The Specialist - Issue 130 by AssociationofSalariedMedicalSpecialists

T H E M AG A Z I N E O F T H E A S S O C I AT I O N O F S A L A R I E D M E D I C A L S P E C I A L I S T S

Where to for the specialist workforce?

130 | MARCH 2022

Inside this issue ISSUE 130 | MARCH 2022

Want to know more? Find our latest resources and information on the ASMS website www.asms.org.nz or follow us on Facebook and Twitter. Also look out for our ASMS Direct email updates. This magazine is published by the Association of Salaried Medical Specialists and distributed by post and email to union members. Executive Director: Sarah Dalton Magazine Editor: Elizabeth Brown Designer: Twofold Cover: Cartoon – Chris Slane. If you have any feedback on the magazine or contribution ideas, please get in touch at asms@asms.org.nz.

Prefer to read The Specialist online? We have listened to your feedback and are aware that some members prefer not to receive hard copies of the magazine. If you want to opt out of the hard copy, just email membership@asms.nz and we can let you know via email when the next issue is available to read online. The Specialist is produced with the generous support of MAS.

ISSN (Print) 1174-9261 ISSN (Online) 2324-2787

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Pain and parsimony Data and insight Deep diving into our IMG workforce Taking on the biggest job in health MECA – frustration meets facilitation Pulling the PIN About the size of it… Safe work Slow but determined battle on gender pay Gaining ground outside our DHBs Seismic funding shift needed Farewells A very personal sabbatical When you are asked to work outside your area of expertise Did you know? Five minutes with Dr Marlize Alberts Stop press New Years Honours Your industrial officers

Pain and parsimony Dr Julian Vyas | ASMS President

edical care has evolved over time. Not just with scientific breakthroughs, but also in terms of recognising that partnership between clinician and patient is in the best interest of the person presenting.

We hear the patient’s history and ask about symptomatology, and then consider a differential diagnosis of causes. Even if the symptoms presented are not indicative of definitive pathology, we know that if a patient repeatedly complains of the same problems, there is likely to be some ‘dis – ease’ at work which still needs further investigation and management. When providing care we act promptly, to the best of our ability, and to address the symptoms as best we can. This approach is adopted for anyone for whom we have a duty of care. It is basic good practice. In the MECA negotiations, and in general dealings with our employers, we as clinicians have been reporting symptoms of a health system suffering serious difficulty in performing its routine daily activities. The DHBs are responsible for evaluating those symptoms and responding in good faith and with good intention. Instead, in this topsy-turvy world, the DHBs have spent many years telling us that we are wrong, that the symptoms we report don’t exist or that we simply need to be more resilient. Any evidence we offer to prove the veracity of our symptoms and concerns is either disregarded or not acted upon adequately.

…the DHBs have spent many years telling us that we are wrong, that the symptoms we report don’t exist or that we simply need to be more resilient. In short, this is basic bad practice. There is no small irony here. If we

took a similar dilatory approach to our clinical work, we would not only be roundly censured for failing in our duty to act in the patient’s best interests, we would also risk losing our authority to practise. This is not the case for employers. Members will know that meaningful action over adequate staffing and safe workloads can be deferred ad nauseam, yet somehow DHBs avoid suffering any consequences for not properly meeting their duty of care to their staff.

If we took a similar dilatory approach to our clinical work, we would not only be roundly censured for failing in our duty to act in the patient’s best interests, we would also risk losing our authority to practise. By the time you read this I sincerely hope we will be close to a fair settlement of our MECA claims. The DHBs have talked loftily about ‘valuing’ the work our members do. Yet they simultaneously undercut themselves by sticking to a pay offer that has remained unaltered despite months of negotiation. Confusing ‘cost’ with ‘value’ is a famous description of cynicism. The phrase from the DHB negotiators about having to have ‘a year of pain’, which all members will now be familiar with, is similarly cynical. It suggests that we must be made to suffer some form of punishment for problems that are not of our making. It also talks to a notion that DHBs don’t understand the ‘pain’ our members

have endured over several years (preexisting excessive workload affecting personal and family wellbeing, unpaid additional work, and moral injury from not being able to give patients the standard of care they need). Our claim is predicated on measures intended to improve safe staffing and our members’ workplace wellbeing, including an acknowledgement of the damaging effects of overnight shift work. The aim is to increase the health system’s ability to provide high quality care without causing further harm to its staff. Our pay claim is to ensure we do not have to suffer a ‘real-terms’ pay cut, which no workforce should be required to take. For many years our employers have responded to our reporting of symptoms with platitudes, prevarication, and parsimony. As I write (late February 2022), Omicron is picking up steam and will markedly worsen the strain on a system which was already close to breaking point before Covid-19 came along. Our members tell us that, for the reasons outlined, the years of them routinely going the extra mile for the good of the health system are coming to an end. On the off chance that our employers are reading this article, I would like to close by saying that the pay settlement you have tabled is derisory. A pay increase that keeps pace with CPI cannot be argued as excessive. The responsibility to prevent further loss of senior doctors’ goodwill, if not actual workforce numbers, lies squarely with you. Recognise what is basic good practice and do the right thing. Kia kaha

WWW.ASMS.ORG.NZ | THE SPECIALIST

Data and insight Sarah Dalton | Executive Director

ast month we sent you a brief note asking you to help us make sure we have your current contact details. We also asked you to share some ethnicity information with us.

Firstly, thanks so much to those of you who’ve grabbed some time to respond – we really appreciate it! Secondly, a few words about why it’s helpful to know a little more about you, both individually and as a cohort. There is a saying, “You can’t improve what you don’t measure”. We have a serious and intense focus on all things workforce this year: MECA pay and conditions, staff shortages, mechanisms to achieve safe work, and so on. Part of this focus includes the establishment of an ASMS Ma-ori Advisory Committee, and new research into our sizeable IMG workforce. Knowing a little bit more about how you identify and whakapapa helps to ensure we include you in our conversations, research and advocacy. We know ASMS has a diverse membership, but knowing exactly how diverse and in what ways has sometimes slipped through our net. We also continue to ask about gender. We have moved past old-school binaries but remain interested in gender identities as well, especially given the documented gender pay gap in medicine, which we continue to work on.

We know ASMS has a diverse membership, but knowing exactly how diverse and in what ways has sometimes slipped through our net.

We have a number of individual gender pay and wrong salary step cases in progress. We have also stepped away from

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a shared project with TAS that was aimed at addressing gender pay across the DHBs. Unfortunately, they proved unwilling to overcome barriers put up by the employers around required payroll data collection and analysis. We are now collecting the data ourselves in order to tackle the gender pay gap systematically. I apologise over how long this is taking; however, we will not give up while the gap remains, and will continue to work hard to stop historical inequalities being perpetuated. What you can do •

Make sure local and departmental agreements for after-hours work are documented and reviewed.

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Make sure that retention and recruitment payments are appropriately labelled and documented.

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Insist that special contributions are appropriately identified and documented.

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Ask for all local arrangements to be shared across the SMO group.

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Put processes in place to make sure that these are regularly reviewed and open for discussion.

The MECA is very clear on the importance of fair and equitable scale placements, and about the rules for recruitment, retention, and special contributions. Our industrial staff can help with all of these. We are also aware that some employers are insisting on offering remedies to individual SMOs only if they agree to a confidential settlement. This means that while one senior doctor gets their issue resolved, no one else does, and inequities remain. We maintain that the DHBs that are trying to push this barrow are acting in bad faith.

We’ve raised it with new Health NZ Chief Executive Margie Apa already and made it very clear that this will not be tolerated.

Remember that you can help stop unequal terms and conditions.

These are strange times. On the one hand I’m engaged in discussions focused on how to co-construct decent workplace cultures and conditions where unions and workers have a voice and a say, and on the other, we have our MECA negotiations being forced into facilitated bargaining due to an employer team which refuses to engage and whose stock answer to our proposals across the table has been “no offer”. We know that almost all the people you currently report to and work alongside will still be there doing the same things on 1 July. We know that Health NZ’s agenda for change will be incremental by necessity. We also know that any government aspirations that somehow a new system will save us all money is completely the wrong impetus for change. We have to remain optimistic that genuine engagement across our health workforce, and a solid dose of clinically led decisionmaking, will help us find a way through to a better, safer working environment. Thank you for helping us to do our best to keep on helping you. Ki te kotahi te ka-kaho, ka whati; ki te ka-puia, e kore e whati. If a reed stands alone, it can be broken; if it is in a group, it cannot.

Deep diving into our IMG workforce Elizabeth Brown | Senior Communications Advisor

s we know, New Zealand is heavily reliant on overseas-trained medical specialists. They make up 43% of our senior medical workforce – the second highest proportion in the OECD.

They are critical to keeping our health system going and to the sustainability of the workforce in meeting the country’s growing health needs. Just how reliant our smaller regional DHBs are on international medical graduates (IMGs) is clearly illustrated below. Last year the Medical Council noted a marked increase in overseas doctors seeking specialist registration. However, historically, turnover of IMGs is high, and there is little data on what actually shapes their experience of working in New Zealand and how we can better recruit and retain them. This year ASMS will be embarking on research to better understand why IMGs come to New Zealand, what distinct challenges they face settling and working here, and what specific support they and their families need to help them stay in the country. Ahead of this research we spoke to three IMGs to get some initial thoughts.

IMG DISTRIBUTION Wairarapa Whanganui Tairawhiti Northland MidCentral Lakes Bay of Plenty Waikato Southern West Coast South Canterbury Hawke’s Bay Taranaki Nelson Marlborough Waitemata Capital & Coast Canterbury Hutt Valley Auckland Counties Manukau 0%

10%

20%

30%

40%

50%

60%

Overseas-trained % where country known

70%

80%

90%

100%

NZ trained

Proportion of IMGs among DHB SMO workforce as at 30 June 2021. (TAS)

WWW.ASMS.ORG.NZ | THE SPECIALIST

There was also “moral injury”. She recalls being dismayed by comments from those around her which disparaged minority groups and fed into inequitable provision of care to patients. It was something she hadn’t expected to encounter in New Zealand. She believes having a dedicated group to help IMGs settle would be helpful. In her view it could offer independent professional support and follow up, as well as provide a range of resources, useful information, and networks.

Dr Carolyn Providence Carolyn is an internal medicine specialist who came to New Zealand ten years ago with her husband and young child. She left Barbados and the United Kingdom, where she trained and worked for over a decade. The couple wanted a country which offered good standards of education and living, and somewhere they could advance their careers and happily raise a child. “We thought New Zealand would provide us with all these things, and on paper it looked like the perfect place,” Carolyn says. With active recruitment of IMGs into the regions, they landed jobs in provincial New Zealand. Carolyn says transitioning into regional New Zealand was not easy, amplified by delays in the registration process and having no family support in the country. In her opinion, cultural integration, one of the most important aspects of transition, was managed poorly. While she acknowledges it is a difficult thing to achieve due to the diversity of IMGs and the significant interregional variability in New Zealand, she felt getting this right was critical to successful retention. In addition to the challenges of integrating, she soon encountered what she terms “insidious injustices” which led to professional isolation when she tried to address them. “There were a lot of micro-aggressions from colleagues, which a decade ago were not addressed, and there were no avenues for redress or ability to voice concerns without fear of retaliation,” Carolyn says.

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“It should be a requirement to have something like that in place for people once they get here, and it should be monitored and resourced. A lot of the strain on IMGs comes from the psychological strain of transition to different cultures. I cannot overstate the vulnerability of IMGs during transition,” Carolyn says.

I cannot overstate the vulnerability of IMGs during transition.

She also favours the idea of formal training modules for hospitals to roll out to IMGs, to describe the differences and nuances of the New Zealand health care system and cultural expectations. Being separated from family is one of the biggest challenges for IMGs and brings its own set of pressures. “There is no one to fall back on to help deal with things like childcare or day-to-day stresses, and there’s often constant guilt or anxiety over ageing relatives at home.” “If you can’t connect with your family, the risk of not being able to stay goes right up,” says Carolyn. The couple relocated to Auckland where her experience has been overwhelmingly positive. Carolyn is excited and fully supportive of ASMS’ plans to measure and gather data on the IMG experience because while she’s hopeful things have changed over the past ten years, in her view there is still a lot of room for improvement. “With such a reliance on IMGs, looking after them should be an obvious thing to do,” she says.

Dr Erin Doherty Erin is an internal medicine specialist from the US who, along with her ED specialist husband and three children, arrived in New Zealand eight years ago to work in Northland. She says moving to New Zealand and working in a completely different health system is a huge undertaking, and finding the right support wasn’t always easy. “If you’ve been working in Australia or the UK, you’re going to have a sense of how the system works and what a patient pathway might be, but if you’re coming from any other system, unless it’s UK-based, it’s going to be completely different and there’s nothing to guide you.” “No one told me really basic, practical things apart from broad overviews about how it’s a universal system – no one walked me through what that actually meant. Eight years down the track I still feel like I’m bumping into walls sometimes.”

Eight years down the track I still feel like I’m bumping into walls sometimes.

She was thrown into the inpatient service, taking call from day one with absolutely no orientation. She says while things may have now changed, it also took a year to get enrolled in the basic hospital orientation for all new employees. “Locum agencies and hospitals advertising positions spend time chasing you and telling you how

much they want you, and then you get dropped into the system with little support.” Erin believes it would be helpful for IMGs if there was a targeted online manual or video which outlined specific and practical differences between the New Zealand health system and others. She said it would be even more meaningful if it was done on a culture-to-culture basis so that someone from your own country of origin could share their experiences and observations in a relatable way. As an American, Erin also says she didn’t appreciate the subtle cultural differences or attitudinal barriers she would face. “Kiwi culture is a bit stoic, and it’s like, ‘Harden up and take your concrete pills’. People in the States are more expressive and emotional and give hugs easily. Here you just don’t touch people – it’s way more reserved.” Then there are the fundamental everyday life adjustments, which Erin feels DHBs need to give more consideration to when welcoming new IMGs into their new roles. “The DHB had both of us starting our new jobs on July 14th, which unbeknown to us was right in the middle of the school holidays. We were fresh here, didn’t know anybody and our kids were 6, 9 and 12. There was no school and we didn’t have a babysitter – we had no idea what to do.” Erin felt lucky to have had a good friend who grew up in New Zealand but had lived in the States come up to Whanga-rei and help her navigate basic things like supermarket shopping so she could find the things she needed. Erin admits moving her family to New Zealand and working in a different health care setting was more difficult than she’d anticipated. She is keen to see more resources made available and better processes put in place so that IMGs feel “super welcome and super supported”.

ASMS will be surveying our overseastrained members later in the year. We are also interested in contacting IMGs who have left New Zealand to involve them in the survey. If you know anyone and can help us contact them, please get in touch with our Director of Policy and Research, Dr Charlotte Chambers (charlotte.chambers@asms.org.nz).

Dr Mohana Maddula with his family at Mount Maunganui before heading back to the UK

Dr Mohana Maddula Mohana is one of those valuable IMGs who has just been lost to New Zealand. He recently returned with his young family to Britain, saying Covid-19 and Government immigration policy combined to force his hand. He came to New Zealand with his wife and baby son in 2016 to take up a job as a geriatrician at Tauranga Hospital after training in the UK and spending two years there as a consultant. Initially the plan was to stay in New Zealand only for a few years, but they liked it so much they decided to settle long term, built a house, and had another child. Mohana says he didn’t have any problems adjusting to living and working in New Zealand and felt well supported and welcomed by his DHB in terms of his induction and orientation. He says the systems were very similar to what he was used to in the NHS, with happily less bureaucracy. The one improvement he would make would be to have cultural competency training as part of his induction programme, rather than a few months in. Overall, he felt professionally satisfied. He was taking on leadership positions, and his family was enjoying everything the Bay of Plenty lifestyle has to offer. As an only child, and with his mother living in India, what really changed things for Mohana was Covid-19 and the difficulties of not being able to travel or bring family here. The big problem was the parent category. The Government has reiterated that no decision has been made on when the programme will re-start, and it is not part of the border re-opening plan.

“Even in the lead up to Covid I was trying to bring Mum over but couldn’t get longer-term visas for her. They were about to reopen the parent residency category just before Covid hit, but it’s still closed. During Covid you couldn’t even apply for a visitor visa, so essentially there was no way for her to come to New Zealand.” When his mother got sick last year, it fell on him to take care of her, but he didn’t want to leave because he didn’t know when he could come back. In October he decided to resign. “In terms of retaining IMGs, as lovely as New Zealand is, the Government needs to pay attention to immigration options for families and parents,” Mohana says.

In terms of retaining IMGs, as lovely as New Zealand is, the Government needs to pay attention to immigration options for families and parents.

“It’s really important that you do whatever you can to retain the overseas-trained workforce, but current policies are not supportive of that. I know of at least 2–3 other specialists where I worked who are returning for precisely the same reasons. Covid made it all worse.” Mohana isn’t ruling out returning to New Zealand in the future, saying it offers a great work–life balance, but with the UK allowing visitor visas, his mother can now join them at their new home in Cornwall. “Having family around is more important at the moment, and it’s a shame the immigration policies in New Zealand could not support that.”

WWW.ASMS.ORG.NZ | THE SPECIALIST

Margie Apa

Taking on the biggest job in health Elizabeth Brown | Senior Communications Advisor

epulea’i Margie Apa was involved in setting up the country’s District Health Boards more than 20 years ago. Now she is heading up the single organisation replacing them.

her family village on the island of Savai’i), Margie has held many senior positions in the health sector over the past 24 years. Most recently she was Chief Executive of Counties Manukau DHB.

Margie has been appointed as the interim Chief Executive of Health New Zealand. She started the job early this year and will lead Health NZ when it officially comes into being on 1 July. Health NZ will merge the functions of the existing DHBs and lead the day-today operational running of the health system. Significantly it will become the country’s largest employer with a workforce of about 80,000.

Motivation

Raised in south Auckland and proudly Samoan (Fepulea’i is a chief title from

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The opportunity to “really get traction on improving health equity” is what pushed her to want to take on such a large and challenging role. “We know there are pockets of our communities - Ma-ori, Pacific, low income, rural – and we need to support a diversity of models that will reach out to those communities more easily and that’s what really motivated me to apply.”

Simplifying and taking out what she calls “unwanted variation” in patient care, added motivation. “I think one of the advantages of being one organisation is that we can simplify funding arrangements. We can make decisions and move more quickly to implement them and try to get the balance right in developing enough flexibility locally, but also assure New Zealanders that they are getting consistency and quality of care or access, although it may look different for their local area.” With the clock ticking down on July 1, exactly what Health New Zealand will look like and how it will run, is still unclear.

There is no national leadership team for the organisation yet, but Margie says she is not frightened by the tight deadline. She says her immediate focus is to lay out a clear plan and timelines to give people working in the system some certainty. “I want people to understand that actually large parts of the system aren’t going to change. The new bits are really shaping up national and regional functions, but for most people who work in a hospital, their boss won’t change come July 1.”

I want people to understand that actually large parts of the system aren’t going to change.

to build on what she believes was her successful work at Counties Manukau - embedding clinical and managerial partnerships and giving clinical leaders clear roles in setting strategic development for their services. “We’re going to be really transparent about how we make decisions because it’s not about trading off clinical issues for managerial priorities – they should really be the same. We’re all aiming for the same outcomes and the same improvements in clinical care.”

We’re going to be really transparent about how we make decisions because it’s not about trading off clinical issues for managerial priorities – they should really be the same.

Clinical networks Working with SMOs to strengthen clinical networks is something she wants to happen quickly, supported by better data and digital resources. “Imagine in a clinical network being able to see how we are delivering and offering care to people, not only in their own hospital or setting, but being able to see that regionally and nationally – that’s quite exciting to me.” Margie says these networks will be critical in identifying what is needed, especially where there are vulnerable national services. Clinically led decision making In terms of the future of local and clinically led decision making there is no intention “to grow a monolith in one place that’s going to make decisions for the country,” according to Margie. “I think it’s important that clinical leaders are well placed in our system to be part of decision making because they have a professional obligation to tell us if we are doing things to put patient safety at risk and I value that input absolutely.” ASMS members regularly express frustration with top-down management or poor management culture. In terms of shifting that culture, Margie intends

Workforce planning With what are now entrenched staffing shortages in hospitals, combined with the woeful lack of workforce planning, Margie says she’s heard the views of ASMS on the need for urgent action on a centralised, co-ordinated approach to workforce planning and supply. She says work is already underway to prioritise the issue. “It’s not something we can do on our own – we need all the players at the table. Tertiary and training institutions need to have a look at their pathways, the colleges need to be part of the conversation, and the Ministry. If there are regulatory settings getting in the way, we need to get them out.” “We need to be active. We can’t spend three months planning. We need some interventions to collectively take on. Unions are central to this,” she says. Margie is careful to avoid comment on the current ASMS-DHB MECA negotiations, except to say that “it’s a challenging point in time.” However, she acknowledges the need to retain talent, skills, and experience, and for more resources and support at the frontline.

“We need to support the capacity so people can take the time out and we can roster and schedule people to really be supported in their wellbeing. I know there’s variation in practice and support and we want to make that a more consistent experience for your members.” Unwelcome distraction? There has been criticism that transitioning to Health NZ during a global pandemic, is an unwelcome distraction. There is also concern that with such high workloads, SMO/SDOs simply do not have time to engage in clinical planning and change process. Margie’s response is that Covid has exposed the realities of workforce shortages and infrastructure investment and the reasons why “we need to push on.” She promises she is not tone deaf to the pressures of the frontline. “We have to be careful and mindful as Health NZ that we are inviting our clinical leaders who are trusted and respected in their field by their peers and that we free up and support their capacity to be able to contribute.”

We have to be careful and mindful as Health NZ that we are inviting our clinical leaders who are trusted and respected in their field by their peers and that we free up and support their capacity to be able to contribute.

“What I’m hearing is that we need to be mindful of the pressures, but I’m not hearing anyone say stop, because the pressures we’re seeing were there before Covid.” As Health NZ Chief Executive, Margie will remain Auckland-based but with a lot of time spent in Wellington. She is currently organising visits to DHBs and has accepted an invitation to speak to the ASMS National Executive in June.

The Specialist will feature the head of the new Ma-ori Health Authority Riana Manuel in the June edition.

WWW.ASMS.ORG.NZ | THE SPECIALIST

MECA – frustration meets facilitation E

fforts to resolve the deadlock in the MECA negotiations and ultimately reach a settlement have now moved to facilitation.

Earlier this month the Employment Relations Authority accepted a joint application from ASMS and the DHBs for facilitated bargaining. Under facilitated bargaining, an Authority member works with both sides in an effort to bring a resolution. They meet separately with the parties in the first instance and review each side’s position, before bringing them together for joint discussions. This joint meeting was due to happen in Wellington on March 18th.

The outcome might be to arrange further meetings, or the Authority member could deliver written recommendations. The recommendations are not binding but could help move towards a negotiated settlement. Look out for updates in your inbox. ASMS is continuing to put pressure on the Government over the DHBs’ bargaining approach and comments that all health workers are required to experience a “year of pain” before they can expect a pay increase. This is happening at high level meetings and in the media.

We have also been using recent JCCs to let DHB Chief Executives know how poorly served they have been by the DHB’s negotiating team, whose determination to give “no offer” responses in place of reasoned discussions have led to the current negotiation difficulties. In addition, there are indications that with inflation running at almost 6%, the Government’s pay restraint guidelines to the public sector are increasingly difficult to justify. Senior Government figures are no longer promoting them.

@ASMSNZ

MECA expiry – what happens on 31 March? The MECA formally expired on 31 March 2021. Normally a collective agreement only remains in force for 12 months after its formal expiry date. This is to give the parties time to negotiate a new agreement. If a new agreement has not been settled, then 12 months after expiry, employees would usually be deemed to be employed on an individual employment agreement based on the collective agreement. That is, while your terms of employment would continue as they are, they would come under an individual agreement. However, in April 2020, by Order in Council, the Government suspended the 12 month “double expiry” provision. Effectively the expiry clock stopped ticking on all collective agreements and will not start ticking again until the relevant Epidemic Notice is revoked. An Epidemic Notice has been continuously in force since 24 March 2020, before the MECA expired, and understandably will continue in place for a while yet. Only once revoked will the 12-month expiry period start ticking.

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Member action Late last year we asked members to write to Government ministers and DHB executives to express in their own words, their personal frustration and anger over the DHB negotiating team’s entrenched position and attitude. There was a great response. Hearing directly from members sends a powerful message. Here is an abridged example of just one of the letters sent to the Health Minister Andrew Little.

18 February 2022 Dear Mr Little Re: ASMS MECA negotiations I am a Senior Medical Oficer at Auckland DHB. I am writing to you, despondent at the nature of the MECA negotiations between ASMS and the DHBs. I have been a doctor for 21 years, and a specialist for 11. This is the lowest that I have seen morale amongst my consultant colleagues, and the health workforce in general. I worked in Australia for six years, initially completing a fellowship in a ffeld for which there was no experience in New Zealand and was committed to returning to work in the public health system in Aotearoa. You will no doubt be aware of the signiffcant pay disparity for medical specialists between Australia and New Zealand. In 2016, this represented a 30% pay cut when I made the decision to return home. I do not regret this decision, but equally I cannot judge my fellow New Zealand-trained specialists who have made Australia their home, inadvertently adding to the critical medical workforce shortages in Aotearoa New Zealand. The Covid-19 pandemic clearly represents an unprecedented challenge to the New Zealand health system. The Labour Party was well aware of the systemic decimation of our system when you came into government in 2017, and I welcomed your government's additional investment in health. But for our union representatives to be told that we "must endure a year of pain" before we could even be offiered a settlement equivalent to inflation is frankly, insulting. In my specialist area our outpatient clinic has been added to the DHB Risk Register because patients are now waiting over nine months for a ffrst specialist appointment. That weighs heavily on me. In December, I performed emergency surgery on a patient who had been waiting for elective surgery for a supposed benign condition since February. She should have had surgery by u J ly 2021. Instead, she has now been diagnosed with cancer, and will require chemotherapy. I carry the burden of these situations, which are beyond my control. And yet, day after day, I get up, don my face mask, sanitise my hands, and put on my "game face" for another day at the front line. All of the leading ffgures in government and the Ministry of Health have thanked us for our hard work and told the public how proud they can be of our health system. But your thanks ring hollow when I am faced with rising costs of living. I do not have the choice of moving to a less expensive city than Auckland. My colleagues and I have endured "our year of pain". In fact, it has been YEARS of pain, with no end in sight. All we want is to not fall behind as inflation rises. We're not unrealistic. We know that it does not play well in the court of public opinion for "rich doctors" to complain about our pay. Our DHB managers know that our professionalism and commitment to our vocation, to our patients and to our colleagues, means that we are unlikely to walk offi the job and stand on a picket line. But this is the closest I have come to breaking those promises to my patients. We talk about burnout, about moral injury. I am now at the point of being burnt out from burnout. I implore you, as an experienced unionist yourself. Please listen to the frontline workers and pay us more than lip service. It is the very least that we deserve. He aha te mea nui o te ao? He tangata, he tangata, he tangata. Nga- mihi nui, Dr Saman Moeed, MBChB, FRANZCOG Senior Mealdic Ocer Auklandc DHB

WWW.ASMS.ORG.NZ | THE SPECIALIST

Pulling the PIN Andrew Chick | Senior Communications Advisor

ealth and safety issues caused by unsustainable workloads and understaffing in our public hospitals have seen almost a dozen ‘PINs’ issued in the last 12 months. PINs can be a useful legal tool in holding employers to account. We spoke to nurses involved in some of the recent action to find out more. A Provisional Improvement Notice (PIN) is a written notice issued by a Health and Safety Representative (HSR) to an employer asking them to address a health and safety concern in the workplace within a set amount of time. It represents a serious escalation of a health and safety issue and means management has a legal obligation to respond and come up with workable solutions. A PIN carries the same weight as an improvement notice served by a WorkSafe inspector. Ben Basevi is a nurse at Auckland DHB. As a union HSR for the Safe Staffing Team, he has assisted other reps across the hospital and has more experience than most of issuing a PIN. “Over the last year and a half, I’ve probably issued three for non-supply of staff. I’ve issued one for when they had an unsafe visitor policy, and in October I issued six to one workplace.” Those six related to formaldehyde exposure, where a 150% increase in the

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number of workbenches in a pathology lab and the introduction of lower government exposure standards meant the ventilation system couldn’t cope. The issue reached crisis point when air quality measuring devices kept sounding the alarm, requiring evacuation. Management’s initial response was to remove the devices. Ben says PINs are a completely last resort and are usually issued after all efforts to get management to listen fail.

than happy to be there if my life needed saving. But I am also very much aware of how difficult it is when you have patient after patient and it’s just full on. You don’t get a break. You don’t get a chance to breathe,” Anne says.

We went through the whole process of reporting it and escalating it to different people.

Breaking under the strain In mid-2021, patient volumes, staffing shortages and fears patients could die waiting for treatment, led Dunedin nurse and HSR Anne Daniels to issue a PIN in the Emergency Department at Dunedin Hospital.

On her days off, Anne was getting up to six texts a day asking her to come in to cover shifts. She also had colleagues getting in touch with her in tears, breaking under the strain.

It was a move wholeheartedly backed and applauded by SMOs in the department.

She recognises that her immediate managers understood the problems, but it was becoming tougher and tougher.

“I would say Dunedin Hospital ED is a pretty tight team, and I would be more

“I think issuing a PIN is a sign of the failure of the system,” says Anne.

Risk to psychological wellbeing In July last year, Sonya Rider, a nurse and elected HSR for the elective and acute cluster at Palmerston North Hospital, also issued a PIN. “We went through the whole process of reporting it and escalating it to different people. For six months we got staff to put into our risk management system that they were feeling burnt out, that patients were being held in ED for a long time and that it was affecting them psychologically.” She says senior managers were aware of the problems but said they could do nothing to change the situation. “I attended the hospital’s health and safety forum, and they were informed of how dire things were. We were facing a lot of staff resigning or walking off shift completely in tears.” The last straw came when one day there were 83 patients for the 24-bed unit. “We had them lining every spot of the corridor. And we only had our normal eight staff. The department had been in the red zone for three days and nothing had been done about it,” Sonya says.

The department had been in the red zone for three days and nothing had been done about it.

She issued a PIN over the risk to staff psychological wellbeing. Health and safety representation Ali Witton is the lead for worker engagement, participation, and representation at WorkSafe – the country’s workplace health and safety regulator. He acknowledges that health and safety representation in DHBs has a way to go. “I spoke to a forum of health and safety managers at the DHBs last year. Something I picked up was that some in the room saw PINs as a problem and wanted to try and stop them happening, rather than seeing them as a symptom of something.” Anne Daniels says the process of issuing a PIN can be quite challenging, and

Sonya Rider dealing with WorkSafe was not without its frustrations. “I wanted to make sure I did it right. I’d never done it before in my life. I knew the legislation, I had the form in front of me, but really, through the entire process, there is no assistance from anyone but our union.” Colleague support Sonya agrees, saying using the Health and Safety Act can seem difficult in a hospital setting, but overall, the PIN was an important part of getting proper attention for staffing problems. She stresses that support from colleagues was invaluable. “Some of our SMOs attended meetings along with myself and the Nurses Organisation. That was really helpful because it took the pressure off it being just a nursing problem.”

Some of our SMOs attended meetings along with myself and the Nurses Organisation. That was really helpful because it took the pressure off it being just a nursing problem.

Sonya’s PIN gave the DHB 14 days to respond to a list of things her colleagues wanted the DHB to do: increase staffing (including health care assistants to help with the workload), improve patient outflow, and provide more psychological support for staff. “We had a whole of department meeting which our managers came to. We asked that things be escalated to the Board so they were all informed of the current

Ben Basevi

Anne Daniels

situation. And from that we ended up getting some extra FTE.” That included FTE for nursing as well as a dedicated ED cleaner overnight and one Health Care Assistant per shift. WorkSafe’s Ali Witton believes it is important to keep in mind what can be done in DHBs. “What we are really talking about is worker participation and the ability for workers to influence the way work is done where they are doing it. That flow of information – up the hierarchy – is often blocked. As opposed to information down the hierarchy, which is usually free-flowing.” He says his key message to leadership is “listen with a view to be influenced rather than listening with a view to just respond.” He also thinks the role of HSRs is often misunderstood. “Often they are seen as mini health and safety advisors, but they should be seen to be participating with other workers. As soon as they are leading something, like an audit, they are seen by their peers to be policing compliance. That creates this prevailing culture that being a rep is a thankless task – technically a voluntary position that you get voluntold to do.” Meanwhile, Auckland nurse Ben Basevi is convinced that the Health and Safety Act and PINs are powerful tools. “They have been very under-utilised in the health arena, and WorkSafe do seem much happier going to a factory and saying you haven’t got a guard on that saw, that’s why the man’s hand got cut off. But you’ve got to act in good faith, and you’ve got to believe the employer will act reasonably and will act as any other good employer would in reasonable circumstances. And you really can make things safer.”

ASMS is not aware of any SMOs who are elected health and safety reps in their workplaces and have the necessary training to issue a PIN (NZQA unit standard 29315). If you are a health and safety rep, we’d love to hear from you. Email andrew@asms.nz. If you would be interested in becoming a rep in your workplace, please contact your industrial officer for more information.

WWW.ASMS.ORG.NZ | THE SPECIALIST

About the size of it… Andrew Chick | Senior Communications Advisor

hen you’re up against entrenched staffing shortages and battling to keep your head above water, job-sizing can be a useful way of matching staffing levels to service requirements. “Between MECA negotiations, job sizing is one of the most important things we do. It is a great organising opportunity and can give members a renewed sense of control over their work,” says ASMS Senior Industrial Officer Henry Stubbs. Clause 13 of the DHB MECA is the job sizing clause. It states any employee’s hours of work and job size “shall objectively reflect the requirements of the service and the time reasonably required for the employee to complete their agreed duties and responsibilities, as set out in their job description”. It is a provision that has been there since the first DHB MECA was negotiated in 2003. Importantly, the clause also says that a job size must be “mutually agreed” between employer and employees – neither can unilaterally change it. And the words “objectively” and “reasonably” mean the conclusion of any job sizing can be evaluated by a third party – it is not just a negotiation. “A mechanism that gives that kind of shared control over work and workloads is unusual for collective agreements in this country, let alone what most working people on an individual employment agreement experience,” says New Zealand Council of Trade Unions Legal Advisor Gayaal Iddamalgoda.

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A mechanism that gives that kind of shared control over work and workloads is unusual for collective agreements in this country.

“Despite any ups and downs in actually doing job sizing, ASMS members should recognise the strength this job sizing process gives them and the level of high-engagement it encourages.” There is at least one job sizing review going on in most of our DHBs at any given time. Henry Stubbs says requests for job sizing have come up from groups of members when services feel they are under particular pressure. “As we see more and more pressure on DHBs, we have seen increasing demand for job sizing. But job sizing should be under regular review in all services for all DHB members.”

Job sizing should be under regular review in all services for all DHB members.

Valuable process Job sizing can take several months to complete.

ASMS Senior Industrial Officer Lloyd Woods says firstly all members of the team need to get together for the initial exercise, then review what they come up with, before finally presenting it to management. Management then has time to respond. “It is the best tool we have to increase staffing levels, but it can be a very slow process. Sometimes it can be fast but not often,” Lloyd says.

It is the best tool we have to increase staffing levels.

Henry agrees that despite the time commitment, job sizing is incredibly valuable. “To have an accepted process to objectively define how much work is required to do your job – agreeing on that is a massive step in tackling the endemic problems of excessive workload.” That said, a job-sizing exercise does not always result in a recommendation for more SMOs. “It can be more registrars, more nurse specialists or more administration,” says Lloyd. “And, even where it is more SMOs, it can be impossible to recruit. Then it can become a very challenging question of the size of the service being delivered and having to reduce that.”

What does job sizing involve? The process of job sizing starts at the service or team level. It produces an average total weekly number of clinical hours to deliver the full range of clinical duties required in that service. From there it can be converted into a full-time equivalent number of employees required to provide that service. With the addition of time allocated for non-clinical tasks and leave within the service, the number of SMO hours required to provide that service may be arrived at. There are slightly different approaches to establishing routine duties and measuring after-hours call work. Both are done collectively with your colleagues. For routine work, all your colleagues in the service gather round a whiteboard or a computer spreadsheet and start by listing all the clinical activities that are required in your service. Then you agree among yourselves how much time, based on reasonable averages, each of those activities requires. It can take some time to remember and capture all the various aspects of your service’s clinical work – not everyone performs every task. But you want to capture all tasks. Also, it can also be easy to just assume how long a task can take based on how long it is usually scheduled to take, but it is important to recognise how many hours are reasonably required and should be allowed for that activity. “Members sometimes ask why we only calculate clinical hours or how in fact you define clinical hours,” says Lloyd.

“The fact is, when a service is understaffed, the first thing that is lost is non-clinical time. Trying to measure how much non-clinical work is happening is pointless.” ‘Clinical’ is defined as any activity directly relating to the diagnosis, treatment and/ or management of a named patient, and clinical activities are clearly spelt out in Clause 48.2c of the MECA.

The overriding message is do not wait until you and your colleagues are feeling tired, cannot take your leave or do not get decent non-clinical time – or worse, suffer burnout. Contact your ASMS industrial officer and talk about it.

While non-clinical time is not initially considered, it is still important. MECA clause 11.7 defines non-clinical duties. The MECA also recommends a recognised standard of 30% non-clinical time, and job sizing must reflect this. After-hours duties are done slightly differently and are measured by keeping diaries. Over the appropriate roster-cycle period, members tick boxes daily about the types of after-hours call work they are required to do. That information is then collated and analysed at the end of the period.

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Working updates Safe work

specific focus for our industrial team is enforcing current MECA clauses and supporting various services to negotiate additional payments for the extra duties caused by the Covid surge and short staffing.

No SMO should be put in an ongoing position of being expected to supply additional hours or duties without additional remuneration. The MECA provides that “alternative arrangements and/or compensation” must be put in place where vacancies and gaps arise and where no locum arrangements are in place. Having written agreements, rather than informal arrangements, provide certainty for you and your colleagues about hours of work, and ensures that any adjustments to your workload will be remunerated. Formal service-level agreements also ensure the employer records the ongoing cost of staffing gaps. This is really important. When staff are pressured to cover ongoing vacancies and gaps as part of “business as usual” the true cost of providing healthcare in your service remains hidden. It means that SMOs (and other clinicians) are subsidising the cost of maintaining care.

Recently there has been some pleasing progress on these issues. Auckland metro DHBs are now implementing some minimum additional payments which will apply during the surge. This should mean a fairer and more transparent remuneration landscape across the Auckland region which ASMS will continue to monitor. A significantly improved shift agreement has been negotiated at Taira-whiti DHB’s emergency department which has been struggling with significant vacancies. The new agreement means SMOs who are currently employed will be more fairly paid for the work they do, and the improved local terms and conditions are one less barrier to recruitment. A surge agreement has also been negotiated with the Auckland Regional Public Health Service. Covid has placed major burdens on our largest public

health service. Now there are written provisions to support a fairer distribution of extra work, along with recovery and remuneration arrangements. Because it is a formal arrangement it both enforceable and reviewable. Work is underway to put similar arrangements in place with several mental health services. This will help stop unreasonable workplace demands being placed on SMOs, and solidify existing MECA arrangements around recovery time, extra duties and work done after hours. The pathway to genuine SMO wellbeing is to ensure that services are fully staffed, job sizing occurs regularly, increases in demand and workload are funded, and individual SMOs can access a balanced clinical and non-clinical load. Organising with your colleagues to enforce your MECA is a way forward. Contact your industrial officer if you would like advice or help.

Slow but determined battle on gender pay Dr Charlotte Chambers | Director of Policy & Research

t’s been slow going, but some progress is being made as ASMS works to close the gender pay gap in the specialist workforce. A bit of history In 2019, ASMS-commissioned research on the gender pay gap in the specialist workforce found female specialists were paid 12.5% less per hour than their male colleagues. It also found that gap widened for female specialists with children. The issue was taken to the National JCC where it was agreed between ASMS and the DHBs to develop and test a mechanism to address the existing pay gap. However, attitudes to privacy and

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a general reluctance to share data by the DHBs and TAS meant this initially promising project slowly ground to a halt, and the pilot was never completed. In the meantime, ASMS continued to pick up individual cases with a mixture of success and challenge. A handful of DHBs have required ‘confidential settlements’ as the only mechanism they are prepared to use to adjust individual SMO remuneration, with no public acknowledgment of the problem. ASMS believes this is no way to fix the issue and is now pursuing a more direct approach.

Steps being taken ASMS has written to every DHB, requesting detailed payroll information so that we can run our own data analysis of the national picture. This data includes the salary step and anniversary date for every member. This will mean we can progress the work nationally, without recourse to TAS or the DHBs. Once we have this data, we can match it with the vocational registration status and medical college information from the Medical Council database. This will give us a sound basis for identifying the root causes of the gender pay gap, from which we can then initiate action or intervention.

A good example Leading the way forward is South Canterbury DHB, which responded promptly to our request for payroll information. Our industrial officer Kris Smith is working closely with their HR Department and the Chief Operating Officer, along with ASMS Branch President Peter Doran to investigate the data with a view to making corrections reasonably quickly. It’s an example of good practice, and we hope more DHBs will quickly follow suit. The political context Government MP Camilla Belich has submitted a members’ bill which would seek to amend the Employment Relations Act 2000 to allow employees to disclose their remuneration. The bill “would seek to ensure that employees can discuss and disclose their own pay rate to others without detrimental repercussions to their employment”. If this bill succeeds, it will further change the legislative context against genderbased pay discrimination and would be a welcome development in terms of ASMS’ work to achieve gender pay equity for members.

Gaining ground outside our DHBs Lloyd Woods | Senior Industrial Officer

hrough targeted recruitment, ASMS is steadily increasing its reach into organisations outside of DHBs.

• • •

Over the past five years, we’ve seen a 20% increase in membership in this sector, with a 9% increase in the past year alone. But there is much more work to be done.

• • • •

Many years ago ASMS offered membership and assistance to all senior doctors and dentists employed anywhere across the health sector in Aotearoa New Zealand.

• • • •

Historically, conditions of employment for salaried specialists, particularly GPs and some dentists, have been poorer than for their colleagues in DHBs, and it’s something ASMS has been actively working to change.

• • • • • • •

We now have around 290 members in this group (about 6% of total membership) with collective agreements in the following organisations:

Hospices ACC Te Ru-nanga o Toa Rangatira (Ora Toa) Wellington Union Health Services Ministry of Health Family Planning Wellington Southern Community Labs Central Otago Health Services NZ Blood Service Waitaki District Health Services Christchurch Union and Community Health Centre Hokianga Health Enterprise Trust Golden Bay Community Health COMPASS Health Wellington Clutha Health Otara Wha-nau Medical Centre Ashburn Clinic Nga-ti Porou Hauora

Some of these collective agreements mirror or are close to mirroring the DHB MECA.

We are currently in, or planning negotiations in, the New Zealand Defence Force, ESR, Gore Health and Nelson Hospice. Recruitment We are actively recruiting in any organisation which employs doctors and/or dentists, and there is a requirement for an annual practising certificate. All these employees are eligible for ASMS membership. Currently we are writing to dentists employed at Lumino and the bigger corporate GP providers to offer collective employment agreements to better recognise their work. We also encourage membership from smaller groups, down to individuals working on their own. If you know any salaried specialist working outside of the DHBs, please advise them to give us a call or email lloyd.woods@asms.org.nz to talk about the benefits in joining ASMS.

WWW.ASMS.ORG.NZ | THE SPECIALIST

Seismic funding shift needed Lyndon Keene | Health Policy Analyst

gainst a backdrop of a worldwide health pandemic, long delays for treatment, overwhelmed mental health services, staffing shortages, burnout, and dilapidated hospital buildings, how will this year’s health Budget shape up?

On the face of it, the Government’s Budget Policy Statement, released in December, looks encouraging. With a $6 billion Budget operating allowance for 2022/23 (the amount of new operational spending available government-wide) – this is the largest spend since the Global Financial Crisis of 2008. Covid-19 spending aside, Vote Health could see at least a third of this figure. Unfortunately, this potential $2 billion increase to Vote Health is not as rosy as it may seem at first blush. Much, if not all of the additional funding could be swallowed up by the costs of inflation, demographic changes, DHB deficits and Budget pre-commitments. The Covid-19 pandemic has helped draw attention to the lack of investment in health, but, as the Health and Disability System Review found, the system was struggling to cope well before Covid-19 arrived in New Zealand. Even the Health Minister Andrew Little has conceded this failure, saying, “It did not help that funding for our public health system failed to keep up with population growth for many years, that much-needed investment in new facilities and modern IT systems was simply not made, and that pay for nurses went backwards in real terms.” Among 15 comparable countries1, New Zealand ranked second-to-bottom in 2019, both on per capita spending and total spending per GDP. New Zealand 1

would have needed to add $4.5 billion to match the median country spend per GPD of Norway. It would be higher still this year. This is the scale of funding needed to address entrenched staff shortages and unmet health need. New Zealand’s low funding levels have contributed to relatively low rates of surgeries, poor access to new medicines and poorer cancer survival rates when matched against other countries. Funding of DHBs continues to be well short of what is needed to run a properly functioning health service.

GDP among OECD countries, the size of budget allowances has more to do with politics than affordability.

An ASMS analysis has also found that to be on a par with Australia, New Zealand needs approximately 1,500 hospital specialists (private and public), 1,600 GPs and 12,000 nurses. This recently led ASMS to call for the declaration of a health workforce emergency, which attracted the support of other health unions and the Medical Association.

The Government’s aspiration of everyone being able to have timely access to effective health care according to their need is not radical, but it will take a seismic shift in funding to get anywhere close to that. This requires relinquishing old ways of thinking where health services are viewed as costs that need to be controlled. Rather, we need to take a broader social and economic perspective which recognises the overwhelming evidence that spending in health is an investment resulting in substantial social and economic gains. Whether or not the new system meets this funding challenge is about to be tested.

Despite this, the potential remains to put financial substance into the Government’s ‘Build Back Better’ slogan for health services over the coming years. But to do so would require the Government to continue with annual budget operating allowances to at least the levels announced for this year’s Budget. Currently, the Finance Minister Grant Robertson is saying this year’s allowance is a ‘one-off’. But in New Zealand, with its low government debt and low government spending per

What is clear then, is that each year’s health Budget will be shaped by the health politics at play. With Health NZ looming, much is expected from the restructured system, the managers, and those working at the front line of health care provision. But as the Health and Disability System Review put it: “No system can operate effectively without adequate funding.”

* the figures used are based on detailed research. If you are interested in seeing a more comprehensive analysis and breakdown of the figures, please look for this article on our website www. asms.org.nz

USA, Germany, Switzerland, France, Sweden, Canada, Belgium, Norway, Netherlands, UK, Denmark, Australia, Finland, New Zealand, Italy

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Farewells who’d been at the helm for 30 years, announced his intention to leave. Months of work went into navigating and managing the recruitment process. “We took it extremely seriously and did our homework. No matter who was chosen, I wanted members to feel the process had been robust.” As a self-confirmed data geek, Murray says he wanted to make the most of ASMS’ research. “My research background meant that I was keen to see good data on important issues to help drive improvement. I was therefore very supportive of increasing the research capacity of ASMS.” For Murray, research on doctor shortages, burnout and the gender pay gap were top of mind. Without his ASMS commitments, Murray is planning more time on his tractor.

Professor Murray Barclay

“I felt strongly that we needed to focus on the 40% of our members who were female and getting treated worse than the other 60% of our membership. I wanted to see that there was a process for that to be fully addressed and corrected.”

SMS’ immediate past President and Canterbury DHB gastroenterologist and clinical pharmacologist Professor Murray Barclay decided late last year to step down from the National Executive.

The need for ASMS to put patients at the middle of any debate was another strong focus for Murray, and he worked to highlight concerns and data around unmet need and long waiting times.

He was elected on to the Executive in 2013 and served as President between 2018 and 2021.

He found he was what he describes as a “naturally aggressive negotiator” when it came to leading MECA negotiations, and he enjoyed the bargaining environment.

He says he took over at a pivotal time when the immediate focus was to find a new Executive Director after Ian Powell,

“It is my firm belief that at the end of the day, the way we are going to solve doctor

Dr Annette van Zeist-Jongman Annette served as Waikato Branch President from 2012 to 2018 and was elected on to the National Executive in 2018. She resigned early this year to move back to her home country of the Netherlands. She had worked in New Zealand since 2007 as a consultant forensic psychiatrist. ASMS President Julian Vyas says Annette was “a keen supporter for work ASMS has been doing to address unfairness in the workplace – such as the gender pay gap and equity of member representation.”

shortages and burnout is to have better salaries and conditions to help doctors stay in New Zealand or attract them from overseas.” His goal was to make an ambitious attempt to overcome the pay gap with Australia and was disappointed when Covid-19 interfered in the 2020 negotiations and “we had to step things back”. Murray is proud of establishing a Charter and a Code of Conduct for the National Executive, which he says gives it a firmer footing going forward. Focusing on clinical leadership and creating a document around the role of the clinical director was another key piece of work that he prioritised. He’s keen to see it actively promoted and discussed. What Murray enjoyed the most about his time as President was not so much centred on personal achievement but rather on the people he met and worked with – members, National Executive colleagues, ASMS staff and people from different organisations. National Executive member and former Vice President Dr Julian Fuller says despite holding so many other professional responsibilities, Murray devoted an enormous amount of time to ASMS. He describes him as a calm and thoughtful President who was unflappable and dedicated. “He has been a great asset to us over his time. We will miss his quiet determination, and contribution, and wish him and his family well.”

Tim Frendin We want to acknowledge the retirement of Hawke’s Bay geriatrician Dr Tim Frendin from both clinical practice and ASMS after a long association. Tim spent ten years on the National Executive from 2009 to 2019. Tim said, “The association I have had with ASMS over the past 30 years has been one of the most outstanding aspects and privileges of a professional life and career, in particular the 10 years I was fortunate enough to spend on the National Executive.”

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Jack and his son Alex after completing the 34-week immersion course

A very personal sabbatical Dr Jack Hill | Auckland Anaesthetist

Ko taku reo, taku ohooho, ko taku reo, taku mapihi mauria. My language is my awakening, my language is the window to my soul

Tuatahi, te-nei to-ku mihi maioha ki te wha-nau o Toi Mata Hauora. Te-na- koutou e a-ku rangatira. Tuarua, he mihi nunui ki Te Wa-nanga Takiura o Nga- Kura Kaupapa Ma-ori o Aotearoa. He ta-ngata manaaki, he a-whina, he tu-manako hoki a ra-tou. Mauri ora e te wha-nau wha-nui o Takiura. Tuatoru, ka tukuna e ahau i te-nei mihi ki a Papa Tawhiri Williams (Kaitiaki Huhua) ra-ua ko Nanny Kaa Williams (Pouako Matua). Ko nga- poutokomanawa o te reo. He manukura o te ao Ma-ori.

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Ko Jack Hill ahau. He uri o Nga-ti Wha-tua, ko Nga-ti Kahungunu, ko Nga- Puhi, ko Ngati Tu-wharetoa ra-tou ko Nga-ti Raukawa. In 2021, I enrolled in a 34-week total immersion course in te reo Ma-ori at Te Wa-nanga Takiura o Nga- Kura Kaupapa Ma-ori o Aotearoa. Takiura was established in 2000 for the purpose of teaching te reo Ma-ori to teachers, but over the years it has broadened its student base, offering a rumaki reo course.

Is learning te reo Ma-ori a legitimate CPD activity? A fair enough question, considering my CPD allowance helped finance my tuition. As an anaesthetist working in a tertiary obstetric hospital, like many, I have observed health care inequities and inequalities experienced by Ma-ori. There are multiple determinants for these inequities and inequalities – unconscious bias, microaggression, internalised racism, institutional racism, and negative

stereotyping. Addressing these inequities and inequalities is a complex matter for many DHBs. Integrating tikanga Ma-ori and ma-tauranga Ma-ori into institutional culture is seen by many to be a strategy to counter these negative determinants. These strategies are centred around te reo Ma-ori. I grew up observing te reo Ma-ori being used for po-whiri, poroporoaki, hui, and tangihanga. Despite my four grandparents being fluent speakers, neither my parents nor I got an opportunity to learn from them. Understandable, given the prevailing negative attitudes regarding the worth of te reo Ma-ori and tikanga Ma-ori. My niece, who had been a student at Takiura, believed a total immersion course was the best way for me to nurture my reo. Hence my haerenga to Takiura.

Despite my four grandparents being fluent speakers, neither my parents nor I got an opportunity to learn from them.

Organising and applying for a sabbatical is a time-consuming process – in my case, nearly two years. In preparing my application, I sought support and advice from my kuia (Dame Naida Glavish), as well as consulting my directorate and clinical services managers.

I was fortunate to have enough annual leave to cover the weeks not covered by sabbatical leave. I was also able to continue my after-hours on-call obligations during the year. To ensure that I kept my ‘hand in’, I elected to return to the day roster during term breaks. I started in a class with 29 other students, one of whom was my son Alex, a secondyear law student. Most students were tangata Ma-ori, with a range of ages, te reo proficiency, and demographics. Despite these differences, my akomanga quickly bonded, developing a strong sense of whanaungatanga and kotahitanga. We often drew on the support of one another as we faced the rigours of our course. For the first few weeks we could speak English, and after that we were encouraged to speak te reo Ma-ori on campus. In the course of the year, I managed to compose a mo-teatea referencing important tribal relationships and a waiata tautoko. My waiata was specifically composed to acknowledge our babies, our mothers, and their wha-nau. It was a fundamental component of my work and that of my colleagues. In recent times when I have spoken at hui at work, I have used this waiata to complement my ko-rero. Reflecting on my year, I must admit to being cocky before starting Takiura. How hard could this be? Three-years BSc, six-years MB ChB, five-years Fellowship, I’m sure I will be a kaiwhaiko-rero pu-kenga in next to no time. Aue-!!! Four weeks into the course, these expectations were

completely dashed, and I was in a state of perpetual confusion. I was trying to write things, creating Excel spreadsheets with grammatical rules, hoping things would stick. Many a morning I would share my anxieties with my son on how difficult it was.

Four weeks into the course, these expectations were completely dashed, and I was in a state of perpetual confusion.

One day he said to me, “Haki, kia whakarongo koe, ka taka te kapa” (Jack, when you listen, the penny will drop). I eventually took his advice and my fluency improved. I made the effort to speak te reo Ma-ori as often as I could, even if it meant making occasional grammatical mistakes. Through the patience, support, and perseverance of my kaiako and my akomanga, I was able to make progress. This became my wero to myself to push onwards. To encapsulate what learning te reo Ma-ori has meant to me, I recall that during my sabbatical year, my son gave a whaiko-rero on behalf of our akomanga at the tangihanga for a classmate’s father. A big responsibility on young shoulders, particularly as he was addressing a taumata of esteemed Tainui kauma-tua. In that moment, his whaiko-rero embodied the ngako of te reo Ma-ori, te reo rangatira. It is summarised in my whakataua-ki-.

He aha te mea nui mo- te reo rangatira? Ko te kotahitanga, te whanaungatanga, te manaakitanga, te a-whina, te tautoko me te aroha. What are the important things about the esteemed language? Unity, connectedness, respect, care, support and love

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When you are asked to work outside your area of expertise Dr Mark Burns | Medicolegal Consultant, Medical Protection

here may be occasions when management requests that you work outside your designated scope of practice. This is usually during periods of significant staff shortages such as pandemic illness and absence, RMO and nursing industrial action, and resource-limited environments when the appropriate vocationally trained specialists are unavailable. You may also be called on to assist in other emergency situations. Scopes of practice The Medical Council defines ‘scope of practice’ as the type of work a doctor can perform in New Zealand. It categorises three broad types of scope of practice: • General – usually RMOs and doctors in vocational training • Vocational – for doctors who have completed their vocational training and hold a postgraduate qualification that has been approved by the Medical Council • Special purpose – for doctors visiting New Zealand for a specific reason such as to undertake research. Most doctors practising in New Zealand are registered in a general scope of

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practice and may also have vocational scope. Doctors with unrestricted general scopes – typically New Zealand, Australian, UK and Irish medical graduates – can work in any area of medicine in any setting. Doctors may have conditions on their general scope, such as a ‘hospital-based practice’, meaning they can work in any area of medicine in a hospital setting. Covid flex At the beginning of the Covid-19 pandemic, to allow for flexibility for expected staff shortages, the Medical Council allowed that doctors holding general scope with limitations, and those holding vocational registration only (with no general scope), would be authorised to work outside their scope to provide health services related to Covid-19. This included providing cover

to relieve other doctors providing Covid-19 related care. This authorisation expired in November 2020, although the Medical Council continues to consider options to support the Covid-19/Omicron response. Assisting in an emergency The Health Practitioners Competence Assurance Act 2003 states in section 8 that health practitioners must not practise outside their scope of practice. However, there are exceptions, such as being required to assist in a medical emergency. The Medical Council expectations are that when faced with or called to attend an emergency, a doctor has an ethical obligation to respond and apply their knowledge and skills to assist. It is acknowledged that doctors have different skill and knowledge levels, and if you do

not have the right skills, you should assist where possible within your own skill set. The assistance must be provided to a reasonable level of care and skill, consistent with Right 4 of the Code of Health and Disability Services Consumers’ Rights. If you are asked to perform a duty that you would not normally undertake, regardless of the circumstances, you need to assess whether you have the skills and competency to proceed. If you do not feel it is safe or you would place the patient at greater risk of harm, then you should make your concerns clearly known. Working in another area of medicine Doctors registered in a vocational scope of practice who also have general scope are able to work in any area of medicine. However, if you are working within your general scope of practice in another area of medicine, you must have a collegial relationship for the area of medicine in which you are working. In a pandemic or RMO strike, you may be asked to work on a medical ward, for example, and you would sensibly take on a junior doctor role and be supervised by the physician in the team.

You may be asked to work in an area that is from a Medical Council perspective within your vocational scope of practice but is in a subspecialty you may not be experienced in – for example, a cardiologist being asked to run a general medical ward, or an adult community psychiatrist being asked to work in child and adolescent psychiatry. The Medical Council determines the scope of the 36 areas of medicine, and the scope of practice called psychiatry would include working in child and adolescent psychiatry. Cardiology and general medicine are both covered under internal medicine. So, from a Medical Council perspective, this is not problematic. However, if you felt you didn’t have sufficient experience, skills or knowledge in the subspecialty, you would be wise to have supervision. This can sensibly be part of advance pandemic planning. Whenever you are working outside your area of expertise, it is prudent to consult senior colleagues and keep documented records. In resource-limited environments, specialists may be asked to work in an area not within their vocational scope. An example might be if urologists are

not available, general surgeons might be considered to have the best skill set to offer limited urological care. In addition to raising concerns with management about the situation (and keeping an email paper trail), if this was outside the scope of a general surgeon it would fall under general scope and would require a collegial relationship with a urologist. What does Medical Protection provide? The purpose of Medical Protection is to provide support and assistance for issues arising from clinical practice. We are able to deal with unpredicted problems members might face such as Good Samaritan acts in an emergency, additional duties to ensure patient safety during strike action, and redeployment during pandemic staff shortages. We have the flexibility of discretion to determine the type and level of assistance we can provide. Our indemnity is not limited by ‘small print’ exclusions. ASMS also has advice on what to do if you are asked to undertake other duties, work additional hours, or work a staggered roster during the Covid-19 pandemic. It’s at www.asms.org.nz – search for ‘surge agreement’.

review that “might result in significant changes to either the structure, staffing or work practices affecting employees”. Indeed, before undertaking any review “that might impact on the delivery or quality of clinical services” the DHB is required to seek ASMS endorsement as to the “purpose, extent, process and terms of reference of such review”.

Good consultation is your right and critical to your overall wellbeing The need for timely consultation with employees in the health system is covered by law through the Employment Relations Act. Among other things, it states that “promoting productive employment relationships” requires the parties to commit “to engage constructively and participate fully and effectively in all aspects of their employment relationship”. To avoid any doubt, the DHB MECA makes this more definite in Clause 43, requiring DHBs to include formal consultation “at the earliest practicable opportunity” for any

DHBs must consult with you and ASMS about anything that might affect your patient care or your working lives. This includes things like setting or changing CME, sick leave, annual leave or other DHB policies, along with any change to staffing or model of care. Sadly, some DHBs have become very lax about fulfilling their obligations to the Employment Relations Act and the MECA. If your DHB implements or changes policies, procedures, and models of care which affect you as an ASMS member, contact your industrial officer straight away. WWW.ASMS.ORG.NZ | THE SPECIALIST

Marlize in one of her hand-knitted creations

Marlize on the job

with TE

MINU

Dr Marlize Alberts

Marlize is an SMO in the emergency department at Waikato Hospital and is Vice President of ASMS’ Waikato Branch. She trained in South Africa and came to New Zealand in 2006. What inspired you to get into your field of medicine? I have always wanted to be a doctor, at least since I found out that girls could become doctors! My love affair with emergency medicine began with first aid training in primary school. I guess it is the variety and unpredictability that appeals to me, and of course the adrenaline! I did, however, opt out of specialist training. The study doesn’t scare me, but the pressure of competing for training positions and the nomadic lifestyle of a registrar just put me off. So, I work as a MOSS at Waikato ED. I am currently working on the Emergency Medicine Diploma through ACEM. What are some of the challenging aspects of your job? The biggest challenge over the past few years has been short staffing in the face of growing patient numbers. We see more 24 THE SPECIALIST | MARCH 2022

than double the number of patients that we saw six years ago. Patients also tend to be older, with higher acuity and more complex pathology. What do you find rewarding about your job? When people come to the emergency department, they are generally having a pretty bad day. My aim is always to try and make a terrible experience a little less bad. Getting a half smile from someone who was crying a little while ago is a good feeling! I also love the technical part of my work, like getting a good reduction on a broken wrist or putting a complicated wound back together. What do you see as the biggest challenge facing the health system? Besides Covid-19? Inadequate funding. We are expected to deliver first class medical care, but Governments do not want to pay for it. I am afraid I am a bit of a socialist,

I do not believe that health should be reserved for the wealthy. It should be universal, appropriate and tax funded. I believe that the country can afford anything we prioritise. As someone said: we have the health system we pay for. What keeps you happy outside work? My husband and my cats! I read A LOT, and I make stuff. I sew, knit, quilt, crotchet and do embroidery. I have also taken up pottery in the last year. Doing something creative is a physical need for me, like eating and sleeping. It also forces me to slow down and to let go – accepting little imperfections as part of the process. Why did you want to be involved with ASMS? Being involved with the union gives me a voice. We all struggle and complain about stuff to each other; being able to express these concerns to the people at the top is quite empowering.

ay of Plenty psychiatrist Dr Mark Lawrence (Te Rarawa, Te Aupo-uri and Nga- Puhi) has been confirmed as ASMS’ new National Executive member. He was elected unopposed to the vacant position in region two left by Annette van Zeist Jongman. Mark is part of a community adult psychiatry team and works within an integrated model of care within both kaupapa Ma-ori and mainstream services at Tauranga Hospital. He is also a senior lecturer at the University of Auckland School of Medicine, teaching and

examining undergraduate psychiatry students. Last year Mark was elected as a Director of the Royal Australia and New Zealand College of Psychiatrists. He is looking forward to learning more about ASMS and believes he will bring a different perspective to the National Executive. Welcome Mark, we look forward to working with you.

Dr Mark Lawrence

New Years Honours S

everal ASMS or former ASMS members were recognised in the New Year honours list. Professor Joel (Jim) Mann became a Knight Companion of the New Zealand Order of Merit. Professor Mann has pioneered research relating to noncommunicable disease prevention and management at the University of Otago’s Departments of Medicine and Human Nutrition since 1988. His epidemiological and nutrition-related research has informed world-leading interventions in the fields of coronary heart disease and diabetes. Mr Prodhumun Dayaram was appointed an Officer of the New Zealand Order of Merit for services to orthopaedics. Mr Dayaram was an orthopaedic surgeon on the West Coast for more than 35 years – ten of those as the sole orthopaedic surgeon for the region. He led the West Coast in many ‘first’

surgeries in New Zealand, including the first to use the technique of arthroscopy and first of two surgeons to perform carpal tunnel surgery through keyhole surgery for faster recovery time. Mr Dayaram retired last year. Dr Clare Healy was appointed an Officer of the New Zealand Order of Merit for services to medical forensic education. Dr Healy has been working for and with people affected by sexual assault, abuse, family violence and non-fatal strangulation through Medical Sexual Assault Clinicians Aotearoa (MEDSAC) for more than 25 years. She has helped lead the primary health care response to family violence in Canterbury. Dr Lindsay Francis James Mildenhall was appointed an Officer of the New Zealand Order of Merit for services to neonatal intensive care and resuscitation training. He specialises

in the care of newborn babies and until recently held the position of Clinical Head of Kidz First’s Neonatal Intensive and Special Care Service at Auckland’s Middlemore Hospital – a role he had been in since September 1998. Dr Christopher David Moyes was appointed an Officer of the New Zealand Order of Merit for services to health. Dr Moyes, who previously worked at Whakata-ne Hospital, has been treating those with hepatitis B and C virus for 40 years, in addition to his work as a paediatrician. He played a key role in researching the prevention and treatment of hepatitis B and convinced the Government to roll out a fully funded hepatitis B vaccination for all infants. He has been Medical Director of the Hepatitis Foundation of New Zealand for many years, supporting 30,000 patients.

WWW.ASMS.ORG.NZ | THE SPECIALIST

Your industrial officers There are some new faces in the ASMS industrial team. Tina McIvor has joined us from the Problem Gambling Foundation, where she was their Health Promotion Lead. Jenny Chapman joined in November last year from the New Zealand Nurses Organisation and is based in Hamilton. Tanja Bristow, who has worked for a number of unions - most recently the Independent Schools Education Association – arrived in February and is based in Auckland. Our industrial officers work in three regional teams. Northern: Steve Hurring, Georgia Choveaux, George Collins, Jenny Chapman and Tanja Bristow. Central: Henry Stubbs, Ian Weir-Smith and Tina McIvor. Southern: Lloyd Woods, Kris Smith, and David Kettley. Once Health NZ is established, we will continue to provide an initial point of contact for your workplace, but work may be shared within our regional teams.

Lloyd Woods

George Collins

Steve Hurring

Jenny Chapman

Ian Weir-Smith

Tina McIvor

David Kettley

Tanja Bristow

Henry Stubbs

Georgia Choveaux

Kris Smith

If you’re not sure which industrial officer to contact, go to www.asms.org.nz or phone our support team 04 499 1271 to be put in touch with the right person.

26 THE SPECIALIST | MARCH 2022

ASMS staff Executive Director Sarah Dalton Communications Senior Communications Advisor Elizabeth Brown Senior Communications Advisor Andrew Chick Industrial Senior Industrial Officer Steve Hurring Senior Industrial Officer Lloyd Woods Senior Industrial Officer Henry Stubbs Industrial Officer Ian Weir-Smith Industrial Officer David Kettley Industrial Officer Tina McIvor

ASMS services to members As a professional association, we promote:

ASMS job vacancies online

• the right of equal access for all New Zealanders to high quality health services

Check out jobs.asms.org.nz a comprehensive source of job vacancies for senior medical and dental specialists/ consultants within New Zealand hospitals and health services.

• professional interests of salaried doctors and dentists • policies sought in legislation and government by salaried doctors and dentists. As a union of professionals, we: • provide advice to salaried doctors and dentists who receive a job offer from a New Zealand employer • negotiate effective and enforceable collective employment agreements with employers. This includes the collective agreement (MECA) covering employment of senior medical and dental staff in DHBs, which ensures minimum terms and conditions for more than 5,000 doctors and dentists, nearly 90% of this workforce • advise and represent members when necessary • support workplace empowerment and clinical leadership.

Contact us Association of Salaried Medical Specialists Level 9, The Bayleys Building, 36 Brandon St, Wellington Postal address: PO Box 10763, The Terrace, Wellington 6143 P 04 499 1271 E asms@asms.org.nz W www.asms.org.nz Follow us facebook.com/asms.nz twitter.com/ASMSNZ Have you changed address or phone number recently? Please email any changes to your contact details to: asms@asms.org.nz If you have reason or need to seek a reduction or waiver to your annual subscription, please write to us. Our constitution allows for this in certain circumstances. Emails should be addressed to sarah.dalton@asms.org.nz

Industrial Officer George Collins Industrial Officer Kris Smith Industrial Officer Georgia Choveaux Industrial Officer Jenny Chapman Industrial Officer Tanja Bristow Policy & Research Director of Policy and Research Charlotte Chambers Policy Advisor Mary Harvey Health Policy Analyst Lyndon Keene Support services Manager Support Services Sharlene Lawrence Membership Officer Saasha Everiss Support Services Administrator Cassey van Riel Finance and Technical Support Advisor Vanessa Wratt

PO Box 10763, The Terrace Wellington 6143, New Zealand +64 4 499 1271 asms@asms.org.nz

WWW.ASMS.ORG.NZ | THE SPECIALIST

Join the insurer that’s driven by purpose, not by profit. Life and income insurance that’s inspiring healthier communities. Join today. mas.co.nz

The Specialist - Issue 130

Articles inside

Your industrial officers

A very personal sabbatical

Five minutes with Dr Marlize Alberts

Did you know?

When you are asked to work outside your area of expertise

Farewells

Seismic funding shift needed

About the size of it

Deep diving into our IMG workforce

Gaining ground outside our DHBs

Data and insight

MECA – frustration meets facilitation

Taking on the biggest job in health

Pulling the PIN

Pain and parsimony