The Specialist No 140 | September 2024

ISSUE #140 SEPTEMBER 2024

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: Andrew Chick

Journalist: Matt Shand

Designer: Twofold

Cover Image: Shutterstock

The Specialist is produced with the generous support of MAS.

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A

Lester Levy spoke to The Specialist about what he thinks success looks like reshaping Health New Zealand.

PROFILE:

Jo Sinclair is working to see greater recognition, and measurement, of the mental health of clinicians at Te Whatu Ora.

WHOSE FAULT IS IT ANYWAY?

KATIE BEN, PRESIDENT

It is specialists who bear the real brunt of resourcing decisions higher up an organisation. We need to remind managers of that.

Whose fault is it anyway? It is a question that is being thrown around a lot when it comes to the health system. It is grim reading for anyone working in health right now.

The media is full of stories of people waiting in ambulances for hours and in emergency departments for hours or even days, people languishing on acute operating lists for days and weeks while waiting for a slot, and health care staff working through staffing gaps and working without adequate, essential resources.

As doctors we are required to practise medicine to the highest standards, and there is no allowance made for resource limitations and current working conditions.

We are contractually obligated to meet the ethical standards set by our governing bodies, the Medical Council and our colleges. Each patient we see has the right to the highest standards of care whether they are in Auckland or Invercargill, as laid down in the Code of Health and Disability Services Consumers’ Rights.

When I am working on call, I am the only anaesthetist in the hospital. This often requires me to be in two places at once. I can be in ED with a major trauma, heading to theatres with a long and complex laparotomy and, at the same time, be called to obstetrics for a much-needed epidural in a woman who has been labouring some hours, or (my recurring nightmare) a Category 1 caesarean section when we are already in theatre with another case on the table.

There is no second on-call anaesthetist. There is no backup theatre team. None of my medical training to date has grounded me in this sort of triage decision – the 35-year-old man who may lose his life, or the 35-year-old-woman who may lose her baby?

The stark reality is that those are the sorts of decisions our managers are all asking us to make.

While our senior leaders are making the decisions about where the money is spent, it is the clinicians on the ground who are being forced to make the difficult decisions about where their time is spent. And it is the clinicians on the ground who will be held accountable if –or, more likely, when – something goes wrong.

As clinicians, therefore, we must hold our employers accountable for the resourcing decisions they make.

We have to make them face the cold hard truth that a health service cannot be run on the ever decreasing goodwill of the staff who are doing their best, and we absolutely cannot allow them to pay for the health of the nation with our own health and wellbeing, which is what we sacrifice every time we agree to cover one more session, one more on call, one more extra weekend.

We need more colleagues at every level. We need to remind our employers that the ‘non-patient facing roles’ do as much good for the patients as the ‘patient facing roles’, and that cuts to anything are cuts to frontline services as a whole.

We need to be aware that in continuing to prop up a failing system, we become as responsible for its shortcomings as the managers who expect us to keep on doing so.

I apologise to those who feel angry reading this, and especially to those who feel ASMS could do more. Believe me we are doing as much as we can to highlight the systemic issues, and we will continue to do so.

We know you are struggling. We hear you. We are you. He waka eke noa – we are all in the same boat and all navigating the same storm. Here’s hoping for some clearer skies ahead.

While our senior leaders are making the decisions about where the money is spent, it is the clinicians on the ground who are being forced to make the difficult decisions…”

WHAT PRICE DINNER?

SARAH DALTON, EXECUTIVE DIRECTOR

When the price of groceries goes up, is it fair to label shoppers who can no longer afford them as being ‘financially illiterate’?

The reality is prices are going up everywhere and the health care system is not immune to rising cost pressures.

The newly appointed Commissioner of Te Whatu Ora, Professor Lester Levy, has suggested that the now-removed board members were not across Te Whatu Ora’s finances.

This has sparked a debate about whether the board was irresponsibly overspending, or if the health system as a whole is underfunded. Our research shows it is the latter.

Politicians argue this is not the case. They use words like ‘record investment’ in health, but closer analysis shows this year’s real increase to health spending –the spending that will benefit frontline patients – is only $93 million, or about 0.4 per cent of Vote Health.

If you buy 0.4 per cent more groceries, would you say you had a ‘record breaking’ shop?

Professor Levy has been tasked with cutting $1.4 billion from the never-ending grocery bill of the health system. He has claimed he can do this without affecting frontline staff.

I say that is impossible. Taking our grocery example (likely too far, but bear with me), if the frontline product was a meal, what can you realistically cut from that bill that will have no effect on the front line?

You can cut the portion size, purchase lower quality ingredients, change the type of meal you serve, but all of these changes will have some tangible, detrimental effect on the end product.

You will still serve a meal, but it will be smaller and less nutritious. You’ll most likely still be hungry afterwards.

Professor Levy’s claim that 2,500 jobs from ‘management bloat’ can be cut without any impact on frontline services is unrealistic.

Are we saying these 2,500 people did nothing during their workday? None of them coordinated clinical rosters, none of them managed cleaning of emergency departments? Can we say none of them ordered clinical equipment, curated needs of clinical wards, helped organise patients, provided after-support to patients or did anything that could not be connected to the front line?

Efficiency is always a goal, but hospitals do not run on profits, nor should they. Health will always carry a cost

of provision. Politicians get too caught up in numbers and bottom lines –often to fund tax cuts – to realise that the health care system is about, you guessed it, health and care.

The answer to the health care crisis is more money, not less spending. It is not financial illiteracy to point this out. This is not a popular political opinion, regardless of what political camp you are in. Political parties have long taken credit for any health care gain and blamed any negative aspect on the ‘previous government’.

Our see-sawing political system means there is little ‘continuity of care’, and this is why ASMS has released a paper in the New Zealand Medical Journal calling for an independent review of health care funding.

Politics tends to deliver answers such as targets and spending cuts, and lacks the long, long view. We need health decisions to be measured across decades, not political cycles.

An independent inquiry could look at the system, see the increasing demand for acute care – well outside the rising population numbers – see the growing wait times, and conclude that people are living longer with more complex medical needs.

It will also see the health care system is already scrimping and saving – doing as much as it can with the limited resources available.

New Zealand’s investment in the health system tends to be lower than comparable countries and its productivity relatively higher. In 2021, New Zealand’s total public and private health expenditure was 10 per cent of its gross domestic product, compared to an average of 11.7 per cent for 14 comparable OECD countries.

An independent inquiry could see that in order for New Zealand to match this spend it needed to invest another $5.8 billion, not cut $1.4 billion.

We need the inquiry to take a good, honest look at our health care grocery bill.

The alternative is that New Zealand will have to decide what dishes to cut from our menu or, the worst-case scenario, let our people know they cannot come to dinner.

Not everyone agrees with this, but I believe there is a lot more we can deliver with the resources we have got.”

- LESTER LEVY

A LEVY ON HEALTH

MATT SHAND, JOURNALIST

One week into his role as Commissioner for Health New Zealand, Lester Levy spoke to The Specialist about what he thinks success looks like reshaping Health New Zealand.

The new Commissioner for Health New Zealand says he will not waste time figuring out what went wrong with the previous board. He is simply going to play the cards he has been dealt and focus on fixing the financially dire situation.

The board of Health New Zealand was removed, and Lester Levy was appointed to the position of Commissioner in July by Minister of Health Shane Reti, after papers provided to Cabinet showed Health New Zealand was overspending by $130 million per month.

Extrapolated out, this represented a potential $1.4 billion annual deficit, and Prime Minister Christoper Luxon said Health New Zealand suffered from a lack of financial control and had “no great understanding or literacy around cash flow analysis whatsoever”.

“The board not being aware and not being financially literate, and not being able to get a financial picture in itself is a real big problem,” he added.

Members of the removed board included Vanessa Stoddart, Amy Adams and Naomi Ferguson, and doctors Curtis Walker and Jeff Lowe.

Levy’s appointment follows the Minister’s decision to appoint a Crown Observer to the Board of Health New Zealand in December last year. The Crown Observer’s role will also end now that Levy has been appointed.

As well as avoiding a potential deficit, Levy has set himself the additional challenge not to cut jobs that will affect frontline services will be

affected. Levy says most of his cuts are aimed at management positions and he has specifically committed not to cut any SMO terms and conditions such as long service leave.

“The number of management-type roles has increased by about 2,500 since 2018,” Levy says.

“That is true. That’s where a lot of the numbers come up. At the moment we are trying to get the data and then begin the process.

“I have seen triplication and quadruplication of roles within Health New Zealand all over the show. I think when these organisations came together it would have been a good idea to get some coherence about that. You don’t need six people doing the same thing.

The targeting of management has already seen National Director Hospital and Specialist Services Fionnagh Dougan and National Director Commissioning Abbe Anderson lose their jobs.

The four Regional Director roles at Health New Zealand have been replaced by four regional Deputy Chief Executives, with three of the incumbents – Chris Lowry in Te Manawa Taki, Russell Simpson in Central and Ngarie Buchannan in Te Waipounamu (an interim Regional Director) – being overlooked for the new roles.

“It is extremely difficult to cut jobs,” Levy says. “I’ve been through this a few times before and, to be completely frank about it, you are never the same person afterwards.”

Data concerns create confusion

Levy has been tasked with cutting what the Government has called Health New Zealand’s “bloated bureaucracy”. However, Health New Zealand has proven a difficult organisation to take an axe to.

As many ASMS members can attest, staffing reports solely about SMO numbers are of variable quality and accuracy across the districts of Health New Zealand.

Levy says there are “many concerns” with the data he has access to and whether the data he receives is accurate.

“We have really had to dig deep, probably deeper than anywhere else, to make sure we have the right data and the data we’re dealing with is accurate.

“You can’t just push a button and get it. We’re looking at the entire structure and looking to get the right information before making decisions. Once we have the data we will be talking to staff and unions about the process [for redundancies] and that is where we will begin.”

Productivity top of mind

Levy is vocal in his belief that Health New Zealand can do better with the resources it currently has.

“Not everyone agrees with this, but I believe there is a lot more we can deliver with the resources we have got,” Levy says.

“People do not like to speak about productivity, but I do not just see productivity as a commercial or financial construct. I see it as a clinical construct.

“If we can get more out of the resources we’ve got, then we can accelerate this waiting time reduction and we can help people get to more services. And we can definitely achieve that.

“We need to transform this organisation into a health delivery organisation, get productivity up, empower the front line and ensure jobs support that effort. Health delivery is the main show in town.

“When I talk about that, I am not just talking about nurses, doctors and allied health, I am talking about the administrators in that front line – the electrician keeping the lights on and the cleaner. It’s all part of the front line. That’s what I want to power up.

“I think Health New Zealand looks more like a public bureaucracy sector organisation and it needs to be recalibrated so that it looks like a health delivery organisation.”

As well as management bloat, Levy wants to see better use of the locum workforce. When asked about the expenses of hiring locums to fill vacant positions, he says there needs to be reduced reliance on a contingent workforce.

“We have a very big budget for contingent workforce and that budget is being overspent quite a lot,” he says.

“We need to increase our permanent staffing, for senior doctors in particular, and reduce the reliance on locums. That is in all areas, not just the hard-torecruit areas. Maybe we have not been very good at doing this [recruiting] or maybe there are legitimate shortages, but this will be a big focus.”

Wait times and the return of targets

Another key focus for Levy is a reduction in wait times, in line with Minister Shane Reti’s national health targets. “I have always said the shortest wait [for a patient] is the safest wait,” Levy says.

“My priority is getting wait times down. We have national targets, and I know some people do not like targets. I never see targets as the end, they are the means to an end. The end is to have proper flow and managed demand across the health system.

“That is not just in the emergency departments. The ED is where it manifests the most. But we need to make fixes across the system. At the moment the system is very vertically siloed and that is unhelpful.”

RIGHT: LESTER LEVY, COMMISSIONER FOR HEALTH NEW ZEALAND. BELOW: MARGIE APA AND LESTER LEVY.

People do not like to speak about productivity, but I do not just see productivity as a commercial or financial construct, I see it as a clinical construct.”

- LESTER LEVY

Levy says his experience as a board member of Waitematā DHB from 2009, and chair from 2016, shows how targets can be met.

“When I was appointed in 2009 it was on the back of a very negative review from the Health and Disability Commissioner,” he says.

“It showed that people had come to harm and died as a result of being left in corridors. We were only at 61 per cent of our target. There was a lot of tension at the hospital and a lot of the advice I had from clinicians was to close down.

“We didn’t and we managed to open 24/7, which was a good day. We got over the 95 per cent target, and the thing I will never forget about that is the people who were working there, leading the change, were the same people, other than the odd one coming and going, that got the 61 per cent.

“They got to 95 per cent and kept it there. So, yes, this can be done and done by the same people. There are different approaches needed. We’re going to have a level of clinical involvement and engagement that has not been seen within Health New Zealand. I want to see all our major decisions made in the clinical frame of reference, and I will be getting groups together to help advise me as a commissioner because you cannot be a Lone Ranger. You need to connect with people.”

Perception versus reality

The same hospital he helped reach the 95 per cent target has since dropped below that figure and Levy admits it has gotten worse.

Is it truly possible to get more results from the same people when the health workforce is calling out the shortages, burnout and continued overwork?

“Sometimes perception is reality and sometimes it isn’t,” Levy says.

“Never before has there been so much money in the health sector. That’s a fact. Never before have we had so many FTEs as we have right now.

“Over May and June Health New Zealand hired 2,603 people, including 132 SMOs, 844 nurses, 70 midwives and 419 allied health workers.

“Now that is cold comfort for a particular area that is short staffed and can’t staff up. That’s why we want to push things much closer [to a regional model]. Then the management and clinical leadership understand what the problems are.

“What has also happened is the output has remained relatively stagnant. This is the productivity issue. We can and need to do more with the resources we have got. How do we make the work more seamless? How do we make it easier? I think we will get there with these targets.

“People say health professionals are resistant to change. I don’t believe that. I just think they are reluctant to change because they have had so many bad experiences.

“We need everything orientated to deliver our goal of being a health delivery organisation.

“We need to orientate towards the front line doing that and supporting them to do that. To not be so multi-layered and so complex.”

What will happen to the multi-layered aspects of the organisation that are deemed surplus to requirements?

“We’re looking for performance,” Levy says.

“If people do not perform, then the inevitable will happen. If people perform, then we will have confidence in them.”

What does success look like?

To Levy success in this role is seeing a health system that meets its targets, is financially sound and returns to a normal government structure. With just 12 months, initially, to achieve this, it is a tall order.

“A year is short,” Levy says.

“Commissioners are appointed and can be extended. We want to solve the financial

problems. By the end of the first year I want to have solved a lot of the financial issues and be getting wait times down.”

Levy says there is no recruitment freeze and points to figures above showing increases in hirings.

“If there is a clinically vacant position it should be filled,” he says.

“If somebody is not filling it then we need to know about it. We are still open for business.”

Asked about a regional allowance for hard-tostaff locations, he is not against the idea.

“We need to pull every lever we can to ensure areas have the staff,” he says.

“People are entitled to live wherever they want. There are some good ideas about what can be done. We want to see regional services stronger, not weaker.

“If we had doctors we could put into these positions, we would have. I think this is where having clinicians involved in the organisational hierarchy is going to be important, as that is where we will find the innovation to change.”

Personal drivers

“What motivates me to do this work is that New Zealanders are waiting too long for health services – from the emergency departments, first specialist appointment and planned surgery.

“In my view the safest wait is the shortest wait. The priority for me, then, is to find ways to bring the wait times down.”

In regard to what went wrong with the previous board?

“I just have to take a constructive, positive approach and just deal with this,” Levy says.

“I’m not looking back. I’m not picking over the pieces. I’m not going to be criticising anybody. I’m just moving forward, playing the cards I have been dealt.”

FINDING THE MONEY

VIRGINIA MILLS, SENIOR POLICY ANALYST

In August, ASMS’ policy team published an editorial in the New Zealand Medical Journal highlighting, despite the Government’s claims about record health spending in Budget 2024, the funding is at best only treading water.

In July this year, citing financial mismanagement, the Minister of Health sacked Te Whatu Ora’s board and appointed Professor Lester Levy as Commissioner. Levy has been tasked with finding $1.4 billion in savings.

At the end of May, the Government’s 2024/25 Budget trumpeted a $1.43 billion funding increase to meet health sector cost pressures.

That figure had been signalled in Treasury documents in 2023. However, in March 2024 Te Whatu Ora officials appeared before Parliament’s Health Select Committee and said Treasury’s figure would no longer be enough to meet cost pressures.

Following Budget 2024 ASMS conducted a line-by-line analysis of new money allocated to health for 2024/25, including a comparison with estimated actual spending for the 2023/24 year and identification of money that had been removed from other parts of the health budget.

What ASMS found is the cost pressure increase is barely enough to maintain the already underfunded status quo, with the actual net increase in operational funding in Vote Health a mere $93 million (0.4 per cent) on the previous year. Much of the money for new initiatives is recycled or relabelled money from discontinued time-limited funding streams and funding cuts.

ASMS also notes that capital spending including Holidays Act remuneration made up most of the net increase in the Budget compared to actual estimated spending last year.

ASMS published our findings in a report entitled Just Treading Water and, drawing on further details obtained under the Official Information Act, submitted an editorial to the New Zealand Medical Journal.

The media flurry generated by the editorial prompted a response from Commissioner

Levy in the New Zealand Herald. He asserted ASMS was wrong and the $1.43 billion cost pressure funding hadn’t been directed to capital funding and Holidays Act remuneration. However, this is not the point ASMS made, and the figures in our analysis are easily verified in the Vote Health Estimates of Appropriations.

Equally Dr Levy did not address other revelations in the editorial. For example, no extra money was allocated to meet planned care targets - in fact $110 million previously allocated to address the planned care backlog from COVID-19, is not continued. That was despite the Minister of Health receiving a briefing that estimated an extra $723 million will be needed over 2024/25 and 2025/26 have no patient waiting more than 15 months for a first specialist assessment, and no patient waiting longer than 12 months for treatment.

New Zealand’s spending on health has become less transparent. Spending previously broken down by District Health Board has been aggregated under Te Whatu Ora. However, the Pae Ora Act 2022 requires Te Whatu Ora to produce a three-year costed health plan that also assesses population health need. The plan is yet to be published this year. The Ministry of Health used to publish Health Expenditure Trends in New Zealand to support informed debate on New Zealand’s health expenditure, including international comparisons. Unfortunately, the series ceased fourteen years ago.

ASMS welcomes the interest our analysis generated. We want to see a robust public conversation continue, and increased transparency of health funding information. That is why ASMS is calling for an independent inquiry into health funding – to look at both how governments have funded health to date, the social and economic consequences of under-investment and what needs to change for governments to invest in our system properly.

ASMS’ editorial in the New Zealand Medical Journal, “The cost of everything and the value of nothing: New Zealand’s under-investment in health”, appeared in the issue published 23 August 2024. See http://nzmj.org.nz/journal/vol-137-no-1601

See the New Zealand Herald’s coverage of the editorial at www.nzherald.co.nz/nz/health-nz-cantcut-14-billion-without-eating-into-front-line-analysis/5XDNEU2XJBGDFKHUDKWXIL7UCE

See Lester Levy’s response at www.nzherald.co.nz/nz/health-funding-we-are-getting-moremoney-we-need-to-ensure-we-get-more-value-lester-levy/235LLBOPQZFTFD37FKM3MD54EQ

To read ASMS’ analysis of Budget 2024/25, Just Treading Water, see asms.org.nz/health-budgetjust-treading-water

The Vote Health Estimates of Appropriations are available at www.treasury.govt.nz/publications/ estimates/vote-health-health-sector-estimates-appropriations-2024-25

We have to put our own oxygen mask on first. There is abundant evidence that, aside from the personal benefits, clinician wellbeing is associated with better quality care and patient safety.”

– JO SINCLAIR

WELL MEASURED

MATT SHAND, JOURNALIST

Jo Sinclair is working to see greater recognition, and measurement, of the mental health of clinicians at Te Whatu Ora.

Dr Joanna Sinclair, the interim National Clinical Lead for Employee Wellbeing at Te Whatu Ora, says New Zealand is “decades behind” where it needs to be in terms of the mental wellbeing of doctors and medical staff.

This lack of care is contributing to a growing rate of burnout and exacerbating issues such as depression.

Sinclair hopes to be part of the change helping move things forward to avoid further losses.

“Year after year we see that burnout and stress are issues,” she says.

“It is my ‘why’ and it’s why I am here despite the challenges of trying to effect change. I want to make mental health a priority for all staff because this story is sadly not new, and people are left wondering why.”

Sinclair wants to see a system where clinicians and all health employees put their mental health and wellbeing first.

“That is the most important thing we can do for our patients. We have to put our own oxygen mask on first. There is abundant evidence that, aside from

the personal benefits, clinician wellbeing is associated with better quality care and patient safety.

“[As an anaesthetist] we get made aware quite early on in our training about some of the issues our speciality is more prone to,” she says.

“Things like substance abuse, suicide and burnout. I’ve always carried a sense of injustice about the lack of attention paid to managing the inherent stress of the job.

“You put so much of yourself into becoming a doctor and establishing your career that it tends to be a bit later before you think about having a family. You might get behind on the property ladder, many rack up student debt and then you end up in a highly stressful job where the expectations on you to be ‘excellent’ are high. Yet you increasingly feel like the system is working against you.

“It seems really unfair. We can see other businesses understanding the value of ensuring their workforce can thrive, but we haven’t experienced that in our health care organisations.”

Sinclair spent a lot of her continuing medical education leave looking into mental health issues within a medical workforce context.

“I conducted a survey of SMO groups at Counties Manukau and presented a paper to the CMO and HR director at that time.

“The survey showed high levels of burnout and distress. Previously the bulk of work in staff wellbeing had been in the ‘people and communications’ space not in the hands of clinicians. We championed the importance of clinician voice at Counties and started to shift the dial towards a collaborative approach.

“This was pretty novel at the time. When the health reforms happened, my colleagues and I proposed including of clinicians in the planning of a national workforce wellbeing programme. That is how I find myself in my current role.

“As part of my role at Counties, we introduced the Well-Being Index developed by the Mayo Clinic as a tool to measure health care worker wellbeing.”

While it is a small step forward, she encourages clinicians to consider the Index and conduct regular self check-ins using the Well-Being Index app, an internationally validated tool that is being rolled out nationally later this year to help Health New Zealand employees track their mental health and identify when stress or burnout is affecting them.

“It is not the be-all-and-end-all tool for mental health but it is a start,” Sinclair says.

“This two-minute check-in is akin to getting your blood pressure checked regularly or having age-appropriate cancer screening. A personal dashboard helps you understand your results, see how you compare to your peers, and gives you access to a locally curated catalogue of resources.

“Over time it allows you to notice things about your mental health, like ‘what occurs when I take a holiday?’, or ‘are there dips due to a period of high workload?’”

Sinclair wants to make it clear that this is not a substitute for addressing the systems issues that are at the front of everyone’s minds.

“Eighty per cent of our wellbeing at work is tied

up in workplace issues. That’s what I want to work on at a national level.

“But we need to keep looking after ourselves, because many of those workplace issues are not quick fixes.

“The data from the Well-Being Index app is 100 per cent anonymous. The value to my role is in the de-identified aggregate data that is collected.

“I’ve seen some powerful examples of the weight this data can add to our stories. The data shows it is not just one person’s story.

“There is a huge body of research that shows the impact our wellbeing at work has on patient safety, patient satisfaction, retention of our workforce, engagement… the list goes on.”

One initiative Sinclair is working on is encouraging the medical workforce to connect and talk to each other.

“There is a culture that rewards stoicism,” she says.

“Those who suck it up, do extra shifts and contribute when things are behind, are rewarded. Those who cannot are seen as lesser, even when they have valid reasons. We have this ‘it’s how it was done in my day’ mentality.

“This culture means issues are often missed because people may not feel safe to speak up.

“Some hospitals have started introducing Schwartz Rounds where people talk about the emotional impact of providing care. These are open to all staff, from surgeons to cleaning staff, as health care impacts everyone. At these Schwartz Rounds a lot of people voice things for the first time having support around them to talk about it.

“Whilst I continue to advocate for systems change, I want to acknowledge change is slow. Sometimes the best thing we can do to create change is to look out for the person standing next to us.”

Sinclair is also working on a peer-to-peer ‘stress first aid’ programme and she will be running a discussion group at ASMS’s annual conference in November.

It is not the be-all-andend-all tool for mental health but it is a start.”

– JO SINCLAIR

If you are interested in trying the WellBeing Index app. Use the QR code to sign up and the invitation code HRTNZ to get free access to the app. Make sure you check out the resource library, which has just been updated and is loaded with useful websites, reading and listening recommendations, and all the helplines and ways to get extra support.

To learn more about how you can engage about workplace wellbeing, contact Joanna.Sinclair@tewhatuora.govt.nz

LESS THAN SUPER

ANDREW CHICK, JOURNALIST

There is clear evidence that many SMOs and SDOs employed by Te Whatu Ora are not maximising the opportunity for employer contributions to their superannuation scheme. The question is whether that is by choice or because of system failings.

Matched superannuation contributions from your employer are an obvious benefit to any individual’s retirement savings. For an employer they are also an important staff retention tool. But for an employer like Te Whatu Ora – which is highly dependent on attracting staff from overseas – they are a significant recruitment issue.

The ASMS–Te Whatu Ora SECA states the employer “will pay a matching subsidy up to a maximum of 6% of an employee’s gross taxable salary” towards superannuation.

While the 6 per cent employer contribution is relatively generous in a New Zealand context (most New Zealanders only receive the statutory minimum 3 per cent employer KiwiSaver contribution), it is far less generous than in Australia or the UK.

But recent ASMS data shows many senior medical and dental officers are not receiving full employer superannuation contributions, and some are missing out altogether.

As part of its annual Te Whatu Ora salary survey, ASMS requests information from Te Whatu Ora’s districts on the superannuation schemes currently used by senior medical and dental staff.

ASMS has been conducting the survey for 30 years. For most of that time it only asked DHBs for the total number of contributions the employer was making and did not ask the employer to compare this to the number of employees.

In 2017 this comparison was made for the first time and found the DHBs had 660 more SMOs employed than they were making employer contributions for.

Like much of the payroll information coming from DHBs – and now districts of Te Whatu Ora – there are significant anomalies and gaps in the data.

However, the 2023 survey still showed 9.1 per cent of SMOs employed by Te Whatu Ora were not receiving any contributions towards their superannuation. Equally, 44.4 per cent were receiving an employer contribution of less than 6 per cent.

“The employer contribution is only ‘matching’ any employee contribution, and employees can choose to contribute less than 6 per cent for legitimate reasons. However, having almost half of SMOs not maximising the employer

contribution, and 1 in 10 not participating at all, seems particularly high,” says ASMS Industrial Director Steve Hurring.

According to Inland Revenue, in 2023, for the whole New Zealand workforce, there were 193,000 opt outs from KiwiSaver, compared to 2,757,150 members aged 18–65 in the scheme. As some context, 8.3 per cent of all those KiwiSaver opt outs earned $120,000 per annum or more. A large proportion of those members opting out would be opting into a non-KiwiSaver retirement scheme.

Problems with superannuation contributions are a common issue members raise with ASMS industrial officers.

Two common themes relate to staff coming from overseas who are ineligible for KiwiSaver and staff who transfer between districts and are contributing more than 3 per cent to a KiwiSaver scheme.

Non-residence

Under the KiwiSaver legislation it is an employer’s responsibility to ensure all eligible employees are enrolled in the scheme. However, to be eligible for

The employer contribution is only ‘matching’ any employee contribution, and employees can choose to contribute less than 6 per cent for legitimate reasons. However, having almost half of SMOs not maximising the employer contribution, and 1 in 10 not participating at all, seems particularly high.”

My employer did not mention KiwiSaver/superannuation at all. I only found out through a friend. I lost out on about 12 months of possible savings.”

– ANONYMOUS RESPONDENT TO THE ASMS IMG SURVEY

KiwiSaver you need to be a New Zealand resident. When some international medical graduates arrive in the country, they do so on a work visa that does not immediately confirm their residence.

On that basis some districts have felt they were not obligated to mention other superannuation arrangements that can apply to non-residents. The SECA is intentionally broader and references “approved superannuation scheme”. KiwiSaver schemes are approved, but so are at least five other superannuation schemes that are not KiwiSaver schemes.

While non-KiwiSaver schemes do not attract the $520 annual government contribution, they do have a level of portability and flexibility for employees who may not end up residing in New Zealand long term. Even more importantly, employees can start contributing to approved superannuation schemes from day one of their employment, whether they are New Zealand residents or not.

ASMS has seen letters of offer from some districts that only include KiwiSaver (and only then on page 9 of a 10-page document). This has led to a number of cases where ASMS has reclaimed employer contributions where new employees from overseas were not aware they were entitled to participate in a superannuation scheme let alone receive employer contributions.

Half Kiwi

Another common problem occurs for people who are part of a KiwiSaver scheme – either for part or all of their retirement saving. The SECA allows members to split their employer contribution with a minimum 3 per cent in KiwiSaver and the other 3 per cent in another approved superannuation scheme.

Members who are paying more than 3 per cent into KiwiSaver and move their employment between districts of Te Whatu Ora can find the

administrators of the payroll system in their new district do not feel they have appropriate authorisation to deduct more than the statutory minimum 3 per cent for KiwiSaver. When they revert to that lower figure, it then attracts a lower employer contribution as well.

Common complaints

In 2023 ASMS also conducted a specific survey of members who were international medical graduates. Superannuation generated a high number of qualitative responses.

“My employer did not mention KiwiSaver/ superannuation at all. I only found out through a friend. I lost out on about 12 months of possible savings,” said one member.

A second member was able to top that: “I was wrongly advised by payroll in the DHB that I couldn’t do KiwiSaver so missed 5 years of this.”

“I was given KiwiSaver forms and filled them out,” said a third, “assuming it would take some time to get started. When I followed up a number of months later, I was told as a non-resident, I was not eligible for this, although there was another superannuation pathway. It was disappointing to have lost out on that opportunity for employer contributions. Additionally, I was given only a list of providers with no information on their products or how to compare them, which is quite a contrast to the available resources for KiwiSaver accounts.”

Worth checking

Sometimes members are confused when they see their superannuation contribution doesn’t numerically match the amount being contributed by their employer. This can be because the employer contribution to your superannuation gets taxed and they are matched on a before-tax basis. However, this can also be because of an error.

Another thing worth checking is whether contributions are being calculated on the basis of total gross earnings, as set out in the SECA, or as some DHBs did, based on the potentially lower gross taxable salary.

Back in 2019 ASMS identified that over a quarter of SMOs at Waikato DHB were not receiving the full employer superannuation contribution, and an eighth were receiving none at all.

ASMS sought information from other DHBs in the central North Island. There were 18.5 per cent receiving less than 6 per cent at Lakes DHB, 23 per cent at Taranaki DHB, 57.8 per cent at Tairāwhiti DHB, and 62 per cent at Hawke’s Bay DHB.

In Hawke’s Bay, ASMS worked with superannuation fund provider Medical Assurance Society (MAS) to contact members to clarify that they were choosing to contribute less than 6 per cent (and qualify for less than 6 per cent from the employer). It soon became apparent that some of the problem was a standard letter of offer in the district that only discussed KiwiSaver.

The results of the 2023 salary survey show significant variation between districts. While earlier outliers like Tairāwhiti and Hawke’s Bay have improved, Capital, Coast and Hutt Valley district still records 33 per cent of SMOs not receiving any employer contribution.

Employer response

In some instances, local employers have argued they do not have any specific legal responsibility to inform staff of their superannuation eligibility, other than in relation to KiwiSaver.

When asked whether Te Whatu Ora was concerned about employees not taking advantage of the employer superannuation contribution, Te Whatu Ora Chief People Officer Andrew Slater says they make superannuation payments in line with the employment agreements in place, but the payments are reflective of regional practices.

“Circumstances where KiwiSaver or superannuation payments are not made would be due to individual circumstances where the staff member concerned is not signed up to a KiwiSaver or superannuation scheme for payments to be made to.

“Any staff member who has questions or is concerned about their KiwiSaver or superannuation payments is encouraged to contact their local payroll team.”

Like many payroll issues, Te Whatu Ora does not have a nationally standardised approach to explaining and offering participation in a superannuation scheme to newly appointed SMOs.

There are options

Jules Riley, an adviser with MAS, says, “As a doctor employed by Te Whatu Ora, you are most likely eligible for a matching 6 per cent superannuation contribution on top of your regular salary. This matching contribution is a significant benefit and is double the rate received by most employees in New Zealand.

“KiwiSaver is only available to New Zealand residents. However, both New Zealand residents and non-residents are welcome to join a participating superannuation scheme, such as the MAS Retirement Savings Scheme.

“Members who receive their contribution into a participating superannuation scheme (as opposed to a KiwiSaver scheme) can withdraw their entire balance if they depart New Zealand permanently. If members remain in New Zealand, they can also withdraw their savings from the age of 55 as opposed to the age 65 in KiwiSaver.”

Rural health running out of revenue 16 Decades-old funding debacle 19

RURAL HEALTH RUNNING OUT OF REVENUE

MATT SHAND, JOURNALIST

There are 26 rural hospitals dotted around New Zealand with eight of them being privately owned or run by trusts. This series looks at the plight of Otago’s rural hospitals, as a case study of what happens when healthcare providers are not funded adequately to meet community need.

Asking a patient if they have the means to pay for medical treatment is an awkward conversation to have at the front door of a hospital. But this is occurring in rural locations around Central Otago due to funding constraints and budget cuts faced by the region’s rural hospitals.

“It’s not what you expect to hear when you turn up for treatment,” Dunstan rural doctor Jonathan Wills says.

“Secretly, we treat them anyway. What else is there to do? Send them several hours by car to Dunedin Hospital or just ask them to leave and close the doors?”

Discussions about closing the doors of rural hospitals are happening with greater and greater frequency in rural locations. There are 26 rural hospitals in New Zealand, eight of them run independently of Te Whatu Ora.

In the southern half of the South Island this includes hospitals in Gore, Balclutha, Clyde and, until recently, Oamaru.

The picturesque location of these hospitals often coincides with an accompanying remoteness from major centres. Without these hospitals, patients in some key rural areas would have to travel many hours by road to the closest treatment centre.

In the late 1990s the Government stopped directly providing health care through these hospitals because of the cost. However, through a variety of arrangements, local communities found a way to keep them open.

Some were purchased by councils, others saw GP clinics band together. All relied on a level of goodwill from the community and from their staff.

Twenty years on, again, nearly all of them are facing significant financial challenges. These challenges have been brought on by funding shortfalls, cost of living pressures, pay equity commitments and spikes in acute demand.

The spike in demand has been in both the number and the complexity of cases. Coupled with shortages in staffing, it is creating a perfect storm.

If rural hospitals close, or lose the ability to provide certain services, patients will have to try to access already-strained services in urban centres or go without.

Oamaru Hospital is the first rural hospital to cease operating independently, but it may not be the last. The hospital was running a $2 million a year deficit (“Decades-old funding debacle”, p19) before Te Whatu Ora resumed operational control, on behalf of central government, on 1 July this year. But many in the community are worried the history of cutting services is going to repeat itself.

“The failure caused by underinvestment in the health care system will be felt first in rural regions,” Corporate Services Director at Oamaru Hospital Andrea Cairns says.

“We were underfunded in 1924 [when central government first took control of the hospital] and have struggled for finances for more than 100 years.

We [rural doctors] are definitely seeing more patients than we used to and working harder. There is only so much extra we can do, which results in wards and beds being closed down.”

- SARAH CLARKE, TE WHATU ORA NATIONAL CLINICAL DIRECTOR FOR PRIMARY AND COMMUNITY CARE

“What will happen to the communities if trust hospitals like ours must close their doors? Can people live here? And up until what age? People are living longer and with more health complexity, but funding does not keep up with this fact.”

Chief Executive of Clutha Health Gary Reed says all rural hospitals are on life support.

“Funding is not and has never kept up with costs.

“We are always told we are valued but there is no actual money. Unless we can secure additional funding, it is unlikely we will be here in 12 months.

“If we cannot see the patients in the community, where do they go?”

Jonathan Wills says the situation is beyond dire, and it is only possible to keep the hospitals open because of the goodwill of clinical staff.

“If trust hospitals run out of money or go over budget they cannot just say sorry and ask the Government for more money,” he says.

“If they run out, they have to declare bankruptcy and close down. We are always playing catch up with staffing rates and resources and are reliant on goodwill just to keep the doors open.

“We want to help the community. It’s what a hospital does. We are lucky to have such good staff, but there is always a limit and we’ve reached that.”

ASMS’ analysis of Budget 2024 found it did not provide the needed funding boost to stave off shortfalls across the health care system.

“On a per capita basis operational funding will fall both in nominal and real terms,” ASMS researcher Lyndon Keene says.

“Health services are being asked to do more with less for every patient.

“Vote Health’s budget only increased 0.4 per cent on estimated actual spending from 2023/2024.

No additional funding has been provided for the backlog of planned care following the Covid-19

pandemic, and this will make reaching Government health targets impossible.”

In the regions, the lack of further funding will exacerbate the problems providing services and that health care need will need to be met by metro hospitals.

GARY REED, CHIEF EXECUTIVE OF CLUTHA HEALTH.

What will happen to the communities if trust hospitals like ours must close their doors? Can people live here? And up until what age? People are living longer and with more health complexity, but funding does not keep up with this fact.”

- ANDREA CAIRNS, CORPORATE SERVICES DIRECTOR AT OAMARU HOSPITAL

That will require resources to transport patients to and from the hospital, place additional pressure on those and just domino into more people unable to get health care.

The sacking of Te Whatu Ora’s board has seen the financial situation at Health New Zealand thrust into the limelight. New Commissioner Professor Lester Levy says the organisation as a whole is losing $130 million every month, with a projected deficit of $1.4 billion if left unchecked.

A few weeks after this initial assessment he revised this statement to say the situation at Te Whatu Ora was “worse than expected”.

While this compounds the specific pressures faced by Otago’s rural hopsitals, Te Whatu Ora has committed to a new initiative called the Rural Sustainability Project.

Te Whatu Ora National Clinical Director for Primary and Community Care

Sarah Clarke says there are geographical gaps in the provision of medical care is in New Zealand, and the project hopes to keep rural hospitals, especially those that are struggling to stay open.

“We have a worldwide shortage of health professionals, and New Zealand has its own shortage,” she said.

“We have a population that is 18.9 per cent rurally based. I do not have a percentage for the number of rural doctors working compared to the city, but we know it is not as high.

“We do know there are 92 GPs per 100,000 head of population in rural regions as opposed to 103 per 100,000 in metro areas.

“We [rural doctors] are definitely seeing more patients than we used to and working harder. There is only so much extra we can do, which results in wards and beds being closed down.

“The Rural Sustainability Project is about maintaining safe and sustainable rosters, and it is important we not only look at financial sustainability but clinical sustainability as well so we can come up with better models for the future.

“We know if care is not available and people have to travel for it, they often won’t, which adds to unmet need.”

The question hinges on what new models of care and sustainable health will look like. It is made more relevant by calls to cut costs across the health care sector and what that will mean practically to rural hospitals.

But if we need a reminder of what could happen with sustained underfunding of the wider health system, the plight of rural hospitals gives us an insight.

Will telehealth replace face-to-face doctors, and what happens when things go wrong? Will patients have to travel to Dunedin to get treatment, and will people over a certain age or illness threshold simply have to leave town due to limited health care options?

These rural hospitals are hanging on waiting to hear what will occur while struggling to keep the lights on in the interim.

ANDREA CAIRNS.

DECADESOLD FUNDING DEBACLE

“Unique and significant financial challenges” apparently caused one independent rural Otago hospital to be bailed out by Te Whatu Ora. But the reality is all the region’s trust hospitals report large-scale issues born from a funding formula called the Price Volume Schedule.

Oamaru Hospital was just one of several trust hospitals struggling to keep up with the ever-increasing cost pressures.

Speaking before Te Whatu Ora’s decision to reacquire Oamaru Hospital was made, Corporate Services Director Andrea Cairns told The Specialist, “We are in dire straits.”

“We are spending $2 million a year on locums to keep services running. This is costing us dearly and we are worried we can’t even keep the lights on.”

Oamaru Hospital faced closure before in 1998 after Southern Health decided it was no longer “financially viable” to maintain the hospital. This followed cuts in 1991 when hospital surgical services were threatened and 13,500 residents participated in a street march.

In 1994 surgical procedures were cut for inpatients, and in 1997 all surgical operations requiring anaesthesia were cut. Then the maternity annexe was closed.

So in 1999 Waitaki District Council set up a holding company, took ownership of the hospital and started to run services itself. The site of the hospital was moved down the hill into the township. Since then, grounds kept by volunteers have helped save costs, and donations from the community have allowed the purchase of new equipment and the expansion of services.

The model worked for nearly 20 years. Oamaru’s 22,000 residents had access to care. In the year of 2023/24 the emergency department saw 8,713 patients through its doors, up from 7,507 the year previously. It also welcomed 65 new residents in its maternity ward.

Dark maths of the Price Volume Schedule

As the population of Oamaru has increased, so too has the demand for health care services.

So called “trust hospitals” like Oamaru traditionally received central government funding through a system called the Price Volume Schedule. This essentially outlines what services each hospital will provide and the amount of money each hospital will receive from Te Whatu Ora to deliver them.

The issue is these contracted arrangements hail from the days of the former DHBs and locally arranged rates.

There is a lack of consistency. Speaking to different trust hospital heads reveals they all receive differing amounts to provide similar services.

“There is not enough funding for the rural hospitals,” Cairns said.

“Te Whatu Ora provides about 85 per cent of our income. We get some through ACC and private patients from time to time.”

But the Price Volume Schedule has never allowed for increases to staff salaries.

As a result hospitals have been expected to face year-on-year, real-terms pay reductions. This only creates issues for staff retention. Nurses and doctors can earn more living in more populous areas and get better entitlements.

To combat the issue, Cairns says Oamaru committed itself to pay parity, but it came at a much higher cost than expected.

“In Oamaru we dedicated ourselves to ensuring that everyone received pay parity,” she says.

“We have to recruit staff, and we cannot recruit staff if they can easily earn more money working in non-rural hospitals. If we did not give pay parity to nurses, we would risk them leaving. We are already short of nurses and doctors.”

But shortages had already led to a greater reliance on locums and a subsequent ballooning in the costs associated with using a contractual workforce. Those costs started a cycle that saw Oamaru Hospital become increasingly financially unviable.

Other rural hospital leaders say the Price Volume Schedule is not fit for purpose.

“The Price Volume Schedule is an absolute dog’s breakfast,” says Clyde-based doctor Jonathan Wills.

“It is wildly inconsistent across the country. It is never adjusted for increased demand and the increased costs that have occurred over the years. It has starved rural hospitals out.”

Requests from The Specialist to Te Whatu Ora to view the Price Volume Schedule, and to engage about the rationale behind it, have gone unanswered.

Official Information Act requests to view the relevant documents have not been particularly fruitful either. There is too much complexity, and unpicking the data is too costly.

What is known are the total amounts each rural hospital in the Southern region receives.

Clutha Health received $8.2 million, Gore Health received $9.6 million, and Central Otago Health (Dunstan) received $16.4 million, as did Oamaru.

The rationale behind why some receive more than others is not known.

Equally, what is also known is the demand, complexity, age and expectations of the community have all increased.

“Over the last 15 months presentations have increased month on month,” Wills said.

“The funding needs to grow in line with our population. We have more over 65s who have complex needs and are living longer with those needs. It is just the world we live in now, and the Price Volume Schedule should reflect that.

“As a trust hospital, if we ran over budget we could not just say sorry and ask the Government for more money.

“If we run out, we have to declare bankruptcy.”

The issues at the rural hospitals show that public health care does not work well if treated as a business. So on May 28 this year, Oamaru Hospital had to be bailed out after the books no longer balanced.

Te Whatu Ora stepped in and announced it would not renew the hospital’s annual contract due to “unique financial and clinical challenges”.

Oamaru Hospital was sold back to Te Whatu Ora for about $1 million, including the clinical equipment (some bought by the community), leases, service agreements, and $250,000 for hospital supplies.

“For staff, the decision to roll back into Te Whatu Ora is good,” Cairns says.

“It means they will no longer have to fight to get pay increases and terms and conditions other staff at city hospitals get.

“But our community will be a bit more apprehensive. They have seen this model before and they have long memories. We have received a letter from Chief Executive Margie Apa stating they do not intend to close the hospital. We will have to see how the community reacts.”

The letter from Apa states, “I can confirm there is no plan to close Oamaru Hospital or withdraw any of the current services.”

But the letter also states that Te Whatu Ora needs to “ensure future health service provision is clinically and financially sustainable. This means looking at models of care that enable better access for Waitaki communities and reduce the inconvenience of travel that many experience with care.”

This letter was also received before the appointment of Commissioner

Funding falls flat in other centres

Oamaru may be the first to falter, but every private or trust hospital visited by The Specialist had similar issues.

Cairns says health, and rural health, has been underfunded for years.

“We were underfunded in 1924 and have been struggling for finances for more than 100 years.

“Rural health is always, to an extent, reliant on the community and the goodwill of the medical staff to push through. It needs to change.”

In Balclutha, chief executive Gary Reed echoes the sentiment.

“The short answer is, it [funding] does not keep up,” Reed says.

“There are many additional costs, and the Health New Zealand contracts do not cover their way or, at best, are cost neutral.

“All the staff require pay parity, and that means we will face a significant trade deficit. Unless we see additional funding, it is unlikely we will be here in 12 months.”

Reed says the big concern is what happens when that money does run out as expected.

“We will come to a point where we will run through our reserves and then face closure,” he says.

“The question is, can we even do that? It is irresponsible to run a company into financial ruin. Our shareholder is the community, and they will expect better.

“We need pay parity and the cost of delivering services to be reflected in the Price Volume Schedule, and for that schedule to be fair.”

Chief Executive of Gore Health Karl Metzler goes further and says the funding discrepancies are creating a “financial apartheid” in the rural regions.

“The average life expectancy of a Māori male in Mataura is 50 years old,” Metzler says.

“The average life expectancy for a man in Queenstown is 85. That’s not fair.

“I believe the affluent Pākehā populations and impoverished populations deserve proper access to health care regardless of their financial status.”

Metzler says Gore ran at a $300,000 deficit last year, and this year it will likely be the same mainly due to matching urban pay rates that have not been funded for.

We have to recruit staff, and we cannot recruit staff if they can easily earn more money working in non-rural hospitals. If we did not give pay parity to nurses, we would risk them leaving. We are already short of nurses and doctors.”

- ANDREA CAIRNS, CORPORATE SERVICES DIRECTOR AT OAMARU HOSPITAL

“We should be looking towards a Ministry of Education system where all the wages are handled in Wellington to remove regional fluctuations,” he says.

“Or move away from the Price Volume Schedule and into specific purchasing of the services Te Whatu Ora wants to provide. Last year we had a 22 per cent uplift in ED presentations but not a 22 per cent increase in funding.

“All our services and capability come from this Price Volume Schedule, and it is different for all the hospitals. We need consistency across the regions.”

Rural Sustainability Project

Te Whatu Ora National Clinical Director for Primary and Community Care Sarah Clarke says the sustainability of rural hospitals puts the practice of using the Price Volume Schedule in a new light.

“There are currently 26 rural hospitals in New Zealand, and eight of those are privately owned trust, charitable or limited liability organisations,” she said.

“The Price Volume Schedule is the way that some of them are funded, some are contracted differently, and it does vary really greatly between regions. It’s a mosaic.”

“I guess this reflects the District Health Board priorities and approaches that also varied across the country. So, the Price Volume Schedule is a mosaic at the moment, and we are trying to figure out its current state and then work on what long-term sustainability and maximising rural hospitals looks like.

“There is amazing work being done in the communities right now. But rural hospitals always say they are at the end of the drip line in

terms of resources, be that human resources, clinical resources or funding. They have not been allowed to maximise their opportunity.”

The Rural Sustainability Project is set to look at the current state of play of rural hospitals and make them sustainable for the 2024/25 year.

“The next piece of the puzzle is to determine what future sustainability looks like and sort that mosaic out with a national commissioning approach.”

Clarke says the difference in funding does relate back to the former 20 DHBs, and she hopes a core part in unifying Te Whatu Ora into one organisation is to create more consistency across the rural hospital networks.

One area casting doubt on the project is the recent announcement from Commissioner Lester Levy about financial insolvency and potential cuts across Te Whatu Ora.

“This is a tricky space for rural hospitals,” she said.

“We know some hospitals prioritised paying their staff the same rates as Health New Zealand or close to the same rates where they could, because they are competing for staff.

“But we do not have the funds to be able to fund pay equity separately. There does need to be another carrot, another incentive, as attracting staff to work in rural places has always been a challenge.”

Clarke is aware only too well what happens if there are cuts to services on the front line. She says in her hospital role there are often beds closed when roster gaps cannot be covered, and this means patients miss out.

Seeing this happen across rural regions is not a scenario she wants to see.

“For people, that means having to travel to another hospital for treatment,” she says.

“Often that is not even an option. They may not have a car, they may not have petrol, or they have both but no registration, and public transport is terrible in the regions.”

Clarke is optimistic good changes are on the horizon. “It is an exciting time,” she says. “We have a team and we have a rural health strategy, which we have not had before.”

How do rural hospitals respond?

Andrea Cairns says the Rural Sustainability Project is a positive move for rural health in Aotearoa.

“I believe this will help, and it is certainly a step in the right direction; however, as with anything, this piece of work will take time to achieve the flow-on effect.

“For Oamaru Hospital, it did miss the boat, but hopefully the other NGO rural hospitals will benefit from it soon.”

Gary Reed says Clutha Health has received a revised offer of contract from Health New Zealand with some increased funding provisions to put the hospital into a “cost neutral” position.

“The caveat to this is there is no surplus or ‘profit’ provision to what is being paid, which means the company has no revenue beyond the cost of service delivery for sustainability, service development or maintenance.

“This will have to be addressed in the 2025/26 contract provision.

“To date, Clutha Health has had no engagement or seen any terms of references [for the Rural Sustainability Project], timelines or principles. It may have hit somewhere, but to date it remains an unknown entity in my neck of the woods.”

PRIVATE PATIENTS PROP UP PUBLIC HEALTH

Rural hospitals in Otago are relying on fees charged for primary care to top up the shortfall in funding for other public health services. It has helped to keep the lights on, but demand for those other health services keeps growing.

The main way many private and trust hospitals have been able to survive in the remote locations of Central Otago has been by leveraging the primary care aspect of their businesses.

This approach has been an effective way to allow rural communities to have access to not just primary care but acute services as well.

But it means that many communities are essentially paying for their broader health services when getting primary care treatment.

However, as demand for acute care continues to rise faster than population growth, cracks are starting to show in this approach as more and more hospitals face financial issues.

Gore provides a good example. Gore Health has seen a 22 per cent increase in its emergency department presentations since 2016, from 6,764 per year up to 8,685 presentations last year.

Over the same period the population of Gore has only increased by about 5 per cent. Still, on that basis, the equivalent of 70 per cent of the population of Gore visit the ED each year.

Despite this, funding for the emergency department has not increased with demand. In fact, the healthier the residents of Gore are, the less funding their acute health care system will get.

“Hospitals do not break even by their nature,” Chief Executive of Gore Health Karl Metzler said.

“The innovation into providing private health care is the only way we can prop up our emergency department and hospital services.”

The primary health services offered cater for about 8,500 people per year, bringing in much needed revenue for the hospital.

For the past 20 years this model has seen the wider hospital services be able to keep their doors open but staff in the acute wards know the model is starting to fail.

At Gore Hospital, Dr Fazel Mann sees the influx of patients first hand.

“The challenge here is that management is running a business, but clinicians are running a hospital,” he said.

Last year we ran into a deficit of $300,000, and we will likely be facing that again this year.”

– KARL METZLER, CHIEF EXECUTIVE OF GORE HEALTH

“Hospitals do not make money. They simply cannot. They will always run at a deficit.”

Nurse practitioners or – more concerning from ASMS’ perspective – physician associates are a more common sight on the wards.

Measures have been taken to fund alternative treatment pathways to reduce costs. This has become critically important as roster gaps have become more common.

“It used to be much quieter here,” Mann says.

“I used to work on call, but now we are so busy there is no on call. We had to introduce a swing shift from 1 pm to 9:30 pm to help keep up with demand.

“We have about 16 beds but can only staff 14 of them. We have to use physician associates and nurse practitioners to get by.”

“We are unique in that we have a physician associate and a nurse practitioner working in ED,” he says. “NPs or PAs should never be covering ED by themselves, but we are short on options now.”

The ageing population also puts a strain on resources, coupled with reduced allied health services.

“We have four patients in bed right now waiting for a rest home,” Mann says. “That’s four beds costing money and tied up for people just waiting for space. One has been here more than a month. There is just not enough space.”

There is also a lack of GPs to help reduce acute demand through primary care.

Te Whatu Ora says there are currently 824 doctors working in 190 rural GP practices across the country, which works out to be about 92 GPs per 100,000 population in rural areas.

This is compared to 103 per 100,000 population in urban areas.

Gore Health is predicted to run at a large deficit this year unless things change. Metzler says the private funding model is no longer making ends meet and intervention is required.

“Even this model is starting to no longer pay its way,” Metzler said.

“Last year we ran into a deficit of $300,000, and we will likely be facing that again this year.

“The issue is the Price Volume Schedule, and how we are funded just does not keep up with increased demand and cost.

“Health care is in crisis across the region. That is the fact. We need help, the country needs help.

“We had to come up with unique solutions because we have had no other choice, but that time has run out. It is an issue no matter what electorate you are in.”

The hospital has survived by leveraging goodwill to provide the level of care expected by the community.

Similar issues are being reported in Balclutha.

Clutha Health started up to create efficiencies for health care services in town.

“About 10 to 12 years ago the GPs in Balclutha were mostly single GPs and there were diseconomies of scale associated with that model,” Chief Executive Officer Gary Reed says.

“We made the strategic decisions to take over the general practices in town to ensure that primary care remained a viable option to local residents. We put the hospital in the centre of town as that is what the community wanted, and we have run since then.”

The medical centre has 8,300 enrolled patients and will conduct about 35,000 patient consultations per year. As a result the centre can remain open 7 days a week for 78 hours total.

“For many years the Te Whatu Ora contracts have been used as loss leaders or, at best, cost neutral offerings that we have had to support with other revenue streams,” Reed says.

“We have got to find a better way of balancing the books and a better national strategy for providing health care to regions. Without additional funding it is unlikely we will be here in 12 months’ time.

“No one wants to see a repeat of Oamaru here in Balclutha, but all the regional hospitals are on life support.”

TOP: KARL METZLER, CHIEF EXECUTIVE, GORE HEALTH. BOTTOM: DR FAZEL MANN, GORE HEALTH.

THE SWISS ARMY KNIFE OF MEDICINE

Due to their remote location, rural health professionals are forced to upskill rapidly and demonstrate their versatility. Could rural training hubs help address rural staffing shortages and foster clinicians’ adaptability?

Doctors in rural New Zealand say they are always impressed by how quickly the remote location forces them to broaden their practical skillset.

Reacting to wildly different situations quickly builds confidence and requires them to take charge sooner than they might otherwise.

“We are the Swiss Army Knife of medicine,” rural doctor Jonathan Wills says.

“It is challenging but rewarding work. You will have babies with fevers, end-of-life care, and patients at Trauma 1 and 2 all in the same day.

“It is up to you to manage, treat and care for that range. You are exposed to a great deal more than a standard round in a city hospital.”

“There is a degree of autonomy that comes with the role, which makes for good medicine and good doctoring.”

Those running rural health services agree and there are calls for rural hospitals to become early training grounds for new doctors.

Chief Executive of Clutha Health Gary Reed says the ability for staff in rural hospitals to upskill is great and it should be utilised more often by Te Whatu Ora.

“We need to encourage people to head out to the regions and use them as training grounds for doctors, nurses and any form of clinician,” he says.

Nurses will do all sorts of work to triaging, running ECG and running bloods.”

- GARY REED, CHIEF EXECUTIVE OF CLUTHA HEALTH

“The work adds up quickly and our nurses become highly skilled and highly sought after from all the on-hand work they do.

“Nurses will do all sorts of work from triaging to running ECGs and running bloods.

“There is also a lot of respect for the medical staff from the community. The community appreciates what having a doctor in the community means.”

Gore Health Chief Executive Karl Metzler says if a centralised model to hire and assign doctors was employed, the health system could benefit from the rapidly upskilled workforce.

The only thing holding this up, he says, is that working in cities is incentivised.

“Instead we need to be directing resources and dedicating strategies to bring people out to the regions,” he says.

“It makes sense to incentivise people to work where they are short.

“If wages were handled in Wellington and physicians shopped out according to need, we could create a strong health workforce.”

A specialist who has worked across a wide range of rural hospitals is Dr Fazal Mann. Currently he works three days per week in Gore and works the remainder of his time in Christchurch.

“The rural locations have a good bunch of doctors and nurses and that is why they stay,” he said.

“The biggest challenge we have is the lack of funding to keep our staff here forever.

“It makes sense for there to be allowances, or incentives, monetary or training, to work in the rural areas where we desperately need more doctors.”

Mann says workloads in the rural hospitals are getting more demanding and more doctors will be needed.

“People are living longer, not healthier,” he says.

Te Whatu Ora National Clinical Director for Primary and Community Care Sarah Clarke works in a rural hospital and echoes the sentiments of her colleagues.

“I am a city kid who ended up loving rural health and now I practise rurally,” she says.

“It is a fantastic place to practise. You have got the real sense of community who care about you, and you care about them.

“But if you have not been exposed to that then you never know. Rural practice is quite tricky and you need to be able to deal with whatever comes in the door, and that can be things you do not get much exposure to.

“There is a degree of bravery required, and clinical courage, to undertake rural practice, and that can be scary to some.”

Clarke says there needs to be more ways to incentivise doctors and nurses to undertake rural work but warns finances alone will not fill the demand.

“The Rural Sustainability Project gives us this chance to look at this. I do not think we will suddenly get a cavalry charge of SMOs who all want to go work in rural areas even if we incentivised it financially. We need to look carefully at our models of care and think about things like telehealth as an additive.

“It’s not all about money but delivering good medicine.”

Clarke says rural immersion placements have been increasing year on year and she hopes to see more medical students taking up roles in rural hospitals.

“This always increases the chances of people practising rurally,” she says.

DR JENNY MAYBIN IN A TREATMENT ROOM AT DUNSTAN HOSPITAL.

PROVIDING

MEDICAL CARE IN A MILITARY COUP

MATT SHAND, JOURNALIST

Working in a secret hospital at the front line of Myanmar’s civil war takes the challenges of providing health care in a resource-constrained environment to a whole other level. Through UnionAID, ASMS is making a small contribution to help that happen.

In a secret underground hospital near the front lines of fighting in Myanmar’s long-running civil war, a junior doctor, identified only as TC, treats patients while coordinating volunteer efforts to get health care to people who desperately need it.

Myanmar erupted into violence three years ago when the military retook full control of the state in a coup, ousting the democratically elected government of Aung San Suu Kyi’s National League for Democracy and ending six years of shared rule between elected government and the armed forces.

The day after the coup, peaceful resistance began, including a strike by public sector workers, initiated by doctors and nurses. But growing acts of civil disobedience were met with the imposition of martial law, arrests and the use of force. As a result, as well as ongoing peaceful protest, armed resistance re-escalated in regions across Myanmar.

Today TC must keep their hospital’s location a secret to prevent it becoming a target of attack. International news agencies report the destruction of hospitals as part of airstrikes and artillery bombardment by the forces of the State Administration Council (the administrative body put in place by

the military to replace the democratically elected government).

“We had to build the hospital underground and keep it hidden so we can protect ourselves from the airstrikes,” TC says.

“It is protected and so far, the enemy does not know where it is.

“It is our health centre. The only health centre many people can access. We treat people from the conflict frontlines and perform emergency medicine and paediatrics for the people.”

TC is not yet a fully qualified doctor and juggles completing their medical training with coordinating the volunteer effort to ensure the hospital continues to run within a warzone.

“We have four doctors and about 23 nurses as volunteers at the hospital. Next year, when I qualify, there will be five doctors.

“All of us know people who have lost their life in the fighting. We decided we need a hospital. If we were not here, it would take six hours –maybe more – to get treatment.”

Running a hospital in a war zone is a constant struggle for resources and for safety.

“It is hard,” TC says. “We need anaesthesia. We need more doctors. We need vehicles to transport people to hospitals. The conflict keeps going. We hear the planes and hide in bunkers. Luckily, the hospital is underground.”

One day the hospital staff had to perform more than 30 surgical procedures on patients during a 24-hour period.

“We will cure about 6,000 patients in a year –including soldiers and civilians,” says TC.

“It is hard work. The risk and danger is real. We have to keep ourselves secret – the hospital secret and the people secret. We have to hide, and it is traumatising.”

The efforts of TC’s hospital are being supported by charitable donations.

New Zealand based charitable organisation UnionAID has been liaising with partners in Myanmar and helping with relief efforts. An urgent appeal for donations to the

Myanmar Democracy Fight Back Fund is currently underway.

The funds are used to support initiatives such as TC’s hospital, organise workers to peacefully oppose the military coup, and provide legal aid for those arrested for peaceful protest.

Evaluation by UnionAID shows their funds have been used to recruit nurses and doctors and source medical equipment.

TC says their hospital is extending its work to support local women to make mosquito nets to prevent the spread of malaria. They have sewing machines, but they need fabric.

As the conflict continues, the hospital is also taking on a role as an education facility, as schools have also been the target of airstrikes.

“We started up an education centre and we will teach English and Chinese courses as well as digital literacy and development programmes,”

TC says. “In our wider work we also work with water sterilisation projects.”

Visit unionaid.org.nz/nursesmyanmar if you would like to donate.

ABOVE: DOCTORS PERFORM SURGERY IN AN UNDERGROUND HOSPITAL AS SOME SHELTER FROM AIR RAIDS. LEFT: A TREATMENT CLINIC IN AN UNDISCLOSED LOCATION.

AN ADDED BARGAIN

ANDREW CHICK, JOURNALIST

As part of the process to renegotiate our collective agreement with Te Whatu Ora, ASMS undertook a claims survey of affected members and the findings were presented at paid union meetings around the country in July.

Over 17 days in May, ASMS received responses from 2,417 members employed by Te Whatu Ora as part of the pre-bargaining claims survey.

The gender split for responses matched ASMS’ membership. In terms of ethnicity, responses were roughly proportional to the limited data ASMS has. The distribution of responses by district was also generally reflective of the wider membership.

Base pay

Unsurprisingly, adequacy of base salary was rated as the most important claim, with two-thirds of respondents rating it extremely important. Wellbeing allowances were the only area where less than 85 per cent of respondents rated the area important or extremely important.

Existing allowances

The question about existing allowances indirectly identified a lack of awareness around special contributions allowances. While 70 per cent of respondents rated all other allowances at least important if not more so, less than half considered special contributions important.

1. SURVEY RESPONSE BY DISTRICT

But members also noted the application of allowances was creating inequities.

“It is very clear that there are people getting massive amounts of money for say a Saturday operating list,” one member noted, “but someone doing registrar work on a weekend gets significantly less, despite it being way more gruelling, dangerous and awful.”

As another noted, “The challenge with all the ‘extra’ allowances is that they are used to game the system, and thus create inequity between individuals, services and hospitals. They contribute to a gender divide too.”

New allowances

The survey asked members to consider four possible new allowances: rural hospital, public only, hard-to-staff specialty and hard-to-staff hospital. The hard-to-staff allowances received the greatest support, but all were considered important or extremely important by two-thirds of members.

Private practice

Over a third of members in the survey were doing private clinical or surgical practice (37 per cent). This dove-tailed closely with the 65 per cent who rated a claim for a public-only allowance important or extremely important.

Non-clinical time

Questions about rostered non-clinical time raised some concerning results. Almost a quarter of respondents said they didn’t get any. Even those who do did found it eaten up by both general time pressures and short-staffing.

As one respondent noted, “In theory I do [have rostered non-clinical time]. In practice it is filled with patient-related admin tasks, so most non-clinical tasks are usually done after hours and at weekends.”

Another respondent wrote, “It has proven to be unrealistic to roster nonclinical time in the past. When needed, I will block out time in advance, sort of like leave.”

“My contract states zero rostered non-clinical time,” noted a third respondent, “although allowance is made for 8 hours of ‘valid’ non-clinical time per week. Specifically, my contract cynically allows for 3 hours of ‘journal reading’ each week. Ha, flipping ha! Actually realising any nonclinical time is another story altogether.”

Whether the time was rostered or not, only 16 per cent of SMOs got to access at least the 30 per cent of non-clinical time recommended in the SECA. Over two fifths got less than 20 per cent.

Non-salary issues

When asked to rank the importance of recovery time, SMO staffing ratios, RMO staffing ratios, non-clinical time and access to admin support, members showed a clear preference. Just shy of half rated patient staffing ratios for SMOs as the most important.

While only a third of members had ever sought to increase their nonclinical time in line with SECA recommendations, those who had tried had been unsuccessful by a ratio of 3 to 1.

2.

GEARING UP

MATT SHAND, JOURNALIST

ASMS’ kaumātua and kuia, Te Pona Martin and Marama Rewiti-Martin, talk about their hopes for their new roles.

Health statistics for Māori are not flash, and having ASMS members understand what that means and provide quality service to address those issues is critically important.”

– MARAMA REWITI-MARTIN

TOP LEFT: MARAMA REWITI-MARTIN. TOP RIGHT: TE PONA MARTIN. BOTTOM LEFT: MARAMA AND TE PONA WITH NATIONAL EXECUTIVE MEMBERS RUDI JOHNSON (LEFT) AND MARK LAWRENCE (RIGHT). BOTTOM RIGHT: MARAMA AND TE PONA PERFORMING ASMS’ WAIATA ‘TE MAURI TAURITE’.

After 22 years driving trucks in Australia, ASMS kaumātua Te Pona Martin switched gears to improve equity and tikanga me ona te reo Māori (Māori cultural practices and language) in the health sector.

Te Pona, and his wife Marama Rewiti-Martin, accepted the position of cultural leaders, navigators and mentors for ASMS, to help the organisation further develop our cultural competency.

As kaumātua and kuia, their role is to provide guidance to the National Executive, Te Mauri Taurite and the Executive Director, support the association to connect with mana whenua, and help incorporate mātauranga, tikanga and te reo Māori into ASMS’ activities.

Te Pona is also employed by Te Whatu Ora in the Bay of Plenty region as Te Pou Kōkiri, an advocacy services liaison for patients and whānau.

The role is part of a range of hospital and community-based services available at Tauranga Hospital, performed by clinical and non-clinical staff who have strong knowledge in te reo and tikanga Māori.

“Our people come to the hospital and tell me, ‘This is the end of my journey’,” Te Pona says.

“I ask them why and they tell me, ‘Well, this is where our people come to die’.

“I tell them no. This is where you come to get fixed.”

Te Pona ensures a patient’s treatment is grounded in equity and helps all aspects of the health system to work together to ensure people are not lost in the bureaucracy or cultural misunderstanding.

“We get people from the outback places of New Zealand,” he says.

“They have often come from a rural medical centre and are in an unfamiliar place. That is an environment where things can go wrong culturally.

“I walk around with a book which has a working definition of the expectation of cultural safety and speak to medical staff about this often.

“Even if they do not practise it, I will. That can make the difference to someone.”

Te Pona sees the role of kaumātua as an opportunity to expand health equity across a wider area.

“I wanted to see how you fellas operated,” he says.

“And how clinicians view equity throughout the whole of Aotearoa. There is a lot of work to go, but through projecting the principles of Te Tiriti, we can improve health for all.”

Te Pona is joined by his wife Marama in the kuia role.

Marama works as an associate director in the Institute of Professional Learning at the University of Waikato where she focuses on professional development for teachers working in Māori sectors.

“We’re currently working to address the shortage of Māori teachers and help with the nationwide teacher shortage,” she says.

“We have been supporting children coming through kohanga reo, primary school and, now, starting to see young people come out the other end and enter the teaching profession.

“We are seeing more language-confident children giving back to other students.”

For further information about Te Mauri Taurite email temauritaurite@asms.org.nz

Marama says the issues within the teaching sector have parallels to the health sector, particularly in the equity space.

“It’s been an uphill battle to have the Māori perspective recognised and be better informed than we have about Te Tiriti partnership,” she says.

“We are asking questions like what partnership truly means in Aotearoa, and this has seen it move forward in some areas.

“In health this is vitally important because health statistics for Māori are not flash, and having ASMS members understand what that means and provide quality service to address those issues is critically important.”

Small steps are required to start. Both Te Pona and Marama want to reach out to ASMS’ Māori membership and become more engaged with Māori members.

“At this stage we still do not know how many Māori members there are and what their key issues are, so it is still very much in the factfinding stage,” Marama says.

“We want to embed any learnings we find, to allow us to provide cultural support as needed.

“At the moment we have interacted at the National Executive level, and I want to meet more doctors and have conversations with them to get a clearer picture of what their jobs in the hospital system entail and how we can offer support.

“Also, we can learn what expectations they have of their kuia and kaumātua. We can act as the bridge between management and governance for the people we serve. Not just Māori but across the spectrum of the membership to provide better understanding and communication.”

ASMS Toi Mata Hauora has been working to improve its member data, including ethnicity data – but we can only go off what we currently have. Members can register any ethnicity, including signalling they whakapapa Māori, by updating their details at asms.org.nz/member-details-update/

SOURCE CODE

LUCY GIBBERD, MEDICAL PROTECTION SOCIETY

There are a range of special considerations when you receive unsolicited information from a third party in relation to the treatment of a patient.

Normally when you are working in medicine, you gather clinical information about a patient from the patient or from other clinicians involved in their care. But, every now and then, you receive an email or a phone call from a concerned neighbour or relative who wants to tell us something relevant about your patient. This can put a clinician in a tricky position, particularly if that person specifically ask you not to tell the patient what they have disclosed.

Defining the issue

Third party information is information you obtain about a patient which comes from a source other than the patient, another clinician involved in that patient’s care, or the clinical records made by another clinician about that patient. Unsolicited means the information has not been requested. The person who is providing the information is usually doing so on their own initiative.

Some examples of unsolicited third-party information might include:

• A daughter ringing up telling you that her father is drinking too much

• A neighbour emailing telling you that they believe a patient isn’t fit to drive

• A patient’s friend writing a letter telling you that the patient may be selling their medication.

Unsolicited third-party information would not include a letter from another clinician who is involved in the patient’s care or an email or phone call from the patient themselves, or someone who holds an activated enduring power of attorney for that patient.

Handling the information

The specific rules that govern how you should handle unsolicited thirdparty information are set out in the Health Information Privacy Code (HIPC). However, there are also ethical and professional considerations that clinicians should keep in mind.

Doctors must not lie to or deceive patients and you should never promise, or even suggest, to others that you will. Patients have a right to their own

information, which includes information about them which their doctors are acting on. There are exceptions to this, but generally the above applies.

Third-party information needs to be handled differently from other health information. Under the HIPC there is an obligation to verify any information before adding it to a patient’s notes or acting on it. This normally (but not always) involves talking to the patient about the information you have received. But information should only be added to notes once it has been verified.

There are times when you have discretion not to release information about a patient to a patient, but this would be a rare exception and it is not something you can ever guarantee to someone who is providing you with third-party information.

You can refuse a patient access to their own health information (even if it is in their notes) if you believe that the disclosure would do one of two things:

• Be likely to pose a serious threat to the life, health, or safety of any individual, or to public health or public safety

• Create a significant likelihood of serious harassment of an individual.

The seriousness of the harm or harassment would have to be significant before refusing the patient access to their own information could be justified. If you believe this is the case, you should contact your privacy officer before proceeding (and they may choose to seek medicolegal advice). Just upsetting people would not normally be considered a serious threat.

You also need to ensure that the person providing the information understands that you will need to verify that information before acting on it – and that that may involve telling the patient about the information. Promising that person you will not tell the patient who shared the information with you would be a promise you may not be able to keep.

If the person providing the information will not allow you to verify it and wants the information to remain secret, you have the option of rejecting the information. You should tell the informant you are rejecting the information – because you are unable to collect information from third parties unless it can be verified. In this situation you will not add the information to the notes or otherwise retain it, and it will not be acted on.

“You have discretion not to release information about a patient to a patient, but this would be a rare exception and it is not something you can ever guarantee to someone who is providing you with thirdparty information.”

Implications

In the first instance, if you receive unsolicited third-party information – whether via email, letter or a phone call – you should not record that information in the patient notes. This means those emails should not be added to the inbox, and points from the phone conversations should not immediately be added to the notes – either in the body of the notes or in addendums.

You should let the person providing the third-party information know that, if they wish you to save and act on the information, you cannot guarantee you will not tell the patient about the information or who provided it. You should explain that you have an obligation to verify any such information and normally this would involve discussing it with the patient.

If they want to proceed, and once the you verify the information, it will become clinical information and part of the patient’s health record.

If the informant does not give you permission to verify the information with the patient, you should let them know that you will talk to your privacy officer, but it is likely the information will be rejected, and you will not act on it.

If the informant chooses not to share the information, because they do not want it to be shared with the patient, but there is a serious risk of harm (such as a patient who is driving in an unsafe manner), then the informant should be advised that they can go to the Police with their concerns. The Police do not necessarily have to tell the patient who they have collected information from.

If the informant does give permission, then you can decide how best to approach verifying the information before you include it in the notes.

If release of the information could pose a serious threat to the patient’s or someone else’s life, health or safety, it can be marked as confidential. The clinician can then consider if it is safe to share it with the patient if they were to request it. This situation is likely to be rare and you should discuss it with your privacy officer before you add anything to the notes.

If you are not sure whether the situation would be considered unsolicited third-party information, discuss this with your indemnifier and, in the meantime, refrain from adding the information to the patient notes. Your computer system should have a file where unsolicited third-party information can be held before it is either verified or rejected.

A REAL-WORLD EXAMPLE

The wife of a patient emailed a psychiatrist with information about her husband. She was concerned about his mental health and described his actions and behaviours at home. She specifically asked that this information was not shared with the patient (her husband). The information was accepted and scanned onto the patient’s clinical record.

Some months later the patient asked for a copy of their hospital notes and the email from their wife was shared with them. This had a considerable and ongoing impact on the family.

In retrospect the psychiatrist wondered if they could have redacted this email from the notes before providing them to the patient, on the basis that release would be likely to pose a serious threat to the life, health, or safety of an individual. However, this is a very high bar and the Privacy Commissioner would potentially look at this and consider how serious that threat might be. Just upsetting people would not be considered a serious threat.

It may have been better to consider whether this information should have been accepted in the first place and whether it was appropriate to act on information which had not be verified with the patient.

ASMS Conference registrations open

Telehealth service nurse has HDC complaint upheld

Cost of locums in Dunedin Hospital skyrockets

New Industrial Officers

Budget just ‘treading water’ report says

Training ordered for Health New Zealand Official Information Act teams

IN BRIEF

NEWS FROM AROUND THE MOTU

ASMS CONFERENCE REGISTRATIONS OPEN

The ASMS 36th Annual Conference will be held on November 28-29 at Tākina event centre in Wellington with registrations now open.

The theme for this year’s conference is, “Whatpricehealth?”. The conference will include sessions on clinical and cultural safety in times of resource constraints, speaking up for patient safety, and navigating professional standards in a constrained environment.

Alongside this, there will be a chance to network with colleagues and meet Toi Mata Hauora’s Kuia and Kaumatua. Leave to attend the conference is covered by clause 29.1 of the SECA.

The Conference will close with a keynote address from Professor Peter Crampton on a better way forward for health and the solutions we should be advocating for. A full programme is available online at asms.org.nz/wpcontent/uploads/2024/09/ASMS-Conference-Programme-2024.pdf

Accommodation will be spread across the InterContinental, QT Wellington, and Hilton DoubleTree – all of which are within walking distance of the venue.

There is limited space at each of the hotels and there are no guarantees which hotel members will be placed at. All options are 4-5 star rated.

Registrations for delegates outside of Wellington requiring accommodation will be processed on a “first in” basis so register quickly. Because of accommodation restrictions, members attending both days of Conference will get priority over members only able to attend one day.

The hotels have strict policies on receiving guest information well in advance of the event. Your registration will need to be received no later than 30 days prior to conference to secure your accommodation at either of the three hotels.

Registration can be made at asms.org.nz/event/asms-36th-annual-conference

COST OF LOCUMS IN DUNEDIN HOSPITAL SKYROCKETS

The cost incurred by Dunedin Hospital in employing locums has increased 108 per cent from 2023 to 2024.

Data released under the Official Information Act shows total spending on locums increased from $1,936,000 in 22/23 to $4,033,057 in the 23/24 financial year.

The departments that required the largest increases in locum spending were specialist surgicial services, which saw a 554 per cent increase from

TELEHEALTH SERVICE NURSE HAS HDC COMPLAINT UPHELD

A registered nurse at a telehealth service has been found to have breached the Code of Health and Disability Services Consumers Right’s for failing to provide services of an appropriate standard to a woman in her seventies.

The woman had been ill for three days with vomiting symptoms and abdominal pain when her friend called emergency services.

“The initial call handler advised that the woman was not in immediate danger and a registered nurse of paramedic would call back within 30 minutes to conduict a secondary triage,” the HDC report released in July says.

“The secondary triage was completed by a registered nurse who advised the woman to see her GP the following morning.

“The GP diagnosed an upper gastro-intestinal bleed and called for an urgent ambulance transfer. Sadly, the woman died at hospital later that day from sepsis and a bowel obstruction, secondary to a hernia.”

Deputy Commissioner Rose Wall said the nurse who provided the secondary triage breached the Code for failing to provide services of an appropriate standard.

“In my view the information the nurse gained in the secondary assessment should have highlighted the need for timely consultation with a clinician,” she said.

Wall said risk factors were not taken into account when making decisions regarding the urgency of the woman’s need for medical assessment and her face-to-face assessment.

These risk factors included the woman’s age, the length of time she’d been sick and her medical history.

Wall also made an adverse comment about the telehealth service in relation to the algorithm decision tools and protocols but accepted the triage tool system as a decision-making tool is conditional on the accuracy of the information entered.

Since this event, the registered nurse, the telehealth service and the ambulance service have made a number of improvements.

$109,000 to $713,000, radiation oncology, which saw a 519 per cent increase from $176,000 to $1.09 million, and plastics, vascular and urology which saw a 81 per cent increase from $684,000 to $1.2 million.

The reason for the increase was listed as being “due to vacancies being difficult to fill. This has resulted in long term reliance on locums to ensure ongoing care to patients”.

ASMS says these figures are significant as it shows the long-term cost to the employer being unable to fill positions.

“Achieving better pay and conditions for permanent staff is the best and potentially only way to shift hospitals’ heavy reliance on locums,” executive director Sarah Dalton says.

NEW INDUSTRIAL OFFICERS

Jane Lawless has joined ASMS as an industrial officer for the Whanganui, Wairarapa, Tairawhiti and Palmerston North regions.

She will also be supporting Hawkes’ Bay.

Prior to joining ASMS, Lawless worked with the public health agency as a programme manager and worked in the Covid-19 directorate.

In a union capacity, she was also a longstanding delegate with the New Zealand Nurses Organisation and worked overseas with European health unions.

“Coming back to the health system after a gap, there has been a pronounced shift in workforce issues and I am looking forward to working with ASMS, and members, to address these as much as we can,” she says.

“In the short term I aim to get out into the districts, meet with you all and champion issues facing our health workforce.

“Already I have seen many pressing issues such as poor processes for CME leave, reimbursement and leave entitlements that need to get fixed.

Lawless is an avid bridge player and also was a member of the Lake Geneva Symphony Orchestra where she played the French horn.

Helen Kissell is the new industrial officer for South Canterbury and Waitaha. Kissell has worked for more than 10 years as an organiser for the New Zealand Nurses Organisation and has supported members within Te Whatu Ora, primary care, hospice, private and aged care sectors.

“I am looking forward to bringing this union and health experience to my role at the Association of Salaried Medical Specialists,” she says.

“Prior to these roles, I worked in the Tertiary Education Union firstly as a vice-president and then as an organiser.

“It is an extremely difficult time, and changing environment, within the health sector right now and I look forward to working with members to ensure their issues are addressed.”

BUDGET JUST ‘TREADING WATER’ REPORT SAYS

Deeper analysis of the 2024/25 Health Budget reveals just a 0.4 per cent increase in operational health funding, far short of what is needed to address systemic staffing issues or achieve ambitious health targets set by the Minister of Health.

A joint report by the Association of Salaried Medical Specialists and the New Zealand Nurses Organisation found that, while Vote Health received a total increase of $1,739 million of combined operational and capital funding, most of that increase is capital funding to cover historical claims under the Holidays Act.

“Vote Health’s operational budget only increased by $93 million, or 0.4 per cent from estimated actual spending in 2023/2024,” executive director Sarah Dalton says.

“At absolute best this is a ‘treading water’ budget – barely keeping the system’s head above water. But the water level is rising.

“A lack of real investment means a continuation of the status quo – and that means large workforce shortages and longer wait times for patients.”

The Minister of Health’s proposed healthcare targets also look doubtful.

“We do not believe the wait time targets are attainable, based on the lack of investment in the health workforce,” Dalton says.

TRAINING ORDERED FOR HEALTH NEW ZEALAND OFFICIAL INFORMATION ACT TEAMS

A complaint by ASMS into how Health New Zealand handles Official Information Act requests has been upheld by the Ombudsman.

Both ASMS’ policy and communications teams have had numerous issues getting OIA requests back from Health New Zealand in a timely manner.

The main complaint is that responses occur very close to the OIA deadline and often then request an extension.

An investigation from the ombudsman into one such request found, “At the time HNZ advised that it had made a decision on your request,

“Prior to the Budget Te Whatu Ora advised the Minister the total modelled cost for increased planned care delivery was $723 million if fullyfunded. That is not present in the budget.

“Targets without the funding to support them are just a stick to beat our workforce with.”

The report also raises other concerns:

The Government plans to “save” $14.3 million through people not collecting their prescriptions when the $5 fee is reintroduced. People not using prescribed medicines will only lead to further health needs.

• Medical school placements increase by 25 instead of the proposed 50. The lead time for students to become senior medical officers is more than a decade.

• Pharmac funding is $225 million less than estimated actual spending in 2023/2024

• Manatū Hauora Ministry of Health funding is cut $51 million (18 per cent) from estimated actual spending.

• The Health and Disability Commissioner’s budget has been cut by $2.9 million, and the Health Quality and Safety Commission by $1.4 million. This will impact monitoring and protecting of patients.

The ASMS report Just Treading Water can be downloaded from asms.org.nz/justtreading-water

the necessary work to provide a response had not yet been completed.”

“As a result, I have formed the final opinion that there has been a failure to meet the requirements imposed by the OIA. HNZ’s decision was invalid, and was therefore in breach of section 15(1) of the OIA and contrary to law,” chief ombudsman Peter Boshier wrote in his decision.

The ombudmsman says improvements are needed by HNZ and he recommended several changes that HNZ will introduce.

These include, “weekly refreshers on OIA legislation, mandatory completion of training provided by the Ombudsman for its OIA advisors, clearer communication in its responses to requesters and regular quality assurance testing across OIAs received.”

This decision was reported to the Minister of Health.

ASMS SERVICES TO MEMBERS

As a professional association, we promote:

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

ASMS JOB VACANCIES ONLINE

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.

CONTACT US

Association of Salaried Medical Specialists Level 9, The Bayleys Building, 36 Brandon St, Wellington Postal address: PO Box 10763, The Terrace, Wellington 6140

P 04 499 1271

E asms@asms.org.nz W www.asms.org.nz

FOLLOW US /asms.nz /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

ASMS STAFF

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