The Specialist - Issue 123 by AssociationofSalariedMedicalSpecialists

T H E M AG A Z I N E O F T H E A S S O C I AT I O N O F S A L A R I E D M E D I C A L S P E C I A L I S T S

CAN WE FIX I T...

123 | JUNE 2020

INSIDE THIS ISSUE ISSUE 123 | JUNE 2020

WANT TO KNOW MORE? Find our latest resources and information on the ASMS website www.asms.org.nz or follow us on Facebook and Twitter. Also look out for our ASMS Direct email updates. This magazine is published by the Association of Salaried Medical Specialists and distributed by post and email to union members. Executive Director: Sarah Dalton Magazine Editors: Elizabeth Brown and Lydia Schumacher Designer: Dink Design If you have any feedback on the magazine or contribution ideas, please get in touch at asms@asms.org.nz.

Cover cartoon: Sharon Murdoch

The Specialist is produced with the generous support of MAS.

ISSN (Print) 1174-9261 ISSN (Online) 2324-2787

The Specialist is printed on Forestry Stewardship Council approved paper

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2 THE SPECIALIST | JUNE 2020

COVID-19: PUBLIC HEALTH LAID BARE HEALTH CARE POST-COVID COVID LESSONS AND INFRASTRUCTURE ‘HUNGER GAMES’ MECA 2020: NEGOTIATING, BUT NOT AS WE KNOW IT COVID-19: UNFORSEEN CIRCUMSTANCES HEALTH BUDGET 2020: THE GOOD, THE BAD AND THE ‘BUTS’ NEW FACE AT THE CTU A KIWI IN LONDON: INSIDE BRITAIN’S COVID CRISIS LOSING SLEEP: THE FIGHT FOR BETTER ON-CALL ACCOMMODATION DOCTORS IN THE HOUSE A MAY DAY FAREWELL CALLING TIME ON AN ACCOMPLISHED CAREER TALKING TELEHEALTH POST-COVID MY SABBATICAL THE MENTAL HEALTH CRISIS INSIDE OUR PRISONS WILL THE DOCTOR-PATIENT RELATIONSHIP BE CHANGED FOREVER? THINKING OF BECOMING A CLINICAL DIRECTOR? WOMEN IN MEDICINE WELCOMING NEW POLICY ANALYST DID YOU KNOW? FEEDBACK NOTICEBOARD

COVID-19: PUBLIC HEALTH LAID BARE ELIZABETH BROWN | SENIOR COMMUNCIATIONS ADVISOR

legacy of underinvestment in public health has left the virtual fence at the top of the cliff in desperate need of repair. Will the lessons of Covid-19 turn things around? And what do ASMS members at the centre of the pandemic response have to say?

“Health care is vital to all of us some of the time, but public health is vital to all of us all of the time.” So said American paediatrician and health administrator Charles Everett at the turn of last century. It’s no secret that the Covid-19 pandemic has exposed a lack of capacity and investment in New Zealand’s public health service. Our lack of pandemic preparedness showed up as recently as last October when the Global Health Security Index gave New Zealand a score of just 54 out of 100 points and ranked us 30th among the 60 high-income countries reviewed. New Zealand scored poorly in early detection and reporting of epidemics, along with the availability of doctors and hospital beds. The New Zealand College of Public Health Medicine has repeatedly sounded warnings, most recently in a hard-hitting editorial in the New Zealand Medical Journal last month: “The Covid-19 response has exposed an extremely concerning reality – that there is a massive and hugely problematic shortfall in New Zealand’s public health investment. “It is also evident in the number of public health events over the past few years, including the Havelock North campylobacter outbreak and the 2019 measles epidemic – both of which were preventable had the health system had capacity to manage upstream risks.” Government figures show that $517 million was budgeted in 2010/11 directly for

public health services. Ten years later the budget is $469 million.

“It’s really important that this investment is ongoing and sustainable, so that it’s not just a kneejerk response.”

Looking it at another way – public health services had a budget of about $140 per capita in 2010/11 compared with $94 per capita in 2020/21 – a 33% drop in real per capita funding. In terms of overall Vote Health, public health funding in the 2010/11 Budget represented 3.8% of the vote, compared to 2.3% in the Budget for the coming year. CAPACITY HOLES Currently, several public health units and DHBs do not provide guaranteed training posts for public health registrars, despite lobbying by the College for more positions. It is a situation which College President, Waikato DHB Medical Officer of Health, and ASMS member Dr Felicity Dumble finds deeply frustrating. “We have an excellent, highly skilled workforce which has done an amazing job, but there just isn’t enough.

“We’ve actually had to turn highly competent applicants away just on the basis that we weren’t getting sufficient funding to be able to train them,” she says. That lack of capacity was highlighted in a rapid audit of contact tracing carried out by infectious diseases specialist and ASMS member Dr Ayesha Verrall in April. It stated: “The capacity of the 12 public health units in New Zealand is the primary factor limiting New Zealand’s ability to scale up its case management and contact tracing response to Covid-19.” It also described expansion of the workforce as an ‘urgent need’ and warned DHBs could not keep plugging the holes by seconding staff from other areas once alert level 4 was lifted.

“We’ve actually had to turn highly competent applicants away just on the basis that we weren’t getting sufficient funding to be able to train them”

Dr Verrall, who has become a household name during the Covid crisis, says, “I knew the people whose work I was reviewing were working extremely hard, that they WWW.ASMS.ORG.NZ | THE SPECIALIST

Dr Felicity Dumble

were already exhausted and that what I recommended went against established consensus around how the Ministry and public health units interact with each other.” The legacy of underinvestment stretches to IT systems and contact tracing tools, which were shown to be unfit for purpose. Dr Felicity Dumble points to the need for information systems that can capture all data needs, from clinical and laboratory notification through to case and contact management, as well as real-time monitoring and centralised reporting. According to Dr Verrall, there are also major gaps in our technical capacity to analyse data.

“Public health is also about policy and evidence and influencing”

“We do have excellent people in New Zealand, but mostly we sit in the wrong place. A lot of the analytic expertise in infectious diseases sits in universities. I am working now for the first time with modellers. “I’m more of a clinical epidemiologist, but clearly mathematicians like Sean Hendy are making a big contribution to the modelling space. Why are we only meeting now?” she asks. Dr Verrall also believes having technical expertise sitting outside New Zealand’s policy-focused Health Ministry is ‘catastrophic’, particularly in a pandemic. FENCEPOSTS FOR THE FUTURE There’s clear consensus that New Zealand cannot afford to return to a system that was unable to prepare not only for a global pandemic, but the recent measles epidemic, rheumatic fever, TB, and even syphilis. While national public health services overall did receive a relatively modest 6.6% increase in this year’s Budget, there has been no increase to baseline funding for the country’s 12 public health units. They have received an extra $30 million as part of the Covid-19 response, which will focus 4 THE SPECIALIST | JUNE 2020

Dr Ayesha Verrall

primarily on contact tracing and paying the hundreds of people temporarily brought in to help boost the workforce. Dr Dumble warns while the extra money is welcome, it cannot make up for more than a decade of underinvestment. “It’s really important that this investment is ongoing and sustainable, so that it’s not just a kneejerk response. We need to see better resourcing going forward. It’s not just how we respond to communicable disease but about preventing disease and prolonging life, with a firm focus on improving Ma-ori health, achieving health equity, reducing child poverty, and mitigating climate change.” There are currently about 171 public health specialists in New Zealand. According to the Ministry of Health, the growth in the number of public health medical specialists holding a practising certificate between 2010 and 2019 was 9.6%, compared to 38% across all medical specialities over the same period. The incremental increase is outstripped by population growth. The Ministry says it is considering options to increase the funding available for new public health medicine registrars in 2021. Meanwhile, another ASMS member who has found herself in the Covid media spotlight is the Director for Public Health, Dr Caroline McElnay. She could often be seen fronting the Ministry’s now infamous 1pm briefings. She describes the past few months as a ‘rollercoaster’. She says it is important to point out that the issues in public health are about much more than funding. “Public health is also about policy and evidence and influencing,” she says. She also points out that public health units are only one piece of the jigsaw and the workforce is broader than just specialists. “The public health workforce is an interdisciplinary workforce with only a number being medical practitioners, so when we talk about the workforce pipeline we can’t just look at the medical workforce”. Dr McElnay agrees that New Zealand has a number of unique and complex public

Dr Caroline McElnay

health challenges which “will require a really good look at how we as a country both fund and deliver services to help address these.”

“I hope that what we see now is the unique challenge of planning for infectious diseases, and it’s not a matter of planning for last year’s demand”

In Dr Ayesha Verrall’s view, data, transparency and measurement drive system improvement. She believes the Covid crisis has given us an opportunity to build our public health units and effect structural change. “I hope that what we see now is the unique challenge of planning for infectious diseases, and it’s not a matter of planning for last year’s demand. Infectious diseases can have exponential growth, and what we need to do now is ensure that we build that out to include other aspects of public health practice.” Long before Covid-19 reared its head, several public health experts have argued for a strong national agency to consolidate public health activities and take responsibility for our growing public health challenges. Some are hoping that this will be a recommendation out of the Simpson Health and Disability System Review. Whatever lessons are learned from the Covid-19 pandemic, Dr Felicity Dumble says future proofing our public health service will take political commitment and leadership, strong governance, and a whole-ofgovernment approach, not to mention increased and meaningful investment. She says it also needs to be co-designed with the public health professionals who understand it intimately. Ultimately, she believes we now have the opportunity to move public health service design in New Zealand into the 21st century which we cannot let slip away.

HEALTH CARE POST-COVID PROF MURRAY BARCLAY | ASMS NATIONAL PRESIDENT

ight now, I am very glad to be a doctor in New Zealand and not in the UK, Europe, or the US. As others have said, we dodged a large bullet by going into strict lockdown quickly and, fingers crossed, we can keep Covid-19 at bay and live relatively normally.

Importantly, so far, we have had no health care worker deaths. This could have been so different. Nurses in particular have had to run the gauntlet in caring for infected aged care facility residents.

patients with symptoms, polyp and cancer surveillance, and colon cancer screening.

So, what is the outlook for health care services as we come out of lockdown and reassess health need?

There are two main options to try and catch up with workload post-Covid.

Before Covid, we were faced with: • 10 years of steadily reducing investment on health care as a percentage of GDP • 25% shortage of hospital specialists • decaying and overburdened hospitals running up to and beyond 100% bed occupancy

The graphic shows the way Covid has exacerbated the gap between healthcare service delivery and health need.

1. Run health care teams ragged with overwork. 2. Invest in more staff and hospital beds. The first option will obviously result in loss of health care staff from burnout, including poor mental and physical wellbeing, and worsen understaffing. PATIENT NEED

• 50% burnout rate in hospital specialists (70% in younger female specialists)

UNMET NEED

• an estimated 448,000+ New Zealanders unable to access the hospital specialist services they required. Covid-19 highlighted very specific deficiencies in our health system, including a dangerous shortage of ICU beds compared with other similar countries, and a depleted public health specialist workforce and occupational health workforce at a time when we most needed these people. However, similar deficiencies exist in many, if not all, the medical and surgical specialties across the country. WHAT IS DIFFERENT NOW? We have the same number of medical staff and same hospital capacity, but waiting lists are two months longer. Efficiency is reduced by the need for extra hygiene precautions and cleaning. As a gastroenterologist, the example most clear for me is that endoscopy patient turnover will be reduced by up to 30%. This has enormous implications for all endoscopy indications, including

DHB SERVICE CAPACITY PANDEMIC TIME - WITH COVID PANDEMIC

All DHBs and managers must know that the second option is really the only logical choice for staff and patient well-being. However, until now their arms have been tied by the Ministry of Health and the Government, with threats of ministerial intervention and/or dismissals of boards, chief executives, and other managers for questioning budget restraints. HOW ARE THE GOVERNMENT AND MINISTRY RESPONDING? This year’s Budget sees the largest increase in spending in health care in decades. You can find a Budget analysis on page 10. The Government has recognised and responded to the need for new hospitals.

Let’s hope the Ministry also responds appropriately. Until now it seems to have struggled to understand the real requirements for new hospital facilities. There are a growing number of new hospitals that will not be fit for purpose on completion for several reasons, including too few beds, and poor accommodation for staff. The Covid-19 experience adds to the long list of reasons against large open-plan office spaces and hot-desking. Even more important is the shortage of health care staff, the most important determinant of health care capacity. The Ministry has long appeared to have its head in the sand regarding medical staff shortages in hospitals, and it does not seem to be moved by the high level of burnout in hospital specialists. After several years, Health Workforce New Zealand was finally acknowledged to have failed to deal with workforce issues, and a new entity called the Health Workforce Advisory Board has taken its place. There is hope this new entity will be more productive, but time will tell. SUMMARY Now more than ever, spending on health care needs to be an investment in productivity and well-being for our society and not as a financial drain. The positive financial flow-on effect from treating and improving mental and physical wellbeing is known to far outweigh the cost. Secondly, investing in the recruitment of health care staff to match patient need should be the highest priority with the extra investment the Government is now making. Additional recruitment won’t happen quickly due to the time it takes to train, along with global competition for health care workers, but the correct signals need to be sent to DHBs now. WWW.ASMS.ORG.NZ | THE SPECIALIST

Television interview Covid-style

COVID LESSONS AND INFRASTRUCTURE ‘HUNGER GAMES’ SARAH DALTON | ASMS EXECUTIVE DIRECTOR

ne of these days I will write a column that does not start with the words ‘roller coaster’ or ‘crazy few months’ or ‘how time flies...’ but this is not one of those days.

I am currently sitting at my other ‘desk’ – more accurately my dining room table – although I have started venturing back into the office on occasion. One of the cool things ASMS has learned from lockdown is that we can function effectively from home, by Zooming into our case work and meetings around the country. This is something we will take into the new normal. Personally, I have learned that you can give physically distanced interviews via Zoom, Skype and even on the driveway! I have learned that lockdown hair is not fatal, and that driving and flying less, walking more, and spending more time with the person in my bubble, are lovely things. During the Covid emergency many of our members led and contributed to flexible, responsive, focused actions in their DHBs, informed by SMO/SDO advice. These actions helped keep staff and patients safe. In JCC meetings around the motu I am already hearing our members’ hopes that these examples of positive engagement and clinical decision-making will stick. I hope we can hang on to the things that have worked well. Review them, consult with staff, and make sure that as hospital occupancy rates rise, and we resume elective services we do not lose the good things we have put in place. We need to think harder about travel, about telehealth and virtual communication. We also need to remember that face-to-face is often not just better, but necessary. We need to 6 THE SPECIALIST | JUNE 2020

think harder about the long-term failure to resource our essential services and what that means in a crisis. I am glad some light has been shone on several crucial yet under-resourced specialties. I am nervous we are still in a position of robbing Pita to pay Paul for healthcare. Speaking of crime - is it really ok for our DHBs to be locked in a healthcare Hunger Games for capital works? Is it really ok that every new hospital bid is cut back, and that we’re hearing things like “we can’t include mental health in the new build” or “most of the floors will be a shell, that we might furnish in the future” or “we can’t afford air conditioning now” or “our new building will be at maximum occupancy the day it opens” or “everyone agrees our buildings are no longer fit for purpose but our business case has been rejected - again.” I think it is time to centralise responsibility for planned provision and development of key infrastructure. We need to make it very clear, to health workers and taxpayers alike, where the new buildings will go, in what order they will be provided, and the timeframes. The Auditor-General has repeatedly commented on the fractured oversight of hospitals’ capital works. In 2016 she questioned the DHBs’ ability to support future service delivery and noted that “audit work since 2009 shows a sector strongly focused on delivering short-term results within a challenging operating environment and financial constraints.”

It is not acceptable that DHBs are required to develop convoluted, expensive, business cases, which are then cut to the bone; nor is it tolerable that boards are making massive capital works decisions behind closed doors. Overseeing all this – the Capital Investment Committee seems to be giving advice along the lines of - you can have the baby, or the bath, or the water, but not all three. I cannot see any virtue in a bidding war for major public buildings predicated on a sinking lid on capital spend. In 2018, Treasury estimated we would need to invest more than $14 billion in hospital development over the next decade. Yes, this government is putting its hand deeper into its pockets when it comes to the health budget, but the prospect for buildings is gloomy. We know you have suboptimal workspaces. What is not entirely clear is why we are putting up with it. In this issue you will see a sad article about what passes for SMO sleeping accommodation in a number of our hospitals. I see it as symbolic of the larger struggle for decent hospital accommodation for everyone. We need to move past the “sin of cheapness,” and make a serious long-term investment in hospital infrastructure across the country. Given how focused DHBs need to be on the here and now, maybe it’s time to hand the task of imagining our new hospitals to a centralised agency that has the time, clinical expertise, and resource to make a proper job of it.

MECA 2020: NEGOTIATING, BUT NOT AS WE KNOW IT LLOYD WOODS | SENIOR INDUSTRIAL OFFICER/LEAD MECA ADVOCATE

hen I think of MECA 2020, Star Trek jumps to mind and that iconic line, “It’s life, Jim, but not as we know it.” The negotiations were certainly like none which had gone before, and it’s worth reflecting on how it all played out.

We began in February, tabling our very full claim some two months before the MECA was due to expire. It became clear fairly quickly that we were in for a battle and that it would likely take quite some time, so by early March we had agreed with the DHBs to 16 days of talks taking us through to the end of May. The first six days saw us varying some of our claims and gaining agreement overall on five of them, but the big ones were still on the table, particularly those with a clear financial cost. By the end of negotiations on 11 and 12 March, New Zealand (and indeed the rest of the world) was staring down the barrel of what looked to be the biggest medical challenge of the last 100 years with coronavirus rapidly spreading. We agreed to hold more face-to-face meetings in Wellington on 25 and 26 March, but as everyone is aware, the situation ramped up quickly, and, within a few days it was becoming clear that talks would not be able to proceed as planned. Once the Government announced the one-month lockdown, we knew talks would be disrupted for at least two to three months. After hurried discussions between the ASMS team and the DHBs, it was agreed we would go ahead with one day of negotiations on the Wednesday before the lockdown took effect, via Zoom. Negotiating ‘virtually’ was something neither side had ever experienced before. The ASMS team met ahead of the meeting to consider whether to either postpone the negotiations indefinitely or ‘go for it’. We decided on the latter, and by the time the DHBs joined the call we were in the position of offering a package contingent on the DHBs agreeing to a settlement that day. After a lot of back and forth, an offer was left with the DHB team to take back for sign off. This required high-level agreement including both the Ministry and Government – but at the end of the day we found agreement. Basically, this agreement was to ‘roll over’ the MECA with those clauses already agreed, plus three extra clauses agreed on the day, along with a salary increase based on the consumers price index (CPI) of 1.9%. We agreed on a one-year term, which is unusual, but considered the best option given the situation with Covid-19. The new MECA was ratified by the ASMS National Executive after members voted overwhelmingly in favour in an online ballot.

• 12-month term, 1 April 2020 to 31 March 2021. • In underlying principles, Clause 1.1 now reads: The parties acknowledge the fundamental importance of the need to promote and establish DISTRIBUTIVE clinical leadership within the workplace consistent with the principles of engagement in the Time for Quality agreement between the Association and all District Health Boards (refer Clause 2) and the associated need to establish effective employer-employee partnerships, based on good faith, mutual respect and constructive engagement. • All salaries adjusted per CPI (1.9%). • Recovery time is to be applied to shifts as well as to after-hours on-call arrangements. • Safe access to car parking must be arranged during hours of darkness. • A new clause enabling pregnant employees to reduce their hours of work (if they wish) from 28 weeks. • A new professional development clause that provides for SMO/SDOs with clinical leadership roles to undertake relevant leadership training outside of CME time. • The word “posting” has been added to the secondment clause, which will allow for charitable work to be undertaken under this provision. • The words “working (or volunteering) for a medical charity” have been added into the terms of the sabbaticals clause. • An addition to the research and publications clause: “In addition to the right to use sabbatical leave, secondment leave or continuing medical education leave for research purposes, special leave and leave without pay may be used for such research activity.” • Shift work is now included in the vacancies and locums clause. “Notwithstanding any of the above, an employee shall not be required to undertake additional duties and responsibilities caused by an absence of an employee(s) on their on-call or shift roster beyond a reasonable period of time.”

We want to thank the ASMS team for their hard work throughout, and in particular for the rapid acceptance of life as we have never known it on the long, final day of the mass Zoom meeting. We will be back in bargaining for the next MECA in February 2021. MECA 2020 is available on our website: www.asms.org.nz

SUMMARY OF NEW MECA PROVISIONS

ASMS bargaining team

• There is a new clause dealing with domestic violence. • The concept of an accord (or similar arrangement) was agreed over the term of the MECA. Part of that would include exploring the issues facing shift workers, with a focus on looking at the underpinnings of the claim for alternative pay for after 5pm.

WWW.ASMS.ORG.NZ | THE SPECIALIST

Dr Cheryl Johnson and her son Caleb

COVID-19: UNFORESEEN CIRCUMSTANCES ELIZABETH BROWN | SENIOR COMMUNCIATIONS ADVISOR

hen Dr Cheryl Johnson dropped her 10-year old son Caleb off to her ex-husband on 24 March, she drove away wondering if she would ever see him again.

While the country has given collective thanks that Covid-19 spared our hospitals the scenes witnessed overseas, it did take a personal toll on some ASMS members, forcing them into situations and decisions they never imagined. Rewind to the days leading up to the Level 4 lockdown when there was so much uncertainty and fear that New Zealand was about to be hit by a massive wave of sick people which would overwhelm hospitals and services. That is when Dr Johnson and her exhusband decided that Caleb, whom they happily share responsibility for, should go to his dad’s and stay there for the next four weeks. “My workload was really ramping up and we didn’t know what my exposure to Covid-19 was going to be,” says the geriatrician and clinical leader at Waitemata- DHB. “It was the right decision for us, but it was a very difficult decision.” She kept in touch with Caleb regularly, and after almost four weeks she excitedly had him back for some weekends, but then everything changed again. 8 THE SPECIALIST | JUNE 2020

Waitemata- DHB’s older-adults service faced major disruption due to Covid-19, leading to a lot of reshuffling of staff and resources. Dr Johnson was redeployed from North Shore Hospital to Waitakere Hospital, which had become one of the country’s flashpoints. She was looking after patients who had been cared for by nurses who had unfortunately become infected on the job, sparking a full-blown health and safety review. For her it not only brought home the dangers of contracting the virus but also meant at least another four weeks of separation from her son. “It felt like a real rollercoaster – not seeing him, then seeing him a bit, and then suddenly back to not seeing him at all.” While being separated from Caleb was difficult, Dr Johnson was also cut off from her parents, friends and the social networks which are integral to her daily life. It has been an incredibly lonely experience she says. Often, she found herself working late at night or going into work just for the distraction and human interaction.

She knows she is not the only one who has faced personal difficulty through Covid-19. Many of her colleagues, spooked by the scenes coming out of Europe, moved out of their homes or sent their families elsewhere. She brings herself back to the night she dropped Caleb off at his dad’s in March, when she drove away not knowing what the future might hold. “What I have really struggled with and questioned is when you take the Hippocratic Oath and take on this role as a doctor, what is the extent of that oath? What does one person have to give up to fulfil that role?

“It felt like a real rollercoaster – not seeing him, then seeing him a bit, and then suddenly back to not seeing him at all.”

“It’s been extremely hard that I’ve had to sacrifice my family and give up my social networks for that oath I took.”

STOOD DOWN Dr Greta Pearce describes the surreal moment when she was told she had been exposed to Covid-19 and had to stand down from her role as an anaesthetist at North Shore Hospital. “I got a phone call saying the week beforehand someone I had been in contact with at work had ended up symptomatic and had tested positive.” When she got the call her first thoughts were for her colleagues and what her stand-down would mean for them.

“It was stressful coming to that decision and thinking, am I putting my family at risk?”

She also spent time reflecting on how she had ended up in the position she found herself in and questioned her own work practices.

As an anaesthetist Dr Pearce says it is near on impossible to physically distance from patients and colleagues in closed spaces such as the operating theatre.

When she did return to work, she was very mindful of social distancing. “I found myself noticing it a lot more and general behaviour within the work setting. “People have changed a lot of the ways they practice, so much of which is engrained in what we do.” She gives the example of ward rounds where doctors move in groups and see patients behind their bed curtains to maintain privacy. “However, we still have to work within the parameters of the services that we provide.”

“People have changed a lot of ways they practice, so much of which is engrained in what we do.”

Looking back, this was not the scenario through which she would have anticipated an exposure. Fortunately, there was no further infection and she returned to work after a week.

“I was on call that weekend, so it was a little stressful in terms of letting your team members down and other people having to quickly pick up your hours. It was at a time when we were on a Covid call system, so we were already working on additional call rosters.” Because she was asymptomatic, she did not have to trawl back through her contacts, but she did think about whether she may have infected patients and hospital staff. That phone call also prompted some big decisions for her family. After a discussion with her husband they decided they would self-isolate with their two young children as a group. “If I’d tried to separate myself at home or moved out, it would have caused major upset to the children. My threeyear-old still climbs into my bed every night,” says Dr Pearce. “It was stressful coming to that decision and thinking, am I putting my family at risk?” During the stand-down period she received a phone call every day asking how she was. Dr Pearce gets hay fever and was suddenly paranoid about every sneeze.

Dr Greta Pearce

WWW.ASMS.ORG.NZ | THE SPECIALIST

Stuff Limited

HEALTH BUDGET 2020: THE GOOD, THE BAD, AND THE ‘BUTS’ LYNDON KEENE | HEALTH POLICY ANALYST

The good news: Vote Health’s operating budget for 2020/21 is an 8% increase on last year’s Budget Day figures – well above forecast population growth and inflation and excluding the one-off pre-Budget funding for the Covid-19 response. The bad news: Funding for hospital buildings and other capital needs are well off track to meet the DHBs’ needs, estimated in 2018 to require $14 billion over 10 years. The ‘buts’: This year’s Budget, significant though it is, follows years of funding shortfalls and amounts to a good start to catching up. If the real funding hike is unprecedented, so too are the service challenges ahead. THE OPERATING BUDGET While Covid-19 has brought a lot of uncertainty into this year’s forecast population growth (1.8% pre-Covid) and inflation rate (0.8%), and the 10 THE SPECIALIST | JUNE 2020

Supplementary Estimates are likely to be used more than usual to adjust funding as the year progresses, there is little doubt that the scale of the increase in Vote Health is of record levels, even when putting aside one-off spending related to the pandemic. Table 1 compares the main 2019 and 2020 Budget Day allocations. As noted above, the increases must be put into the context of many years of under-investment in the health system and its workforce. Last year’s Council of Trade Unions–ASMS Health Budget analysis conservatively estimated this year’s Budget would need over $2.5 billion extra for 2020/21 to restore the value of funding to 2009/10 levels, which even then were not ideal. This accumulated funding shortfall has contributed to a pre-Covid estimate of more than 440,000 people who are not able to access timely hospital treatment. Even this year’s 9.3% increase in DHB

funding is unlikely to make real inroads into that unmet need while DHBs attempt to address the substantial backlog of cancelled treatments along with all the new acute and ‘elective’ cases coming in during the year. It should also be noted that part of the DHBs’ new budget is to cover pay equity costs. In other examples, the 27% increase for National Disability Support Services starts to evaporate when funding for pay equity, the ‘in-between travel’ settlement for community support workers, and minimum wage increases are considered. The New Zealand Disability Support Network, while welcoming the funding increase, estimates a further $350 million is needed across Vote Health and Vote Social Development to maintain current service levels and meet unmet need. Continuing the incremental funding increases for mental health and addiction

HEALTH VOTE 2020 – MAIN OPERATIONAL ITEMS Service Areas

2019/20 $m

2020/21 $m

% increase

221

250

13.1

13,980

15,274

9.3

National Services

3,221

3,760

16.7

Disability Support Services

1,345

1,707

26.9

Public Health Services

440

469

6.6

Planned Care (formerly ‘Electives’)

396

425

7.3

Primary Health Care Strategy

331

367

10.9

Maternity Services

189

205

8.5

Emergency Services

150

148

-1.3

Mental Health Services

141

208

47.5

Child Health Services

113

112

0.9

Personal Health Services

0.0

Other

6.1

Training & Development

212

219

3.3

Supporting Pay Equity

414

See notes

Monitoring/Protection

-18.8

Other

6.3

Provider Development & ‘Other’

4.7

TOTAL OPERATING BUDGET

18,157

19,618

Ministry of Health DHBs

Misc

NOTES: • 2019/20 figures are 2019 Budget Day figures. • National Services are those funded at a national level and managed by the Ministry. • The National Disability Support Services increase includes funding for pay equity, ‘in-between travel’ for home and community support workers, and funding for expected minimum wage increases. • National Mental Health Services includes a transfer of $15.3 million from Expanding Access & Choice of Primary MHA Support. • National Emergency Services refers to air and road ambulance services. • Pay equity funding was devolved to DHBs and National Disability Support Services in 2020/21.

(MHA) services following the MHA inquiry, National Mental Health Services received, on the face of it, a healthy looking $67 million boost for community-based services. Nearly $8 million of that was transferred from last year’s Budget however, which coincidentally was also the shortfall to pay for new and expanded MHA services estimated in the Council of Trade Unions– ASMS Budget 2019 analysis. That analysis too estimated a conservative $55 million cut in DHB ring-fenced services for MHA clients with the most severe needs. (The ring-fenced allocation for this year was not available at the time of publication. ASMS has requested it under the Official Information Act.) THE CAPITAL BUDGET In December 2017 Finance Minister Grant Robertson, in answer to a parliamentary question, revealed DHBs had signalled a required capital spend of $14 billion

over the following 10 years. Again, this is in large part an outcome of long-term under-investment in the system which led to DHBs, as Treasury put it, “sweating their assets and under-funding repairs and maintenance to help balance their books”. Tracking capital budgets is a messy business as they often involve multiyear allocations which are frequently underspent, overlap, and are adjusted in various ways over time. With that caveat, current and forecast capital funding for sector infrastructure does not appear to be tracking anywhere near the earlier estimated funding need. This year $583 million is budgeted for sector infrastructure costs for 2020/21, though some of that is unlikely to be spent this year as it includes funding for multi-year projects. The Covid-19 lockdown restrictions will of course have had an immediate impact

on construction work, but the forecast for the next few years is not encouraging. This year’s Budget includes a five-year ‘Health Capital Envelope 2020–2025’ totalling $3.115 billion, including the $583 million allocated for 2020/21 and the $755 million additional capital funding announced on Budget Day. Meeting a $14 billion need appears a long way off. WHAT NEEDS TO HAPPEN NEXT? At the time of writing, the release of the Health and Disability System Review’s final report was pending, but its ‘interim report’ had suggested: “If New Zealand is to develop a system that operates effectively with equitable outcomes throughout, it must first operate as a cohesive, integrated system that works in a collaborative, collective, and cooperative way. Behavioural and WWW.ASMS.ORG.NZ | THE SPECIALIST

attitudinal changes are needed. These changes need to be led from the centre and applied consistently throughout the system.” Reports of the pandemic abound with examples of this. When health professionals have an opportunity to lead, to make the best use of their knowledge and experience, to collaborate, and to form alliances, with support from managers and quality leadership from the centre, they can work wonders. There is a wealth of international evidence showing this. The pandemic has put it in the spotlight, and, critically, underlying it all has been a strong sense of mutual trust. Before the pandemic, the health system was already well over-stretched, as

described in the ASMS’ Hospitals on the Edge report. It made recommendations to the Government aiming to bring about the kind of working environment outlined above. Now, with even greater challenges ahead, it is more urgent than ever to get this going. As the Health and Disability System Review says, attitudinal changes are needed throughout the system. That must include the politicians and those who advise them. Transforming the health system will not happen through policies focused on three-yearly election cycles. It requires long-term timeframes, unified values among policymakers, and constancy of policy approaches for both operational and capital planning.

This requires a mind shift away from an adversarial style of politics to one that is more collaborative and constructive, which has been more evident during the pandemic because that is what the public has wanted to see. But as one commentator said, “Some politicians have proved more able to do that than others” – which may be something for voters to consider in September. A vital part of a more constructive, long-term approach to policymaking concerns future funding. This year’s Budget is a job well started after many years of under-investment. The job now is to continue on a track to build service capacity, in real per capita terms, to help secure not only a strong health system but also a stronger economy.

NEW FACE AT THE CTU DR CHARLOTTE CHAMBERS | ASMS HEAD OF POLICY & RESEARCH

ndrea Black has recently taken over from Bill Rosenburg as Policy Director and Economist at the Council of Trade Unions (CTU). Originally a tax and policy specialist working at Inland Revenue and Treasury, Andrea has also worked on criminal justice reform as Policy Coordinator for JustSpeak (JS) and with Yoga Education in Prisons. Andrea took time out of her busy schedule to share some thoughts on Budget 2020 and priorities in a post-Covid future.

What were you hoping to see in this year’s Budget, and how did it measure up? I was hoping to see measures that looked to address the past and current challenges – low wage etc – but at the same time looking to mitigate unemployment and have our public services recover. There was a lot to like in the Budget – increased health spending, conservation work, trades training, increased funding for domestic violence and Ko- hanga Reo. I would have liked to see a greater emphasis on the ‘Future of Work’, which Bill Rosenberg is leading for the CTU. That is all about moving to a high-wage path for the country and giving much better support to working people to help them through the changes along the way. I would also have liked to see more emphasis on housing, particularly affordable rentals. There is a large cohort earning too much for a social house but paying large amounts of disposable income in rent. I was also disappointed that at a time of rising unemployment there is no

12 THE SPECIALIST | JUNE 2020

further increase in benefits, no move to individualise them and that the in-work tax credit is still lost if people lose paid work. What do you think are the main issues facing New Zealand in a post-Covid environment? Unfortunately, they are exactly the issues we were facing pre-Covid but are now more urgent. New Zealand is a low-wage, low-productivity, high-rent, high-carbon economy, with decayed public services but now has rising unemployment as well. The risk is that – like post-GFC – we return to a less good version of the economy and society we had when we went into lockdown. Also, recessions don’t hit everyone evenly. Those at the bottom tend to get hit much worse than those at the top. For example, even though we are about to get 9.8% unemployment – which will probably be about 20% underutilisation when you include those who want more work and those that are discouraged – the stock market, while it has fallen, is currently at much the same levels as November last year.

What are your future work priorities? Looking at our immigration settings in a world where the borders are closed. I believe immigration in the past has been used as an alternative to training and investment in the people already in New Zealand and/or investing in capital. This is starker with rising unemployment. Looking at ways the Government can fund the recovery. There is an automatic assumption this will need to be paid for with future taxation. While this will play a part, there are tools the Government can use, as the Bank of England is currently, where it is paid for by the Reserve Bank creating money. It’s also known as Modern Monetary Theory and I really want to understand it properly. I also want to explore why, when the gender pay gap is falling generally, it is rising in the public sector.

Andrea Black

A KIWI IN LONDON: INSIDE BRITAIN’S COVID CRISIS DR WILLIAM RUSH

e all saw the horrifying pictures of overwhelmed hospitals and health care workers in the UK as Covid-19 swept through. Dr William Rush is a Kiwi doctor in London. He shares his experiences and observations of working in a busy hospital during the crisis.

Two and a half years ago, we moved to London with our three young children. I left my job as an emergency consultant in south Auckland, exchanging it for a post at a busy major trauma centre in East London. Far, innit? I was told the NHS was a juggernaut, that it was unsinkable, perhaps because it was already sitting on the bottom? A complex system of bespoke solutions compounded by the British dependence on bureaucracy, queuing, and the fax-machine. As we all know, Covid-19 arrived, ignoring Brexit, and crossing into the UK rapidly, easily, as if it were just another part of Europe. Undoubtedly, the virus had a clear intent to Remain. Like everywhere else in the world, we dropped everything to ready ourselves for the hordes of patients dying from Covid-19. Within a week the National Health Service had become the National Coronavirus Service. House officers and registrars did not rotate as planned; most were redeployed. Some juniors, bless them, actively volunteered to switch into ED. Extra consultant shifts were created, non-clinical time was halved, daily Zoom meetings were instigated. The preferred debriefing venue – the local pub – shut its doors. There were one or two ‘horror nights’ back in March where the ED was almost overrun, but the nurses, doctors, and other health care workers stepped up and weathered the storm just as they would have in any New Zealand ED. I thought of heading back home to New Zealand, deserting my adoptive, dysfunctional country of residence. But my Stockholm syndrome took over, I signed up for extra shifts, dialled into the next Zoom meeting, turned my camera and mic off, and bought better life insurance online at my wife’s insistence. For us, PPE was consistently available. My clinical lead was brilliant at sourcing kit for the department, though it pains me to think how much he spent at Amazon. Nevertheless, the near-complete lack of testing meant Captain Boris was sailing with all his usual bluster through a fog. Thanks to the UK being slow to lock down, a large proportion of the health workforce was subject to a de facto, dumb, shortlived ‘herd immunity’ experiment. I strongly

suspect that the early community spread was far greater than imagined. Many of us went off sick, to isolate, protect the NHS, and return to work after our 7–14 days were complete.

surgical masks, bore the brunt of the surge. The hospital emptied out behind us, and finally, we were not bed blocked. Now the threat of corridor patients carried real consequence and weight.

We will probably never know if that headache, runny nose, and bout of diarrhoea were from Covid-19 or not. I have three children who regularly supply me with new germs. There was not enough testing for frontline health care professionals when I fell ill.

Do I feel proud? No. I feel fortunate. The team that I am with is excellent. I would encourage them to move to New Zealand if it did not adversely affect my chances of re-employment.

The science was lacking, and the systems were new. We endeavoured to maintain business-as-usual standards of care. Just because this was ‘unprecedented’ did not mean we could redraw the line a little bit lower and deny people ventilation or a hospital bed. The government could artificially lower the PPE requirements, but redefining hypoxia just was not going to work for our patients. Every so often someone would say something like, ‘In times like this, we need to be pragmatic.’ I thought we should always be pragmatic, but the official line was to not alter thresholds of care until NHS England said we must.

“We were left gut wrenched and angry that our patient had died before we could ‘throw the kitchen sink at them’.”

Our own ICU capacity increased sixfold, and ventilation mega centres were opened but thankfully were never used. Despite our best efforts, some patients did not receive all the care we wanted to provide. System errors, which led to delays caused by newly derived bottlenecks, combined with a nastier and more aggressive disease than initially expected. We were left gut wrenched and angry that our patient had died before we could ‘throw the kitchen sink at them’.

The NHS is full of saints, working selflessly. Too many have died or been admitted to intensive care during the pandemic. The weekly clap (8pm Thursdays) is nice but will soon be forgotten as it fades into tokenism. Perhaps now the UK will value its health care professionals and bail them out like the bankers in 2008? Rounds of applause do not make up for over 10 years of fixed wages or compensate for the increased personal risk of intubation or death. There will be a national inquiry, closeddoor decisions uncovered and critiqued. Outrage will come and pass. The clapping and free food will stop, but I am confident the controlled chaos of emergency medicine, and the wider NHS, will carry on.

“Just because this was ‘unprecedented’ did not mean we could redraw the line a little bit lower and deny people ventilation or a hospital bed.”

I suspect that the London Ambulance Service, those knights in forest green, complete with flimsy plastic aprons and

Dr William Rush

WWW.ASMS.ORG.NZ | THE SPECIALIST

Shared office which doubles as an on-call sleep room at Waitemata- DHB

LOSING SLEEP: THE FIGHT FOR BETTER ON-CALL ACCOMMODATION ELIZABETH BROWN | SENIOR COMMUNCIATIONS ADVISOR

or SMOs who work overnight and weekend on-call, having somewhere comfortable to catch some decent shuteye is crucial, but unfortunately it is something many can only dream about.

The ASMS–DHB MECA states that employers should provide sufficient good quality overnight accommodation. “This accommodation should be secure, private, quiet and self-contained. It should be within reasonable walking distance of the workplace, having regard to any emergency and other duties the employee may be required to attend to overnight.” It also specifies that the accommodation should include at least: “a bedroom or bed-sitting room; private bathroom with toilet and shower facilities, access to basic kitchen facilities for cooking or heating food, a television set, a comfortable lounge chair and a workstation or desk with telephone, computer terminal and internet access”. Earlier this year members caused a stir at the Northland DHB JCC meeting, when they wheeled in a fold-up bed to highlight the inadequate SMO accommodation in the Obstetrics and Gynaecology (O&G) Department. The bed is available in a prefab used as a shared training room. 14 THE SPECIALIST | JUNE 2020

Dr Charlotte Farrant is one of six O&G consultants at Wha-nga-rei Hospital who do 1-2 calls per week and a 48-hour weekend shift every six weeks. She says some of her colleagues were bringing in squabs and a sleeping bag to put on the training room floor before they asked the DHB for a bed. “What appeared was this fold-up thing. It is quite narrow, very thin, and rickety when you’re on it. There are no sheets provided, so you have got to go find some sheets, make up the bed, and find a pillow. When you might only have an hour to catch up on a bit of sleep, that all takes time,” she says. The prefab is also designated office space, so technically no one is supposed to sleep in it. Dr Farrant adds that it is cold, and you must walk outside to get to it.

by the midwives’ station and is noisy and brightly lit. “We just need somewhere quiet and dark but close to the ward where when you’ve got the opportunity to have a sleep you can just get into a bed and sleep. I get there are bigger things in the world, but this is part of the contract, and it’s just a little bit sad that the provision isn’t there for us.”

“What appeared was this fold-up thing. It is quite narrow, very thin, and rickety when you’re on it.”

The hospital does have two houses which provide SMO accommodation for paediatrics, anaesthetics, ICU and ED, but they are too far away from the O&G ward to safely walk to in the middle of the night.

What she would like to see is a room within the building, not having to go outside, and somewhere which is just a short run back to the ward. A bed with sheets which are changed each day would be the icing on the cake.

Dr Farrant says she personally goes into a clinic room and sleeps on a couch, but it is

The Northland DHB had promised to do something about the situation by this

Accommodation at Lakes DHB

month’s JCC meeting. Dr Farrant has no doubt there is a will to address the problem, but that was before Covid came along, and now she says, “We’ll wait and see.” ADEQUATE WITH A SMALL ‘a’ At Rotorua Hospital, where there is overnight accommodation provision, the focus of complaint is around the standard of it. Lakes DHB ASMS Branch President and anaesthetist Dr Andrew Robinson describes them as a row of rooms on one side of an echoey, cold corridor with no ensuite or lounge facilities and desperately out of the way. “Very basic really,” he says. “I don’t use them much because they are such a long way away from intensive care, and if I’m worried about a patient in ICU, I just go and find a sheet, find a spare bed and bunk down in it. If I can, I prefer to go home.” His colleague and fellow anaesthetist Dr Murray Williams says the rooms are adequate with a small ‘a’.

“Most of us appreciate it is hard to find accommodation areas in an active busy hospital, and many consultants don’t want to make a fuss or be accused of elitism, so they just make do.”

When he does an overnight on-call shift, he prefers to stay at the nearby Ibis Hotel, which he pays for himself, but with the Covid emergency he was forced back in the rooms due to the hotel closure. “I’ve done a few night shifts and it’s reminded me that the rooms are less than

Fold out bed for O&G SMOs at Northland

salubrious. They are rudimentary, cold and noisy, and the toilet is a bit of trek down to the end of the corridor.” If I were a house surgeon, I probably wouldn’t mind, but I’m getting towards the end of my working years and I’m getting a little fussy.”

“I’ve done a few night shifts and it’s reminded me that the rooms are less than salubrious. They are rudimentary, cold and noisy, and the toilet is a bit of trek down to the end of the corridor.”

Lakes DHB Human Resources carried out an investigation and found the accommodation to be adequate. However, ASMS Executive Director Sarah Dalton, who had a tour of the rooms in March, says they are far from MECA compliant. It was raised at the JCC meeting, and the DHB has promised to take another look. AN ESTIMATED $1 MILLION ON MOTEL ROOMS SMOs at North Shore Hospital in Auckland have been wrangling with the Waitemata- DHB over workplace accommodation for years, with meeting notes dating back to 2008. ASMS Branch President and intensivist Dr Jonathan Casement says the DHB has now set up a working group with a budget set aside for planning. “It’s a major gain for us as we’d never had any scoping money assigned to project plans. It’s been a really frustrating past ten years, but I think with persistence we’ve now created some momentum. Covid-19,

Dr Andrew Robinson and the cold, echoey, faraway accommodation at Lakes DHB

has slowed things down a bit but we hope to continue plans in the near future.” Where he works in ICU, he shares an office with another consultant, and it has a bed in it. He describes it as a shared officecum-sleep room which is pretty basic but at least close to the ward. Ideally, he would like to see a room with a bed, a table, a chair and an ensuite bathroom, like a bedsit unit. Arrangements for SMOs in other departments vary, but Dr Casement points out none meet the MECA standard. He says the situation is worse at Waitakere Hospital which is also managed by the Waitemata- DHB with anaesthetists known to sleep on an old sofa in the admin office.

“I get there are bigger things in the world, but this is part of the contract, and it’s just a little bit sad that the provision isn’t there for us.”

The lack of accommodation means the DHB does allow and pay for nearby motel rooms to be hired out by on call and emergency staff. “We haven’t seen the receipts and we’ve done a bit of maths on the back of an envelope, but we reckon they (the DHB) has paid over $1 million in motel rooms over the past ten years,” says Dr Casement. “Most of us appreciate it is hard to find accommodation areas in an active acute hospital and many consultants don’t want to make a fuss, so they just make do, but providing good SMO accommodation is one part of the MECA which DHBs have not taken seriously enough.” he adds. WWW.ASMS.ORG.NZ | THE SPECIALIST

DOCTORS IN THE HOUSE ELIZABETH BROWN | SENIOR COMMUNCIATIONS ADVISOR

here are just two MPs in the New Zealand Parliament who are medical doctors – one in the red corner and one in the blue. They both sit on Parliament’s Health Select Committee and both were on the Epidemic Response Committee, formed to assess the impact of the Covid-19 crisis. What leads a doctor into the bear pit of politics, and what contribution do they feel they can make?

DR LIZ CRAIG Dr Liz Craig is a first-term Labour list MP from Invercargill – a job she likens to a first-year house surgeon. She entered Parliament after a career as a public health physician. Her interest in public health developed when, following two years as a house surgeon at Taranaki Base Hospital, she headed to Australia, first working in Canberra, where she earned a Diploma in Paediatrics, before spending four years training Aboriginal and Torres Strait Island health workers in Queensland. Returning to New Zealand she entered the public health training scheme, completed a PhD in epidemiology and went on to establish the New Zealand Child and Youth Epidemiology Service, monitoring and collating data on the health of the country’s children and young people. The move to politics seemed like a logical step. “I’d seen during the course of my work that we had high rates of children coming into hospital for poverty-related conditions. Tracking back, I could see child poverty rates surged in the early 90s, with the Mother of All Budgets, benefit cuts, market rates for state houses and the Employment Contracts Act. “Children are looked after well in hospital but then they go home to damp, cold houses and I thought about how to make a bigger impact on that, so I joined the Labour Party in 2010 with a view to helping them write children’s policy. “From there I got more involved in thinking through the broader social policies we might need and became a

16 THE SPECIALIST | JUNE 2020

candidate in 2014 and then got into Parliament at the last election,” she says. As a new MP her life is now split between Invercargill and Wellington. The hours are long, especially when Parliament is sitting and it is a travel day. “There is no training manual, so you’re very much working from your own experience but liaising with senior colleagues. It just feels very like those first few years in medicine where the learning curve is steep, the hours are long, yet it’s really rewarding.” A lot of Dr Craig’s time is taken up with select committee work. She sits on the Environment Committee, where she takes a keen interest in zero carbon initiatives and climate change. As a member of the Health Committee she likes the overview she gets of district health boards and the Ministry of Health, and her background helps her understand some of the complexities and policy interface.

“It just feels very like those first few years in medicine where the learning curve is steep, the hours are long, yet it’s really rewarding.”

She appreciated the opportunity to be part of the Epidemic Response Committee on the Covid crisis, hearing from the range of health professionals and groups which appeared before it. For the long-time public health advocate, it was heartening to see the value of epidemiological modelling and public health advice recognised and

incorporated in political decision making, not to mention the additional investment in the country’s public health units. Dr Craig does not deny that parts of the health system are struggling but argues the Government has inherited a decade of underinvestment and realistically has only had two budgets to address it, with the first two focusing on primary care access, mental health, where there has been huge unmet need, and infrastructure development. “This year the Government has moved to significantly expand our public health capacity in response to Covid-19, with this month’s budget also investing a record amount in DHBs to relieve basic cost pressures and help them catch up on the backlog created by Covid-19. “But it’s not just about what’s in this year’s budget, you have to take a longer, strategic approach. You have to look over three, seven, ten years in terms of what is the broader investment strategy and asset management plan.” Workforce training and retention also requires “some strategic thinking,” she adds. What really spins Dr Craig’s MP wheels is that on any given day she can be looking at water issues, employment issues, community development, housing, employment, or health. For now, politics is very much in her future. She has been selected again to stand as Labour’s candidate for the Invercargill electorate. “It would be good to be able to continue. In the first term you focus on the basics of being an MP, and the next step is being available where you are needed. Given my background, the health sector is definitely where I’d like to make a bigger political contribution.”

Dr Liz Craig

DR SHANE RETI Dr Shane Reti is in his second term as the National MP for Wha-nga-rei. He is a GP and dermatologist and served three terms on the Northland District Health Board. He worked at Harvard University in the US, where he specialised in informatics, helping foreign governments fix their broken health systems. It is his firm view that doctors and politics are inextricably linked. “If politics is the ability to persuade towards a point of view, that’s what doctors do day in and day out with our patients. Medicine always has a political interface because we are the advocate for our patients, especially around funding and servicing.” “I don’t think you can be a doctor without having political engagement,” he says. On a personal level, his time on the Northland DHB, along with his work with overseas governments during his time at Harvard, consolidated a long-held interest in politics. When five-term Wha-nga-rei MP Phil Heatley announced his retirement in 2014, Dr Reti was enticed home and successfully campaigned to retain the seat for National.

responsible for an electorate of 85,000, so I can reach and help more people.” Dr Reti keeps up his medical registration, and during parliamentary recesses and the summer break he dons his stethoscope and sees patients. He also keeps in close contact with medical colleagues by running a Maintenance of Professional Standards (MOPS) group once a month.

”Medicine always has a political interface because we are the advocate for our patients, especially around funding and servicing.”

He believes “staying on the tools” adds value to his role as an MP and as the Deputy Chair of the Health Select Committee. “I bring technical expertise and I bring the coalface to Wellington. Officials will tell me about some great policy and great programme in one ear, and then I go and find the truth to that by speaking to patients and my doctor colleagues. I find out exactly what is and isn’t working.

He says he often hears from voters that New Zealand needs more doctors than politicians. He has a ready response.

“That’s not to diminish the advice and hard work that officials do, but there’s a difference between the blackboard and the patient bedside.”

“In general practice I can service maybe 1500 to 2000 patients, but in this role I’m

Dr Reti says health systems everywhere are a challenge. He says there will always be

Dr Shane Reti

unmet need, which New Zealanders need to accept. The solution he believes is to make the most of the resources we have and improve the system through better measurement and public service targets. Fundamentally, he believes New Zealand boxes above its weight in terms of what we do with the resources available and in relation to the percentage of GDP spent. He adds however, there is room to do better and sitting on the Epidemic Response Committee to Covid-19 has brought some of that into sharp focus. “Coronavirus has pushed and stretched our system and made more evident some of the holes we have, especially in public health. What I’m hoping we may get out of Covid-19 is greater resourcing and funding of public health and maybe even more people interested in it as a career specialty.” He believes the beauty of the Epidemic Response Committee was that it allowed professionals to tell their stories and highlight the issues. Dr Reti has no plans to quit politics at this stage. He is currently National’s associate spokesperson on health and would be up for a larger role, though he is quick to add “that would be up to the leadership.” As to whether he’s a future health minister in the making, again he reiterates that would be the decision of the National Party leader, but says, “I keep my head down and work hard and my observation over several careers is that good things happen.” WWW.ASMS.ORG.NZ | THE SPECIALIST

Angela Belich

Virtual farewell party

A MAY DAY FAREWELL SARAH DALTON | ASMS EXECUTIVE DIRECTOR

ay Day marked ASMS Deputy Director Angela Belich’s last day in the paid workforce. It was strangely fitting that these two events coincided.

Angela has spent her working life in the pursuit of better pay and conditions for working people. In particular, she has been a fierce and persistent leader in the pursuit of equal pay and fair and equitable entitlements for working women. She is a proud and staunch feminist, not to mention a passionate and utterly reliable friend, colleague, and comrade. And she is always kind. If you dip into New Zealand’s electronic archives you will find glimpses of her student activism in the 1970s and reference to her contribution to New Zealand’s left-wing political struggles, including a visit to China in 1974. She has been a strong and effective voice on various gender pay and pay equity inquiries and taskforces and has fought for the betterment of New Zealand’s public service. Angela’s working knowledge of the state sector legislation in all its myriad forms is such that she is the acknowledged expert in this field, and who knows what poor souls (because it will surely be more than one person needed) will have to try and fill this gap. As noted at her virtual Zoom farewell on May Day (actual party pending), when 18 THE SPECIALIST | JUNE 2020

encountering someone from the public service, it is not uncommon for Angela to remark that she knows that person, whether they were a PSA delegate, a public service manager, or someone she’d advised or advocated for at some point in the past. Angela’s networks are broad and strong, and her institutional knowledge will be truly missed. We know that the whole point of union endeavour is to ensure that whole systems support people, and that we do not need to rely on one person. Together we are stronger, but people like Angela also remind us that our union movement is enriched, strengthened and nourished by individuals of her calibre. And we celebrate that. She also leaves numerous collective agreements that bear the hallmarks of her shrewd advocacy and intelligent approach to negotiation. Most recently our members at Family Planning, and those in a range of rural hospital and urban primary health care settings, have reason to be grateful for her tenacity in securing improvements to their conditions of work. It would not be proper to mark Angela’s retirement without commenting on her love and care for her wha-nau, be they immediate, extended, or adopted. Angela always makes time to ensure the people

around her are nurtured and cared for. As her daughters noted at her farewell, Angela has always role-modelled what it is to be a working parent and has inspired them to grow up as feminists and activists in their own right. Angela’s decades of commitment to the working people of Aotearoa cannot be encompassed in a short farewell. Her service to the PSA and ASMS has been significant both in quantity and quality, and her leadership and mentorship of many union activists, organisers, delegates, and members means that her legacy is much more than the work of a single person. Her contribution is marked by a network of women and men engaged and enriched through her intellect, leadership, and support. We were proud to achieve further gains for women in our recent MECA negotiations, along with an assurance from the DHBs that they will address the gender pay gap across the SMO/SDO workforce. These initiatives will continue, and as we continue to tackle equity issues across the health sector we will do so strengthened and encouraged by the legacy of Angela’s commitment to the labour movement.

COLLEAGUES PAY TRIBUTE TO ANGELA “I thank Angela for her mahi, for being a great comrade in arms and for being a generous person and colleague. Angela played a significant role in the development and roll-out of the Health Professionals Competency Assurance Bill (now Act) in the early 2000s, bringing together health professional and health trade union groups. She worked relentlessly, effectively and determinedly to make sure that the legislation was based on respect and recognition of health professionals and their needs and concerns. Angela – you are appreciated, you are hugely valued, and you will be much missed.” – EILEEN

I PAY TRIBUTE TO ANGELA BELICH AND THE COMMITMENT OF OVER 40 YEARS OF HER WORKING LIFE TO THE ADVANCEMENT OF WORKING PEOPLE AND THEIR UNIONS. SHE WAS AN ACTIVIST AND EMPLOYEE OF THE PSA AND WAS ONE OF THE KEY PEOPLE IN THE BUILDING OF ASMS INTO THE STRONG ORGANISATION IT IS TODAY. ANGELA IS A GOOD FRIEND, AND I WISH HER ALL THE BEST FOR HER RETIREMENT.” – JOHN RYALL, FORMER E TU

ASSISTANT NATIONAL SECRETARY

“Angela and I first met at CTU meetings and I was in awe of her obvious intellect and the high esteem that people held her in. It was not until starting work with ASMS that I realised that alongside that intellect and Angela being a deeply committed union activist, she was also one of the kindest and most generous people I have ever met and would become the best boss I have ever had. Her vision and strategic thinking has been invaluable, but it is the kind colleague that we are going to miss the most.” – LLOYD WOODS, ASMS SENIOR INDUSTRIAL OFFICER

BROWN, CTU SENIOR POLICY ANALYST

CALLING TIME ON AN ACCOMPLISHED CAREER DR CHARLOTTE CHAMBERS | ASMS HEAD OF POLICY & RESEARCH

SMS’ former head of policy and research Lyndon Keene has formally retired from his role at the union. He is well known to members for his insight and deep understanding of the health sector, along with his sharp analyses of health policy and politics.

When Lyndon arrived in New Zealand in the mid-1970s from Britain, little could he imagine the contribution he would make to the country’s public health system. Despite a stint at art college in the UK, Lyndon went on to forge a career in journalism in New Zealand, working for The Listener before freelancing. It was at the New Zealand Nurses Organisation (NZNO) where Lyndon first delved into the health union sector, first editing Kai Tiaki Nursing New Zealand and then taking on the role as public relations officer.

(then Minister of Labour). After his time in Parliament, Lyndon once again undertook contracts for ASMS before joining its staff as a part-time researcher in 2012.

Lyndon left NZNO to act as coordinator of the New Zealand Coalition for Public Health through most of the 1990s. During this time, he also began work for ASMS on a contract basis, as well as campaigning alongside former CTU president Ross Wilson against the privatisation of ACC.

“Through Lyndon we came to understand exactly what we needed to say. Lyndon was the primary writer and developer of a huge series of press releases. There was always more data and detail in his releases to back up our arguments.”

From 2000, Lyndon moved to the corridors of power at the Beehive, working for eight years as a ministerial advisor and occasional press secretary in the Clark Government. He continued with stints as a press secretary for Annette King (then Minister of Health) and Margaret Wilson

Dr Peter Roberts, a former ASMS president, has had a long association with Lyndon that began in 1991 with the Coalition for Public Health as it battled privatisation of the health sector. He says the Coalition became a real force thanks to Lyndon’s tenacity and journalistic know-how.

As a successful painter and printmaker, Lyndon is planning to use his retirement to pursue his passion for art. He also plans to keep hitting the waves south of Sydney where he has been based for the past few years. The good news for ASMS members is that Lyndon will continue to do some contract work and articles for The Specialist. You can read his latest contribution – an analysis of the Budget on page 10.

He describes Lyndon as one of the most insightful and logical thinkers he has ever known. ASMS wants to acknowledge the contribution Lyndon has made to the shape of New Zealand’s health system, along with his personal commitment to fairness, and the values of unionism and equity.

Lyndon Keene

WWW.ASMS.ORG.NZ | THE SPECIALIST

TALKING TELEHEALTH POST-COVID DR JULIAN VYAS | ASMS NATIONAL EXECUTIVE MEMBER

he Covid-19 pandemic has meant a rapid increase in the use of IT to support distance consultation through telehealth. ASMS National Executive member and Auckland paediatrician Dr Julian Vyas has been thinking about the implications for members.

The current coronavirus pandemic has highlighted that ongoing distant contact with patients is inevitable and can generally be thought of as a desirable adjunct to health care services. Where geographical or financial constraints disadvantage some patients, telehealth can help address areas of inequity of patient access. However, the disparate nature of clinical work and patient complexity means that each service must assess how telehealth might be implemented for patient groups within its case mix. We would encourage members who are considering expanding their clinical support for patients through telehealth to take a circumspect approach to the numerous implications and ramifications for their usual practise before committing to this. Where necessary, clarification from the employing DHB should be obtained beforehand, on issues such as liability, equipment purchase and maintenance, along with funding and workforce consequences of telehealth contact. If you are contemplating initiating or increasing the use of telehealth in your clinical work, it pays to get acquainted 20 THE SPECIALIST | JUNE 2020

with the recently updated Medical Council statement, as well as respective College guidance and your DHB’s policy guidelines. In addition, the New Zealand Telehealth Project website (www.telehealth.org.nz) links to many relevant documents and guidelines for clinical practise as well as technical requirements. Looking at other peer-reviewed literature on telehealth relating to your specific area of practise would also be useful. There are several platforms via downloadable apps and online that can host video or audio meetings. At present Zoom seems to be the platform of choice in New Zealand and globally. Members who wish to use other platforms (e.g. doxy. me) are advised to clarify if their DHB will support the use of alternative video conferencing platforms rather than just using them. ASMS is reviewing the industrial aspects of telehealth. These have not yet had much consideration from health unions, either within New Zealand, or internationally. The ASMS MECA has no specific reference to

telehealth, although many of the clauses relating to workplace equipment provision will encompass it. Whether there is a need for a specific clause will be discussed by ASMS’ leadership in the future. Nonetheless, aspects of care provision and ultimate consequences of virtual clinics may need to be agreed upon by services and their DHBs, before embarking on a long-term change in service provision. The MECA is very clear that DHB’s cannot introduce or increase service delivery via telehealth without adequate consultation and engagement, and ultimately agreement, with clinical staff. Telehealth is not a panacea for problems of ensuring patient contact with clinical services. Ultimately, use of telehealth must be the patient or carers’ choice, and not be insisted upon by the clinician, or DHB. Look out for further ASMS research and advice on the issue and if have any concerns around telehealth get in touch with your ASMS industrial officer. A fuller discussion document on telehealth by Dr Vyas is on the ASMS website.

Dr Genevieve Ostring

A wintry walk to work in Vancouver

MY SABBATICAL DR GENEVIEVE OSTRING

arly this year Auckland paediatrician and paediatric rheumatologist Dr Genevieve Ostring spent time in Vancouver, Canada, as part of her sabbatical. She took some time to share her experience.

I am probably one of the few people who managed to take (part) of my sabbatical in early 2020. I work in a small national team of four paediatric rheumatologists, and in a larger team of general paediatricians. For the first half of my sabbatical I chose to spend time with the paediatric rheumatology team at the British Columbia Children’s Hospital (BCCH) in Vancouver, Canada. I chose BCCH for many reasons, but a key one was that Professor Ross Petty, who is widely considered the grandfather of paediatric rheumatology, still spends 1–2 days a week in the hospital with the team, despite being officially ‘retired’. I had met Ross several times over the years and was impressed with his extensive clinical expertise, combined with a very kindly, gentle, humble personality.

What I had not realised was how similar British Columbia’s medical system is to our own here in Aotearoa New Zealand, at least in terms of paediatrics. Similarities include population (5 million in New Zealand, 5.1 million in British Columbia), a predominately public health system (no private paediatric rheumatologists in either), and a small team covering a large geographical area. Our consideration of the inequalities in health care outcomes for Ma-ori and Pacific Islanders in New Zealand is echoed by their emphasis on ensuring equity for the indigenous First Nations population. So there were many issues, other than specific management of clinical conditions, which I found directly applicable to my role and teams back in New Zealand.

“Our consideration of the inequalities in health care outcomes for Ma-ori and Pacific Islanders in New Zealand is echoed by their emphasis on ensuring equity for the indigenous First Nations population.”

The BCCH team culture was enlightening. There were diverse ideas, nationalities and backgrounds, but despite the difference, it was a highly functional team and a very positive environment to work in. Due to shortages of space in the hospital (another similarity to my workplace in WWW.ASMS.ORG.NZ | THE SPECIALIST

New Zealand), I ended up sharing an office with the fellows (juniors in training) and was able to explore quietly some of the team dynamics. They verified my impression that it was a positive place to both work and learn. I believe the concept of ‘psychological safety’ was what made things work so well. It was fascinating to watch fairly vigorous discussions regarding patient investigations and management between the more ‘grey-haired’ members of the consultant team, who tended to rely on clinical experience, versus the more recently trained consultants, who relied more on the latest ‘consensus protocol’. Many of the diseases we treat in paediatric rheumatology are rare, and therefore randomised trials of management are not available. However, I believe these vigorous but respectful discussions resulted in better patient outcomes, as well as development of a very healthy team culture. I found Canadians to be friendly, practical and inclusive and instantly felt at home while exploring beautiful Vancouver and its surrounds. We were there for a record-breaking snowstorm, which brought the most snow since records began in 1899 and the coldest weather in over 50 years! As a visitor I was thrilled, but the huge dump certainly caused havoc for 22 THE SPECIALIST | JUNE 2020

Vancouverites. The news videos poking fun at themselves for their lack of ability to cope with ‘real snow’ (something the rest of Canada does on an annual basis) were hilarious. I had the appropriate gear as we did some skiing while in Canada, however, getting to and from work involved more than an hour’s walk each way (in my ski gear) as no public transport was running. Those that did try and catch buses to work found themselves in lines of up to 15 buses which had all become stuck in snow! These walks provided me with some spectacular photo opportunities.

“These vigorous but respectful discussions resulted in better patient outcomes, as well as development of a very healthy team culture.”

The biggest difference between the paediatric rheumatology team in BCCH and here in Starship is resourcing. Although access to drugs and treatments were similar, the resource of ‘time’ was far in excess in BCCH. They literally had 10

times as much FTE for medical staff and 5 times as much FTE for nursing staff and physiotherapy staffing, as well as access to other staff such as a psychologist. This all could have been depressing, but I came back to New Zealand with a sense of pride in our team here in terms of what we achieve for our patients despite the very small current FTE available.

“There were diverse ideas, nationalities and backgrounds, but despite the difference, it was a highly functional team and a very positive environment to work in.”

The sabbatical time has given me increased knowledge and expertise in regard to paediatric rheumatology conditions, an opportunity to create links with a wonderful team overseas, renewed admiration for my colleagues and the work they do back home, and an ongoing love affair with the spectacular natural beauty that snow creates. I would recommend a sabbatical to anyone.

THE MENTAL HEALTH CRISIS INSIDE OUR PRISONS DR CHARLOTTE CHAMBERS | ASMS HEAD OF POLICY & RESEARCH

hortly before Covid-19 dominated world headlines, Dr Erik Monasterio and other clinical directors from New Zealand’s forensic services co-wrote a powerful editorial for the New Zealand Medical Journal. Entitled ‘Mentally ill people in our prisons are suffering human rights violations’, it followed on from other articles he and his colleagues have written, highlighting the grim plight of forensic psychiatry patients in our country’s prisons. Forensic psychiatrists deal with the pointy end of the mental health spectrum. Many patients with the most acute mental health needs are in custody. Unfortunately, services available to treat prisoners with serious mental health issues have not benefitted from the increase in funding announced by the Government for mental health services in relation to the growing demand and growing prison population. As Dr Monasterio and his colleagues detail, much of the prison population falls between the cracks of the system. Many require mental health treatment yet cannot access the services that would benefit their own health and wellbeing and bring down reoffending rates. It is a problem which Dr Monasterio says is not only pressing, but likely to get worse. He took the time to respond to a written interview during the Covid lockdown and is interested in the views of ASMS members on the subject. Why have you and the other clinical directors of the New Zealand Forensic Service written this editorial? What are the main arguments you are making? The editorial looks at the substantial disadvantage faced by persons detained

in custody who have serious mental illness. In particular, having limited access to treatment for serious mental illness, especially when they are too unwell to accept treatment by consent. As highlighted in the editorial, those on urgent waiting lists can spend extended periods of time in Intervention and Support Units (ISUs) in conditions of solitary confinement without receiving treatment and while continuing to experience considerable disability and distress. The conditions of ISUs breach national and international standards for minimal care of prisoners and is in breach of human rights, Te Tiriti o Waitangi, the Mandela Rules for prisoners, the Bill of Rights and the United Nations Convention on the Rights of Persons with Disabilities, along with other international agreements to which New Zealand is a signatory. Why does this matter? There has been rapid growth in the New Zealand prison population over the past decade which is not explained by changing patterns of recorded crime, particularly violent crime. The incarceration rate in New Zealand is very high (per capita 30% higher than Australia, with a rate of 220/100,000 cf. 167/100,000) and the prevalence of mental illness continues to increase in prisons. It is not rare for persons with serious mental illness, social disadvantage and low-risk offending to be detained in custody, as there is insufficient general adult mental health service support and services. Those persons can then end up in the ISU in unacceptable conditions (for example, persons with serious untreated schizophrenia remanded to custody with minor charges such as breach of court conditions, shoplifting or theft). This affects some of the most vulnerable and disabled persons in our community, particularly Ma-ori.

Dr Erik Monasterio

Given the high prevalence of Ma-ori in prison, this is also a breach of Te Tiriti o Waitangi.

Lack of adequate resources to provide care to persons with mental illness in custody also increases the risk of reoffending and is inconsistent with the Government’s priority to decrease the prison population number and to target improved treatment for mental illness. What do you want the Government to do? We believe that this needs to be considered a health crisis, and in the short-term, focus on health solutions, while in the longer term, political approaches need to decrease systematic bias against Ma-ori, inequality, poverty, lack of affordable housing and stable employment. There is an urgent need for additional psychiatric hospital resources to manage those who have acute and severe mental illness, particularly those with high and complex mental health issues. An extension of culturally appropriate treatment interventions is crucial. Specialist mental health courts and diversion initiatives to avoid incarceration of the seriously mentally unwell, particularly when associated with low-risk offending, need to be considered. Extension of drug courts, which have been successfully piloted in New Zealand, and increased access to additional drug and alcohol treatment would relieve pressure on the prison system and provide early intervention. Prior to Covid-19 restrictions, work on a number of initiatives between Forensic Mental Health Services, the Ministry of Health, Corrections and Mental Health and Addiction Services for improved access and flexibility for the provision of mental health care in New Zealand prisons commenced. The aim of these initiatives was greater flexibility and interagency integration in the provision of services, including culturally appropriate interventions in custody. However, while these initiatives are likely to relieve pressure within New Zealand prisons, they will not adequately deal with the use of ISUs for those inmates with acute and serious mental illness requiring inpatient hospital care. WWW.ASMS.ORG.NZ | THE SPECIALIST

WILL THE DOCTOR-PATIENT RELATIONSHIP BE CHANGED FOREVER? DR PALLAVI BRADSHAW | MEDICOLEGAL LEAD, RISK PREVENTION AT MEDICAL PROTECTION SOCIETY (MPS) FOREWORD BY DR TIM COOKSON | MEDICOLEGAL CONSULTANT, MPS (NEW ZEALAND)

FOREWORD

he following is a transcript of a talk Dr Bradshaw gave at the recent UK ‘Risky Business’ virtual conference on lessons learned from Covid-19, and it is very instructive to see the pressures and medicolegal implications from the Covid-19 crisis in the UK compared with New Zealand. In New Zealand, the Medical Council significantly changed the wording of the statement on telehealth in a way that provides additional protection for doctors conducting remote consultations. The Health and Disability Commissioner also stated to the RNZCGP just prior to level 4 commencement that any complaints during this time would be assessed taking into consideration the changed circumstances. The extent of complaints relating to delays in treatment or issues relating to remote consultations is not yet known, but each will be considered according to the particular situation, and also taking into consideration the Medical Council statement on safe practice in an environment of resource limitation. Thankfully, due to the low numbers of Covid-19 cases in New Zealand, we are not likely to see many cases directly relating to care provided to infected individuals. The estimated 78 billion NHS liability for claims already existing prior to Covid-19 does put things into perspective compared with New Zealand.

24 THE SPECIALIST | JUNE 2020

Dr Pallavi Bradshaw

The relationship between the doctor and patient is crucial, and it is influenced by the practice of medicine, ethics and the law – all of which have been disrupted by Covid-19.

the utilitarian ideals advocated by some to act for the greater good, and is this compatible with our sense of empathy or indeed the criminal law?

Patients have been physically and emotionally separated from doctors by use of PPE, remote consulting and fear of accessing health care, leading to an imbalance between the art and the science of medicine.

Consent is fundamental to the trust and respect within the doctor–patient relationship and relies on there being a competent patient in receipt of sufficient information, free of coercion. I do question whether informed consent is always possible in the current climate when hearing of patients receiving letters regarding their DNR status and ED staff discussing options with elderly, vulnerable patients attending alone. I also wonder what unintentional influence society has had on those patients’ decisions in our unremitting focus to save the NHS.

Empathic and clear communication is seen by patients as a proxy indicator of competence and skill. In fact, poor communication is often the differentiating factor between those doctors who are sued and those who are not, even if clinical incident rates are equitable. Telemedicine relies heavily on communication, which is impaired by loss of verbal and non-verbal cues and our impatience. The need for full and open dialogue at this time is highlighted from claims experienced during SARS and MERS. In some cases, physicians were unduly influenced by the pervading context and incorrectly attributed patients’ symptoms to those diseases. These risks are heightened if examination is limited but can be mitigated to some degree by altering our consultation style – listening actively and checking back information and warmth of tone. Cost, convenience and risk means telemedicine will remain a fundamental tool but potentially to the detriment of the protective connection we have with patients. TURNING TO THE ETHICAL ASPECT OF THE RELATIONSHIP. We see the interests of our patient as paramount, and yet in the time of Covid-19 many have received less care due to constraints, or no care at all due to many patients opting to stay away from hospitals. We have struggled to agree on fundamental issues of resource allocation and withdrawal of treatment, though at this stage we have been mercifully saved from having to decide whether to withdraw ventilation from one Covid-19 patient to benefit another as worries about ventilator shortages have not materialised. Should we accept

HOW HAS OUR LEGAL RELATIONSHIP CHANGED? While we normally enjoy the right of self-determination, the Coronavirus Act 2020 saw the UK Government assuming responsibility for managing our risk. Most settled into this passive role without resistance, with many now unwilling to assess or assume the hazards posed and seeking direction from authority. Does this mean that we will not tolerate risks in health care either or expect guarantees and absolutes before accepting treatment? Or will patients look to us to make a judgement call and tell them what to do – a return to paternalism maybe? I wonder if the respect and empathy being shown by the public and press towards health care workers will translate to greater tolerance of medical error. Can we now accept that stretched staff and resources will not always deliver high quality care and that on occasion patients will be harmed? Even in a country which takes pride in its citizens’ constitutional rights and freedoms, the US Senate Majority Leader recently stated, “We are going to protect the healthcare workers who have been locked in combat with this mysterious new disease. We are not going to let healthcare heroes emerge from this crisis facing a tidal wave of medical malpractice lawsuits.”

Dr Tim Cookson

The New York State Governor has granted legal immunity to health care workers during the pandemic. In the UK, MPS has called for emergency laws to protect health care workers from criminal and regulatory investigation – a call supported by two thirds of the public, according to a YouGov survey of over 2,000 adults in Britain.1 If immunity from criminal and regulatory investigations is not offered, then we must look to judges to interpret the current law and reflect the attitudes of society. They must question whether it is fair that a psychiatry trainee asked to cover an acute ward in the pandemic be judged at the same level as a medical registrar, as per the Bolam test. Does Bolitho [Bolitho v. City and Hackney Health Authority] allow them to overlay the Covid-19 context to a logical interpretation of negligence? Should the legal test be what a ‘reasonable society’ expects rather than the ‘reasonable’ patient? Will the judiciary who have upheld patient rights for so long intervene to protect our health care system and its workers? There is also fear that a tsunami of claims may be approaching, particularly owing to delayed and missed non-Covid-19 diagnoses. With outstanding NHS liabilities estimated at £78 billion,2 this again raises the challenging question as to whether patients should be prevented from seeking compensation at this time. The crisis may have escalated the breakup with our patients but perhaps there is a new love affair between the profession and society. Covid-19 has brought disruption to the practice of medicine, our ethics and even the law – it is no surprise then that it has changed the doctor– patient relationship forever. REFERENCES 1 https://www.medicalprotection.org/uk/ articles/covid-19-public-support-for-doctorslegal-protection-overwhelming 2 https://resolution.nhs.uk/wp-content/ uploads/2019/08/NHS-Resolution-AnnualReport-2018-19.pdf WWW.ASMS.ORG.NZ | THE SPECIALIST

THINKING OF BECOMING A CLINICAL DIRECTOR? A

SMS has created a new document about the role of the clinical director. Many of you will hold this role at some stage of your career but may not receive specific training in what’s involved.

The document covers the ins and outs of what to expect from the role, the reasons you might choose to do it and some of the duties involved. There are also useful tips about decision making, information sharing and some of the relationships involved as clinical director. Our aim is to help you better understand and tackle this important role, and to support better outcomes for patients, improve staff cultures and increase your job satisfaction. Search ‘The role of the Clinical Director’ on our website to read the whole document and let us know what you think. We’re interested in your feedback and intend to update it on a regular basis.

WHAT MAKES A GOOD CLINICAL DIRECTOR? • Decision-making through consultative processes, based around providing best possible patient care and enabling staff to flourish • Accurately analyses service requirements to provide best possible patient care • Makes these requirements known to management to enable good decision-making • Considers cost-effectiveness of tests and treatment in decisions • Shares information freely and frequently with department staff • Encourages staff to develop

26 THE SPECIALIST | JUNE 2020

• Utilises skills and talents of staff and is not threatened by this

• Actively guards against gender bias, ethnicity bias and ageism

• Knows and understands staff contracts

• Supports staff requirement for nonclinical time to protect staff wellbeing

• Seeks department consensus for all important decisions • Questions themself and reassesses if their view is clearly at variance with most colleagues • Puts the department team before themselves • Recognises that all department members are equally important • Enables contribution, without interruption, from all team members in meetings

• Informs themself and staff of bullying behaviours so these can be actively discouraged • Gives regular positive feedback to staff • Ensures adequate time for the role • Accepts others’ points of view • Welcomes constructive feedback and advice

WWW.ASMS.ORG.NZ | THE SPECIALIST

WELCOMING NEW POLICY ANALYST A

SMS has welcomed Mary Harvey to its Policy and Research team.

Mary comes to ASMS from the Australian and New Zealand College of Anaesthetists (ANZCA) where she had been working as senior policy analyst.

Mary Harvey

Before that she had built an impressive career working across government. In particular, she worked at the Ministry of Health, and the Office of the Auditor-General where she managed a portfolio of central government agencies, advising Parliamentary select

committees on key issues. The Covid-19 emergency meant an unusual start to her new role at ASMS. Mary had only been in the office a day or two when the country went into lockdown and has had to rely on Zoom to get to know the team. “The team has made me feel very welcome. I’m looking forward to working with ASMS and shining a light on relevant issues in the health sector” Mary says.

remuneration schedule, particularly if you are reducing your hours/FTE or duties. Be aware that reductions in hours of work and job size may also affect other entitlements e.g. superannuation, on-call and availability arrangements, CME and existing and future leave entitlements. If you’re thinking of reducing your hours of work, we encourage you to contact your ASMS industrial officer for advice. CHANGES TO JOB DESCRIPTION – CLAUSE 48.1

ABOUT WORKPLACE CHANGES AND THE NEED FOR CONSULTATION AND AGREEMENT ASMS is aware that Covid-19 has meant changes to work practices around the country, and District Health Boards are beginning to consider what business as unusual might look like in the short to medium term. It is important to remember that the DHB Collective Agreement contains multiple provisions which protect members’ interests when change is being considered. CONSULTATION – CLAUSE 43 Where a DHB proposes a review that may result in significant changes for members, the DHB must consult both ASMS and 28 THE SPECIALIST | JUNE 2020

our members. The consultation clause requires DHBs to first consult and seek the endorsement of ASMS as to the purpose, extent, process and terms of reference of such review. Only after that first stage of consultations should DHBs begin to consult affected members. CHANGES TO WORK HOURS OR JOB SIZE – CLAUSE 13.1 Your hours of work and job size must be mutually agreed. This means that your employer may not make changes to your hours of work or job size without your express and prior agreement. ASMS advice is that any changes should be in writing, together with an amended

Your job description must also be mutually agreed. Again, this means if the DHB wants to introduce any changes they are obliged to seek and obtain your prior agreement. If your employer wishes to discuss changes to your job description, we strongly advise you to read MECA clause 48. This clause sets out what should be in a job description and observes that the Council of Medical Colleges of New Zealand endorses that non-clinical activities should make up at least 30% of the total job size, not counting average after hours on-call rosters. WORKPLACE FACILITIES & EQUIPMENT – CLAUSE 53.1 Finally, if your work or office space is being ’redesigned’ to meet Covid occupational health requirements, it is important to remember that you are entitled to facilities that are of good quality, safe, suitable for your needs and generally ’fit for purpose’. If you do not feel they are adequate, you should seek advice from your ASMS industrial officer.

FEEDBACK Dear Dr Fuller, Re: Your Article “Not Unwell Enough” We agree entirely with the views you expressed in the March 2020 edition of The Specialist. The Canterbury Charity Hospital Trust (CCHT) has treated thousands of patients with unmet secondary elective healthcare needs (USEHN) of the types you describe since 2007 (NZMJ 2010; 123:58-66. & 2013; 126:31-42). Such unmet needs are not life-threatening but are neverthe-less very serious correctable disabilities for the sufferers. It is inhumane and makes no economic sense to frequently defer or deny treatment. It has been clear to us at CCHT since 2014 that vital datasets not measured in New Zealand are the amount and nature of this USEHN. These data are measured by some countries in Europe, North America, Asia and Africa. They are commonly viewed as important for effective health service planning and as excellent overall indices of how well any national health service is functioning. In order to fill the gap in our New Zealand health service data, we got together a national group of experts. They defined a 23 question population questionnaire for the purpose. Then, with funding contributions from ASMS, Canterbury Medical Research Foundation and other benefactors, we conducted a pilot study in Auckland and Christchurch. These relatively small samples we used demonstrated that our questionnaire was externally valid and estimated the overall USEHN to be about 9% for the adult population (NZMJ 2017;130;23-38). We then applied twice to the New Zealand Health Research Committee for funding for a national survey. These applications were turned down on the erroneous grounds that the data were not important and were available from other sources! However, with support from the current Minister of Health, the Ministry of Health agreed to help with the acquisition of these vital data. Unfortunately, at the time of writing this letter, they have only agreed to include one of our survey questions in next year’s National Health Survey and perhaps six questions in the 2022 survey. Furthermore, next year they will only ask about USEHN in the previous year. This will produce a large underestimate of the prevalence of USEHN; our pilot showed only 39% of the total eventuated in the previous year. In conclusion Dr Fuller, we totally appreciate your concerns about the large group of patients with USEHN, whose plight is chronicled by no one and heralded by few of us. We contend that the first step to addressing this muffled issue is to measure its size and nature. Please help us to convince the Ministry of Health to work with our expert group to do the job properly. We’d be eternally grateful if you and all your like-minded colleagues would support us to do so. Yours sincerely,

Phil Bagshaw Chair, CCHT To read “Not Unwell Enough” see page 14 of the March 2020 Specialist

WWW.ASMS.ORG.NZ | THE SPECIALIST

NOTICEBOARD ASMS MEMBERS RECOGNISED IN QUEEN’S BIRTHDAY HONOURS

SIMPSON REVIEW The Health Minister David Clark has reportedly received Heather Simpson’s long-awaited Health and Disability System Review but as The Specialist was going to print, it had not been released. The review was completed by its 30 March deadline but has been delayed due to the government focus on the Covid-19 pandemic. ASMS is planning a comprehensive response and analysis once it is made public.

ON THE MOVE OR CHANGING HOURS – GET IN TOUC H! When you move DHBs or change your hours it is importa nt to let us know so your membership does n’t lapse and yo u are paying the right amount. Most members pa y by salary dedu ction, and when you m ove DHBs your de duction stops, indicating to us that you no longer wish to be a mem ber. If that is not the case, it is best to let us know so we can make sure it does n’t happen. It is also importa nt to tell us if yo ur contact details or hours have chan ged. It’s easy to get in touch, by emailin g membership@as ms.nz or calling 04 499 1271.

30 THE SPECIALIST | JUNE 2020

Dr George Ngaei, a Southland surgeon, has become a companion of the New Zealand Order of Merit (CNZM) for his services to health and the Pacific community. Professor Alec Ekeroma, an obstetrician and gynaecologist who worked at Middlemore Hospital, has been made an Officer of the New Zealand Order of Merit (ONZM) for his services to health and the Pacific community. Dr Garry Forgeson, a medical oncologist at Palmerston North Hospital, has been made an Officer of the New Zealand Order of Merit (ONZM) for his services to oncology. Dr Janet Catherine Turnbull, a Wellington consultant geriatrician, has become a Member of the New Zealand Order of Merit (MNZM) for her services to health.

TO READ LINE? PREFER ON CIALIST E THE SP edback to your fe d e n rs e st li e membe We have that som re s a w ie a p o c re and a e hard t to receiv prefer no zine. If you want to ail ga em of the ma e hard copy, just th f e can o w t d u n o opt ms.nz a s a @ next ip h th when e members via email online. w o n k u let yo read vailable to issue is a

ASMS STAFF Executive Director Sarah Dalton COMMUNICATIONS Senior Communications Advisor Elizabeth Brown Communications Advisor Lydia Schumacher INDUSTRIAL Senior Industrial Officer Steve Hurring

ASMS SERVICES TO MEMBERS As a professional association, we promote:

OTHER SERVICES

• the right of equal access for all New Zealanders to high quality health services

ASMS job vacancies online

• professional interests of salaried doctors and dentists • policies sought in legislation and government by salaried doctors and dentists. As a union of professionals, we: • provide advice to salaried doctors and dentists who receive a job offer from a New Zealand employer • negotiate effective and enforceable collective employment agreements with employers. This includes the collective agreement (MECA) covering employment of senior medical and dental staff in DHBs, which ensures minimum terms and conditions for more than 5,000 doctors and dentists, nearly 90% of this workforce • advise and represent members when necessary • support workplace empowerment and clinical leadership.

Check out jobs.asms.org.nz a comprehensive source of job vacancies for senior medical and dental specialists/ consultants within New Zealand hospitals and health services.

Senior Industrial Officer Lloyd Woods Senior Industrial Officer Henry Stubbs Industrial Officer Ian Weir-Smith Industrial Officer Phil Dyhrberg Industrial Officer Miriam Long

Industrial Officer George Collins

Association of Salaried Medical Specialists Level 11, The Bayleys Building, 36 Brandon St, Wellington

Industrial Officer Georgia Choveaux

Postal address: PO Box 10763, The Terrace, Wellington 6143 P 04 499 1271 F 04 499 4500 E asms@asms.org.nz W www.asms.org.nz Follow us facebook.com/asms.nz twitter.com/ASMSNZ

POLICY & RESEARCH Director of Policy and Research Charlotte Chambers Policy Advisor Mary Harvey SUPPORT SERVICES Manager Support Services Sharlene Lawrence Senior Support Officer Vanessa Wratt

Have you changed address or phone number recently?

Membership Officer Saasha Everiss

Please email any changes to your contact details to: asms@asms.org.nz

Support Services Administrator Angela Randall

If you have reason or need to seek a reduction or waiver to your annual subscription, please write to us. Our constitution allows for this in certain circumstances. Emails should be addressed to sarah.dalton@asms.org.nz

PO Box 10763, The Terrace Wellington 6143, New Zealand +64 4 499 1271 asms@asms.org.nz

WWW.ASMS.ORG.NZ | THE SPECIALIST

We’re here to help. COVID-19 Response If you use MAS for your insurance or investments, then we have a number of ways we can help you and your loved ones at this time. Your mental, physical and financial wellbeing is important to us. To learn more about our response to COVID-19, options for financial support, and the free wellbeing and counselling resources available to all Members and their families, please visit mas.co.nz And if you’re one of our nation’s frontline heroes in this crisis, you and your families have our deepest gratitude.

The Specialist - Issue 123

Articles inside

DOCTORS IN THE HOUSE

A KIWI IN LONDON: INSIDE BRITAIN’S COVID CRISIS

COVID-19: PUBLIC HEALTH LAID BARE