Building the workforce pipeline, stopping the drain
Introduction It’s no secret that many of the pipes and infrastructure which run the length and breadth of New Zealand are leaky and broken. Unfortunately, the same can also be said about the pipeline feeding into the public health system’s specialist workforce. And like a lot of infrastructure, our workforce pipeline is largely hidden, lacking maintenance and repair, easily overlooked. Ask our members what is the one thing that would most improve their working lives and they will, almost unfailingly, answer with a plea for more staff. As the union for senior doctors and dentists, we work hard to achieve safe, sustainable working conditions. But our own research shows there is an average 24% shortage of specialists in our public hospitals. The impact of that shortage on our members is high levels of burnout and stress, a lack of non-clinical time and, ultimately, longer patient waiting times and growing unmet need. The workforce pipeline is complex. It involves medical schools, the professional colleges, on the job training of junior doctors by senior doctors, specialist recruitment, reliance on attracting overseas-trained doctors, ongoing mentoring and training at all levels, holding onto the senior doctors and dentists we do have and, of course, it’s reliant on overall health workforce funding. And now the Covid pandemic has added further uncertainty. We don’t know how easy or hard it will be to bring senior doctors to New Zealand (early signs are that demand from potential Covid refugees could be high) and we are already seeing disruption to the Australasian training pipeline, not to mention further afield. What this will mean to the current medical workforce in training, we can only speculate. While it is important to keep highlighting the problems, we also need solutions. All up it can take 12-18 years to train a specialist and we are staring down the barrel of an ageing workforce. We need solutions to start flowing into the pipeline and we need them now. Work on this is beyond urgent. Without action specialist numbers will continue to be outpaced by population growth and increasing acute demand. Already we know hundreds of thousands of New Zealanders are missing out on treatment due to lack of access to primary care and stretched specialist services. Mental health, oncology, and neurology are three areas of significant under-supply, but we could name so many more. We also need a medical workforce that better reflects the people who live here in Aotearoa. We know that the more we ‘grow our own’ doctors and dentists and the more we include under-represented groups in the medical and dental pipeline, the more effective it becomes. If we keep doing the same things we have always done, we will get the same outcomes, and the current state of our health outcomes are not good enough. This publication looks at the specialist workforce pipeline from both ends: from medical school intakes to medical workforce retirements. We also examine the pipeline with reference to projected health and workforce needs. While the purpose of the medical pipeline is to ensure a sustainable medical workforce, we focus in this publication on the sustainability of the hospital-based specialist workforce. To quote from
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the now-defunct Health Workforce New Zealand in its last published report on the ‘health of the health workforce’: “The most important issue is the impact of a prolonged period of medical labour market shortages on the workloads, wellbeing, and productivity of DHB-employed senior doctors”. Health is an investment, and we need to invest in the people who hold our system together. Ko te mea nui ko te hauora Ngā mihi
Sarah Dalton Executive Director of the Association of Salaried Medical Specialists
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Snapshot
24%
The health workforce is the most critical component of the health system and salaried medical specialists are a critical component of the Estimated national health workforce. It typically takes 12-18 years to become a specialist shortage of after entering medical school but education and training remain a core specialists part of specialists’ work throughout their career, both as trainers in the apprenticeship model of medical training, and as lifelong learners. The flow through this career ‘pipeline’, however, is far from smooth. The pipeline is fragmented, with leaks and obstacles. Most importantly supply falls well short of the population and health needs of Aotearoa. • There has been a historic lack of workforce planning, management, and governance. • Data on workforce development and planning is non-existent. • There is significant under-representation of key ethnic groups in the specialist workforce. • There are entrenched specialist shortages resulting in high levels of burnout and stressed working environments. • The specialist workforce is ageing. • New Zealand has a comparatively low rate of medical graduates per capita and numbers fall well short of numbers required to supply future workforce needs. • An inadequate supply of domestic doctors has led to high dependency on International Medical Graduates (IMGs). • IMG retention rates are not high, creating significant workforce ‘churn’. • Funding shortfalls in the health system have led to staffing constraints and limited advertised vacancies budgeted. • Senior doctor shortages and increased clinical workloads are putting pressure on the apprenticeship model of medical training. • Greater flexibility such as enabling part-time work is needed in medical training programmes. • An increasing number of registrars are not in specialist training. • Considerable attrition from the medical workforce is expected within the next decade as many senior doctors approach traditional retirement age. • Careful planning is needed when older senior doctors reduce their hours as it affects workforce needs.
50
The average age of DHBemployed senior doctors
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Blockages and leaks Concerns about doctor shortages are not new among countries in the Organisation for Economic Co-operation and Development (OECD) and they are exacerbated by the prospective retirement of the ‘baby-boom’ generation of doctors. This has prompted many OECD countries to increase the number of students in medical education programmes over the past decade to train more doctors and avoid a ‘looming crisis’ in the health workforce.1 In New Zealand, medical school intakes were increased incrementally between 2004 and 2015. However, because there had been no increases in the previous 22 years, New Zealand still has a low per capita rate of medical graduates compared to other OECD countries (Figure 1). 35
Graduates per 100,000 population
30 25 20 15 10 5
FIGURE 1: MEDICAL GRADUATES PER 100,000 POPULATION IN OECD COUNTRIES Source: OECD Health Data 2020
43%
Overseas-trained doctors (IMGs) in the specialist workforce – the second highest in the OECD
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Ireland
Belgium
Denmark
Latvia
Lithuania
Portugal
Slovak Republic
Hungary
Czech Republic
Australia
Netherlands
Italy
Austria
Spain
Iceland
Sweden
Slovenia
Greece
United Kingdom
Mexico
Switzerland
Turkey
Finland
France
Germany
Poland
Estonia
Norway
Chile
New Zealand
United States
Canada
Israel
Korea
Japan
0
New Zealand’s low supply of homegrown doctors has resulted in high dependency on overseas trained doctors, or IMGs in a bid to fill gaps in medical services. (Figure 2)
Overseas-trained Drs as % of workforce
70 60 50 40 30 20 10
Israel
New Zealand
Irealnd
Norway
Switzerland
Australia
Unite Kingdom
Sweden
United States
Canada
Chile
Finland
Slovenia
Germany
Belgium
Portugal
France
Spain
Denmark
Hungary
Czech Republic
Austria
Latvia
Estonia
Slovak Republic
Netherlands
Poland
Italy
Lithuania
Turkey
0
FIGURE 2: OVERSEAS-TRAINED DOCTORS AS A PERCENTAGE OF THE MEDICAL WORKFORCE IN OECD COUNTRIES Source: OECD Health Data 2020
Unfortunately, many IMGs do not stay long in New Zealand creating significant workforce ‘churn’. As Figure 3 indicates, this high turnover is problematic in all age groups but especially among doctors under 30 and over 60. This has the effect of increasing workload pressure on the relatively stable portion of the workforce aged 30-60 who are mostly hospital specialists and GPs. 70
Percentage of IMGs Retained
60 50 40 30 20 10 0 1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
Years Post-Registration <= 29
30-39
40-49
50-59
60+
FIGURE 3: RETENTION RATES FOR OVERSEAS-TRAINED DOCTORS IN NEW ZEALAND BY AGE GROUPS, 2000-2017 Source: MCNZ. The New Zealand Medical Workforce in 2018
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16
Proportion of active doctors (%)
14 12 10 8 6 4 2 0 <25
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70+
Age Group Main Urban
Rural
FIGURE 4: PROPORTION OF DOCTORS (%) BY AGE GROUP (MAIN URBAN AND RURAL), 2018 Source: MCNZ. The New Zealand Medical Workforce in 2018
The aging senior medical officer (SMO) workforce indicates potentially worsening shortages ahead as a significant proportion of the workforce approaches traditional retirement age. In 2001 the largest group of specialists fell in the 40-44 age group. It is now in the 55-59 age group. The effect of the sharp drop-off in numbers in the 60+ age group worsens as those doctors who stay on tend to work fewer hours. District Health Board (DHB) services outside the main urban centres face an especially challenging time ahead (Figure 4). These are also the services that rely most heavily on IMGs.3
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45%
Percentage shortfall of SMO FTEs
40% 35% 30% 25% 20% 15% 10% 5%
West Coast (2019)
Bay of Plenty (2020)
Northland (2019)
Wairarapa (2019)
Hawkeâ&#x20AC;&#x2122;s Bay (2020)
Waikato (2019)
Southern (2019)
Capital & Coast (2016)
Whanganui (2019)
Hutt (2019)
Lakes (2019)
Tairawhiti (2019)
South Canterbury (2019)
Canterbury (2017)
MidCentral (2020)
Taranaki (2019)
Auckland (2019)
Waitemata (2018)
Counties Manukau (2016/17)
Nelson-Marlborough (2016/17)
0%
District Health Boards
FIGURE 5: ESTIMATED PERCENTAGE SHORTFALL OF FULL-TIME EQUIVALENT SMOs Source: ASMS Surveys of Clinical Leaders
The combined effect of low numbers of domestic doctors, poor retention of IMGs, increasing population health needs2 and funding constraints has resulted in entrenched shortages of SMOs3 in all DHBs. ASMS surveys over the past four years of DHB clinical leaders on how many SMOs they need to provide safe and quality services for patients, found an average 24% shortfall across the country. This shortfall ranged from 17% in Nelson-Marlborough to 43% on the West Coast (Figure 5).
References 1. 2. 3.
OECD. Recent Trends in International Migration of Doctors, Nurses and Medical Students, OECD Publishing, 2019. ASMS. Hospitals on the Edge, November 2019. MCNZ. The New Zealand Medical Workforce in 2018, MCNZ December 2019.
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A history of poor pipeline management From the late 1980s health workforce governance and planning underwent constant change involving a series of different organisations. These changes had an adverse impact on the development of the health workforce and health service delivery. It is not clear how the latest handover, from Health Workforce New Zealand (HWNZ) to the Health Workforce Advisory Board, will make a difference.
1980s:
1990s:
2001:
2007:
New Zealand’s health system is relatively stable until the late 1980s and health workforce planning is centralised. The Department of Health reports directly to the Minister of Health on the health workforce with plans informed by stock and flow modelling.
Rapid and dramatic restructuring and fragmentation significantly impacts the health workforce. The Minister of Health establishes a Committee Advising on Professional Education (CAPE). CAPE proposes that a health education agency be established, but this advice is not acted on. Health sector employers continue to determine plans based on market needs, which continues into the 2000s.
The Health Workforce Advisory Committee (HWAC) is established to independently advise the Minister and assess workforce capacity and foreseeable workforce needs. HWAC sets up a Medical Reference Group which argues the case for self-sufficiency for the medical workforce in response to shortages and proposes a national body with a coordinated planning function. This does not happen. HWAC produces a series of reports and some actions are undertaken with DHBs, but little progress is made. HWAC concludes its work in September 2006.
The Medical Training Board (MTB) is established, reporting to the Ministers of Health and Tertiary Education. Its mission is to oversee and co-ordinate an integrated system of medical education and training, to meet the current and future needs of the medical workforce. Significantly, it concludes that the impact of historic poor planning will continue for 15 years.
Structural and health system ‘reforms’ arrive which neglect workforce planning and leave workforce issues to health sector employers. Key Ministry of Health directorates are disestablished, leading to loss of workforce planning, development structures and knowledge.
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2009:
2018:
2020:
Lack of workforce development progress over the past 30 years results in serious workforce shortages. The MTB is disestablished, and the Clinical Training Agency Board is established ‘to unify workforce planning’. Its name is changed to Health Workforce New Zealand (HWNZ) and it is given an expanded role to reflect a national focus. While it succeeds in improving health workforce intelligence, it is not so successful in addressing workforce problems, and fails to create a clear strategy, or provide sector leadership.
HWNZ is restructured to become the Health Workforce Directorate. This is centralised within the Ministry of Health with a Health Workforce Advisory Board established to provide strategic oversight and sector leadership for New Zealand’s health workforce. A year later, the Health and Disability Services Review Interim Report is released and notes the lack of clarity on where responsibility sits and who is accountable for making sure the workforce pipeline is proactively managed over the short and long term.
The final report of the Health and Disability Services Review is published. No changes are recommended for the Health Workforce Advisory Board. The Review considers there has been fragmentation over the years and little progress made despite all the attempts to deal with workforce planning. The report notes the absence of a health and disability workforce plan and recommends that the Ministry of Health lead the development of a plan with a 10-15-year view. The Review believes that strong central leadership will be required.
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The Building Blocks The ‘medical pipeline’ refers to the process through which graduated medical students become vocationally registered – from house officers to registrars to hospital specialists or GPs. The purpose of this pipeline is to ‘ensure a sustainable medical workforce’, with emphasis on reducing dependency on IMGs (to reduce high turnover rates) and supporting the GP workforce.1 It is a process involving multiple players including the Ministry of Health, medical schools, medical colleges, the New Zealand Medical Council, DHBs, health unions and the New Zealand Medical Association – all subject to government policies.
Medical students • In 2020, 584 students began study at medical school. After a gradual increase of total new entrants since 2004, numbers have been steady for the last five years and are expected to remain so.2 • International students make up about 5% of total enrolments on average. • The gender balance of students has remained marginally under 60% in favour of females. The proportion has changed very little in the last decade. • In 2020, 476 Māori students were enrolled (17.6% of domestic students). This is up from 368 Māori enrolments in 2017 (13.3% of domestic students). This year 20.6% of new entrants were Māori.
Graduates 525 medical students graduated in 2019. 548 are expected to graduate in 2020, including international students.3 The projected number of future graduates depends on the attrition rate for each year, which can vary widely. Figure 6 assumes a reduction of 1.6% of final year students – that being the average final year attrition rate over the last four years.
10
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600
Number of graduates
500
400
300
Projections
200
100
0 2010
2011
2012
2013
2014
2015
2016 Domestic
2017
2018
2019
2020
2021
2022
2023
International
FIGURE 6: NEW ZEALAND DOMESTIC AND INTERNATIONAL MEDICAL SCHOOL GRADUATES AND PROJECTIONS Source: Medical Deans of Australia and New Zealand. Student Statistics Report 2019-20
The growth in graduates continues to 2021 then flattens out. Consequently, this will not change New Zealand’s low position in the OECD regarding number of graduates per capita. Nevertheless, it may reduce dependency on IMGs.
Practice intentions Exit surveys4 of medical graduates indicate that virtually all domestic graduates prefer New Zealand as their country of future practice. Only 30% intend to practice in regional centres with the majority hoping to work in a major city (60%) and the remainder in smaller areas or overseas. Around half of the respondents had decided on a preferred future medical specialty. Training and work environments influence future specialty preference with the highest ranked factors being: • atmosphere/work culture typical of the discipline • influence of consultants/mentors • general medical school experiences in addition to interest in helping people. By contrast the least influential factors reported were: • financial costs of vocational training • financial costs of medical school education and/or debt • perceived financial prospects and perceived prestige of the discipline.
30%
of medical graduates intend to practice in regional centres
The exit survey reports caution that findings reflect career intentions and that actual career choices may differ. Nevertheless, the importance of the general work environment in influencing choice of specialty, along with the ability to work flexible hours, is echoed in findings of Australian studies on the specialty preferences of their medical graduates and trainees.5, 6 Significantly these findings suggest that specialties currently experiencing the most severe workforce shortages and heaviest workload pressures are in a vicious cycle of being the least likely to attract new recruits.
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Pre-vocational training After completing medical school education, graduates are allocated house officer positions with DHB employers. This is a centralised process involving an ‘algorithm match’ from graduates’ lists of preferred employers, and employers’ rankings of preferred graduates. Graduates will only be matched to one employer. If a graduate declines an offered position, they are not offered another opportunity to be matched to any other employer.7 In 2018, just over 56% of house officers were female and 8.4% of house officers were Māori and 3% Pasifika.8 From the information available, there are not enough first-year house officer placements in community settings but there appears to be enough positions in hospitals. However, health budgets indicate the standard number of first-year house officers subsidised by the Ministry of Health (490) is fewer than the number graduating (estimated to be 548 in 2020).9 In the 20 years to 2015, on average nearly one in five New Zealand graduates training as house officers were no longer registered in New Zealand three years after graduating. But since 2010 the attrition rate has more than halved to less than 10% after three years (Figure 7).10 This may be largely a result of reduced opportunities for resident medical officers (RMOs) and specialist positions in Australia – the destination for the vast majority of New Zealand doctors who head overseas. Australian Government policy aspirations for health workforce “self-sufficiency” saw domestic medical student intakes doubling between 2003 and 2008, and still growing.11 From 2005 to 2018 Australian medical graduates increased by 120% - twice the growth rate of New Zealand’s medical graduates over that period.12 The rapid growth in Australian domestic medical graduates has put pressure on the capacity of the medical system to train, with competition increasing for intern places, as well as pre-vocational training posts and vocational training. It is a situation that shows no sign of improving.13, 14 MCNZ data show the improved retention rate for New Zealand house officers is reducing dependency on IMGs, with IMGs comprising 16% of the house officer workforce in 2018, compared with 24% in 2010.
Becoming a registrar After 2-3 years as house officers, doctors can apply for registrar positions in a particular specialty with DHBs as they arise. Improving retention rates have contributed to an increased proportion of New Zealand graduates progressing to the registrar workforce. They comprised 64% of registrars in 2018 – up from 59% in 2010. Medical Council data shows historically, retention rates for New Zealand graduates have tended to hold steady for a few years, before falling off at around 6-7 years post-registration. More recent trends suggest a similar levelling off (Figure 7). It is too early to know whether retention rates will continue to hold steady for registrars. The higher proportion of New Zealand graduates in the registrar workforce should lead to some improvement.
9.79
Medical graduates in NZ per 100,000 people – the seventh lowest in the OECD
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A 2018 analysis of specialist workforce exit and entry trends and projections suggested public hospital specialist workforce entries needed to increase by about 100 more per year over and above current growth rates in order to meet increasing health needs and address workforce shortages. However, even when accounting for increased graduate numbers (many will take up careers in primary care), and assuming 90% registrar retention, the annual increase in public hospital specialists would fall well short of that. Many more will be needed to reduce dependency on IMGs. The future supply of New Zealand-trained specialists is further hampered because many registrars employed by DHBs are not in specialist training programmes.
Average percentage of registered graduates retained
100 90 80 70 60 50
Period when most NZ graduates would usually be expected to be a registrar training to become a specialist
40 30 20 10 0 1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
Number of years after graduation Graduates 1995-2018
Graduates 2010-2012
FIGURE 7: AVERAGE PERCENTAGE OF REGISTERED NEW ZEALAND GRADUATES RETAINED BY POST-REGISTRATION YEAR Source: MCNZ Note: Excludes around 5%-6% of graduates (including overseas fee-paying students) who do not register in New Zealand after graduation.
References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.
Ministry of Health. Medical Workforce Pipeline. www.health.govt.nz Medical Deans of Australia and New Zealand. Student Statistics Report 2019-20. Ibid MSOD. National report on students graduating medical school in New Zealand in 2013-2017, New Zealand Medical Schools Outcomes Database (MSOD) Steering Group, October 2018 Scott A, Joyce C, et al. Medical career path decision making: an Evidence Check rapid review, brokered by the Sax Institute for the NSW Ministry of Health, 2013. Harris M, Gavel P, Young J. Factors influencing the choice of specialty of Australian medical graduates. Med J Aust 2005;183(6):295–300. ACE. Advanced Choice of Employment. MCNZ (2019). Treasury. Vote Health Estimates and Appropriations 2017/18 - 2020/21. MCNZ. The New Zealand Medical Workforce in 2018, MCNZ, 2019. Health Workforce Australia. Australia’s Future Health Workforce – Doctors Report, October 2014. OECD. OECD Health Data, 2020 Health Workforce Australia (2014) Lindsay T. Career cliff: an end to the Australian training model? MJA InSight Issue 20, 27 May 2019.
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Providing opportunity and reflecting who we are There is significant under-representation of key ethnic groups in New Zealand’s health workforce. In 2018, Māori made up 16.6 % of the population and Pasifika 8.1%.1 By contrast, only 3.5 % of New Zealand’s doctors were Māori and 1.8 % were Pasifika.2 Of the DHB-employed specialist workforce, only 2.0% are Māori and 0.9% Pasifika.3 The benefits to society of having a diverse health workforce are internationally documented. It is recognised that having medical students from minority backgrounds shapes their career choices in terms of place of practice and the types of populations they serve. Overall, this diversity and the career choices that follow lead to better health outcomes for diverse populations.4 The Ministry of Health is working towards addressing the stark under-representation of Māori and Pasifika in all levels of the New Zealand health workforce. The Ministry promotes a health workforce with proportions of Māori and Pasifika well above their representation in the wider New Zealand population. The justification is partly due to the recognition of future workforce shortages, but more fundamentally the recognition that this will ensure more equitable health outcomes for Māori and Pasifika. A key aspect of this work is assisting Māori and Pasifika with entry into the health and disability workforce and ensuring their retention. One aspect of this is encouraging universities to improve the ability for Māori and Pasifika as well as other minority groups (e.g. those from rural areas) to have better access to tertiary education opportunities, including entry into medical qualifications.5
Preferential pathways One example of this is the University of Otago’s Mirror on Society policy, adopted in 2012. It promotes selection of students through affirmative pathways to create a health workforce that reflects New Zealand’s diverse communities, particularly Māori, Pasifika and rural.6 The Division of Health Sciences implemented the policy mechanism to ensure all its health professional programmes produced graduates who would be better equipped to meet the needs of society. In 2017, two further pathways were included for students from lower socioeconomic and refugee backgrounds.7 The policy is making a difference to the health workforce pipeline. This year, for example, there are 65 Māori medical students out of a total of 282 students at Otago University and 25 Pasifika. This compares with 25 Māori students in 2010 and fewer Pasifika.8 Earlier in the year, the University’s Pro-Vice Chancellor of Health Sciences, Professor Paul Brunton said the University had an obligation to train health professionals who were equipped to meet the health needs of New Zealand’s diverse communities. “For Māori students there is a Tiriti of Waitangi obligation to ensure equitable participation by Māori in the health workforce. For students from rural, Pacific, low socioeconomic and refugee backgrounds a social justice Māori in the rationale applies”.9
2%
DHB specialist workforce
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Recently, there have been media reports that a proposal to cap the Māori entry pathway to 56 students a year had been considered by the Medical Admissions Committee.10 However, the University of Otago has stated that “no changes will be made to the admissions regulations or processes this year” and that it “will not be stepping away from the Mirror on Society policy”.11 The policy is due for review in 2021 and the university has stated that it will consult broadly.
0.9% Pasifika in the DHB specialist workforce
Increasing the diversity of the medical workforce and thereby improving health equity requires redressing the balance of systems and structures that have disadvantaged a range of groups that suffer inequities in health outcomes. This includes groups in terms of ethnicity, gender identity, sexual orientation, geographic isolation, disability status and combinations of these various factors.
Legal basis for affirmative action Preferential pathways are lawful under the New Zealand Bill of Rights Act 1990.12 Section 19(2) permits preference for Māori and Pasifika due to inequality. Under the Act, institutions can take measures in good faith for the purpose of assisting or advancing persons or groups of persons disadvantaged because of discrimination. In addition, the Human Right Act 1993 prohibits discrimination unless it is affirmative action. Section 255(4) of the Education and Training Act 2020 says that where a university limits the number of students who can enrol in a programme, it “may, in the selection of the students to be enrolled, give preference to eligible persons who are included in a class of persons that is under-represented among the students undertaking the programme”. Section 224(6) of the Education Act 1989 similarly allows for preferential selection among students who are under-represented in a programme or training scheme. Further, there is nothing in the law to suggest preferential selection needed to be limited to numbers that reflected New Zealand’s ethnic population.
References 1. 2. 3. 4.
Statistics NZ 2018 Census population and dwelling counts Medical Council of New Zealand (2019) The New Zealand Medical Workforce in 2018. TAS (March 2020). District Health Board Employed Workforce Quarterly Report 1 April to 30 June 2020. Crampton, P., N. Weaver and A. Howard (2018) “Holding a mirror to society? Progression towards achieving better sociodemographic representation among the University of Otago’s health professional students.” The New Zealand Medical Journal, 131 (1476) 5. Ministry of Health and Health Research Council of NZ (2007) “Rauringa Raupa: Recruitment and Retention of Māori in the Health and Disability Workforce.” 6. University of Otago (2018) Mirror on Society (MoS) Selection Policy 7. www.rnz.co.nz/news/te-manu-korihi/425211/otago-medical-school-admission-cap-debate-it-has-come-a-bit-out-of-the-blue 8. E-Tangata (2020) “Putting the brakes on equity” 9. www.stuff.co.nz/national/education/300013779/medical-schools-boosting-maori-and-Pacific peoples-numbers 10. www.rnz.co.nz/news/te-manu-korihi/425011/otago-university-facing-legal-challenge-over-medical-school-admissions 11. www.newsroom.co.nz/ideasroom/otago-on-mirror-on-society 12. http://legislation.govt.nz/act/public/1990/0109/latest/whole.html#DLM225519
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Vocational training
“Doing on calls for the rest of your career with no registrar house surgeon cover is not very appealing.”
New Zealand medical graduates would usually apply to take up registrar positions to train as a hospital specialist 2-3 years post-registration. However, unpublished Ministry of Health data shows an increasing number of registrars are not in specialist training programmes – amounting to 29% (698) of the full-time equivalent (FTE) registrar workforce in 2018 (Figure 8).
At the same time, paradoxically, an increasing number of ‘Establishment FTE’ registrar training positions are not being filled. In 2017 over 200 positions were unfilled (11% of the total Establishment FTEs). Most specialties had unfilled training positions, most significantly in anaesthesia, intensive care medicine, psychiatry paediatrics and obstetrics and gynaecology.1 It is unclear why these trends are occurring and raises questions as to whether many ‘Establishment FTE’ training positions are not being advertised; whether trainer capacity is overstretched; whether many trainee applicants are not finding suitable positions in their preferred speciality and location and whether funding constraints are driving trends. On the latter, Health Workforce Training and Development funding for DHBs dropped by approximately 2% in real (inflation-adjusted) terms between 2016/17 and 2019/20, despite increasing numbers of graduates entering the system.2 And while Ministry of Health data indicates there were 2322 DHB total registrar ‘Establishment FTEs’ in 2017, funding via Vote Health simply requires that “The number of training units for vocational registrars (excluding general practitioners) supported by Ministry of Health funding is equal to or greater than 1206.” That figure has remained the same for at least the last four years. Of the total Establishment FTEs, 1814 were for training positions but 1611 were actually employed in those positions.
2500
Registrars (FTE)
2000
1500
1000
500
0 31 Dec 2013
30 Sep 2014
31 Mar 2015
30 Sep 2015
Registrars in training
31 Mar 2016
30 Sep 2016
Registrars not in training
31 Mar 2017 Total registrars
FIGURE 8: FTE REGISTRARS BY TRAINING AND NON-TRAINING STATUS, 2013-2018 Source: Ministry of Health unpublished data
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30 Sep 2017
31 Mar 2018
A similar situation is occurring in Australia where non-training registrars, or â&#x20AC;&#x2DC;unaccredited registrarsâ&#x20AC;&#x2122;, have become common in specialties with highly competitive entry processes. They are seen by doctors-in-training as a way to gain further experience in a specialty before applying or reapplying to a specialist training programme. The value of unaccredited registrars has long been questioned. They do not exist in many comparable health systems and have been criticised as a source of inefficiency in medical training. Their developmental value has also been questioned due to the lack of formal training, appraisal, or supervision. Further, there is no cap to the number of years someone can work as an unaccredited registrar, and there is no guarantee of career progression. In Australia it is reported that many of these doctors work for years on end hoping to finally get onto a training programme.3 A further issue emerging in New Zealand concerns shortfalls of registrar trainees to replace older specialists approaching retirement (Table 1).4 In order to match the health needs of a growing and ageing population, and address current specialist shortages, workforce entries must not only exceed DHB workforce retirements but exceed them sufficiently to match future need not only for DHB services but also for private specialist health services. For example, while workforce projections indicate a growing number of orthopaedic surgeons and ophthalmologists, workload projections indicate that workforce growth is likely to be insufficient to match population needs for both specialties. TABLE 1: REGISTRAR TRAINEES COMPARED WITH SPECIALISTS AGED 55+ BY SPECIALTY, 2015
Specialties with fewer registrar trainees than specialists aged 55+
Specialties with more registrar trainees than specialists aged 55+
Cardiothoracic Surgery Clinical Genetics Family Planning and Reproductive Health General Practice Intensive Care Medicine Medical Administration Musculoskeletal Medicine Neurosurgery Occupational Medicine Otolaryngology head and neck surgery Paediatric Surgery Pain Medicine Pathology Psychiatry Public Health Medicine Rehabilitation Medicine Sexual Health Medicine Urgent Care Vascular Surgery
Anaesthesia Dermatology Diagnostic and Interventional Radiology Emergency Medicine General Surgery Internal Medicine* Obstetrics & Gynaecology Ophthalmology Oral and Maxillofacial Surgery Orthopaedic Surgery Paediatrics Plastic & Reconstructive Surgery Radiation Oncology Rural Hospital Medicine Urology
Source: HWNZ Medical Workforce Taskforce 2015 * Internal Medicine: Overall there are more registrars than specialists aged 55+. However, there are no registrars recorded in the sub-specialties of clinical pharmacology and nuclear medicine, and shortfalls of registrars in neurology, geriatrics, and rheumatology.
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“We are a small subspecialty and while we have lots of interested trainees there are not many funded training jobs. It’s so hard to have the tap producing trainees at the exact time we need them.”
A chart summarising similar data was published by HWNZ in 2015. While the list of the most vulnerable specialties had been growing before then, there appears to have been no further monitoring of trends since.6 Similarly, annual monitoring and analysis of house officer and registrar workforce trends, including trends in non-training registrars, stopped in 2017. Collection of workforce data stopped altogether in 2018. The evident lack of commitment towards addressing current and future hospital specialist workforce shortages was reinforced in HWNZ’s approaches. Despite acknowledging the shortages and increasing workloads, the agency adopted a planning philosophy shifting from a “do we have enough?” towards “how can we more effectively deploy?” – questions which arise in part from budget constraints but which failed to recognise their mutual dependency.7, 8 The Health and Disability Service Review also emphasises developing ‘new models of care’ as a way of mitigating ‘unsustainable’ workforce growth.9, 10 The Review acknowledges that workforce planning requires much better data than is currently available, and the Ministry of Health is now in the process of resuming data collection of the house officer and registrar workforces.11 However, the Review considers “there is much better data for the DHB, medical and regulated workforce, but not for the non-regulated or non-DHB workforce” and investing in better data for the latter should have priority before “adding more depth” to the DHB, medical and regulated workforces.12
References 1. 2. 3. 4. 5. 6. 7.
HWNZ. Medical Workforce Governance Group, Agenda, 13 September 2017 Treasury. Vote Health Estimates and Appropriations 2016/17-2019/20; Reserve Bank of NZ inflation data, 2020. Lindsay T. Time to end unaccredited registrar positions, MJA InSight Issue 5, 11 February 2019. HWNZ. Medical Workforce Taskforce Report on the Senior Medical Officer (SMO) workforce profile data collection, unpublished 2015. Ministry of Health. Health of the Health Workforce 2015: A report by Health Workforce New Zealand, February 2016. ASMS. ASMS submission on the Voluntary Bonding Scheme 2017 to Health Workforce New Zealand, June 2016. Rees G. The evolution of New Zealand’s health workforce policy and planning system: a study of workforce governance and health reform, Human Resources for Health, 2019, 17:51 8. ASMS. Submission to Health Workforce New Zealand on the discussion document ‘Investing in New Zealand’s Future Health Workforce’, May 2017. 9. Health and Disability System Review. Health and Disability System Review - Interim Report. Hauora Manaaki ki Aotearoa Whānui – Pūrongo mō Tēnei Wā. Wellington: HDSR, 2019. 10. Health and Disability System Review. Health and Disability System Review – Final Report – Pūrongo Whakamutunga. Wellington: HDSR, 2020. 11. Ministry of Health. Correspondence with ASMS, October 2020. 12. Health and Disability System Review (2020)
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BUILDING THE WORKFORCE PIPELINE, STOPPING THE DRAIN NOVEMBER 2020
Underinvestment and shortfalls
“Our DHB is not willing to consider the need for more SMO and nursing time despite over 10 years of service reviews stating this. There have been no staffing changes for 13 years.”
Years of under-investment in the health system and its workforce has resulted in a conservative $2.5 billion health funding shortfall. Prior to this year’s Covid response Budget, this is the amount of additional operational funding needed to restore health funding to 2009/10 levels. Even these levels of funding in 2009/10 were less than ideal.1
This estimated shortfall takes account of the costs for new services, claimed savings announced in each Budget, the actual expenses each year, inflation, demographic growth including ageing (estimates supplied by the Ministry of Health), and actual increases in wages. The decade of funding shortfalls and political pressure on DHBs to cope with tight budgets has resulted in staffing constraints including limiting budgeted (advertised) vacancies for senior doctors and dentists. Surveyed DHB clinical leaders have estimated budgeted vacancies cover only an average 35% of the number of staff required. (Figure 9). They also estimated an average 24% staffing shortfall across the country.2
Budgeted vacancies as a proportion (%) of estimated addtional staff needed
140% 120% 100% 80% 60% 40% 20%
West Coast (2019)
Waikato (2019)
Taranaki (2019)
Tairawhiti (2019)
Northland (2019)
Lakes (2019)
Nelson-Marlborough (2016/17)
Hutt (2019)
MidCentral (2020)
Counties Manukau (2016/17)
Waitemata (2018)
Whanganui (2019)
Southern (2019)
Wairarapa (2019)
Capital & Coast (2016)
Hawke’s Bay (2020)
South Canterbury (2019)
Auckland (2019)
Canterbury (2017)
Bay of Plenty (2020)
0%
District Health Boards
FIGURE 9: BUDGETED SMO VACANCIES AS A PROPORTION (%) OF ESTIMATED ADDITIONAL SMOS NEEDED (FTE) Source: ASMS Surveys of Clinical Leaders
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Further, DHB funding earmarked for workforce training dropped by approximately 2% in real terms between 2016/17 and 2019/20, despite increasing numbers of graduates entering the system.3
“Everyone is constantly covering clinical sessions for leave, there’s not enough SMO FTE funding, not enough nurses/allied health staff, senior SMOs and management don’t care.”
This year’s Budget increased Vote Health operational funding by $1.46 billion – the first time that funding had exceeded estimated needs in a decade. It also signalled further real increases are likely.4 ,5 Broadly speaking, Vote Health requires at least $800m additional funding each year to maintain the status quo, plus the cost of any new initiatives. The economic impact of the Covid pandemic means funding forecasts are likely to need more adjustment than usual. That aside, Treasury forecasts at the time of Budget 2020 suggest health is likely to continue to receive real additional operating funding for at least the next three years, determined by how much of the government’s significant unallocated allowance for “new operating spending” is allocated to Vote Health.6 There is potential for increased investment in the medical workforce over the coming years. Much depends on how the government prioritises additional funding given that many other parts of the health system are under-resourced.
References 1. 2. 3. 4. 5. 6.
20
Rosenberg B, Keene L. Did the 2019 Budget provide enough for health? Working Paper on Health No. 22, NZCTU-ASMS, August 2019, ASMS. Surveys of Clinical Leaders on Senior Medical Officer Staffing Needs, 2016-2020. https://www.asms.org.nz/publications/researchbrief/ Treasury. Vote Health Estimates and Appropriations 2016/17-2019/20; Reserve Bank of NZ inflation data, 2020. Ibid Treasury. Vote Health: The Estimates of Appropriations 2020/21 - Health Sector B.5 Vol.6. Treasury. Budget Economic and Fiscal Update 2020.
BUILDING THE WORKFORCE PIPELINE, STOPPING THE DRAIN NOVEMBER 2020
Need outpaces supply Modelling by the Ministry of Health shows New Zealand’s projected need for specialist health services is greater than the projected growth of the specialist workforce. Additionally, this modelling is conservative as it does not consider current unmet health need, nor does it acknowledge current specialist workforce shortages (Figure 10). 140
DHB specialists/100,000 pop.
120 100 80 60 40 20 0 2018
2019
2020
2021
2022
Projected DHB specialists
2023
2024
2025
2026
2027
2028
Projected DHB specialists needed
FIGURE 10: PROJECTED DHB SPECIALISTS PER 100,000 HEALTH-NEEDS-WEIGHTED POPULATION Source: Ministry of Health 2019; ASMS 2018
The Ministry’s forecasts weighted for proxies of health need (age, ethnicity and deprivation levels) show that by 2028 health service needs will have increased by 23% over 10 years while the projected public and private specialist workforce will increase by 21%.1, 2, 3 This means the current estimated workforce shortage of approximately 1000 specialists4 is projected to continue.
“We have the reputation of being a really busy ED whose staffing levels are not commensurate to our patient numbers nor complexity.”
Some specialties will be more affected by shortages than others. For example, two case studies covering both private and public services produced by the Ministry of Health5, show the workload per orthopaedic surgeon will need to increase by 7% by 2028 to match current service levels (Figure 11). This does not take account of the already significant unmet need for orthopaedic services currently. The other study examining ophthalmology demand shows inpatient workloads per ophthalmologist will need to increase by 20% (Figure 12). This will likely result in a worsening of current levels of unmet need. The projections assume the current service model will remain unchanged.
7%
Increase in workload needed per orthopaedic surgeon to match services by 2028
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200,000
400
180,000
350
160,000
300
140,000
250
120,000
200
100,000 80,000
150
60,000
100
40,000 50
20,000
0
0 2018
2019
2020
2021
2022
2023
Acute & non acute weighted hospital discharges
2024
2025
2026
2027
2028
Number of orthopaedic surgeons - Hdcnt
FIGURE 11: FORECAST ORTHOPAEDIC CASE-WEIGHTED EVENTS AGAINST FORECAST ORTHOPAEDIC SURGEON WORKFORCE Source: Ministry of Health 2019
25,000
200
20,000
150
15,000 100 10,000 50 5,000
0
0 2018
2019
2020
2021
2022
2023
Acute & non acute case-weighted events
2024
2025
2026
2027
2028
Total opthalmology workforce - Hdcnt
FIGURE 12: FORECAST OPHTHALMOLOGY INPATIENT CASE-WEIGHTED EVENTS AGAINST FORECAST OPHTHALMOLOGIST WORKFORCE Source: Ministry of Health 2019
“We have an extremely busy unit with not enough consultants on the floor for acute work. We have complex patients and rising volumes of complex operating. It’s physically and mentally exhausting.” References 1. 2. 3. 4. 5.
22
Ministry of Health. Workforce Forecast Models, 2016 & 2018 (unpublished). Ministry of Health. DHB Demographic Model 2018, V1.0 (unpublished). ASMS. Assessing the extent of senior medical officer workforce shortages. ASMS Research Brief, Issue 14, 2019. Ibid. Ministry of Health. Ministry of Health. Orthopaedic and Ophthalmology specialist workforce and demand projections. 2018 & 2019 (unpublished).
BUILDING THE WORKFORCE PIPELINE, STOPPING THE DRAIN NOVEMBER 2020
Pulling the plug
“I wanted to keep working but the duty roster was horrendous.”
There are a variety of reasons why senior doctors may wish to leave DHB employment. Understanding these reasons helps identify interventions that might encourage them to stay.
A 2017 study of ASMS members found that a quarter of respondents intend to quit DHB employment within the next five years.1 Nearly half of respondents aged 55 and over were unlikely or extremely unlikely to continue with some form of DHB-based employment. The top reasons why these doctors signalled wanting to leave are summarised (Figure 13). The most significant factors associated with intentions to leave were increasing age and low job satisfaction.
Retiring, age or feeling too old to continue
217
Disillusionment with DHB management, NZ public health system
82
Exhaustion, burnout, pressure of work
74
Low morale, job satisfaction, inability to make changes
70
Want time for leisure or other interests
51
Call, night shifts, weekend work
51 0
50
100
150
200
250
FIGURE 13: SUMMARY OF MOST FREQUENTLY EXPRESSED REASONS FOR INTENDING TO LEAVE
The research found a strong link between feelings of disillusionment and frustration with DHB management and intentions to leave, particularly for those in the older age groups. It is possible that older doctors may not be leaving simply because of their age. More than a third of respondents reported feeling their working conditions and DHB culture were beyond redress. The data shows that 73% of the overall 24% intending to leave could remain if improvements were made to levels of job satisfaction (Figure 14).
“Management does not seem to address reasons why people leave the service, rather just filling gaps as they arise.”
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Better management culture, less bureaucracy
31%
Nothing
20%
Better resourcing, staffing levels
17%
Better remuneration, improvement to financial situation
14%
Flexible working hours, part-time work, ability to take leave
14%
More respect, greater professional freedom
13%
Less work, more enjoyable work
13%
Reduced on-call, shift work, after hours
9%
Family reasons, children
2%
Improvements to health, age
2% 0%
20%
40%
60%
80%
100%
FIGURE 14: REASONS THAT MIGHT ENCOURAGE RESPONDENTS TO RECONSIDER INTENTIONS TO LEAVE DHBBASED EMPLOYMENT
Of the 75% intending to remain in DHB-based employment 40% would like to reduce their FTE, 30% would like to reduce their after-hours on-call or shift work, and 8% indicated that they would like to cease on-call or shift work duties altogether. Flexible working policies coupled with effective retention strategies could mitigate the potential to lose some of these senior doctors. As noted in this report, a high proportion of ASMS’ membership suffers from burnout symptoms, with 42% of respondents in a recent survey attributing this burnout directly to conditions of work.2 The changes cited above may also assist with reducing the propensity for this workforce to experience burnout.
“I work a 10 or 11 hour day. On days off and holidays I need to keep up with e-mails or will be swamped when I return. We are ignored by management when we try to raise issues. Hence I am leaving.”
References 1. 2.
24
ASMS Health Dialogue (July 2017): Future intentions of the New Zealand DHB-based senior medical workforce Chambers, C. N., C. M. Frampton, M. Barclay and M. McKee (2016). “Burnout prevalence in New Zealand’s public hospital senior medical workforce: a cross-sectional mixed methods study.” BMJ Open 6(11): e013947
BUILDING THE WORKFORCE PIPELINE, STOPPING THE DRAIN NOVEMBER 2020
Getting older New Zealand has an ageing medical workforce. The average age of DHB-employed senior doctors is 501 and the average age of vocationally registered doctors is 52 years, up from 48 years in 20052. In 2018, the largest group of doctors was those aged 55-59 (12.8%)(Figure 15). 20
Proportion of doctors (%)
16
12
8
4
0 <25
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70+
Age group 1980
1990
2000
2010
2018
FIGURE 15: AGE DISTRIBUTION OF THE ACTIVE WORKFORCE (1980-2018) Source: MCNZ The New Zealand Medical Workforce in 2018
Considerable attrition from the medical workforce is expected within the next decade as many senior doctors approach traditional retirement age. Studies have shown that the process of losing medical doctors from the workforce starts directly from graduation and persists throughout their career3. It has been shown that dissatisfaction with working conditions is strongly associated with intentions to leave the medical workforce. Evidence shows that flexibility in work is a positive driver of job satisfaction and doctors’ desire to remain. In particular, reducing working hours and improving opportunities for part-time employment are successful strategies to facilitate retention and retirement planning.4 It should be recognised that careful planning is needed when older senior doctors reduce their hours as it affects workforce needs. This also applies for people at different life stages, for example when doctors take parental leave. The potential impact of losing these experienced doctors from the workforce can thus be mitigated by enabling older doctors to ‘downshift’ their work commitments by decreasing their hours or type of work rather than facing a ‘cliff-edge’ of choosing between either full-time work or full retirement.5 Retirement should be viewed as a process of adjustment or a late career development phase, whereby doctors can move into new roles as a way of continuing their career.6 To support this type of approach, there needs to be education and support programmes to assist older doctors’ transition to retirement. Such programmes should include general advice (including financial and emotional resources) and recognise work as a core part of self-identity. They should be provided within continuing professional development (CPD) programmes and receive funding from the medical colleges.7
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“It’s difficult to reduce your hours and still be important and relevant to the department.”
In addition, DHBs (and other employers) should include end of career planning when re-credentialling older doctors, including discussions on succession planning, flexibility of job size, work hours, case load and case type choices, job sharing and career changes such as retraining options.8
In this way, doctors can be supported to actively plan for retirement, determine how long they wish to remain in active clinical practice, find out about other medical roles, and develop interests to ease adjustment into retirement. Health service delivery depends critically upon an appropriate workforce. It needs the “right numbers of doctors, in the right specialities, in the right place”9. It is incumbent on employers to strike a balance between encouraging preparation for doctors’ retirement and delaying the timing and eventual transition to retirement of its most experienced staff.10
55-59 years
The age group with the largest number of specialists
References 1. 2. 3. 4. 5.
TAS (2019). District Heath Board Employed Workforce Quarterly Report 1 April to 30 June 2019. MCNZ (2019). The New Zealand Medical Workforce in 2018. Degen, C., Li, J. & Angerer, P (2015). Physicians’ intention to leave direct patient care: an integrative review. Hum Resour Health 13, 74. Silver, M.P., Hamilton, A.D., Biswas, A. et al (2016). A systematic review of physician retirement planning. Hum Resour Health 14, 67. Davidson, J. T Lambert, Parkhouse J, Evans J and Goldacre M (2001). Retirement intentions of doctors who qualified in the United Kingdom in 1974: postal questionnaire survey. 6. Santiago, P., Martinez M, Monreal-Bosch P (2013). Managing the Process of Retirement: The Medical Professionals’ Perceptions. 7. Wijeratne, C., J Earl, C Peisah, G Luscombe and J Tibbertsma (2017). Professional and psychosocial factors affecting the intention to retire of Australian medical practitioners. 8. Health Workforce New Zealand (2011). Retention of doctors in their “third age”. A Report for Health Workforce New Zealand. 9. Davidson, J. T Lambert, Parkhouse J, Evans J and Goldacre M (2001). Retirement intentions of doctors who qualified in the United Kingdom in 1974: postal questionnaire survey. 10. Silver, M.P., Hamilton, A.D., Biswas, A. et al (2016). A systematic review of physician retirement planning. Hum Resour Health 14, 67.
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BUILDING THE WORKFORCE PIPELINE, STOPPING THE DRAIN NOVEMBER 2020
Workplace pressure and burnout Stress, fatigue, and overwork are taking a toll on New Zealand specialists. Research by ASMS over the past five years has highlighted issues with sickness presenteeism, burnout and bullying, which suggest a workforce under significant stress. Doctors who are burnt-out or suffering from bullying are more likely to consider leaving employment than those who are not.1, 2 Addressing the factors which negatively influence wellbeing at work are likely to pay dividends in terms of reducing attrition from the medical workforce.
â&#x20AC;&#x153;Burnout is common in my DHB and I have seen a number of colleagues leave due to the poor working conditions.â&#x20AC;?
The first nationwide study into rates of burnout in the DHB senior medical workforce found half of those surveyed were scoring with burnout, with 42% indicating burnout attributed directly to their conditions of work. Significant correlations were found between hours of work and burnout, with those not getting enough recovery time or working long hours more likely to score with burnout.3 Qualitative data from the research emphasised the negative impacts of issues such as under-resourcing, workload, poor management, and short staffing. Another study found 80% of DHB senior doctors surveyed routinely worked through illness with the main reason cited being concern that patients would miss out on care, and fear of letting colleagues down. Comments from this study emphasised the pressure of short staffing on decisions about taking sick leave and suggested a system with little flexibility.4 The challenges in terms of cover for short-term sick leave were also noted in nationwide surveys of Clinical Directors and in the latest ASMS membership survey where 31% of respondents felt they seldom or never had sufficient internal cover to facilitate taking sick leave when needed (Figue 16).
2020 ASMS membership survey
44%
Summary of clinical directors surveys 2017-2020
25%
32%
0%
10%
31%
17%
20%
30%
Strong agree and agree
40%
50%
50%
60%
Neither agree nor disagree
70%
80%
90%
100%
Strongly disagree or disagree
FIGURE 16: VIEWS ON WHETHER THERE IS SUFFICIENT INTERNAL COVER TO ENABLE SHORT TERM SICK LEAVE
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“System frustrations, inadequate staffing, limited access to diagnostics, poor leadership at higher levels of management, are all contributing to burn-out and desire to end my career in medicine as soon as possible.”
Bullying was reported by 31% of ASMS members who responded to another survey in 2017. The research found all measures of bullying were strongly associated with high workplace demands, and low support from peers and non-clinical management. The findings emphasised the common antecedents of bullying, including high workloads, stressful workplaces with poor organisational structures, and workplace cultures where bullying may be normalised as a coping strategy.5 ASMS has developed a practical and collaborative framework to address these concerns. The Standard for Sustainable Work is a 13-point guide to managing issues and stresses that can cause burnout and unsafe practices. Measures outlined include the need to correctly assess the number of senior doctors needed in clinical services (through an agreed process called job sizing), recovery time provision, identifying burnout risks, and promoting restorative practices for relationship issues. It advocates a national safe staffing accord, but DHBs have yet “Work pressure has to agree to engage over developing an agreed accord, while the increased. Covid-19 has Health Minister is yet to provide leadership.
had an insidious effect of increasing many workplace stressors.”
References 1. 2. 3. 4. 5.
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Hämmig, O. Explaining burnout and the intention to leave the profession among health professionals – a cross-sectional study in a hospital setting in Switzerland. BMC Health Serv Res 18, 785 (2018) Hoel, H., et al. “Organisational effects of workplace bullying.” Bullying and Harassment in the Workplace: Theory, Research and Practice (2020): 209. Chambers, CNL, et al. “Burnout prevalence in New Zealand’s public hospital senior medical workforce: a cross-sectional mixed methods study.” BMJ open 6.11 (2016): e013947. Chambers, CNL, et al. “Presenteeism in the New Zealand senior medical workforce-a mixed-methods analysis.” The New Zealand Medical Journal (Online) 130.1449 (2017): 10. Chambers, CNL, et al. “‘It feels like being trapped in an abusive relationship’: bullying prevalence and consequences in the New Zealand senior medical workforce: a cross-sectional study.” BMJ open 8.3 (2018).
BUILDING THE WORKFORCE PIPELINE, STOPPING THE DRAIN NOVEMBER 2020
Blocked access to non-clinical time If we are serious about “stopping the drain” there are some obvious, existing employment provisions in the ASMS collective agreement (MECA) that, when implemented, make positive differences to the working lives of senior doctors and dentists. At the top of this list is non-clinical time.
“All this rostered nonclinical time is taken up with ‘clinical’ work - triaging, patient notes, letters, organising appointments and follow up phone calls.”
Non-clinical duties are not optional extras. They are an essential part of a clinician’s practice. The Council of Medical College endorses ASMS’ long-held position that non-clinical activities should make up at least 30% of a clinician’s job size. The ASMS MECA requires that job descriptions include a comprehensive list of nonclinical duties. These are, in the broadest terms, anything that doesn’t have a patient’s name attached and may include administration, attendance at departmental meetings, formal teaching sessions, audit or other quality assurance activities, and personal professional development, including journal reading and research. Non-clinical time also supports senior doctors and dentists to get involved in wider DHB and College activities, and to lead and contribute to service and specialty development activities. Without it, junior doctors miss out on teaching and learning, departments lose forward momentum and the ability to plan and implement improvements to patient services and care, and senior doctors lose critical time to reflect, to learn, and to collaborate with colleagues. Ensuring regular access to non-clinical time is often a factor in overall job satisfaction as well as overall quality of care. If the clinical component of a doctor’s workload is too high or out of balance, non-clinical activities and individual wellbeing suffer. Time dedicated to non-clinical activities is crucial to ensure doctors stay up to date with best practice and the standards expected by the wider medical profession, the public and the law.
“If the definition of nonclinical time is admin, yes, I get that time. If this is time to teach, research, audit, read then absolutely not.”
A recent survey of ASMS members found 69% have some rostered non-clinical time but over a quarter do not. Of those who do have non-clinical time, the majority access less than the recommended 30% (Figure 17). Clinical administration also often swamps non-clinical time. Many respondents noted that while the time may be rostered, the creep of heavy clinical workloads meant that much of the allocated time would be taken up with clinical work.
BUILDING THE WORKFORCE PIPELINE, STOPPING THE DRAIN NOVEMBER 2020
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Other
7
I’m not sure
5
None
5
<10%
14
10-19%
22
20-29%
29
30%
17 0%
5%
10%
15%
20%
25%
30%
35%
FIGURE 17: HOW MUCH NON-CLINICAL TIME ARE YOU ABLE TO ACCESS IN YOUR CURRENT ROLE? (N=2098)
Findings from recent ASMS surveys of clinical directors suggest just over a third of departments are often and always able to access non-clinical time with a third of clinical directors stating their staff Never or Rarely manage to access the recommended 30% (Figure 18).
33%
0%
33%
20%
40% Never and rarely
34%
60% Sometimes
80%
100%
Often and always
FIGURE 18: SUMMARY OF CLINICAL DIRECTORS’ VIEWS REGARDING ACCESS TO THE RECOMMENDED 30% NONCLINICAL TIME
To foster a strong, motivated senior medical and dental workforce, adequate non-clinical time must be provided and protected, and become a bottom line requirement for safe sustainable work. Without that, we will continue to see senior clinicians burning out, RMOs missing out on critical learning, and patients unable to access best care.
30
BUILDING THE WORKFORCE PIPELINE, STOPPING THE DRAIN NOVEMBER 2020
Finding time to mentor and teach The apprenticeship model of learning, where the balance between learning and patient care gradually shifts as practitioner competence increases, has been the core of training in medicine for hundreds of years. Apprenticeship teaches more than just technical competence. The guidance of a senior practitioner is vital as doctors-in-training develop skills in approaching the doctor-patient relationship and navigate the ethical issues they encounter.1, 2 Several factors are now impacting adversely on the availability of senior doctors to teach doctors-in-training, including:3, 4 • shortage of senior doctors and high levels of burnout • rapid expansion in biomedical knowledge doctors in training must absorb • increasing clinical workloads and increasing complexity of cases for both senior doctors and doctors-intraining, limiting their ability to effectively participate in the training • changes to case-mix in which fewer complex cases are seen in outpatient clinics or community settings • changes to RMO working hours and rosters, which reduce contact (and therefore teaching opportunities) between senior doctors and doctors-in-training. The Resident Medical Officer Commission set up in 2009 to investigate long-standing issues facing the RMO workforce, including “dissatisfaction, industrial conflict and fragmented approaches to workforce management and planning” found many RMOs reported “their employers view them as units of labour to be deployed to cover service need rather than professionals in training, with families and lives outside the workplace”. The Commission stated: “We have long relied on the goodwill and professionalism of the health workforce. In the face of endemic workforce shortages, increasing demand, health system restructuring and poorly performing information technology, resident doctors have often put the needs of patients and of the health system before their own. In recent years it is clear that some are reviewing this decision.
“I have tried for 5 years to establish an effective teaching programme and just haven’t been able to due to demands on mine and trainees’ time. We need more junior staff.”
The goodwill on which the health service has relied has been eroded. RMOs feel that they are not valued by their employers and have sought solutions through industrial means. Employers, committed to meeting the service needs of their communities, report that providing care in a way that is compliant with the RMO employment agreement and within budget is now almost impossible.”
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It commented further: “Too often resident doctors’ contribution to service delivery takes precedence over their training.... For RMOs to be treated primarily as an in-training workforce requires changes to a system that relies on them as a frontline workforce.” A decade on, following acrimonious industrial disputes between DHBs and RMOs in 2016/17 and 2019, it appears the required changes to the system identified in 2009 have yet to be achieved.
32
BUILDING THE WORKFORCE PIPELINE, STOPPING THE DRAIN NOVEMBER 2020
“We are constantly asked to be more efficient. Non ‘clinical’ activity such as teaching and being taught suffers as a result. We feel we don’t have enough time to teach.”
Percentage of HoDs reporting their SMO staff lack time for training and education duties
80 70 60 50 40 30 20 10
MidCentral (2020)
Hawke’s Bay (2020)
Bay of Plenty (2020)
Taranaki (2019)
South Canterbury (2019)
West Coast (2019)
Lakes (2019)
Southern (2019)
Wairarapa (2019)
Hutt (2019)
Auckland (2019)
Tairawhiti (2019)
Whanganui (2019)
Northland (2019)
Waikato (2019)
Waitemata (2018)
Canterbury (2017)
Counties Manukau (2016/17)
Nelson-Marlborough (2016/17)
Capital & Coast (2016)
0
District Health Boards
FIGURE 19: PERCENTAGE OF DHB HEADS OF DEPARTMENT REPORTING THEIR SENIOR DOCTORS LACK TIME FOR TRAINING AND EDUCATION DUTIES Source: ASMS surveys, 2016-2020
A survey of DHB heads of department reveals the extent to which similar pressures of service delivery are also squeezing out time for senior doctors to carry out training and education duties. An average 41% of respondents estimated their staff lacked time for these duties (Figure 19).5 As the RMO Commission points out: “Senior medical staff need to be recognised for their roles as supervisors and educators. Moreover, government and health service providers need to recognise that quality education and supervision take time, and the allocation of appropriate funding.” In contrast the Health and Disability System Review viewed the hospital medical workforce through a more productivity-oriented and cost-containment lens, noting: “Senior medical officers spend relatively less time with patients as, over the years, employment conditions have changed with longer annual leave periods (five weeks), time for study (including a substantial training and travel budget), and assigned non-clinical time.” And: “In the last round of negotiations with resident medical officers, the required changes to rostering arrangements increased the number of staff needed to provide a roster”, which it estimated would cost more than $35 million. Time for good-quality teaching, mentoring and continuous learning, with all their benefits, did not appear to rate as high priorities for the reviewers. References 1. 2. 3. 4. 5.
Commission on the Resident Medical Officer Workforce. Treating People Well: Report of the Director-General of Health’s Commission on the Resident Medical Officer Workforce. Ministry of Health, 2009. MCNZ. Prevocational Training Requirements for Doctors in New Zealand: a discussion paper on options for an enhanced training framework, May 2011. Commission on the Resident Medical Officer Workforce (2009) MCNZ. Prevocational Training Requirements for Doctors in New Zealand: a discussion paper on options for an enhanced training framework, May 2011. ASMS. Surveys of clinical leaders on Senior Medical Officer staffing needs, 2016-2020.
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Finding flexible training pathways All medical colleges allow part-time or interrupted training. However, part-time training is not well supported by DHBs due to the way jobs are structured. Obtaining flexible or part-time positions is very difficult and may rely on job-sharing opportunities that have to be self-organised.1 People who want to work less than full-time are “considered exceptions, rather than the reality of a diverse workforce”2 and those who do succeed in finding flexible training roles have generally managed to do so through navigating the system on their own. The New Zealand Resident Doctors’ Association (NZRDA) is undertaking an ongoing study on the inadequate access to flexible employment. A survey found that only 16% of respondents are currently employed parttime. At the same time, 96% indicated they would like to be employed part-time in the future. The barriers that discourage trainees from pursuing part-time work include fear of lack of support from employers, negative attitudes from superiors, and unawareness and misinformation of part-time training and employment.3 In addition, the lack of pathways for those who seek flexible/part time jobs at some stage has the effect of prolonging the time to complete their training.4 Structural changes supported by both DHBs and the medical colleges is required to accommodate more part-time positions. In ASMS’ view: Both men and women coming out of medical school are seeking different ways of working and finding meaningful ways to participate in medicine. Many are seeking greater flexibility in training patterns and work hours. For these demands for greater flexibility in training and practice to be realised, however, structural, and attitudinal change is required. Enabling legitimate opportunities for those entering medicine to work differently must be accompanied by better planning for medical staffing and rethinking training programmes and work schedules. It will require significant leadership, vision, and a commitment to improve the working lives of all. Without this, it is likely that those who seek to practise medicine part-time will be subtly discriminated against as seeking working patterns that suggest a lack of commitment and dedication to their medical career.5
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The respondents in the NZRDA’s part-time employment study reported the following advantages of part-time work: • Work-life balance (64.3%) • Improved mental and physical health (43%) • Increased family time (31%)
“Design a system that can let the ageing intensivist share their experience and skills in a less stressful environment -like dayshifts in HDU/ICU or teaching.”
• Increased job satisfaction (17%) • Academic reason (17%). The following perceived disadvantages were reported: • Negative impact on training (52%) • Patient care (24%) • Stigma/discrimination (20%) • Overworking (15%). The NZRDA also noted the advantages for employers of providing part-time posts include “the availability of more candidates for recruitment, increased productivity, lower rates of staff turnover, and employee longevity. Job satisfaction of staff influences job retention which may eventually result in a decrease in workforce shortage.”6 Common reasons for pursuing part-time employment cited in the study included childcare (76%) and pregnancy (37%). It is recognised that a diverse cohort of doctors is better able to meet the health needs of the population and one study noted that:
“Colleagues can be resistant to having other colleagues working part-time. It is entirely due to the onerous oncall component.”
If women drop out of hospital medicine, simply because of difficulties in achieving part-time training posts, the arithmetic shows starkly that there will not be enough hospital consultants in the future, particularly in some of the acute specialties.7
References 1. 2. 3. 4. 5. 6. 7.
NZMA. (2013) Position Statement Medical education and training. New Zealand Medical Association. Poole, P. (2018) Choosing a medical specialty. The New Zealand Medical Student Journal Issue 26. NZRDA. (2020) Feature: Part-time Employment Study. Resident Doctor June 2020. Resident Doctors Association. Poole, P. (2018) Choosing a medical specialty. The New Zealand Medical Student Journal Issue 26. ASMS (2019).’Making up for being female’ Work–life balance, medical time, and gender norms for women in the New Zealand senior medical workforce. Health Dialogue. Wellington, New Zealand, Association of Salaried Medical Specialists NZRDA. (2020) Feature: Part-time Employment Study. Resident Doctor June 2020. Resident Doctors Association. Gascoigne, C. (2008). Making part-time work. [PDF]. London: The Medical Women’s Federation.
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Recommendations – a 12-step plan Who’s responsible
MoH/ Government
• Develop a Health and Disability Workforce Plan (HDWP), listing key stakeholders and targets for medical training and progression which will address equity and diversity of our medical workforce as well as distribution by geography, rurality, and specialty, as a matter of urgency. • Ensure the Ministry of Health is properly resourced to lead implementation of the HDWP.
Universities
• Increase the annual intake of medical students to ensure a supply of graduates to address specialist workforce shortages. This will also increase the intake of students through preferential pathways for Māori and Pasifika to address significant underrepresentation in the health workforce.
• Co-ordinate, publish and maintain a medical workforce census, sufficient to support high-quality independent expert advice to the MoH on all aspects of workforce policy, education, training and development, planning, and purchasing for the health and disability services sector. • Develop comprehensive, regularly updated data on unmet health need, and projected need, to inform health workforce planning. This data must be published.
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DHBs and Medical Colleges
• Introduce structural changes to accommodate more part-time and interrupted training options for trainees.
MoH and DHBs
• Increase funding and implement policies that enable senior doctors to access appropriate nonclinical time to undertake education and training roles. • Undertake a review of how well the registrar training programme is working to produce the right number of doctors, in the right specialities, in the right place. • Implement ASMS’ Standard for Sustainable Work guide to managing issues and stresses that can cause burnout and unsafe practices; and develop a national safe staffing accord.
Government
• Develop a cross-party political accord that agrees on a sustainable funding path to secure a stronger health system with the capability and capacity to address health needs. • Empower key stakeholders, including unions, colleges, iwi, employers, and other health regulators, for direct and multi-party engagement and collaboration in the development and implementation of the workforce timeline and strategy.
DHBs
• Provide greater support for older doctors to actively plan for retirement by considering such matters as succession planning, flexibility of job size and work hours, case load and case type, job sharing and career changes.
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