Building Capacity Amongst Specialist Disciplines

Building Capacity Amongst Specialist Disciplines: Swans & Legs

FUTURE HEALTHCARE WORKFORCES CONFERENCE, RYDGES HOTEL, AUCKLAND, 19 JUNE 2013

Ian Powell
EXECUTIVE DIRECTOR
Association of Salaried Medical Specialists

In preparing for this presentation I wondered how I might best describe the workplace environment of public hospital specialists. Features of this 24/7 environment include intensity, complexity, highly skilled, passionate and labour intensive. I could not find a suitable comparison but did come across a very busy PowerPoint slide on stability in Afghanistan that at least was comparable in respect of complexity and inter-connectivity.

Its features included coalition capacity, government capacity, coalition domestic support, tribal governance, population conditions and beliefs, popular support, support to insurgent factions, infrastructure, and narcotics. They highlight a high complexity system although not all of these features apply to our health system thank goodness.

Swans also have something to offer in painting the picture of workforce reality but I’ll leave that to the end. Another feature of our health system is the ability of participants to talk past each other and, either inadvertently or deliberately, misinterpret or misunderstand messages. I am reminded of detective work undertaken a decade ago by a professor investigating the psychology of humour who concluded that the world’s funniest gag came from Spike Milligan of Goon Show and other fame. It went like this:

Two hunters are out in the woods in New Jersey when one of them collapses. He doesn’t seem to be breathing and his eyes are glazed. The other guy whips out his phone and calls emergency services. He gasps: “My friend is dead! What can I do?”

The operator says: “Calm down, I can help. First make sure he is dead.” There is a silence, then a shot is heard.

Back on the phone, the guy says: “Okay, now what?”

Entrenched shortages have become the norm

If I was asked to describe the current state of the specialist workforce in district health boards as briefly as possible it would be as follows:

Entrenched shortages have become the norm. This is not part of our history, however. New Zealand has always been vulnerable as a small geographically isolated country at the bottom of the world with a well-trained and professionally motivated specialist workforce highly employable in an internationally competitive medical labour market.

For a long time we were able to compete including a healthy pattern of New Zealand trained specialists going overseas for further experience before returning back home to continue their careers. But things took a significant turn for the worse around 2006 in response to a tragedy in the rural Queensland city of Bundaberg which involved sub-standard care including avoidable patient deaths. The subsequent enquiries revealed the extent of specialist shortages with one of the outcomes being massive increases in salaries in order to address the safety risk of this workforce crisis. To one degree or another this then extended to other states.

The failure to respond to this in New Zealand has seen our vulnerability escalate and entrenched specialist shortages have become the norm. But specialists are the glue that holds so much of public hospital services together. Earlier this year we produced a major publication, The Public Hospital Specialist Workforce; entrenched shortages or workforce investment? (). Its assessment, based on government documents, published research and the most recent workforce data from the Medical Council and DHBs, was that:

• More specialists are entering the workforce but well short of the numbers needed – and agreed with DHBs – to enable safe and sustainable services. Each year, with every shortfall, the workforce deficit grows.
• Retention of our new specialists and potential future specialists is getting worse, especially among overseas-trained doctors.
• On current trends, in the next five years an estimated 19% of the specialist workforce could be lost due to a drop-off of doctors from the age of 55.

The effect, we concluded, of entrenched shortages was that the invaluable leadership that hospital specialists could provide in order to reduce significant financial wastage and improve cost effectiveness in our public health system is being obstructed.

The response of government (and obedient DHB leaders) was to link our publication to our collective agreement negotiations that had commenced. The fact of the matter is that if we were to comment on weather patterns the Health Minister and his obedient servants would link it to our negotiations. This may be challenged now, however, because, subject to a membership ratification ballot currently underway, that negotiation is now settled. But the tactic of trying to avoid the message by somehow trying to discredit the messenger will most likely continue.

We also need to distinguish between vacancies and shortages. DHBs will cite the former in response to concerns about the latter but they are fundamentally different. Vacancies are positions that DHBs have budgeted for and are seeking to recruit to. Shortages are the positions that are needed if senior doctors are not to be overworked and overstretched. In the past we have looked at this in selected DHBs with the assessment being that shortages can often be at least double the official vacancy rate.

What about the trends?

I agree with what is often said of political polls that it is the trend rather than a particular poll that matters. The description I have provided is bad but trends can offset it particularly if they show a pathway to improvement. Regrettably the trends are not good suggesting further deterioration in the entrenchment of shortages. In particular:

• Newly qualified New Zealand specialists leaving at increased rate.
• Deteriorating retention of recently registered overseas trained specialists.
• Demographic changes.
• Burn-out.

1. Newly qualified New Zealand specialists leaving at increased rate
New Zealand’s newly qualified specialists are quitting practice in this country at an increasing rate. The Medical Council’s latest medical workforce report (for 2011) shows that of the New Zealand doctors who gained vocational registration in 2010, 13.5% were no longer practising here one year post-registration, compared to 5.5% in 2000. DHB specialists account for around two-thirds of new vocational registrations.

The retention trends fluctuate more in subsequent post-vocational registration years but the general direction is towards an increasing loss of doctors. For example: six years post-registration, 11.5% of those who registered in 2005 were not practising here compared with 5% of those who registered in 2000.
It is often argued that many doctors who leave New Zealand tend to return eventually. The data show that over recent years some specialists (not many) have indeed returned, at least for the short to medium term. However, by eight to 10 years post-registration the numbers tend to drift away again and the eventual loss is greater than in the early post-registration years.

2. Deteriorating retention of recently registered overseas trained specialists

Retention of immigrant doctors (international medical graduates - IMGs) who have registered as specialists in New Zealand over the past decade has deteriorated markedly, according to Medical Council registration data.
By three years post-vocational registration, the latest trends indicated more than 25% of IMGs are lost to New Zealand compared with around 15% at the beginning of the 2000s decade. Aside from a few small fluctuations, similar trends emerge in subsequent post-registration years.

By 10 years post-registration, approximately one third of IMGs are no long practising here. Around two-thirds of new vocational registrants are hospital specialists.

These trends are particularly concerning because 42% of New Zealand’s specialist workforce are IMGs (this is by far the highest rate in the OECD). The high turnover has created a high level of instability. It results in an increasing share of specialist posts being filled by locums on costly short-term contracts (many of whom are themselves IMGs). Not only is this wasteful but it reduces the capacity to bring cohesiveness to health services, which can have serious implications for the efficiency and effectiveness of hospital care.

3. Demographic changes
The ageing of the specialist workforce, the increasing proportion of female specialists, and the growing desire for better work-life balance across all generations will together add significant pressure on DHBs to improve recruitment and retention over the coming years.

The ageing of the specialist workforce is evidenced by the fact that the largest group of doctors has shifted from the 40-44 age group in 2001 to the 50-54 age group in 2010. In each year there is a sharp drop-off in numbers in the age groups above the peak age group. On recent trends approximately 19% of the workforce is likely to be lost over the next five years from the effects of the drop-off of specialists from the age 55.

In addition, older specialists who remain in practice tend to reduce their work hours. In 2010, 17.6% of specialists were aged 60-plus and 37% of them worked less than 40 hours per week, including 22% of those aged 60-64 and 46% of those aged 65-69. Over the next five years, despite the losses from early retirement, the proportion of specialists aged 60-plus is likely to increase to more than 20% of the workforce.

The increasing number of women in the workforce is another key factor. In 2011 27% of the specialist workforce were female – up from 19% in 2000 and 13% in 1990. Gender statistics for practising registrars indicate the trend is continuing: In 2011 52% of registrars were female. Because females tend to work fewer hours than males (often due to family circumstances), the working life contribution for female medical practitioners, when measured in total time worked, is estimated at about 80% of that of a male medical practitioner. This must be taken into account in projected workforce requirements.

Furthermore, there is evidence suggesting growing interest in work-life balance for both male and female doctors. Reports from New Zealand and Australia indicate that work-life balance aspirations are becoming increasingly important for new generations of doctors, regardless of gender, and that this affects recruitment and retention. This is more generational than gender although the blokes may be slower in appreciating the importance of better balance in the relationship between work and the rest of life than their female colleagues.

4. Burnout and early retirement

While Medical Council data indicates more medical specialists are working part-time, many continue to work long hours, which is contributing to significant staff burnout.

A survey of New Zealand hospital doctors published in 2004 found nearly 30% of respondents suffered psychological distress, with 10% classified as severe. The most frequent stressful situations reported were associated with work demands, commonly found in other studies.

A study involving 267 consultants at Canterbury DHB in 2006/07 found one in five had symptoms of high burnout, with long work hours and low job satisfaction being key contributory factors. A quarter of the respondents reported working longer than 60 hours per week.

International studies show burnout has major repercussions for patients and employers, including poorer patient care and higher staff turnover.

A survey of senior doctors working in Britain’s National Health Service found less than a quarter of the respondents definitely intended to work in the NHS to normal retirement age; a reduction in workload or shorter working hours were reported as the greatest inducement to stay until normal retirement age.

How can DHBs and Government capitalise on and strengthen the capacity of specialists to meet increasing demands

I hope I have sufficiently outlined the serious situation we are confronted with. But at the same time I need to emphasise that our health system is not broke, performs well, punches above its weight (including by international standards), and is highly innovative. But it is a system that depends in large part on a specialist workforce subject to entrenched shortages and with worsening trends. This is not a sustainable basis for DHBs and government to capitalise on and strengthen the capacity of specialists to meet increasing demands. These demands come from a mix of government requirements, public expectations and demographic shifts (impact of the growing and aging population).

In response the government has done a massive flip-flop. From a position of acknowledging that the brittle state of the specialist workforce in public hospitals was a crisis and the government’s number one problem, they have evolved to a position denying its existence (this denial coincided with the last electoral cycle). This is done through embellishing hospital doctor numbers by misusing workforce data. We call them spread sheet doctors. The problem with spread sheet doctors is that they can’t operate, can’t diagnose, can’t do outpatient clinics, and have no bedside manner.

The New Zealand health system is not going through the same austerity pressure of some European countries such as Greece, Spain or Britain. By comparison it could be called austerity-lite. However, the rate of increased funding has steadily decreased and is falling well below the cost of providing and funding services; in other words, a ‘declining uplift’.

Unfortunately compounding this difficulty, the global recession brought out the worst rather than the best of our health leaders. It encouraged a shorter-term approach to decision-making based on what we call managerialism – that is, decision-making is management led with health professionals pigeon-holed into a reactive role. This is intensifying the pressures on the already entrenched shortages of specialists and has led to our public hospitals creaking under the pressure.

Distributive clinical leadership

The way forward in my view is distributive clinical leadership which we have been advocating for some years. It is more than simply having formal positions of clinical leadership. Instead it is about all hospital specialists having the time to be involved and empowered in professional and organisational leadership activities beyond their immediate clinical practice and their employer providing the supportive culture to enable this. This would become part of their duties and responsibilities for their DHB along with their clinical commitments. International research shows the potential gains are immense – clinical, quality, organisational and cost effectiveness.
This has origins in an agreement we reached with the DHBs in 2008 called Time for Quality. This agreement contained engagement principles including the following:

Managers will support health professionals to provide leadership in service design, configuration and best practice service delivery.

In 2009 this was extended further down the path of ‘distributive clinical leadership’ with the government’s policy statement on clinical leadership In Good Hands.

What makes good financial sense

Sadly this move towards distributive clinical leadership is becoming a casualty of the undermining culture of managerialism that is showing signs of a major revival. Although managerialism is less effective, it is an easier path for short-term thinkers to go down.

The ASMS has argued in the past that if you see things through a quality improvement lens, particularly when addressing process improvement, using the jargon of the day, one of the benefits is that the financial savings are ‘dark green’ rather than ‘light green dollars’. We came to this conclusion with the DHBs when we jointly developed a document called The Business Case: Securing a Sustainable Senior Medical and Dental Officer Workforce in New Zealand (November 2010) which provided an agreed blueprint for the future direction of a sustainable health system.

While the DHBs nationally (under political pressure) have walked away from this blueprint, we remain committed to it. But we are tending to paraphrase the ‘quality improvement lens’ description to more apt plain language. More so we say that if it makes good clinical sense it also makes good financial sense.
It makes a much better sound bite. It recognises that the real intellectual human capital of DHBs rests with its professional workforce and that medical specialists are at the core of this. But to get this point you need the workforce capacity to enable the level of distributive clinical leadership necessary for it to advance beyond a sub-optimum standard. Unfortunately in practice this is not a sufficiently shared view with those in positions of power and leadership with their heads buried in slow quick sand.

Generalism and Specialism

If we could reduce our reliance on overseas recruitment and retain more of those wonderful specialists we train we would be better placed to address another problem in our health system – the imbalance between generalist specialists and sub-specialists.

A country the size of New Zealand needs a significant emphasis on the generalist nature of specialists. But we largely recruit internationally from larger countries that logically have a greater emphasis on sub-specialisation. The more we depend on international recruitment the more the balance between generalism and sub-specialism gets out-of-hand. Sadly, while we and the DHBs agreed with this assessment in 2010, the DHBs national leadership quickly walked away from it the following year.

On the positive side, restoring the role of generalism was a subject of an important conference in Sydney earlier this year organised by the Australian, New Zealand and Canadian royal colleges of surgeons and physicians.

Integrated care

Another area where we need to advance is integrated care between community and hospital care. The health quality and financial gains that have been achieved through the clinical pathways developed between community and hospital care under what is called the ‘Canterbury Initiative’ and through a process sometimes known as ‘alliance contracting’ have been truly outstanding. It is not a tool kit that can be taken to other DHBs. But its principles based on low transaction collaboration through what makes good clinical sense can be developed by clinical leadership in other DHBs.

The benefits of this innovative process were evidenced in a well-attended conference in Christchurch organised by Canterbury DHB, Pegasus and other organisations on the role of primary care in the management of high acuity patients in April.

I am heartened to learn that this appears to have become the basis of the recent agreement between DHBs, PHOs and the Health Ministry. While it is about culture rather than structural agreements, nevertheless this is a positive development. But ‘alliance contracting’, which is strongly relationship based across the continuum of care, is highly labour intensive. It requires a level of specialist workforce capacity that we presently do not have if the full benefits are to be achieved.

Swans and legs

Back to the swans. New Zealand has the potential to be a world leader in health system performance and innovation. Central to this is the specialist workforce, who I would like to compare with swans. Swans are wonderful creatures characterised by beauty and grace. Specialists are also wonderful creatures characterised by high motivation, skill and professionalism.

What we don’t always appreciate about swans is that often hidden from view are legs going flat-out to keep their image of graceful beauty as they glide across the water. But at least they can have a rest. We need to also appreciate that hidden from sight (and ignored by political and bureaucratic masters) is that our wonderful specialist workforce is overstretched and overworked.

In 2010 an academic survey of our members employed largely in public hospitals revealed that only 20% of respondents said they had sufficient time to be involved in distributive clinical leadership. But our public hospitals have a remarkably high level of innovation, much of which is specialist-led. If what is achieved in an environment of entrenched shortages is any indication, what could be achieved with a stable specialist workforce with 80% (or even 100%) having sufficient time, would mean that our public health system would be far more financially efficient and cost effective than it is now.

This has to be addressed if DHBs are going to deliver on fiscal responsibility (including reduction of wastage and duplication), substantive process improvement, reducing imbalances in the specialist workforce, and integrated care.

Our health leadership needs to wake up, shape up, recognise that their intellectual capital resides within their workforce, and focus on long-term sustainability.
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