Address to Marburger Bund Autumn General Assembly

HANNOVER, 25 MAY 2013

Ian Powell

EXECUTIVE DIRECTOR

Association of Salaried Medical Specialists

Guten Tag

Once again I am delighted to attend your Assembly again and to make some brief observations as the relationship between our union, the Association of Salaried Medical Specialists, and yours continues to grow. I also note with pleasure that we have a small but visible number of your former members active in our union – a bit like an internal cadre cell.

Last year I gave a brief outline of our country of four million people with a universal public health system predominantly publicly funded through general taxation with also a high level of public provision. Through our 20 statutory district health boards, responsible for both primary and secondary care (in the main, funding the first and providing the second), our health system by international standards generally punches above its weight in respect of access and quality.

Vulnerable hospital specialist workforce

But in a small geographically isolated island nation at the bottom of the world, our hospital specialist workforce has its vulnerability compounded by very superior salaries and conditions in our much larger neighbour Australia. Shortages of public hospital medical specialists, which have existed for many years in many areas, have become so entrenched that they are now the ‘norm’.

In particular:

1. More specialists are entering the workforce but well short of the numbers needed to enable safe and sustainable services. Each year, with every shortfall, the workforce deficit deteriorates. Furthermore, over the past four years the average rate of increases in specialists has declined.
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3. Retention of our new domestically trained specialists is getting worse.
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5. On current trends, in the next five years an estimated 19% of the specialist workforce could be lost due to a significant drop-off of doctors from the age of 55.
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7. As well as a worsening retention rate, the actual number of New Zealand doctors gaining vocational registration in a hospital specialty, notwithstanding annual fluctuations, has not grown over the past decade and has declined on a per-population basis.
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9. New Zealand has an unhealthy and increasing dependence on overseas trained specialists who comprise 42% of the total specialist workforce. By three years post-vocational registration, 25% of overseas trained doctors are lost to New Zealand compared with around 15% at the beginning of the decade. This high turnover has created a high level of instability. Not only is this financial wasteful but it reduces the capacity to bring cohesiveness to health services, which has serious implications for the efficiency and effectiveness of hospital care.
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11. Entrenched specialist shortages means that the invaluable leadership that hospital specialists could provide in order to reduce significant financial wastage and improving cost effectiveness in our public health system is being obstructed.
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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 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.

Threats to collective bargaining

I now want to discuss threats to our system of collective bargaining in New Zealand. In the 1990s we had industrial law which was designed to undermine collective negotiations and instead favour employer-imposed individual agreements. As a union we fought hard against this with success.

Since 2000 we have had more progressive legislation that actively promotes collective bargaining (including at a national level) and recognises the rights of unions. In fact, International Labour Conventions are expressly incorporated into the law. This has enabled us to negotiate conditions of employment that are more nationally consistent through a national collective agreement which provides significant advantages for our universal public health system and also assists recruitment and retention.

Regrettably our government has recently introduced into our Parliament a bill (Employment Relations Amendment Bill) which, if adopted, will adversely affect our members. Essentially, it will make it more difficult for unions to negotiate and conclude collective agreements and difficult to enforce the provisions in the agreements, particularly with respect to new appointees. For all employees, especially the more vulnerable, collective bargaining is the most effective means of improving or protecting their remuneration and other employment conditions.

Some of the main proposals for change that will affect our union and our members are:

• Removing the requirement to conclude a collective agreement; this could enable our employers to walk away from negotiations.
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• Removing the duty to continue bargaining even where there is a deadlock in respect of a particular matter.
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• Employers who do not wish to enter into collective bargaining for a multi-employer agreement, such as our national agreement covering public hospitals, may opt out of doing so within 10 days of the initiation of bargaining by a union.
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• Where a collective agreement exists, an employer will not be required to offer the collective agreement to new employees who are not members of the union at the time. [Currently there is a 30 day requirement for this to occur – employees can either join the union (within this time) and be covered by the collective agreement or accept the terms of the collective agreement as an individual agreement (without subsequent enhancements)].
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Creaking under pressure

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. Health funding continues to increase and we have not embarked on the destructive and destabilising restructuring that Britain has.

However, the rate of increased funding has steadily decreased and 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.

We as a union have been advocating ‘distributive clinical leadership’ which 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. The potential gains are immense – clinical, quality, organisational and cost effectiveness.

Sadly this risks becoming another casualty as managerialism revives because even though less effective, it is an easier path for short-term thinkers to go down. We believe that what makes good clinical sense also makes good financial sense. Unfortunately in practice this is not a sufficiently shared view with those in positions of power and leadership.

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.

Could there be Mid Staffordshire in New Zealand?

Many of you will be aware of the Mid Staffordshire disaster in this foundation trust in the National Health Service in England. This involved appalling examples of nursing care due to the hospital cutting its already depleted nursing establishment to build up its financial resources to ensure a successful application for foundation trust status which they were under strong government pressure to achieve. The hospital hierarchy became obsessed with finance and targets at the expense of patient care.

The Francis report on Mid Staffordshire identified that the prevailing culture focussed on doing the system’s business rather than the care of patients was at the heart of the problem.

This has led to discussion in New Zealand, presumably in Germany also, over whether we could have a Mid Staffordshire in our country. There are two short answers from many specialists.

The first is that there is no public hospital in circumstances like Mid Staffordshire and nothing appears to be on the horizon. In contrast with England, we have a more integrated health system, we don’t have the same level of obsession with targets (although we are not without risks), we have not had direct cost cutting, and we have not been subjected to the disruptive restructuring of our health system in order to convert it into a privatised commercial market. These are convenient truths.

On the other hand, our political masters and their agents are too willing to turn a blind eye to the risks of having a hospital specialist workforce functioning on entrenched shortages, the negative intimidating effects of micro management, of funding public hospitals increasingly below the costs necessary to run them, and to increased signs of sidelining genuine clinical leadership. These are inconvenient truths.

The specific circumstances of Mid Staffordshire are not the same as in New Zealand. But at a higher level what characterised Mid Staffordshire was the ignoring of inconvenient truths such as the impact of nursing cuts, the raising of critical concerns, and data reporting significant deviance from accepted standards.

Consequently, because of ignored inconvenient truths, the second answer from many specialists is that they simply don’t know whether a Mid Staffordshire could happen in New Zealand – probably not but possibly yes.

Danke schoen

Ian Powell
Executive Director
ASSOCIATION OF SALARIED MEDICAL SPECIALISTS

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