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ASMS RECRUITMENT AND VACANCY REPORT 12 MARCH 2004

1 - SUMMARY OF MAIN POINTS
District Health Board (DHB) negotiators' asserted in negotiations over the multi-employer collective agreement (MECA) for senior doctors and dentists that recruitment of specialists was not a serious problem for DHBs.

This did not fit with the assessment of senior doctors that there was a serious problem recruiting specialists. Accordingly the ASMS decided to investigate by doing an initial pilot investigation in MidCentral DHB to develop a template for investigation elsewhere.

The investigation revealed that MidCentral had between 17 and 19 full time equivalent (FTE ) 1 official vacancies for specialists out of 101 individuals (of which at least 39 work under 40 hours a week) employed as specialists. This gives a "vacancy rate" estimated very conservatively of 19%.2

The staffing that the senior doctors and their colleges' believe is necessary to adequately serve the population they serve shows at least a shortfall of a further 21 to 24 FTEs. 3 This gives a "vacancy rate" measured against the professional standard of at least 43%.

The lead chief executive in the MECA negotiations, Stephen McKernan, stated in a press release "the reality is that there is no significant shortage [of senior medical staff] in most DHBs". He is not reflecting MidCentral DHB's concerns in the negotiations. The MidCentral District Annual Plan indicates that the DHB has problems in recruiting specialists and recognises the risks that follow.

2 - INTRODUCTION
The Association of Salaried Medical Specialists (ASMS) is the union representing salaried senior doctors and dentists. ASMS has over 2,300 members, the majority of whom are employed by District Health Boards (DHBs). About 92% of senior doctors and dentists employed by public hospitals run by DHBs are members of the Association.

Traditionally senior doctors employed by DHBs are settled employees that, once they have chosen a career position, will stay in that position for many years. Turnover figures are consequently low in comparison to other health professional groups such as nurses. In the process of negotiating the first multi-employer collective agreement (MECA) for senior doctors DHB representatives explained that they did not perceive any recruitment or retention problem for senior doctors. Turnover rates were low and DHBs had not briefed their negotiators to the effect that the recruitment of senior doctors was a problem.

Senior doctors in the Association's team greeted this with incredulity. An examination of some DHB District Annual Plans 4 illustrated that the employer's negotiators painted an accurate picture of many DHB's lack of concern. Recruitment of senior doctors was not referred to where recruitment was mentioned 5 and though there were some oblique references to having to meet international pay rates when recruiting that may have referred to senior doctors there was no clear statement of a problem.

This did not fit with the Association's experience of the process of recruiting senior doctors or our members' day to day experience in their jobs. The Association provides advice to senior doctors looking to take up a job offer in New Zealand. It also advises senior doctors when they are negotiating additional terms and conditions above the collective. Senior doctors are facing stresses due to unfilled vacancies on a daily basis. Weekly hours range up to 65 hours or 70 hours per week. Over 50 hours a week is regarded as normal in a number of specialties. After hours on call rosters require senior doctors to remain on call commonly on 1:6 to 1: 4 rosters and sometimes on 1:3 and 1:2. Even where the rosters are much larger a senior doctor's role is shifting from that of the traditional "consultant, who only receives occasional phone calls from experienced registrars, to that of "first on call" where doctors in their 50's and 60's are frequently called in the middle of the night by inexperienced staff. It seems to senior doctors that there is a serious discordance between the DHBs views and reality.

Possible explanations were:

• Sometimes vacancies have been filled for a long-time by locums who are paid well above the rate in the collective agreement. These positions may not appear on the DHB's radar as vacancies.
  
• Some vacancies have been unfilled for so long or regarded as so impossible to fill that DHBs have ceased to count them or contemplate them.
  
• Situations where the number of senior medical or dental staff in a service required by a college or professional body to operate a service safely has not been factored into the "establishment" (or number of positions) in a service.
  
• Situations where a DHB has simply accepted that they will never be able to recruit to a service and either abolished the service or contracted it out overseas.
  
• DHBs, in at least some cases, are happy to pay internationally competitive rates in addition to the collective, or to recruit locums at premium rates because they appear as an "unexpected" contingency but don't appear as if the DHB is planning for a large deficit.
  

The DHB negotiators are not reflecting the recruitment concerns admitted by some DHB's at least.
The Association resolved that we would explore the issue on the ground in the DHBs by piloting one DHB in order to develop a template that could be used at other DHBs.


Extra impetus was given to the study when a short while later in a provocative press statement, Stephen McKernan, Chief Executive of Counties Manukau and the lead Chief Executive for the DHBs' negotiating team said;

The Union keeps beating the recruitment and retention drum but that isn't borne out by the facts. We sometimes have difficulty in specialties where there are international shortages - and in some isolated rural areas - but the reality is that there is no significant shortage in most DHBs and turnover rates for senior doctors are lower than other health groups.
The level of vacancies and locums is normal in a sector employing more than 2000 Senior Doctors. 6

3 - THE PILOT
The MidCentral DHB was chosen for the pilot on the grounds that it was close to Wellington, of a reasonable size and a "snapshot" could be achieved in a timely and relatively simple way. Clearly a more elaborate approach would be required where we examine a bigger hospital.

The approach was informal. An ASMS staff member tried to meet and discuss the questions with the clinical director of each department. If the clinical director was not available the discussion was with another member of the department or a response was elicited by email or phone. The discussions led to some refinements in the questions and questions 8 and 9 were added as a result. Useful background information is the number of individual specialists and medical/dental officers working in the department and the FTEs in the department (information which was not uniformly sought).

The questions were
1. Have you any permanent vacancies for senior doctors in your department? If so how many vacancies are there?
2. Have you any locums (other than those covering leave of various sorts) in your department?
3. How long did it take you to fill your last vacancy?
4. Is the staffing in your department adequate/ideal in the view of the staff?
5. Is the staffing in your department adequate in the view of the college?
6. Are there any vacancies in the department that the DHB no longer advertises because they do no expect to receive any interest?
7. Does the department work on an expectation of very large job-sizes for example 55 hours per FTE or larger?
8. Does the department factor in non-clinical duties into job-sizes? If so, to what level both individually and departmentally?
9. Are there any other factors important to recruitment and retention?(for instance the availability of private practice in the area)

MidCentral DHB serves a population of 160,800 with inter-district flows of 15-20. The area for which it has responsibility includes, Manawatu District, Palmerston North City, Tararua District, Horowhenua District, and the Otaki Ward of Kapiti District.

Secondary and community specialist health services worth $165 million pa are provided by the Hospital Division of the MidCentral District Health Board. These include secondary and lower level tertiary medical and surgical health services, Maori health services, public health services and disability support services.

Lower level tertiary services and some specialist community health services are provided on a wider regional basis, covering other DHB districts. These include regional cancer treatment services (RCTS) to a catchment population of 500,000 breast screening services, haematology, renal and public health services.
About 2500 people, or 2000 FTEs, are employed by the MidCentral DHB. The organisation owns assets valued at over $124 million.

4 - SURGERY
4.1 General and Vascular Surgery
At present 6.3 FTE's are employed. There are currently no vacancies. In the view of the senior medical staff in the department that we talked to, ideally there should be 1 more specialist. The recognised professional standard for 30% non-clinical time has not been implemented. If it was to be implemented then a further 1-2 specialists would be required. The college standard is 1 general surgeon for 12-15,000 people. MidCentral's population would indicate that this would mean at least 10 FTE general surgeons should be employed.

Informants commented that the number of patients that could be operated on had lessened as other demands had increased. More time had now to be spent with patients and their families gaining informed consents or talking through difficult decisions such as whether to operate or not. Often the same decisions were reached as would have been reached in the past by the doctor alone but it took much longer. Where 15 years ago 40 patients could have been seen, now only 10 could be dealt with in the same time. It was agreed that it probably was more desirable to spend the time with the patients but the process had an impact on the number of procedures that could be done per clinician.

4.2 Orthopaedic
At present 6 FTEs are employed and there are no vacancies. The 30% non-clinical time standard has not been implemented

4.3 ENT
At present 2 FTE plus 1 medical officer (MOSS) and no vacancies. The 30% non-clinical time has been implemented. An ideal figure is difficult to ascertain because of the big difference between United Kingdom and United States standards (United Kingdom 1 for every 100,000 United States 1 for every 20,000).

4.4 Ophthalmology
Most of this service is contracted out to a private provider. The DHB needs 2 or 3 and, at present has 1 (1.5TE). After-hours call is provided on the basis of $10 per hour for every hour on call plus a fee for service payment when called in.

4.5 Urology
The establishment is 2.5 FTE. Information is incomplete.

5 - OBSTETRICS AND GYNAECOLOGY
At present there are no vacancies and the department is fully staffed, both in the view of the college and of the staff (4 FTEs). The 30% non-clinical time standard has been implemented. The department has a 3-year locum who has been employed for succession planning and in order to keep high quality specialists in the area. Recruitment is almost immediate. This is a 'magnet' department. Doctors in the rest of the hospital regarded it as an excellent department that had less difficulty attracting specialists because of good rosters and a reputation for excellent work.

6 - PAEDIATRICS
No vacancies at present. It is fully staffed with 4.6 FTEs, which includes 1 FTE in the community, funded as primary care. It took 2.5 years to make the last appointment. At least 1 more specialist is required according to Paediatric Society guidelines. The department has "flat" RMO staffing (i.e. a single RMO and not a registrar plus a house surgeon). The DHB is continually ratcheting up demand by signing up to Ministry of Health projects without making any more provision for staffing (eg the Child and Youth Mortality review, Family Violence Co-ordination and training, Sexual Abuse Guidelines and training).

7 - RADIOLOGY
At present 4.5 FTEs are employed. This includes 0.4 FTE locum. The DHB is advertising 1 vacancy. A recent college report 7 said the department needed 7 or 8 FTEs. It took 6 months to fill the last vacancy and 4 months for the vacancy before that.

Also, increases in other specialities impact on radiology as new specialists will normally need radiology support. A long serving specialist is considering an overseas job offer. The department is considered to be in crisis by other parts of the hospital.

8 - MEDICINE
8.1 General Medicine, Cardiology, Respiratory Medicine, Neurology, Gastroenterology, Renal, Rheumatology, Diabetes/Endocrinology, Dermatology, Infectious Diseases

The general comment was that they do not bother advertising in New Zealand because it is a waste of time. The last vacancy (in cardiology) took 12 months to fill. The department does not normally increase the job sizes to cope with patient load but simply reduces the number of patients that clinicians see when there are vacancies to prevent overwork by the remaining clinicians. Protected non clinical time is included in all the work schedules. Most of the areas are not adequately staffed in the assessment of the clinicians and cardiology, neurology and gastroenterology ,in particular, are not adequately staffed in the view of the college.

There are currently vacancies for 2 specialists in cardiology, 2 in renal medicine and 1 to 2 in gastroenterology. There is a fixed short term appointment in gastroenterology, shorter term locums in cardiology and serial locums in renal medicine. Locums are also utilised when necessary in dermatology. Locums have also been utilised in general medicine.

8.2 Haematology
The DHB presently employs 2 specialists amounting to 1.5FTE (the balance of 0.5 FTE is employed by Medlab). They have 1 vacancy for close to full time. It took 2-3 years to fill the last vacancy.

8.3 Medical Oncology
There are 2 vacancies and 1 locum is currently employed. There are currently 3 FTE but 5 are needed.

8.4 Radiation Oncology
There are 2 vacancies and a locum is presently employed. It took 6 months to recruit to the last vacancy. Currently 5FTE's are employed by the DHB.

8.5 Geriatric and Psycho Geriatric Medicine and Rehabilitation
At present the department for the elderly is 0.5 short of a psycho geriatrician and 0.3 short of a geriatrician and the rehabilitation department is short 0.2 of a specialist. The DHB no longer advertises for geriatricians or psycho geriatricians as they have given up hope of a response. Job size in geriatrics was over 56 hours and is now 44 but service expectations are higher and out puts have been ratcheted up despite the change in the job-size.

In rehabilitation medicine draft guidelines have been issued recently for consultation, which suggest that the department is considerably short of the ideal. For instance the guidelines suggest 0.625 FTE per 10 in-patients and 0.2 per 10 outpatients. The DHB has 52 in-patient ATR beds at Palmerston North (and 12 ATR beds in Levin) and the clinicians see 20-30 outpatients a week. At present there are 0.9 FTE plus an allocation of 0.3 for a clinical director. The 30% non-clinical time standard has not been implemented. Beds have been cut 50% over the last 10 years, on the recommendation of health planners, despite strong concerns expressed by the clinical staff. The department now works in an environment of 100% occupancy with waiting lists for admission or transfer of patients considered "bed-blockers" in other medical/surgical wards.

9 - ANAESTHETICS/INTENSIVE CARE
These 2 departments are staffed jointly. There are 15-16 actual bodies and 2-3 vacancies with 3 locums. The 30% non-clinical time has been implemented in the department. There has been a vacancy in the ICU (which is level 2 and not recognised to train)8 for a specialist for 6 years. The clinical director set up a booth to recruit at a recent US conference. If a high dependency unit is required then there is a shortage of 2 intensivists and 3 anaesthetists. Locum costs for 6 months are typically $190,000 plus $27,000 fee to agency plus car accommodation, air fares etc

10 - EMERGENCY MEDICINE
A vacancy for 1 specialist is being filled. There has been no interest in advertisements placed either in Australia or New Zealand. It took 2 years to recruit the new appointee. The first specialist post was vacant for 4 years. Combined college and Ministry of Health guidelines recommend 5 or 6 specialists. The department has submitted a bid for a 3rd specialist next year. The 30 % standard for non-clinical time is not implemented. There is often a flow on problem where there are not enough specialists to expedite discharges to other departments.

11 - MENTAL HEALTH
The department has 3 vacancies that are all but filled pending registration issues after a good response to national and international advertising in late 2003. That will leave the department with 1 further vacancy. With all funded posts full the department would still be about 2 psychiatrists below WHO recommendations with 1 to 15,000 -20,000 per head instead of 1 per 10,000. The last vacancy was filled in only 3 months but this was unusual with hold ups normally caused by registration and immigration. The department is described as having "sub-ideal" staffing with over reliance on medical officers (MOSSs) and resident medical officers. This causes flow on difficulties with consistent supervision with part-time specialists. Advertising was controlled by the clinical director and the group manager. However the DHB is now starting to ask that advertising for vacancies is run by the general manager (possibly as a response to the deficit?). The merits of advertising costs versus using international agencies is often considered. Regular, ample coverage advertising is very expensive especially where the DHB is almost always forced to go off shore due to a national shortage of psychiatrists. If the department gains a New Zealand psychiatrist then it is at the expense of another DHB. The department has large job-sizes (i.e. 55 hours a week or more). They are significant and time input is driven by increasing demand per case in mental health due to other imposed expectations, legislation etc. Therefore the jobs grow in size and doctors can only manage a smaller patient group. This is not recognised in any formula for benchmarking.

12 - PUBLIC HEALTH
There is no vacancy and no locums. It took 1 year to fill a vacancy last time one was advertised. The department needs a registrar. The DHB also supplies services to Taranaki. There is no college view of the appropriate level of staffing

13 - SEXUAL HEALTH
There is no vacancy and no locum. Staffing is considered adequate.

14 - DENTAL HEALTH AND ORAL AND MAXILLOFACIAL SURGERY
There are no senior vacancies at present and no locums are employed. There are 2 full time senior dentists in the Dental Unit and 2 full time junior dentists. Filling of senior dental positions is quite difficult. The last position went for a year without being filled. There are locums, mainly from the United Kingdom, but generally they only want to stay 6 months to a year. Staffing at present is adequate from the clinical viewpoint.

In terms of oral surgeons there are sufficient for the volumes within the MidCentral region but as the regional centre for trauma, on call work is shared with Hutt Hospital and Hawkes Bay which is less than ideal. Job sizes for oral surgeons vary. There are 2 part time oral surgeons (totalling 0.6 FTE) who are paid 2 tenths for their part time work which is adequate plus an extra tenth for on call (a 1 in 4 weeks rotation). Non-clinical duties are not factored into job sizes.

Generally recruitment is problematic as Palmerston North is too small for another oral surgeon to share private/public but on a regional basis another specialist would be helpful. Attracting senior dentists is difficult due to conditions offered compared to private practice.

15 - SUMMARY OF VACANCIES

16 - CONCLUSIONS
The information collected suggests that the most conservative estimate possible is that MidCentral have 17 to 19 vacancies for specialists and a short fall of at least a further 21 to 24 in the view of the senior medical and dental staff. At least a further 2.7 FTE s on top of that would be required if college and other guidelines were met. There are presently 6.9 locums, covering for vacancies, in place. One hundred and one specialists are employed at MidCentral as at July 2003 (actual individuals and not FTE's) and 19 medical officers (MOSSs). This suggests a 'vacancy rate' of at least 19% 13 and a 'professional vacancy rate' of at least 43%.

As is always the case the process of collecting the information elicited a number of interesting observations by informants.

• There are fewer young specialists. As specialists become older and families grow up there is less extramural incentive to stay. Increasing public and managerial expectations mean more time spent with each patient and each procedure.
  
• Fewer full-timers carry the departmental load of administration and audit while higher paid locums plug gaps but only the patient contact gaps.
  
• More time had now to be spent with patients and their families and this had an impact on the number of procedures that could be done per clinician.
  
• Vacancies (or an increase in numbers of specialists) have an impact through the system. An increased number of specialists in one area can place a burden on support services such as radiology. Failure to fully staff departments can cause blockages in the Emergency Department. Shortfalls in nursing (numbers and experience) create a need for additional specialist units such as a high dependency unit.
  
• Demand is continually being "ratcheted" up increasing the scope of services (breast screening), by signing up to projects (sexual abuse guidelines and training) by expecting existing staff to pick up from discontinued services (pain clinics) and by adding extra elements to procedures.
  
• Recruitment of New Zealand trained specialists is regarded as the most desirable option but is often not even a possibility.
  
• Within the same hospital one department can be a "magnet "department and others can be almost impossible to recruit to. High levels of vacancies make it almost impossible to recruit to departments in crisis because rosters are more onerous and workloads higher.
  
• Private provision of services (privatisation), though it is more expensive in general to the public system, increases fragmentation, increases monitoring requirements and therefore transaction costs, may be the ultimate outcome when DHBs are not prepared to pay at a sufficient level to attract specialists as employees.
  
• The role of the medical officer (or MOSS) needs to be examined. Are they simply a "second best" alternative to vocationally registered specialists or should they have a long term role in areas such as emergency care and rural hospital staffing?

Interestingly, the comments that those negotiating on behalf of MidCentral in the MECA negotiations do not reflect the MidCentral DHB's concerns. The MidCentral District Annual Plan states;

The availability of a skilled and competent workforce is critical to the provision of appropriate services within the district. The international transferability of health professionals makes it difficult to retain and recruit such professionals.

Within secondary care services, recruitment to some of the key clinical specialist staff positions continues to be problematic particularly in areas such as radiology, dermatology, paediatric services, anaesthetics, mental health, oncology and allied health professions. Maori health workers are also in short supply.

Recruitment issues are compounded by the national and international shortage in supply in some professions, and even more so those with experience in their speciality. In addition, attracting staff to work in rural locations throughout the district poses additional pressures, particularly when the primary sector workforce such as GPs are retracting from rural locations resulting in a reliance on secondary service providers to fill the gap to some degree.

MidCentral Health, together with other similar DHB providers, experiences a staff turnover rate that is at the higher end of the preferred state. 14

The plan then restates the DHB's difficulty with implementing industrial relations strategies that are "within financial resources, whilst recognising "the increasing gap between the supply and the demand for skilled health professionals". 15
The risks that are cited in the plan if a skilled and competent workforce is not retained are;

• Rapid burnout of those remaining in the system.
• Professionals trapped into practicing beyond their scope of practice.
• Service reductions and higher thresholds for access to services.
• Limitations due to work pressure on continuing professional education.
• Isolated and rural communities face reduced or difficult access to primary care services.
  

Reduction in services levels through industrial action. 16
The assessments by senior medical and dental staff recorded in this document suggests that some of these risks are already a reality.

...............................................................................................................................

Footnotes

1. In salaried medical practice full-timers on average work more than 40 hours a week. This report does not include those hours as part of the calculation.
2. See section 14 'Summary of Vacancies'.
3. See section 14 'Summary of Vacancies'. Departments where senior doctors were unable to be specific on the shortfall are not included in this figure.
4. Lakes District Annual Plan 2003-2004, Otago District Annual Plan 2003-2004.
5. Otago District Annual Plan 2003-2004.
6. Media statement for Immediate Release 30 March, 2004 "Doctors' Union Needs A Dose of Realism".
7. Fred Jensen" Review of Bench marks Study of Department of diagnostic imaging MidCentral Health" Oct 2002.
8. "Roadside to Bedside" Ministry of Health.
9. Much of service is contracted to private provider.
10. If a High Dependency Unit is put in place .
11. Three filled pending completion of formalities.
12. Privately provided.
13. Specialists on ASMS's data base have part time hours ranging from 4-36 per week. The hours less than 40 were added up, divided by 40 giving a national FTE base of 87.5.
14. p 62 MidCentral District Annual Plan 2003/2004.
15. p 62 MidCentral District Annual Plan 2003/2004.
16. p 62 MidCentral District Annual Plan 2003/2004.

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