More Medical Student Places Good But There’s A Mammoth In The Room!

Tuesday, 27 June 2023, 10:50 pm
Opinion: Ian Powell

The announcement by Minister of Health Dr Ayesha Verrall of the Government’s decision to increase the number of medical student places in our two university based medical schools (Auckland and Otago) was overdue (the last increase was in 2015) but welcome.

The increase is 50 beginning in 2024. It increases the cap from 539 to 589 annually. This was announced in a ministerial media release on 15 June: Government increases number of funded student places in medical schools.

In the Minister’s words:

We are growing the number of doctors trained in New Zealand to help meet the needs of our population and ensure health equity across the country. We want to train and retain as many local health workers as possible.

We have always been reliant on overseas-trained doctors, and we recognise the skills and knowledge the international workforce brings to our workforce. However, to address inequities in the system and build a sustainable workforce, we must grow and invest in our domestic doctors, especially when there is global competition for internationally trained doctors. 

Training more medical students will help us grow our domestic workforce over time, ensuring we can provide sustainable public health care. [emphasis added]

This is a significant investment in Aotearoa New Zealand’s health system. In 2022 it was estimated that it cost just over $62,000 per student per year to train a doctor.

Over $16,000 was covered by student fees leaving government funding the remaining nearly $46,000.

Positive response

Mainstream media coverage has reported how well received in the health system Dr Verrall’s has been. This coverage included:

1. Stuff journalist Sapeer Mayron (15 June), Government to fund more medical students to become doctors.
2. Radio New Zealand health correspondent Rowan Quinn (15 June), More funding for medical school places welcomed.
3. Otago Daily Times journalist John Lewis (16 June), Medical school intake boost.

These positivity expressions have come from the likes of Auckland University Dawn Freshwater, Auckland University Medical and Health Sciences Faculty Professor Warwick Bagg, and Otago Medical School Acting Dean Professor Tim Wilkinson.  

The New Zealand Medical Students’ Association has also welcomed the decision describing it as a “positive step”. But it sensibly warned that this must be supported by having enough resident (junior) doctor positions to absorb them.

One of the Minister’s strongest critics, sacked Chair of Health New Zealand (Te Whatu Ora) Rob Campbell commented in LinkedIn that it was a step in the right direction.

But there’s a big, up to 1.5 of a decade, ‘BUT’!

Dr Verrall deserves the level of support for her announcement as expressed above and elsewhere. It is the right thing to do even if it took the fourth health minister since Labour’s electoral victory in October 2017 to do it.

However, there is a huge ‘but’. It begins with the two words I highlighted above in her media statement – “over time”.

The context is the objective of training more medical students to help grow the domestic medical workforce. The purpose is to ensure the provision of sustainable public healthcare for New Zealanders.

But the training period for doctors is significantly different to all the other vital parts of the health professional workforce.

To become a vocational registered nurse, for example, one must successfully complete either a three-year Bachelor of Nursing degree or a two-year graduate entry master’s degree.

Give or take the various allied health professionals registration training have similar timeframes.

For a vocational registered hospital specialist the starting point is the six year medical degree. This is followed first by a minimum of two years as a ‘house officer’.

Then there is a further minimum of five years as a registrar training in a specific branch of specialist medicine, such as orthopaedic surgery or paediatrics.

In other words, a minimum of 13 years. It is important to understand why this is a minimum. Deciding what one wants to specialise in isn’t always easy. For many, and for good reasons, there are appealing ‘competing’ branches of medicine.

Some doctors-in training take longer than the first two years to make the call and others change their specialty during their registrar years.

Further, registrars who have completed their full training have often been encouraged to work overseas in different health systems in order to widen their experience before returning to New Zealand. Our health system has benefited from this.

So, in reality, while it takes a minimum of 13 years before one can be vocationally registered as a hospital specialist, for many it is up to one-and-a-half decades!

Consequently, with specialist shortages at around 24%, Aotearoa’s health system is dependent on international recruitment. This is a glaring omission from the Health Minister’s media statement.

Ignoring the mammoth in the room

Unfortunately the Association of Salaried Medical Specialists (ASMS) repeated the same glaring omission It’s media response correctly welcomed the Minister’s announcement: 50 new medical school places a good start but only the beginning.

ASMS also appropriately warned of the need to ensure both the capacity to enable clinical training, placements and supervision for undergraduates and the retention of the senior registrars who our health system trains so well.

Unfortunately ASMS omitted the fact that the announcement will only impact of the hospital specialist workforce in around 13 to 15 years or so.

Further, it ignored this fact; that is, international recruitment was therefore required if improved patient access to hospital care and specialist fatigue and burnout were to be addressed.

This was worse than ignoring the ‘elephant in the room; it was ignoring the mammoth in the room.

However, there is an overwhelming obstacle to our public hospitals recruiting internationally. It’s called Australia.

ASMS’s commissioned survey by BERL economic consultancy in 2019 revealed a hospital specialist pay gap for the basic 40-hour per week remuneration of over 60% between the two countries and not in our favour.

This means that New Zealand can’t effectively compete with Australia internationally. Australia has its own specialist shortages and also needs to recruit internationally, including from New Zealand.

Consequently, New Zealand hospital specialists are incentivised to migrate across the ‘ditch’ as are the registrars we train to become specialists (both countries share similar training systems); and both groups do.

Just saying!

In December 2019 the ASMS National Executive resolved to seek a new salary scale structure in its forthcoming national collective agreement negotiations with the then district health boards. The intent of the new structure was to address the pay gap.

This was not a 60% plus salary increase claim. Instead it would involve a translation to a new competitive scale. The cost would depend on the negotiated translation to the new scale.

Unfortunately the pandemic hit the country. Exigency required a short-term settlement which could not address the pay gap. In the subsequent negotiations ASMS took both a confusing and puzzling bargaining approach which ignored the issue.

Becoming internationally competitive can’t be fully resolved in one negotiation. But each negotiation can provide building blocks for the next bringing incremental recruitment and retention benefits.

Achieving international competitiveness requires the health minister (and government) of the day to recognise that New Zealand is part of an Australian medical labour market (not an Australasian market; there is a difference).

But this will never happen if the union representing hospital specialists does not advocate it, visibly and behind closed doors.

Just saying!

© Scoop Media

Ian Powell

Otaihanga Second Opinion is a regular health systems blog in New Zealand.

Ian Powell is the editor of the health systems blog 'Otaihanga Second Opinion.' He is also a columnist for New Zealand Doctor, occasional columnist for the Sunday Star Times, and contributor to the Victoria University hosted Democracy Project. For over 30 years , until December 2019, he was the Executive Director of Association of Salaried Medical Specialists, the union representing senior doctors and dentists in New Zealand.

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