Paper to Australian Medical Assn Conference: Cusps

CUSPS, CUSPS EVERYWHERE,

NOT A NEW ERA TO SEE (YET!)

PAPER TO

AUSTRALIAN MEDICAL ASSOCIATION

INDUSTRIAL COORDINATION MEETING

CANBERRA, 13-14 APRIL 2011

Ian Powell

Executive Director

Association of Salaried Medical Specialists

CUSPS, CUSPS EVERYWHERE, NOT A NEW ERA TO SEE

‘Cusp’ is an interesting word which has a particular pertinence to New Zealand’s health system at the moment. It has particular usages in astrology, astronomy and anatomy, for example. In plain language it is a point that marks the beginning of a change; hence the expression, ‘on the cusp of a new era’. This is a reasonable description of so much of what is happening at the moment.

Affecting what happens with this cusp are three factors:

1. Confusing and mixed government messages to district health boards (DHBs) and the workforce.

2. Impact of severe funding constraints by halving the rate of funding increases to DHBs reinforced by strong central government monitoring over deficit levels and maintaining an illusion that services are not affected.

3. DHBs are struggling to take a longer-term view under this ‘shock therapy’. In response to these pressures they face strong incentives to make short-term decisions which risk compromising ongoing clinical and financial sustainability. They struggle to develop and maintain a continuous quality improvement process and culture necessary to improve the quality, robustness and cost effectiveness of health services.

1. NATIONAL COLLECTIVE AGREEMENT NEGOTIATONS

Since May last year, the ASMS has been involved in lengthy negotiations over our national multi-employer collective agreement (MECA) with the 20 DHBs (the current MECA expired on 30 April 2010 but still continues in force) which have been characterised by some interesting features. In addition to the usual formal negotiations, these features have been the use of workshops on workforce and clinical leadership, a ‘variation’ to the terms of the MECA while the negotiations continued, the development of a joint ‘business case’ to both inform the parties and government, and a number of ‘short line-outs’ and coffees.

The stakes are high in this negotiation for us, the DHBs and the government. We are potentially on the cusp of a new era with a major reorientation of the medical workforce in DHBs. The outcome of these negotiations will determine whether DHBs have the workforce necessary to make this happen.

Context of the negotiations

At the core of the negotiations is our senior doctor workforce crisis (recruitment and retention) in district health boards and the need to build our workforce capacity to sustain and improve health services and to achieve important, largely shared, government objectives in health policy.

Running alongside this is the recognition by government that if the public health system is going to retain viability and ensure sustainability, clinical governance based on clinical leadership through the comprehensive engagement of senior doctors (and other clinical staff) is necessary. The significance of the difficulty of this challenge was revealed late last year when Associate Professor Robin Gauld (Otago University Medical School) conducted a survey of DHB-employed ASMS members on the implementation of the government’s policy statement on clinical leadership, In Good Hands.

This is discussed further below but, relevant to these negotiations two important facts were revealed. The first was the poor performance of DHBs generally in achieving clinical leadership. The second was lack of time. Respondents reported that only 20% of them had sufficient time to participate in clinical leadership or development activities. Lack of time is the immediate consequence of specialist shortages in our public hospitals.

In September last year there was agreement that we should take the unusual step of ‘varying’ the terms of the MECA, a mechanism available under the Employment Relations Act. This led to a 2% salary increase effective 1 February and the inclusion of a number of largely non-fiscal improvements that had been agreed by the parties at that time. The purpose was to facilitate time in order to develop a joint ‘business case’. This was achieved with an intensive period of activity during September-November achieving a document called Securing a Sustainable Senior Medical and Dental Officer Workforce in New Zealand: the Business Case.

Business Case

The business case jointly developed between the ASMS and the 20 DHBs last December focused on addressing this issue and on the significant quality improvement and cost effectiveness gains that could be achieved through clinical leadership. The intention had been to forward the agreed document to government before Christmas to fit in with its budget cycle. However, for tactical reasons, the DHB chief executives concluded that the timing was not right and that there needed to be an accompanying ‘operational’ document (which would have to be agreed with the ASMS).

On the one hand, this was a surprise change of tack. On the other hand, it was still consistent with our broad direction. Further, both the ASMS and DHBs had envisaged this sort of thing being in the business case itself but ran out of time in respect of the deadline we were then working to.

Resumption of negotiations

Negotiations resumed this year on 9 February and continued on 15 March. The post-business case focus has been on costing various scenarios on remuneration in order to achieve an outcome consistent with the parameters of the ‘business case’. Unfortunately, on the 15th the DHBs’ negotiating team found itself in the position of not having a mandate (or being very uncertain over their mandate) in order to continue this process. The ASMS negotiating team started to doubt the commitment of the DHBs to the full business case.

As a result it was agreed to cancel the next date of negotiations on 23 March and instead use that day to hold a ‘crisis’ meeting with key DHB representatives further up the pecking order and the ASMS. The purpose was to get an understanding of what the road-blocks were and whether we could progress through the impasse that had emerged.

Fortunately, the ‘crisis’ meeting helped get the negotiations back on track. Arising out of this discussion the DHBs and ASMS reaffirmed a commitment to resolve the ‘operational document’ (within the framework of the business case); resolve the relationship between this document and the MECA; and to endeavour to settle the terms of the MECA itself (largely now down to remuneration) by the end of April (subject to ratification by the DHBs’ chief executives and the ASMS National Executive following an indicative ballot of members as well as the go-ahead from government).

The ASMS and DHBs would meet on 31 March to finalise the ‘operational document’ (and its relationship with the MECA) and again on Sunday 10 April. We will resume formal negotiations for hopefully only two further days (18 April and 29 April). Meanwhile the DHBs would continue to keep government informed of progress.

2. HEALTH WORKFORCE NEW ZEALAND

Up until 1990 there was a gradual movement towards developing effective workforce planning and development in the health system. However, the next nine years were one of ideological obsession with the misplaced belief that market forces could sensibly drive the health system. Planning simply did not fit in. To mention the word was to lead to criticism that one was seeking to impose a shipyard from Gdansk.

In the following nine years there was acceptance that workforce planning and development was important and a number of bodies formed to pursue it. In the main, however, while there were some tangible results towards the end of the nine years, the focus was more legitimising, scene-setting and process orientated.

Since 2008 there has been a more operational focus particularly with the formation of Health Workforce New Zealand (HWNZ) based in the Ministry of Health. Again this had a sense of being on the cusp because of the importance of workforce development to the sustainability of the health system. HWNZ is an important and badly needed organisation governed by a board chaired by Professor Des Gorman. It is important that HWNZ gets it right when discussing issues and data publicly.

Unfortunately!

Unfortunately, on National Radio’s Checkpoint programme (28 March), Professor Gorman got it badly wrong in three important areas with his comments on specialist doctor staffing in public hospitals.

1. He claimed that public hospitals have more than 500 extra senior doctors than a year or two ago. But the latest Medical Council data only has 296 new specialists registered in 2009 (10% less than 2005). This figure declines considerably when resignations and retirements are discounted. The ASMS, in joint workshops with the DHBs last year as part of our MECA negotiations, estimated the average annual net gain of DHB-employed senior doctors to be as low as around 136. Further, HWNZ’s own website reports an average annual growth of 423 doctors from 2005 to 2009 but this also includes medical school employed specialists, general practitioners and junior doctors. Specialists are only one part of this number.

2. He was widely astray in suggesting that there is little difference with Australian salaried specialists. The average specialist salary (40-hour week) for a specialist with 14 years service in New Zealand is about the same as the average Australian staff specialist salary with no service. He misleadingly referred to the salaries only being higher in parts of Queensland (ie, outside Brisbane). But Brisbane staff specialist salaries are even higher than the average Australian salary.

3. He exaggerated the extent of clinical leadership in public hospitals which he describes as an attraction for senior doctors to come to New Zealand. This is discussed more fully below but I just note here that in the Gauld survey of DHB employed ASMS members all 20 DHBs were ranked less than 50% over their performance in achieving clinical leadership (between a C- and an E).

Professor Gorman on the basis of these inaccurate assertions then concluded that the tide had turned. The tide may have turned on his beach but it has not yet done so on the medical workforce beach. This sort of blunder must not be repeated. The risk of an organisation (HWNZ), which is badly needed and has considerable potential, discrediting itself is high.

3. POOR PERFORMANCE IN CLINICAL LEADERSHIP

When the government commissioned and adopted the In Good Hands policy statement on clinical leadership in DHBs in 2009 it seemed that we were on the cusp of a transformation of our health system, particularly as it built on the Time for Quality agreement agreed between the ASMS and the DHBs the previous year.

However the previously referred to Gauld survey of ASMS members employed by DHBs on the application of In Good Hands in DHBs revealed a sobering reality. The response rate was 52% of the 3,402 potential respondents.

In Good Hands contains specific requirements for DHBs; in particular:

• establish governance structures ensuring partnership of clinical and corporate management;

• chief executives to enable strong clinical leadership and decision-making throughout their DHB;

• promotion of and support for clinical leadership and governance at every level; clinical governance to cover the whole patient journey with decisions devolved to the appropriate levels; and

• identification of actual and potential clinical leaders and support their development.

Findings: insufficient time

Dr Gauld presented his findings to the ASMS Annual Conference last November. This included the construction of a 13-point ‘clinical governance development index’ (CGDI). This index is work in progress as Dr Gauld and his colleagues continue to revise it, possibly to a lower number of points. But the first results still provide valuable information and food for thought. Overall it reveals disappointing performance with a national mean of 5.41 out of 13. No DHB gets a 50% pass. If this was graded A to E the range would be C- to E.

The most significant factor is lack of time for ASMS members to participate in leadership and engagement beyond their immediate clinical practice. To some extent (but not completely) this involves factors behind the DHBs control. In particular, the effects of the senior doctor recruitment and retention crisis severely constrain the amount of time available for involvement outside clinical practice. A mere 20% of ASMS members believe they have enough time to engage in clinical leadership activities or development programmes. This is significant further evidence of the effects of the crisis and also means that key government objectives in health policy that depend on clinical leadership will not be achieved until the crisis is resolved.

It should be noted, reinforcing this assessment, that the differences in ranking points between the highest and lowest performer is only 1.82 out of 13; all the 21 DHBs surveyed were bunched between this small number. There is no continuum from good to average to poor; only barely average to poor.

Another factor, even more beyond their control, is the fiscal pressures on DHBs from government of the severe reductions in the level of funding increases which make the benefits of clinical leadership more difficult to achieve. When the level of funding increases is halved DHBs find themselves in a potential siege-like environment not conducive to quality improvement.

But there is no escaping the fact DHBs own conduct contributes as well. We don’t have the comprehensive attitudinal clinical governance culture in DHBs to enable more effective clinical leadership.

A positive

Nevertheless there is a positive. Particularly since late 2006 with a change of Director-General and late 2007 with a change of Minister of Health, there has been an increasing recognition in the Ministry of Health of (a) the need for the Ministry to provide more operational leadership and support to DHBs and (b) the importance of clinical leadership based on clinician engagement as being the basis of sound decision-making in DHBs. This was accentuated by Ministry restructuring in 2009-10.

There is greater appreciation now by the Ministry that a focus on quality improvement based on clinician engagement and leadership strengthens clinical and financial sustainability. It is noteworthy that the Ministry is now discussing with Dr Gauld the use of a survey along the lines of the one discussed above annually and as part of the DHBs’ key performance indicators. If this becomes institutionalised in an appropriate manner then it will be a positive step forward. But one positive does not make a summer!

4. QUEENSTOWN

The tourist town of Queenstown by the South Island’s Lake Wakatipu has become the scene of an intense dispute between the ASMS and Southern DHB which has many interesting and challenging aspects to it and poses a challenge to government credibility over its express commitment to clinical leadership and building public hospital capacity. It is intriguing that a small 10-bed hospital (Lakes District Hospital) employing eight fte senior doctors and 17 fte nurses can attract so much controversy. However, it is not surprising that the Wakatipu public are so supportive of the hospital and their staff when they are seen to be under threat.

Background

In summary, the main elements of the current dispute are:

• A year ago the DHB initiated a public consultation process over a proposal that would have contracted the running of the hospital to a trust owned by one of the two (and largest) Queenstown general practices, the Queenstown Medical Centre (QMC). This was under the guise of establishing an ‘integrated family health centre’ (IFHC) latching on to a plank of government policy. Broadly the outcome of this process was some public interest in the IFHC concept but opposition to privatisation, QMC control of the hospital, and GP control of access to the emergency department.

• The ASMS intervened because the DHB had failed to adhere to consultation requirements of our MECA and, in particular, had not engaged with the hospital’s senior doctors. This led to the establishment of a health professional led review.

• Although stymied by the failure of the DHB to provide important information (including financial) the review completed its report in December. The report recommended that the hospital continue to be run by the DHB (ie, not privatised) and also proposed some other improvements and areas of further work.

• In March, after holding discussions with QMC and a property developer (but not the hospital medical and nursing staff), the Chief Executive announced a new proposal involving reducing the senior doctor staffing by 25% (2 ftes; also an 0.8 fte nursing reduction) effective 1 July 2011, putting QMC in charge of the emergency department during daytime, and (by 2013) transferring hospital services to new premises rented by QMC in a shopping complex known as the Remarkables Park). On this occasion the consultation was only with the ASMS due to a specific requirement to try to resolve any serious professional and clinical concerns and, if necessary, agree upon a process for resolution.

Controversy

This led immediately to public controversy. The ASMS maintained that this was privatisation in a different form, the proposal lacked clinical and financial robustness, and it would lead to an undermining of hospital services. It was also strongly criticised by a local community trust (not connected with QMC) and the Nurses Organisation (the nurses’ union).

A specific scandal emerged over a reference in the proposal to a ‘desktop review’ undertaken in 2009 which allegedly said that most attendances at the hospital emergency department more appropriately should have been seen by GPs (reference had been made to this during the health professional led review referred to above but despite requests to see it, management could not find it). Upon receipt of the proposal the ASMS made efforts to find it and was told that there was no written copy. Further, a letter was eventually provided which was written in March 2011, referred to files looked at in 2007 and early 2008 (not 2009), contained no statistical analysis, and did not make the statement that the Chief Executive’s proposal claimed.

The ASMS formally wrote to the DHB identifying our serious professional and clinical concerns which, in summary, were:

• The removal of the medical and nursing swing shift at Lakes District Hospital will result in adverse clinical consequences for patients and will produce an unsafe professional environment in which doctors will be required to practice.

• The provision of a clinically safe service, 24 hours a day, seven days a week, requires a minimum core staffing level of 7 or 8 FTE.

• Low scoring triage patients are not currently a problem at Lakes District Hospital and their diversion to primary care before 8pm will not appreciably reduce the clinical load.

• The proposal is based on information and costings that do not meet professional standards for accuracy or transparency including data on admissions which were not recorded and were therefore unexamined and unexaminable (see comments about ‘desktop review’ scandal above).

• Costs have been inflated by DHB management by cancellation of accreditation visits by the College of Emergency Medicine which were anticipated to result in the employment of registrars who attract clinical training agency funding, thus cutting the costs that would have been borne by Lakes District Hospital.

• The proposal destabilises a highly trained workforce at Lakes District Hospital that includes a potential training module for rural hospital specialists and training in rural emergency medicine.

• The proposal will seriously undermine the prospects of meeting the future growth of health services in Queenstown that would include the option of free secondary care at a public hospital; this is contrary to government commitments and the best interests of the people of Queenstown and Wakatipu.

• The proposal does not satisfy the requirements of government policies in respect of clinical leadership (the Time for Quality agreement, the government’s In Good Hands policy statement on clinical leadership, and the Minister of Health’s ‘Letter of Expectations’ to DHBs) and is contrary to the advice of the DHB’s own clinicians, including in the Dunedin and Southland base hospitals, and the second general practice in Queenstown.

• The proposal shows no evidence of being part of an integrated rural health strategy for Southern DHB.

• The proposal would see the transfer of money intended for the provision of public secondary services to subsidise a local GP practice that currently provides one of the most expensive GP afterhours’ service in the country.

• The proposal is divisive of the community and is already undermining public trust and confidence in Southern DHB and the services it is responsible for providing.

Current position

This led to a lengthy meeting involving DHB management, ASMS (and members) and the Nurses Organisation (and members) on 6 April in Queenstown in which discussion was, to quote the Chief Executive, “free and frank” (correct although an understatement). It was followed by a public meeting that evening of around 500 people at which the Chief Executive’s proposal was ‘roasted’.

Some progress has been made with an agreement not to proceed with the medical and nursing cuts and instead establish a small focussed working group to look at improvements to service delivery (including utilisation of medical and nursing staff) through quality improvement which are also likely to be cost effective. It is also possible that the controversial proposal may be overtaken by a collaborative exercise involving the DHB, ASMS and Nurses Organisation, looking at the future direction of health services in the Wakatipu region rather than focusing in the first instance on structural change. This work may involve assistance from the Ministry of Health.

What is clear is that the future direction and outcome of this matter will test and clarify the sincerity of the Health Minister’s commitment to clinical leadership beyond the level of rhetoric and a political slogan.

5. PROPOSED CHANGES TO REGULATORY AUTHORITIES

The Health Practitioners Competence Assurance Act 2003 (HPCAA) established authorities to protect the health and safety of the public by ensuring that health practitioners are competent and fit to practice their professions. The Medical, Dental and Nursing Councils were among these. These are referred to in the Act as ‘responsible’ authorities but are also often referred to as ‘regulatory’ authorities. Professions regulated by the HPCAA range from osteopaths and chiropractors to physiotherapists, pharmacy and psychotherapy. Other professions seeking recognition include acupuncturists and herbal medicine practitioners.

Health Workforce New Zealand (HWNZ), on behalf of the Minister of Health, has prepared a proposal that the Medical Council and all other regulatory authorities are reduced in size and that all the authorities go from having separate secretariats to a shared secretariat. The proposal is projected to make savings of $3.5 million annually for DHBs through less costly annual practising certificates as the paper estimates that DHBs meet about one third of the costs of the authorities. Submissions are due by 15 April.

The primary purpose of the HPCAA and of the regulatory authorities is to protect the health and safety of the public by providing mechanisms to ensure that health practitioners are competent and fit to practise their professions. The system was set up to protect the public by protecting standards and insulating those standards from the day-to-day exigencies of government including the need to control costs.

The HPCAA includes a requirement for a review. The last review was completed in 2009. It found that the Act was being implemented in an effective and appropriate way. However, a number of suggestions were made for closer collaboration between authorities and ways to minimise the authorities’ costs including sharing some services. The next review is scheduled for 2012.

Reduce size of Medical Council

This is probably the least acceptable part of the proposal. The HPCAA specifies that the authorities may have between 5 and 14 members and that the majority must be health practitioners and that there must be at least three laypeople if the authority has more than nine members (and two lay people if the authority has eight or fewer members).

At present the Medical Council has 12 members, four are lay members appointed by the Minister, four are health practitioners appointed by the Minister of Health, and four are medical practitioners elected by the profession. The discussion paper proposes that this number decreases to nine members. Three will still have to be lay members and four still must be elected (while the regulations on elections remain in force). With nine members it is hard to see how the numbers will stack up so a change in the regulations allowing elections must be a possibility.

The Medical Council acknowledges that fewer members will make it harder to have a good spread over various scopes of practice, GPs and academics. For the Medical Council the cost savings for this decrease in members are minimal and are likely to be offset by the need to seek specialist input when required that may be currently available from within the Council itself.

Amalgamate authority secretariats: one secretariat

The other part of the proposal is to amalgamate the secretariat of all the responsible authorities and this is where the paper sees considerable savings. However, the risks include loss of expertise and an even less responsive Medical Council. Our understanding is that the Australian experience with a single health practitioners council has not been good with a ‘call centre’ approach causing frustration and some practitioners practicing illegally without practicing certificates and others ceasing to practice because they did not have them. These problems are likely to be avoidable temporary glitches but suggest that such restructurings need to be approached with care.

Ian Powell

EXECUTIVE DIRECTOR

ENDS

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