Address To Hospital Dentists

THE SOCIAL AND POLITICAL
ENVIRONMENT
IN THE
HEALTH SYSTEM

ADDRESS TO
NEW ZEALAND SOCIETY OF HOSPITAL
AND
COMMUNITY DENTISTRY HOTEL CHANCELLOR

CHRISTCHURCH FRIDAY 26 JULY 2002

IAN POWELL

EXECUTIVE DIRECTOR

ASSOCIATION OF SALARIED MEDICAL SPECIALISTS

Thank you for the opportunity to participate in this discussion and to speak to your Conference today. There are seven broad issues that I wish to contribute as part of this discussion. These are issues that the ASMS is or is likely to be centrally involved in during the coming months and beyond.

1. Funding Public Hospital and Related Services

There is surprisingly little to say about the funding of DHB provided health services because the government has learnt much from the debacle last year associated with the 2001-2002 Budget, which was a devastating blow for the public health system. In response to the critical negative exposure, including a no-confidence resolution from the ASMS¡¦s National Executive, of the numerous mirrors and gross deficiencies that that shocker statement on health funding contained, the government adopted a much more sensible approach with its three-year additional funding package commencing on 1 July 2002. There are three significant components to this package that constitute important advantages:

„h it is a sizeable amount of money additional to what is already provided especially when the demographic adjuster is considered;

„h the three year time frame provides an important certainty factor for DHBs to plan service provision and development; and

„h it is baseline funding thereby abandoning the frustrating system adopted in the mid-1990s by the former government of time-limited funding for initiatives such as waiting times.

However, on the other side of the equation major problems still remain for the funding of existing health services:

„h much of the substantive increase is disproportionately in the second and third years;

„h DHB deficits while disproportionately centred in the Auckland DHB are significant and will absorb a sizeable share of this additional funding ($120m in the first year); and

„h new government policy initiatives as yet not fully clear will absorb some of this funding.

But the government deserves praise for political astuteness. The package makes it difficult for organisations such as the ASMS to be too critical of funding levels aside from general observations of inadequacy. This neutralisation is not sustainable forever but it has been effective in election year.

2. Primary Health Organisations

Primary Health Organisations (PHOs) are shaping up to be an Achilles Heel of the government¡¦s health policy with the government appearing to seriously under-estimate it at its peril. PHOs will not work until they win the ¡¥hearts and minds¡¦ of GPs and to date there is no sign that this will happen. The NZMA¡¦s recent ¡¥Red Letter¡¦ is the most pronounced manifestation of this failure. There are at least three inter-related reasons for this situation.

First, there is ambiguity over whether PHOs are providers of primary care or networks of providers. Different people give different answers to the question and on occasions the same people give different answers. It has much in common with former Health Minister Bill English¡¦s advocacy of the chaotic and destabilising ¡¥there is no model¡¦ approach to health policy.

Second, given their role, particularly as providers, it does not rest comfortably with the independent contractor or small business status of the majority of general practitioners who provide roughly 85% of primary care. A key feature of PHOs is extending governance beyond GPs. But it is the GP who has built up their practice and business including the critical goodwill factor; it is the GP who has made the commercial investment; and it is the GP that takes the risk. And now they are faced with what they understandably regard as a threat because of shared governance that is compounded by the absence of the corollary of shared risk. It is also an obstacle to the involvement of primary dentistry given that it is overwhelmingly provided in a similar manner to much of primary health care.

PHOs as they are currently emerging fit much more comfortably with the ¡¥not-for-profit¡¦ wider organisation structure found in services provided by Maori bodies, union health centres and the various forms of community trusts. These structures play a valuable role providing quality care particularly in areas where the small business model falls short in addressing access. But despite their successful performance this so-called ¡¥third sector¡¦ only provides a proportionately small amount of primary care.

Third, there is a serious risk of unnecessary parallel bureaucratic growth that will be influenced by the extent to which PHOs are providers rather than networks of providers and by their relationship with DHBs. The more they are providers, the more they penetrate into the approximately 85% of primary providers that are small businesses, and the more they are structurally divorced from DHBs, the greater the likelihood that they will employ their own staff with all the increased bureaucratic costs, including transaction, that flow as a consequence. This poses a serious risk of the emergence of parallel bureaucracy and also privatisation under a different banner. On the other hand, if DHBs are closely involved in the servicing of PHOs inclusive of resourcing and staffing, the lesser the risk of an unnecessary parallel bureaucracy.

3. District Health Board Roles: Funding and Providing

As I commented at your Conference last year, a more realistic appreciation of the key DHB roles of funding and providing is important. Much of the market ideology of the 1990s centred on the misplaced belief that there was a fundamental tension between funding and providing and consequently special structures and processes were required to address this.

This belief still pervades among many in the health system today and it still remains a serious problem that has not been sufficiently addressed. It has led to some undue separation and artificial barriers within DHBs including a lack of concern or interest by the funding side of the DHB to ensure capacity building and maintenance by the providing side. In fact I receive many reports where the funding side of DHBs make decisions that in effect reduce services without the involvement of the providing side of the same organisation. It is disappointing that the former separation between the Health Ministry and now disbanded Health Funding Authority is being replicated within DHBs themselves. This is an unnecessary and inefficient bureaucratic impediment to effective decision-making.

While there is inevitably some level of tension between funding and providing, its status has been overstated. It is only one of several tensions within the health system and no more significant than any other. The tension has much more to do with a house-keeping role demarcation and is best addressed by integrating and coordinating them rather than constructing artificial walls. Late last year the Health Minister gave a timely warning to DHBs about this exaggerated emphasis of the tension but it needs to be repeated again and again and followed through with express guidelines.

4. Health Professional Empowerment

If the health system is to advance from valuing cost to valuing value itself then the most effective means of achieving the empowerment of health professionals, inclusive of doctors and dentists, within DHBs. This follows on from the professionalism conference co-hosted by the ASMS and Health Ministry in April. This empowerment involves two broad components:

„h ensuring that the values of health professionals are in the ¡¥engine room¡¦ of DHB decision-making and that they are central to the core DHB values; and

„h what I loosely call ¡§clinical democracy. In other words, DHBs having clinical boards whose clinical involvement is mandated by clinical staff through some locally determined democratic and accountable means. This would also include clinical leaders under their various local titles, heads of department and chief medical advisers.
„h
These are matters that require political and DHB consensus to proceed with but there is one thing medical and dental staff in DHBs can do themselves to achieve both these components and many other matters. They should be prepared to empower themselves to act collectively. If colleagues are united and tolerant of individual characteristics and differences then they are effective.

If medical and dental staff are sufficiently determined to focus on what unites them rather than what divides them and are prepared to collectively say no to proposals and plans that they consider unwise, inefficient or undesirable, then coupled with a bit of organisational ¡¥nous¡¦ they will be effective. Empowering our members to take collective control over their own working lives is something that the ASMS needs to seriously consider.

5. Giving Quality Real Grunt

We have this dichotomy in our health system between the relentless call for quality improvement of various forms and the relentless determination of those who exercise operational power within DHBs to avoid providing the wherewithal to deliver quality improvement.

Given the nature of their work the greatest resource that doctors and dentists need is time; time for quality. This includes non-patient contract time both in relation to the care of an individual patient and also activities not directly involved with the care of an individual patient. In the latter case the ASMS has made an assessment that a minimum of 30% of the time for routine duties and responsibilities should be allocated for these duties (eg, teaching, clinical audit, peer review, departmental meetings and journal reading).

Over time this will become an industry standard that DHBs will be assessed against. The ASMS¡¦s collective bargaining will be part of its implementation but much more important will be membership empowerment discussed earlier. Members themselves in their various departments will in my view, eventually determine what the hours are that they need for realistic quality improvement and other non-patient contact activities. Then, in the event that they act collectively backed by the ASMS, they will achieve it leaving managers with the choice of being supportive or being trampled by the onslaught of progress.

6. Workload Pressure and Stress

Through a combination of factors (eg, shortages of a wide range of health professionals, increasing acute pressures, inept or indifferent management) senior medical/dental staff working in DHBs are confronted with increasing workloads, work pressures and stress. I believe the situation is becoming so serious that it is a potential time bomb waiting for an inadvertent detonator. The consequence is inevitably patient safety. Many of our members are simply working too hard in an increasingly dangerous environment, are too under-resourced, lack time for quality improvement initiatives, struggling to take essential rest and recreation, and are confronted with managerial and policy decision-makers oblivious or indifferent to the seriousness of this situation. Until the seriousness of this situation is fully appreciated it won¡¦t be resolvable leaving patients the inevitable casualty.

It is time for medical and dental staff to take control of their own working lives. By acting collectively they should be prepared to make the harsh calls that others above them have lacked the fortitude to make. They should be prepared to reduce the level of services they are currently providing to a level that they can reduce workload stress, be more confident about safety and quality, realistically engage in quality improvement and professional development activities, and take the rest and recreational time that they deserve and need. This and only this will then shift the accountability and responsibility for access to and quality of services to where it belongs ¡V to DHBs and government.

7. National DHB Collective Bargaining

Finally I wish to briefly conclude by reporting that the ASMS will be having one of its most important debates at our Annual Conference in November. In the context of the fairer Employment Relations Act we will be debating whether to return to national DHB collective bargaining. In 1992 we were in effect prohibited by the former National government under the inequitable Employment Contracts Act from national bargaining.

Despite our dislike of the system the ASMS did well under single employer collective bargaining. Crudely speaking we ¡¥ratcheted¡¦ throughout the land achieving over time many significant gains. However, for various reasons such as the more nationally cooperative and coordinated health system, organisational effectiveness, recruitment and retention, and developments with other health professionals, we are reconsidering this and encouraging membership discussion and debate.

I encourage those of you who have the good fortune to be ASMS members to join in this discussion with your colleagues and on that note thank you for the opportunity to address your Conference.

Ian Powell
EXECUTIVE DIRECTOR

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