as a party to those negotiations.
General Practice
All of the employers that we negotiate with in this category come under the category of practices with very low fees. The Minister of Health has recently announced that additional money will become available for practices in this situation. Some of his statements have tied this extra money explicitly to the need to recruit and retain GPs. It remains to be seen how much of this money is spent on recruiting and retaining GPs.
An acute shortage of GPs in an area can serve to weaken bargaining for permanent employees as well as weakening the position and even the viability of a practice. We have had the experience in several negotiations where employers who have adamantly refused to agree to competitive salaries have found themselves unable to recruit and either filled the practice with higher paid locums who are not on the collective or had to introduce higher rates outside the negotiations.
The first signs are often difficult for employers to acknowledge because a core of committed stable GPs remain while increasingly newer recruits who do not have the same roots in the area or commitment to the practice turn over with increasing rapidity.
Employers who have stretched to provide competitive salaries sometimes to edge of their financial viability are often in a better position because the government and DHBs cannot afford to let those practices dealing with the very poorest go under. It seems to do no good to predict a crisis; the crisis has to actually eventuate.
Negotiations held on 25 and 26 July resulted in a recommended settlement. The outcome wasn’t as good for doctors as we had hoped and were characterised by the expression of hostility from some of the employers towards doctors’ claims on the grounds that they are paid more than other staff. (At one stage in this negotiation, this resulted in an employer proposal that a cost of living increase applied to all staff in the second year of the term except doctors.)
The settlement is for:
- A two year term.
- An immediate cost of living increase of 4% to all staff plus an increase equivalent to the movement in the consumer price index in the second year.
- Putting the new vocational registrants’ scale into the collective agreement and extending it.
- Getting fees for advanced vocational training explicitly included as a work related expense that the employer pays.
- An improvement in mileage rates.
- An extra week’s annual leave.
- An extra week’s paid parental leave.
- An agreement (again) to a working party on superannuation.
- An agreement to meet when extra funding for “super access” PHOs becomes available to look at recruitment measures and workforce strategies.
Te Oranganui Trust (Wanganui)
The Collective has been signed and provides salary scales slightly superior to those in the current DHB MECA. It also has an explicit allowance of $20,000 pa for the clinical leader. Initially the
Agreement was contingent on the employer getting the money to pay it from the DHB. The employer has now acquired the money through the Iwi and the new collective is in force from 1 April 2006. The previous collective already had a scale similar to the DHB medical officers scale. It now has a vocational registrant’s scale of 10 steps starting at $125,000 per year and finishing at $163,500 per year and a medical practitioners (those without vocational registration) scale of 9 steps starting at $110,015 and finishing at $144,800.
Negotiations are ongoing with Ngati Whaatua (Auckland ), Ngati Pourou Hauora (Gisborne), the Hokianga Health Care Trust, the Union and Community Health Centre (Christchurch) and the Otara and Waitakere Union and Community Health Centres.
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BMJ Careers advertising campaign continues...
On completion of a very successful 12-month advertising campaign with BMJ Careers the Association has decided to strengthen the international advertising campaign by increasing the placement frequency. The decision was based on the growth in international traffic volume to the ASMS website and support of employers.
In October 2006 an ASMS advert will be published on a fortnightly basis in the Clinical Research edition of BMJ Careers which has a circulation of 68,000 mainly doctors working in hospitals or academic environments. The advertisement also appears as an electronic placement on www.bmjcareers.com.
The ASMS initiative is unique in that it is the union, rather than an employer, encouraging qualified candidates to apply for jobs in
Support for the initiative has been very encouraging with two thirds of district health boards utilising the service to date. The Association encourages employers to take advantage of its offer of unlimited online advertising for a whole year at a generous annual cost. The greater the take up of this exciting venture the greater the chance of filling medical/dental vacancies; and at a much lower cost than DHBs advertising directly in BMJ Careers.
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ASMS 18th Annual Conference
Thursday 2 - Friday 3 November
Delegates required
The ASMS meets the costs and makes all travel and accommodation arrangements for ASMS members to attend its 18th Annual Conference as delegates. It will be held at Te Papa on 2-3 November (Thursday, Friday).
Dinner and Pre-Conference Function
In addition to the Conference there is a Conference dinner on Thursday 2 November. Delegates are also invited to attend an informal cocktail function on the evening of Wednesday 1 November.
Leave
Clause 30.1 of the MECA includes provision for members to attend Association meetings and conference on full pay. Members are advised to start planning now and encouraged to make leave arrangements and register without delay.
Registration of Interest
Please help us to plan for another great Conference and to assist with travel and accommodation reservations by taking a minute to fill out a registration form and either post, fax or email the details back to our Membership Support Officer,
Your interest in registration will be confirmed with your local branch secretary as each branch is allocated a set number of delegates. Extra members are welcome to attend the Conference as observers.
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