The Specialist - Issue 124 by AssociationofSalariedMedicalSpecialists

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

124 | SEPTEMBER 2020

WALKING THE TALK ON SUSTAINABILITY | P6 THE GAP BETWEEN HEALTH POLICY AND DELIVERY | P10 HOW THE PARTIES STACK UP | P13

INSIDE THIS ISSUE ISSUE 124 | SEPTEMBER 2020

WANT TO KNOW MORE? Find our latest resources and information on the ASMS website www.asms.org.nz or follow us on Facebook and Twitter. Also look out for our ASMS Direct email updates. This magazine is published by the Association of Salaried Medical Specialists and distributed by post and email to union members. Executive Director: Sarah Dalton Magazine Editors: Elizabeth Brown and Lydia Schumacher Designer: Dink Design If you have any feedback on the magazine or contribution ideas, please get in touch at asms@asms.org.nz.

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

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WE NEED A STRONG UNIFIED VOICE ON HEALTH CARE KINDNESS IS EASY TO SAY BUT HARD TO DO WALKING THE TALK ON SUSTAINABILITY HOW THE HEALTH SYSTEM IS BEING SHORT-CHANGED BY ACC CLOSING THE GAP BETWEEN HEALTH POLICY AND DELIVERY SIMPSON REPORT: A DISSENTING VIEW - PETER CRAMPTON HOW THE PARTIES STACK UP A MULTI-MEDIA HUI FOR BRANCH OFFICERS COVID-19 SHINES A LIGHT ON OCCUPATIONAL MEDICINE IMGS IN FOCUS ASMS WORKING BRIEFS WILL WE GO BACK TO OUR LOVE AFFAIR WITH JET TRAVEL? BOOK REVIEW – THE BAREFOOT SURGEON NEW FACE FOR THE SOUTH WOMEN IN MEDICINE FIVE MINUTES WITH DR ROGER WANDLESS INDEMNITY CLAUSES IN EMPLOYMENT CONTRACTS ASMS HEALTH SOLIDARITY BY THE NUMBERS DR PETER STORMER REMEMBERING A VISIONARY AND HIS GIFT

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WE NEED A STRONG UNIFIED VOICE ON HEALTH CARE PROF MURRAY BARCLAY | ASMS NATIONAL PRESIDENT

ne thing the Covid-19 pandemic has done is to sharpen the focus on our health systemâ&#x20AC;&#x2122;s shortcomings. Most notable have been the dangerously low number of public health specialists and the shortage of ICU beds and ICU specialists compared to other similar countries. There is little doubt our hospitals would have been overwhelmed without our Covid-19 elimination policy, and our ability to deal with our usual patient demands would have suffered badly. However, the deficiencies highlighted by Covid-19 reflect deficiencies across all specialist areas, resulting from more than 10 years of underinvestment in health care. Another result of systemic underinvestment, and the Ministry ignoring clinician advice and placing cost-cutting ahead of patient care, is the situation now occurring at Canterbury DHB (CDHB). The Ministry appointments of Crown Monitor Lester Levy and Board Chair John Hansen to slash the CDHB deficit (which was generated not by CDHB

mismanagement but by government and Ministry policy) has seen a tragic series of events culminating in the loss of arguably the most highly regarded DHB executive management team in the country. The strident and unified support for this EMT by all CDHB staff and the public, and the disdain for the decisions of the Hansenled Board, is a testament to the fantastic

staff/management culture at CDHB developed over more than a decade. This tragedy appears to be the result of poor leadership at the highest levels, i.e. government and Ministry. This poor leadership and underinvestment in health is also manifest in fragmentation and disunity at all levels of health care around New Zealand. When everyone WWW.ASMS.ORG.NZ | THE SPECIALIST

is fighting for the scraps, the natural tendency is to fend for oneself. DHB chief executives seem not to have united views around the country; individual departments are often having to fight for their survival and for their own patient group, at the expense of a unified voice; and even at the union level, divisions are being seen, with two unions now for junior doctors and some divisions within the New Zealand Nurses Organisation.

see exactly what needed to be done and his priorities were good. He was, however, quickly derailed by Ministry officials with faulty logic, plus the Labour Government’s imperative to display ‘fiscal responsibility’ for their political survival, leading to under-correction of investment in health and patients continuing to suffer. A strong clear voice for health in New Zealand is urgently needed. This requires intelligent, compassionate and mature leadership. Leaders must recognise that their primary responsibility is provision of sufficient, high quality health care for all New Zealanders, rather than making budget-cutting the prime goal. They also need to work together to reach agreement and present a unified voice at all levels, especially when addressing the Ministry and government, who can easily blame lack of unity for their own faulty decisions.

Another result of systemic underinvestment, and the Ministry ignoring clinician advice and placing costcutting ahead of patient care, is the situation now occurring at Canterbury DHB.

Over many years, ASMS has worked hard to ensure that we represent members’ views as accurately as possible, and to avoid divisions occurring. We have managed to keep membership levels at around 90% of eligible SMOs/SDOs, and membership continues to grow steadily. ASMS has earned respect from DHB management, media, and other organisations, and might have a growing role in bringing together various parties to

The most significant problem with this fragmentation is the lack of a strong unified voice in health care. This becomes an issue at government caucus where the important funding allocations are debated. As I have discussed previously, David Clark had the potential to be one of our best Health Ministers. At first, he could

strengthen the health voice nationally for our patients. You will have noted that ASMS recently ran a survey to gauge members’ views on a range of important issues before the next MECA negotiations and also to reassess levels of member burnout to see whether this has improved or worsened since our previous similar survey in 2016. The response rate was 45%, which is fantastic when we know members are so extremely busy. The survey was comprehensive, so analysis will take time, but we hope to get results back to members soon.

A strong clear voice for health in New Zealand is urgently needed.

With the political and economic situation in a state of flux, the MECA negotiations are unlikely to be straightforward, and we need to portray member views accurately. At this point, indicators suggest what members need most right now is more colleagues to share the patient load. This would go a long way to resolving our worst problems in health delivery.

ESTIMATED SMO STAFFING SHORTFALL AS PERCENT OF CURRENT STAFFING ALLOCATIONS 100

AVERAGE 24% STAFF SHORTAGE PERCENTAGE OF FULL STAFFING

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MIDCENTRAL (2020)

HAWKES 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)

Data from ASMS staffing surveys

KINDNESS IS EASY TO SAY BUT HARD TO DO SARAH DALTON | ASMS EXECUTIVE DIRECTOR

am writing this in the last week of August – a huge week by any measure. We met with our branch officers for our annual workshop, in a mixed medium webinar. It was held as Auckland continued under Level 3 lockdown and Christchurch found some closure in the sentencing of the terrorist responsible for the mosque shootings. I want to take a moment to acknowledge the terrible loss of so many lives at the Linwood and Al Noor mosques – including one of our people, Dr Amjad Hamid – and the efforts of our friends and colleagues at Canterbury DHB who worked so tirelessly in the service of those injured in the attacks.

It is galling that so many of those people who have sowed the seeds of kindness in Christchurch are reaping a very different outcome from the one they deserve.

It makes me think about what being kind really looks like. As a team of five million we grieved with the families of those caught up in the mosque attacks. Now we are trying to remember to be kind as we navigate the restrictions and frustrations of the various Covid-19 lockdown levels as weeks and months go by with closed borders, limited travel, and tired hospital and community buildings that make infection prevention and control so challenging, not to mention the massive social and economic pressures on many of our communities.

the next DHB, and the next, will not have to pay the heavy price of losing an entire leadership team? Here is some of what I think.

Canterbury DHB. We may not always have agreed with each other, and at times we have shared difficult conversations. But we have never stopped the conversation.

• Innovating for integrated and timely patient care is not cheap and costs money up front – it is an investment.

We must only hope that those tasked with governance in the future learn better than the current Board, Chair, and Crown Monitor, who seem to have abandoned kindness, and whose eyes and ears are closed to the most important part of our health system – our people.

• Sometimes longer-term benefits and savings do not show up on the balance sheets. • People are the most important thing about our health system, and we forget this at our peril. • Political cycles are not very compatible with long-term planning for best patient care. Wouldn’t it be great if we could agree some fundamentals and be given time to put them in place?

People are the most important thing about our health system, and we forget this at our peril.

• Closed-door decision-making is unacceptable. • Clinical good practice needs to drive the work of the planners and funders. Remember that doctors have obligations that are wider and deeper than those of employees to employers. • Being kind is easy to say and hard to do. It is galling that so many of those people who have sowed the seeds of kindness in Christchurch are reaping a very different outcome from the one they deserve. I want to acknowledge the service and leadership of those who are leaving

And to those of you tasked with leading from the centre, we will be holding you to account. Like our members, whose professional and ethical obligations require that they speak up on issues of patient safety, health decision-making, and access to care, we will continue to advocate for standards of health care that are sufficient, that are sustainable, and that are needed by our team of five million. He waka eke noa – te-nakoutou, te-nakoutou, te-na- ta-tau katoa.

But I cannot help but wonder where that sits in the minds of those charged with overseeing hospital planning and funding. Many of you will have been following the unravelling of Canterbury DHB over the last few weeks and will have seen many of our members passionately taking protest action to voice their concern about the future of health care in the region. And while money (or lack of it) is the subject of this cautionary tale, it’s the breakdown of key relationships, the adversarial and dictatorial approaches adopted by the DHB’s Board Chair and the Crown Monitor (both appointed on advice from the Ministry of Health) that are its theme. What can we learn? What crumbs can we pick up and scatter in the hopes that

Cartoon: Sharon Murdoch WWW.ASMS.ORG.NZ | THE SPECIALIST

Dr Rob Burrell with a single use intubation device

Dr Marty Minehan munching a potato starch tray

WALKING THE TALK ON SUSTAINABILITY ELIZABETH BROWN | SENIOR COMMUNCIATIONS ADVISOR

he Lancet has billed climate change as the greatest threat to human health in the 21st century. In many hospitals, specialists are at the forefront of sustainability initiatives, driving culture change with clinical expertise and a desire to make things better for patients, the planet, and the next generation. When it comes to climate change, sustainability and health care, Middlemore Hospital anaesthetist Dr Rob Burrell describes what he sees as “cognitive dissonance”. “You are supposed to be here to help people, but we are creating so much havoc and mess around us by putting piles of crap into the atmosphere and the ground and leaving it for future generations to sort. It’s not acceptable or sustainable.” It is estimated that New Zealand’s health care sector contributes as much as 8% of New Zealand’s total greenhouse gas emissions, and according to the Energy Efficiency and Conservation Authority, health is the largest emitter in the public sector. Our hospitals generate a huge environmental footprint as high-end users of gas, electricity, water, and transport. They churn out hundreds of thousands of tonnes of waste each year, which are dumped into our landfills. They consume

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millions of single-use plastic and plasticwrapped items.

environmental steering group to measure and reduce the DHB’s carbon emissions.

BRINGING CHANGE

At its last audit last year, it had reduced its carbon footprint by 26% through a number of initiatives, including the use of reusable cups, rideshare programmes, reducing anaesthetic gases, and better recycling. It has been recognised as one of ToituEnvirocare’s top carbon reducers for 2020.

But the worm is slowly turning, prodded along by clinicians and hospital staff concerned by the impact of climate change on human health and the environment.

“You are supposed to be here to help people, but we are creating so much havoc and mess around us by putting piles of crap into the atmosphere and the ground and leaving it for future generations to sort.”

In 2011 staff at Counties Manukau DHB took a ground-breaking step and formed an

ICU specialist Dr David Galler was involved from the start and describes it as life changing. “We started off just doing carbon reduction around waste, energy and travel, and it’s turned into a regenerative philosophy which has completely changed my world view.” Standing in a theatre next to recycling bins and cleaner anaesthetic gases, which he successfully lobbied for, Rob Burrell says a lot of progress has been made but there is so much more to do, especially in terms of procurement.

Auckland Renal Department recycling champions Drs David Semple and Jason Wei

A 2019 report by the Ministry of Health titled Sustainability and the Health Sector stated: “Procurement is responsible for an estimated 61 percent of all carbon emissions related to health care … This is the carbon emitted while extracting, manufacturing, packaging, storing, and transporting pharmaceuticals and supplies … Making sustainable procurement part of decision-making processes across all health care sectors will help signal a shift in demand toward a more sustainable health care system.”

“The system is set up to consume. We need to keep pushing hospitals to change the way they make decisions about what they purchase.”

A DISPOSABLE CULTURE Holding up a plastic packet with a single disposable intubation device, Dr Burrell says hospitals are great at throwing things away. The devices, which are currently

popular worldwide for intubating Covid-19 patients, are made in Canada and cost $30 each. Dr Burrell says the same company makes a reusable but much more expensive titanium option. “In the long run, buying five of the expensive ones would be cheaper because we hoover through the disposable ones. Plus, our environmental footprint would be a tiny fraction. We wouldn’t have thrown anything away, there’d almost be no packaging, we’d be safe if Covid hit hard because the supply chain would be local, we’d be employing locals to clean stuff and our carbon emissions would drop because we’re not constantly re-supplying from overseas.” Frustratingly, he says the disposable items come out of the DHB’s operational budget, which is huge, while the reusable devices would come out of the capital budget, which is tightly held. “The system is set up to consume. We need to keep pushing hospitals to change the way they make decisions about what they purchase,” he says. The volume of waste created by surgical gowns and plastic drapes also weighs on

his mind, not to mention the cost of landfill disposal. Thinking big, Dr Burrell says New Zealand should be making compostable gowns or investing in upcycling to turn the waste into items like combs, park benches or cabling.

“We tell the registrars if they’re hungry, to grab a bottle of sauce and start eating them.”

PROVING A POINT Up the road at Auckland Hospital, Dr Marty Minehan is another anaesthetist putting a sustainability lens on clinical practice with some interesting results. Approximately 175,000 plastic drug trays annually were being used across Auckland DHB each year. While the trays could be recycled, most were being sent directly to landfill. Dr Minehan, who works in Women’s Health, took matters into his own hands. He conducted a life-cycle product WWW.ASMS.ORG.NZ | THE SPECIALIST

“We transport patients about 600,000 kilometres a year to and from dialysis because we have a treatment model which is convenient for us, but often not for our patients. If we have units closer to where people are, that’s going to save travel time, carbon emissions and achieve equity goals and better patient care.” “When you’re a junior doctor you focus on the patient in front of you, but as I’ve moved through my SMO role I’ve realised my responsibility to the health of my population and my country as a whole and that health is more than the drugs I can prescribe,” Dr Semple says. ‘POCKETS OF BRILLIANCE’ The number of clinical sustainability initiatives is steadily growing, but the reality is they require corporate sponsorship and partnerships so they can be cost neutral to the DHB. Many of the opportunities have been identified, followed through, and endorsed by senior doctors.

Surgical tool recycling analysis, and after a successful pilot, drug trays made from potato starch are now being rolled out across the hospital. The trays are compostable and biodegradable. He jokes, “We tell the registrars if they’re hungry, to grab a bottle of sauce and start eating them.” He took the project on to prove a point. “I rang each of the suppliers and sent them an email with 20–30 questions about their products. We did a spreadsheet of all the different products and how much they cost. “We took it to the senior leadership team and what we’ve ended up with is a cheaper product, with a significantly smaller footprint, something which is easy to dispose of, has virtually zero environmental impact, is locally made so the money goes back into the economy – and you can eat it.” His advice to his fellow SMOs is to question suppliers about their products. “Ask what their environmental credentials are, what makes their product better in terms of its environmental footprint, how is their company engaged in terms of sustainability?” WASTE AUDITING AND REDUCTION A few floors down in the hospital’s Renal Department, green initiatives began about two years ago, led by technical advisor Dr Jason Wei and supported 8 THE SPECIALIST | SEPTEMBER 2020

by Clinical Director Dr David Semple. They conducted a waste audit and have successfully decreased medical waste from each dialysis process by 40%. According to Dr Wei, “For our clinical related projects to be successful it was up to SMOs’ support because if they are not on board, other staff won’t be confident to ensure all changes will be implemented properly.” Green initiatives are now a standing item in the department’s regular service management meetings. It is estimated four million litres of water a year could be saved from water-heavy dialysis processes. As a result, staff are being educated around simple ways to reduce water use, and Dr Semple has been in discussions with Watercare about potential large-scale infrastructure changes to help achieve that.

“When you’re a junior doctor you focus on the patient in front of you, but as I’ve moved through my SMO role I’ve realised my responsibility to the health of my population and my country as a whole.”

Changing models of care are also being looked at.

They include a recycling pilot in which plastic syringes are being collected and repurposed into things like fenceposts, a programme in which single use medical instruments are converted back to their mineral content so they can enter the recycling chain, and the recycling of PVC products like fluid bags and oxygen masks into playground matting. SMOs have also been behind a push to get more charging stations for electric vehicles in DHB carparks. Auckland DHB has reduced its emissions by 28% in four years, and the achievement has been recognised with several global and local awards. Like Counties Manukau DHB, Auckland DHB has also been recognised this year by Toitu- Envirocare as one of the country’s top carbon reducers. Deputy CMO and Director of Cancer and Blood Services at Auckland DHB Dr Richard Sullivan believes the challenge is to take the “pockets of brilliance” around sustainability and embed them into the organisation’s culture and leadership structure. “Ideally, when we have our strategic imperatives such as Te Tiriti, equity, and digital enablement, in two to three years, there will be one around sustainability. “We are one of the biggest employers in New Zealand and we should be leading that space, and the reality is that doctors have a major influence in those decisions,” he says. The Specialist is distributed by a marketing company which is EnviroMark Gold certified. The plastic wrapping is treated with EcoPure – an organic additive which helps plastic to biodegrade. The magazine is printed on Forestry Stewardship Council approved paper.

HOW THE HEALTH SYSTEM IS BEING SHORT-CHANGED BY ACC DR PETER ROBERTSON | AUCKLAND ORTHOPAEDIC SURGEON & LYNDON KEENE | HEALTH POLICY ANALYST

CC appears to be under-paying its share of the cost of public hospital trauma care by hundreds of millions of dollars a year, according to Ministry of Health and ACC data and modelling by one DHB.

While ACC is responsible for funding the care for those injured in accidents, its funding for those who need acute care in public hospitals, covering the first seven days from injury, is not paid directly to DHBs. Instead, each year it bulk funds the Crown for Public Hospital Acute Services (PHAS) costs, amounting to more than $500 million a year. The Crown in effect purchases public hospital acute services on behalf of ACC. This is included as an un-itemised part of DHBs’ budget allocations in Vote Health.

indicated by official case-weight estimates. The study involved a relatively small number of patients, so strong conclusions cannot be drawn from it. However, if anything, it probably understates the extent to which case-weight estimates fall short of the true costs of care because it excluded patients who needed urgent transfer to a tertiary centre, who are likely to be the most complex of patients requiring ICU care and surgery. It also means the funding gap indicated in Figure 1 is conservative.

But while the PHAS funding increased by 15.5% in real terms between 2009/10 and 2018/19 (slightly higher than the population 12.7% growth), accident-related hospital discharges are increasing at a much higher rate. Acute (case weighted) discharges for injury or poisoning, for example, increased by nearly 23% over the same period (Figure 1). (The low number of discharges prior to 2012/13 is due in part to incomplete data up until that time.)

Recently, Canterbury DHB calculated costings for injury patients that would come under the ACC umbrella and compared this to their DHB share of PHAS funding (estimated according to its share of national DHB population-based funding). Several models of costings were used and resulted in estimates suggesting that PHAS funding is little more than half of what the costs of ACC patients would actually be. Given that PHAS funding for the year of this study was in the order of $500 million, Canterbury DHB’s modelling suggests underfunding of trauma care provided by the DHBs nationwide is likely to be in the hundreds of millions of dollars.

Further, the indications that acute injury related discharges are growing at a much higher rate than ACC funding are only part of the story. A study on the costs of major trauma care in Northland found the total actual cost was markedly higher than

Real ACC funding

Acute discharges (caseweighted)

20 15 10 5

2018/19

2017/18

2016/17

2015/16

2014/15

2013/14

2012/13

2011/12

2010/11

0 2009/10

CUMULATIVE % GROWTH

FIGURE 1: CUMULATIVE PERCENTAGE GROWTH IN ACC FUNDING (DEFLATED) AND ACUTE TRAUMA HOSPITAL DISCHARGES

Sources: National Minimum Data Set, Ministry of Health; ACC annual reports; Stats NZ Notes: Acute trauma discharges include those categorised as ‘injury or poisoning’, including inpatients and daypatients. Data prior to 2012/13 are incomplete. Deflated in 2009 dollars using Reserve Bank of NZ inflation calculator.

INVISIBLE FUNDING SHORTFALL This funding shortfall has most likely grown over many years but has remained invisible due to a lack of regular accurate assessment and monitoring. Since the PHAS funding is absorbed into Vote Health’s general DHB funding, there is no indication of how much of the PHAS funding each DHB receives. The calculation of the value of the PHAS is equally opaque. Accurate financial accounting of the true costs of trauma – and therefore ACC patients – does not appear to occur in most DHBs. There is at best an antiquated classification system for injuries that in no way adequately represents current classification of surgical events. There appears to be no recognition of the extent to which acute accident-related surgery has grown in complexity over the years, often requiring the work to be done in daylight hours – which means that as well as being under-funded, the work displaces other elective surgery. The Ministry has explained that the PHAS funding has been calculated “after periodic reviews that require significant resource yet have low levels of confidence” (presumably related to accuracy). So, it seems that both ACC and the DHBs have little idea as to the true cost of trauma and accident services. The PHAS contribution is simply based on the prior year’s contribution plus an increase in line with general DHB funding increases, thereby perpetuating a head-in-the-sand approach to trauma care funding. A prominent health advisor commented privately that “there is no appetite for change” on this issue. But given the evident gross underfunding of acute services and its flow-on effects for non-acute services, the New Zealand public will surely expect to see a more responsible attitude from government decision-makers. Such funding neglect, to the detriment of many patients, demands urgent attention. WWW.ASMS.ORG.NZ | THE SPECIALIST

CLOSING THE GAP BETWEEN HEALTH POLICY AND DELIVERY LYNDON KEENE | HEALTH POLICY ANALYST

striking feature of the Simpson Health and Disability System Review is the extent to which its recommendations resemble the policy intentions of the New Zealand Health Strategy of 20 years ago. Similarly, the Mental Health and Addiction Inquiry found that over the past couple of decades the mental health and addiction system ‘has not shifted’, despite the stated intentions of earlier strategies. It concluded that “a fundamental disconnect exists between stated strategic direction, funding and operational policy and ultimately service delivery”. Health policy analyst Lyndon Keene examines why such ‘disconnects’ occur and what is needed to close the gap, including the part that doctors have to play. A great irony in democracies is that the people entrusted to make them work tend to be among the least trusted by their populations. Prior to the last election in 2017, a Stuff/ Massey University Election Survey found only 16% of nearly 40,000 respondents were prepared to vouch that in general New Zealand’s politicians ‘keep their promises’, while 58% preferred the option that said they ‘only sometimes keep their promises’, and 26% chose ‘usually break their promises’. In New Zealand, under MMP, it can be harder for candidates to keep all

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their promises due to the coalition arrangements and negotiations. The literature on the policy-implementation gap, or ‘policy failure’, identifies at least four broad contributors. In short:

the same results elsewhere. And those operating at higher levels cannot succeed without having some grasp of what happens on the ground.

• Over-optimism: Political party policymakers underestimate the complexity of the delivery challenges and often lack the evidence base (insufficient objective, accurate and timely information on costs, timescales, benefits, and risks).

• Inadequate collaborative policymaking: Policymaking has tended to be developed in silos. But good policy design requires continuous collaboration with a range of stakeholders at different levels as well as engagement with local communities and the people who are critical to implementing the policy on the front line.

• The local context: In complex systems an intervention that is successful in one location does not necessarily deliver

• Vagaries of the political cycle – shorttermism: Politicians are too easily attracted to the prospect of short-term

results that suit the election cycle, rather than investing in policies which may take years to bear fruit. This can lead to the pushing through of policies as quickly as possible, often half-baked, and the neglect of longerterm projects, which are usually more complex. Think health workforce development, clinical leadership, integrated care and ‘health equity’, for starters – all of which have been talked about for years by successive governments and are still being talked about. HOW TO ENSURE POLICIES ARE IMPLEMENTED For solutions, there’s no shortage of ideas from policy think tanks and political commentators, ranging from strengthening the roles and functions of ombudsmen and parliamentary committees, to setting up policy ‘delivery units’ to track the implementation of policy, and establishing parliamentary policy costings units. Of the various themes running through, one is worth a special mention for the critical role senior doctors could play concerning collaborative policymaking and delivery.

The lack of meaningful engagement between doctors and management in DHBs, let alone between doctors and government, is a long-standing sticking point.

It’s well recognised that those who work on the front line of the health system know more about the challenges of delivery than national policymakers. A crucial part of developing and implementing policy, therefore, is to tap into the experiences of those tasked with delivering it. It involves assessing existing capacity to deliver, knowing what is being done well, what needs improving, and how best to build new capacity. The need for a bottom-up, top-down flow of information in both directions is emphasised in Max Rashbrooke’s research report Bridge Both Ways about transforming the openness of New Zealand Government and improving democracy. Rashbrooke puts forward some key ideas about fixing

problems in the political system, not just in terms of making government more transparent, but also improving its capacity to involve more public participation. Certainly, talk of engagement may invite more cynicism among senior doctors than a belief that it might make a difference. The lack of meaningful engagement between doctors and management in DHBs, let alone between doctors and government, is a long-standing sticking point. But that does not negate the critical need for engagement if policy development is to be well informed and gets traction in practice, especially where the policy is complex and long term. If information flow and openness to engagement from the ‘top’ are weak, there is arguably more reason that activity from the bottom-up must be strong. Researchers suggest engagement between the front line and centre may require some form of intermediary body or bodies that work alongside and often at the direction of government to support effective policy implementation. Whether such arrangements are needed in New Zealand may be worth considering. In the meantime, there is a lot that senior doctors can do to strengthen current engagement avenues, such as through ASMS branches and Joint Consultation Committees, simply by participating in them. The information flow from those forums then feeds into the national forums involving ASMS, as well supporting a range of national advocacy work. When all else fails, particularly where there are specific local issues that remain unresolved due to poor policy or failure to implement good policy, senior doctors have the right to speak out publicly, as outlined in Speaking up for patients and staff (ASMS website). And the experience has been that when doctors do speak up, people, including those in government, tend to listen (The Specialist, March 2020). LESSONS FROM THE COVID-19 PANDEMIC The public’s expectation for a strong health system underpinned by good health policy and delivery has been under the spotlight this year like no other. The extraordinary sacrifices made by the ‘team of five million’ to protect the country’s collective health, despite the devastating effects on the economy, have underlined the high value people place on health above all else.

But the public’s concerns about the effects of under-investment in our health system, as reflected in at least one opinion poll before the pandemic struck, further reinforced with reports on the system’s lack of capacity to respond to pandemics, has raised public awareness of just how precarious many parts of the system have become. This, along with many of the findings of the Health and Disability System Review, highlights the need to develop with urgency a strong health system fit for the future with policies that are informed by the best evidence and knowledge, and with accountability measures to ensure those policies are implemented. Policies must undergo regular and open reviews to ensure they are working as intended, and modified as necessary, rather than quietly fading away as has often happened in the past. The evidence shows this can work when governments are truly open and engage with the public and specifically those with the knowledge to provide the best policy advice – and when parliamentary debate is constructive rather than destructive. These together have been a standout lesson from the pandemic. The Simpson Review calls for the development of a more positive culture and working conditions, improved collaboration and integration, and clinically led service development. All are laudable, but these things do not happen just because you want them to. They require deliberate strategies, hard work, and a commitment to change.

Policies must undergo regular and open reviews to ensure they are working as intended, and modified as necessary, rather than quietly fading away as has often happened in the past.

Whatever the colour of the new Government, 2021 is shaping up to be a significant year for developments in health policy, whether it is putting the meat onto the bones of the Simpson Review recommendations or something entirely different. The participation of senior doctors, in whatever form it takes, in shaping those developments could help to ensure that some of the much-needed policies identified 20 years ago are finally brought to life.

WWW.ASMS.ORG.NZ | THE SPECIALIST

SIMPSON REPORT A DISSENTING VIEW PETER CRAMPTON

Prof Peter Crampton

ne of the most controversial recommendations of the Simpson Health and Disability System Review is around a new Ma-ori Health Authority (MHA). The final report proposes an advisory entity sitting alongside the Ministry of Health and the newly created Health New Zealand. It would be responsible for monitoring and reporting on Ma-ori health outcomes, managing Ma-ori workforce initiatives, controlling Ma-ori-specific innovation funds, and advising Health New Zealand, the Ministry and the Minister of Health on how to redress inequities in the system. However, four of the six panel members, along with the Ma-ori Expert Advisory Group, believe that for health outcomes for Ma-ori to improve, the MHA must have the power to control both funding and commissioning of services. In a highly unusual step, that dissenting position was included in a separate chapter of the Simpson Report, known as the ‘alternate view’.

Dr Peter Crampton, Professor of Public Health in Ko-hatu, the Centre for Hauora Ma-ori at the University of Otago, is one of the panel members who favoured that view. We asked him more about how it might work. Given the new Health New Zealand agency would have “equal numbers of Crown and Ma-ori members”, and the MHA’s potentially powerful role of monitoring and reporting the system’s performance for Ma-ori, why do you see a need for a fully empowered Ma-ori funding and commissioning agency? The proposal to have 50% Ma-ori

composition of the Board of Health New Zealand is indeed a positive step. As a powerful addition to the leadership and governance of the health system, we believe a Ma-ori-led and controlled commissioning agency, with a meaningful budget, would bring a focus of expertise and strategic clarity to the task of commissioning services for Ma-ori that has proven to be hard to achieve in mainstream organisations. History has clearly shown that it will take more than a seat at the table to effect sustainable change.

If, as in your alternate view, the MHA was a budget-holder for commissioning services for Ma-ori, how would you envisage that budget being set? This is an important question that would need to be answered during

12 THE SPECIALIST | SEPTEMBER 2020

the implementation phase of any future changes. This matter was not considered in detail by the panel and requires further work. Part of the challenge is the lack of knowledge and understanding as to what is currently spent on services in this domain. It is important to note that costs associated with many of the report’s recommendations are yet to be quantified, including the entire change management budget. There is much more work to be done to understand the financial implications of change.

associated with integration of hospital and community-based services. From a system design perspective, MHA commissioning would bring focus to commissioning services for Ma-ori.

Would the MHA commission services from hospitals as well as from community service providers, and if so, how would that work in practice? A fully empowered Ma-ori commissioning

I agree that this is a risk, but it is a risk that has been manifest within our health system for a very long time. Our hope is that a fully empowered Ma-ori commissioning agency would model approaches to commissioning that would inspire change across the whole health system. We do not envisage that MHA commissioning would be undertaken in isolation of Health New Zealand and DHBs.

agency could commission services from hospital and community-based providers. The commissioning process would be carried out in close consultation and partnership with Health New Zealand and relevant DHBs. Mixed commissioning is already a wellestablished model within the system (e.g. services funded by the Ministry of Health, DHBs, ACC, Wha-nau Ora). Again, persistent inequities show us that we need to do something differently in order to shift the trajectory of the system from an equity perspective. Integrating hospital and communitybased services remains an important if elusive goal. Would a separate funding agency create additional challenges? The role of service commissioners is to clarify expectations and outcomes, and the role of health service leaders and clinicians at all levels of the health system is to deliver on these expectations. The existence of a Ma-ori commissioning agency would not necessarily, in itself, either amplify or diminish the challenges

Your alternate view suggests the MHA “could more effectively tackle institutional racism via its commissioning role”. Would there be a risk that those services not commissioned by the MHA may feel that addressing institutional racism is less of a priority?

Could private health care providers be commissioned under either system? Yes, the existence of a Ma-ori commissioning agency is entirely consistent with the ability to contract with private health care providers. Could there be public/private partnerships, and if so, do you see potential for conflicts of interest which could be exacerbated with a separate, empowered entity? Public–private partnerships are possible within the proposed new system. I don’t see any additional risks or potential conflicts arising as a result of a fully empowered Ma-ori commissioning agency. ASMS has not yet formed a policy position on whether it favours the MHA as laid out in the report, or the alternate view.

HOW THE PARTIES STACK UP A

SMS reached out to the main political parties in the lead up to the 17 October general election to ask about their policies and priorities on health.

Full responses and comments are on the ASMS website www.asms.org.nz

Research conducted by ASMS shows an average 24% shortfall in the number of senior doctors working in DHBs nationwide. Does your party agree that this shortage must be addressed by increasing the workforce accordingly?

According to the Health Coalition Aotearoa New Zealand has the third highest rate of obesity within the OECD which is inextricably linked to unhealthy diets. Does your party support self-regulation by the food industry as an appropriate way to manage obesity rates and the wider impact of obesity on society?

Would your party ensure DHBs were sufficiently funded to meet their communities’ health needs without clocking up huge deficits every year?

*Comment only

Would your party be willing to commit to cross-party agreements on longer term health investment and health policies that require long time-frames for implementation, such as workforce development, illness prevention and integration of services?

ASMS estimates there are nearly 450,000 people with an unmet need for hospital care due largely to inadequate hospital service capacity. Does your party agree that unmet need is a significant issue for New Zealand; and would your party increase hospital capacity to ensure unmet need is addressed?

*Comment only

* Full comments available on the ASMS website

TOP THREE INVESTMENT PRIORITIES FOR HEALTH • Equity of access for vulnerable populations and those in rural isolation. • Future proof St John Ambulance funding. • Reduce the number of DHBs. • Sector capital, funding for district health boards to address demographic and cost pressures. • Funding to implement recommendations from the Government Inquiry into Mental Health and Addiction. • The Health and Disability System Review. • Devolve primary health care services to allied staff. • Ensure funding follow the patient not the practice. • Increase the remuneration of our nursing workforce. • Increasing public health funding to keep pace with need and the growing population. • Ensure everyone can access healthcare services, regardless of their ability to pay, at the earliest stage possible. This includes working towards providing adequate funding for community-based care and increased resources for wellness and preventative health measures. • Incorporate ma- tauranga Ma-ori into the health system, and fund a provision of primary healthcare through Ma-ori organisations, overseen by a new Ma-ori health agency that focuses on remote areas with significant health disparities. • Primary care funding. • DHB infrastructure. • Workforce development. • Protecting public health in response to COVID-19. • Mental Health. • Addressing the shortfall of qualified medical professionals in the health sector.

WWW.ASMS.ORG.NZ | THE SPECIALIST

Gaeline Phipps

Drs Gareth Harris, Katie Ben, Anette van Zeist-Jongman, Alain Marcuse

Drs Lizi Thirsk, Tanya Wilton, Norman Gray, Neil Stephen

Drs Kai Haidekker, Geoff Shaw, Roger Wandless

A MULTI-MEDIA HUI FOR BRANCH OFFICERS LYDIA SCHUMACHER | COMMUNICATIONS ADVISOR

t was a multi-media affair when ASMS branch officers met for their annual hui at Te Papa in Wellington late last month.

Level 3 Covid-19 restrictions in Auckland meant branch officers in the northern region joined in virtually by webinar. For everyone else who was able to make it to Wellington, social distancing rules applied.

and explained the rules for state sector employees around political statements during election time. Her message was to use your union, and that speaking out makes patients and colleagues safer.

The annual hui provides branch officers with the opportunity to look at and discuss some of the big issues facing members.

The current MECA and the bargaining process for the next MECA were also the focus of discussions.

“You can see what challenges are faced by other DHBs and compare it to yours. It’s also an opportunity to discuss with the executive what the current issues are with health in New Zealand with an SMO focus,” said Waitemata- Branch President Jonathan Casement.

ASMS senior industrial officer Lloyd Woods detailed what had happened during this year’s negotiations with Covid-19 resulting in an early settlement and outlined some of the changes included in the current MECA.

Lawyer Gaeline Phipps delivered the key session of the day about the importance of senior doctors and dentists speaking out on issues of patient safety. She spoke in depth about the provisions in the MECA which enable public comment 14 THE SPECIALIST | SEPTEMBER 2020

Canterbury Branch Vice-President Siobhan Cross said finding out about the changes to shift work and sabbatical was particularly useful. “I think most people are under the impression that there was only the CPI pay rise,” she said.

Lloyd Woods also discussed the initial bargaining strategy for MECA 2021 and said planning is well underway. A briefing was given by senior industrial officer Steve Hurring on the Holidays Act remediation so that branch representatives are fully aware of the processes around rectification. There was much discussion about the Simpson Health and Disability Review and what the recommendations might mean for ASMS members. Branch officers were also given a sneak preview of the preliminary findings from our recent membership survey. Thanks to all the branch officers who took part. The feedback we got was that the webinar aspect of the meeting worked well, but here’s hoping that everyone can get together in person next year.

Dr Roderick Douglas out on the job

COVID-19 SHINES A LIGHT ON OCCUPATIONAL MEDICINE ELIZABETH BROWN | SENIOR COMMUNCIATIONS ADVISOR

hile the Government and health officials have been working to keep the public safe during the Covid-19 pandemic, stretched occupational health teams have been focused on protecting the health workforce.

Hospitals have struggled to manage staff risk assessments and applications from workers with underlying health conditions, due to poorly resourced and understaffed occupational medical services at DHBs across the country. Occupational medicine is about the effect of health on work and work on health. Specialist occupational physicians deal with a range of occupation-related health conditions and try and optimise a person’s ability to work or return to work. They also look at a raft of work-related risks such as heavy lifting, exposure to chemicals, dusts and radiation, night duty, and infectious diseases. According to the Medical Council register, there are around 60 practising occupational medicine specialists in New Zealand. Most work in private companies, ACC or WorkSafe. Some are contracted by DHBs, but only a handful

of DHBs have occupational medical physicians employed directly on staff. There is no funding in hospital budgets to train occupational registrars. During ASMS’ recent round of JCC meetings, occupational health was identified by most DHBs as a vulnerable service with serious training pipeline issues. GAPS EXPOSED The Covid-19 pandemic exposed the gaps. Dr Courtenay Kenny is an occupational medicine physician at Waitemata- DHB in Auckland. He says, “While most specialists in hospitals were quiet, we were incredibly busy. It was a stressful time as we had to develop new understandings and procedures as we went along.” A National Occupational Health and Safety Group was formed to look at Covid-19 and develop a mass screening strategy

to identify vulnerable staff. That meant screening thousands of DHB employees. Dr Kenny says at Waitemata- DHB alone about 1,000 people had an underlying condition who needed risk allocation and a work plan. Insufficient PPE early on caused extra problems and anxiety. “We developed systems and protocols. We co-opted other doctors whose services weren’t seeing patients along with GPs. We had assistance from clerical, admin people, and nurses, and some occupational health specialists outside the hospital service were able to come and help.” The workload at Waitemata- was compounded by a Covid-19 outbreak at Waitakere Hospital involving several nurses. “Covid told us that there is a great need for the health and wellbeing of a workforce to be looked at and that health WWW.ASMS.ORG.NZ | THE SPECIALIST

Dr Courtenay Kenny is concerned about the workforce pipeline workers are valued for what they do,” Dr Kenny says.

Medicine, which sits within the Royal Australasian College of Physicians.

HISTORICALLY LOW NUMBERS

There are currently only 11 occupational medicine specialist trainees, and only one is working in a DHB setting.

He explains that occupational medicine as a specialty has had historically low numbers because many years ago training was abandoned to industry.

“Covid told us that there is a great need for the health and wellbeing of a workforce to be looked at and that health workers are valued for what they do.”

“If you are a junior hospital doctor you can go into orthopaedics, rheumatology or public health and remain in the hospital service and vocationally register – but you can’t do that in occupational medicine. You have to do all your own training, earn the income yourself by contracting with organisations and then arrange to learn everything for your exams and finally become vocationally registered in occupational medicine.” Dr Roderick Douglas is an occupational physician in Tauranga and is the director of training for the New Zealand division of the Australasian Faculty of Occupational and Environmental

16 THE SPECIALIST | SEPTEMBER 2020

FUNDED TRAINING NEEDED In his view, what is needed is a funded occupational medicine clinic within each of the larger DHBs, which would have a registrar working alongside an occupational physician. He would also like to see better lines of communication between occupational specialists and hospital specialists in general. “Having a regular presence within a DHB would help improve this and bring us to mind when other specialists are considering their patients’ needs,” he says. Dr Kenny has concerns about the impact the lack of occupational health specialists in DHBs has on wider community health. “People from the community who are in hospital or are outpatients can’t access an occupational medical assessment through the publicly funded system.” “The only way people in the community can be seen by an occupational medicine specialist and ensure they can go back to their job safely is generally to pay for it independently or do it under ACC,” he says. Dr Douglas points out that the focus of the government agency WorkSafe is on accident and injury, prevention but

according to the statistics, workplace disease and illness is much more significant in terms of morbidity and mortality. He cites accelerated silicosis – a newlyidentified, and very serious lung disease associated with artificial stone bench manufacture.

He also says greater awareness of workplace health and safety, along with legislative changes, have driven demand for occupational medicine services up, but the occupational medicine workforce has not changed to meet that demand. Both doctors agree that DHBs are waking up to the value of occupational medicine and are hopeful some meaningful investment in funded training programmes may follow.

IMGS IN FOCUS

Erin and Michael with their three children

ELIZABETH BROWN | SENIOR COMMUNCIATIONS ADVISOR

hen American couple Dr Erin Doherty and Dr Michael Howard packed up their three children and moved from New Mexico to New Zealand six years ago, they thought they knew what to expect, but there have been a lot of surprises along the way.

New Zealand is highly reliant on international medical graduates (IMGs). They make up about 40% of the specialist workforce, which is one of the highest proportions of IMGs among the 37 OECD nations. Dependency on IMGs is also greater in the provinces where SMO shortages and recruitment difficulties often bite hard. Dr Doherty is an acute general medicine specialist who also does outpatient cardiology, while Dr Howard is an emergency medicine specialist. Finding a place where they could each work was a priority.

“It probably took me a year to feel like I could make competent decisions that were appropriate for the system here.”

After a two-week recce to check out a few job offers, Dr Howard (a Californiaborn surfie) landed firmly on Ngunguru in Northland, and it was not long before they had taken up positions at Wha-nga-rei Hospital. FUNDAMENTAL DIFFERENCES For Dr Doherty, the adjustment was more difficult than she had expected due to what she says are the fundamental differences with the American health system. “I had to unlearn some habits and completely change how I approached patients because the kind of practice I’d fallen into in the US involved a lot of defensive medicine where patients have high expectations about getting tests and having things done.” “You think medicine is a universal thing, but it was apples and oranges. It probably took me a year to feel like I could

make competent decisions that were appropriate for the system here.” She felt disadvantaged having never worked in the NHS or a similar system. After feeding back to her department, she is happy to say changes have been made to the induction process to better support newcomers. Her husband says working in a socialised, universal health care system has been a revelation which has changed his practice. “The thing that really burns out a lot of American doctors is the thought of bankrupting a patient or putting undue debt on them because they don’t have adequate insurance and can’t get the equitable outcomes that you get to see more often in New Zealand,” says Dr Howard. He adds, “Even though I might sometimes feel that I can’t as easily access speciality services for my patients, I certainly see that outcomes are likely comparable, and the costs are much better controlled. It makes my mental, spiritual and moral health better.” He also a big fan of ACC and believes any IMG wanting to come to New Zealand should school themselves up on Te Tiriti. “I realise there are deficits, but trying to attempt to be faithful to a single treaty and bring it out through the health system has been a remarkable thing to witness and one of the best surprises that I wasn’t expecting.”

“I’ve seen things here that I had only read about.”

Having a union and collective bargaining has also been an eye-opener. He says the opportunity to sit in a JCC and “watch ASMS go toe-to-toe with the DHB and hold them accountable on issues of staff safety and welfare” is something he had never witnessed or experienced.

“To go back to a place where that doesn’t happen would be a real crisis. I cannot overstate it.” MAKING A DIFFERENCE Working in a place where they felt they could make a difference was important. Both had worked in areas in the US with poverty and need, including Native American reservations. “In New Zealand you get to practise medicine that is going to be more challenging,” says Dr Doherty. “When you’re working in a provincial place with less specialists and speciality care, you really get to practise at the top of your licence. We get incredible diversity of patients with complex needs. I’ve seen things here that I had only read about.”

“Even though I might sometimes feel that I can’t as easily access speciality services for my patients, I certainly see that outcomes are likely comparable, and the costs are much better controlled. It makes my mental, spiritual and moral health better.”

In turn, they believe having a diverse IMG specialist workforce in New Zealand enhances the system and means everyone benefits from what Michael describes as “the worldwide cross pollination of expertise and information”. Their advice to any IMG thinking of coming to New Zealand is do your homework, ask lots of questions, be humble, and approach it with an open mind and an attitude of learning because the system can be full of surprises. WWW.ASMS.ORG.NZ | THE SPECIALIST

ASMS WORKING BRIEFS TELEHEALTH AND THE COVID-19 RESPONSE The Covid-19 pandemic has led to a rapid increase in the use of telehealth to help manage the spread of the virus and to protect health care workers, while maintaining patient access to health care. ASMS has prepared a Research Brief on the issue. It finds that researchers are concerned that a one- size-fits-all approach to telehealth will be taken which does not consider individual need and circumstance, and that the sudden shift to telehealth may exacerbate inequities for some population groups, such as those with sensory disabilities, language difficulties or mental health illness. Many others cannot use a computer, have no access to a device, or do not have the internet. There is an expectation that telehealth services achieve cost-savings; for example, by reducing staff time. However, the literature highlights that embedding technology is difficult and requires many resources to align it with existing structures, processes, and routines. A major study in the UK found that pressure on financial and human resources was the most significant barrier to successful implementation of telehealth. In particular, high workloads and lack of organisational slack limited front-line teams’ capacity to initiate and maintain the embedding of the technology in their clinical work. Telehealth offers benefits for patients, carers, health care workers and the health system. The current Covid-19 outbreak has given clinicians and patients the opportunity to observe telehealth in action, and they are seeing that it works. Nevertheless, success depends on the extent to which clinicians are enabled and supported to influence its adoption, and the mindset is improving a service rather than implementing a technology. You can read the full research brief on telehealth on our website (www.asms.org.nz).

MEMBERSHIP SURVEY – INITIAL RESULTS Thanks to all ASMS members who took the time to participate in our first ever bi-annual membership survey. We got an excellent 45% response rate. In this survey, we sought feedback on working conditions as well as identifying priority issues as we head into next year’s MECA negotiations. The survey results will be invaluable for our industrial and bargaining work. We also re-ran the Copenhagen Burnout Inventory to see how levels of burnout in New Zealand’s senior medical workforce have changed five years on from the first survey. Preliminary analysis suggests burnout continues to be an issue, with very little change in overall burnout levels. We will be presenting more on this subject at our Annual Conference in November.

GENDER PAY AUDIT ASMS is progressing with a gender pay audit pilot through the National Joint Consultative Committee. We hope to have the green light to start this towards the end of this month. Initially, we will be gathering data concerning starting salary at time of appointment, qualifications and other factors that may influence total remuneration. The aims of this pilot are: • to address the identified gender pay gap across the SMO/SDO workforce • to identify key variables that are required to understand the existence of a gender-based pay gap in medical specialists • to use the insights gained from the pilot study to undertake further gender-pay audits as required. We hope to report back on this work in the near future.

18 THE SPECIALIST | SEPTEMBER 2020

WILL WE GO BACK TO OUR LOVE AFFAIR WITH JET TRAVEL? D

r Rob Burrell and Dr Marty Minehan, who featured in our story on sustainability, ask some tough questions about the future and sustainability of CME travel.

2020 hasn’t been much of a year for many of us. Covid-19 has kept us in our own country, but one thing many of us have gained is a nostalgic respect for the quiet sunny days when we hunkered down. The sky was clearer, the birds came back, and our country literally took a breath of fresh air. Will the post-Covid world see us going back to our love affair with jet travel? Aeroplane trips are responsible for 2.4% of global CO2 production. Health care is responsible for around 8% of New Zealand’s emissions, and sadly doctors’ air travel accounts for about one third of the total emissions for a DHB. At Auckland DHB for instance, in the 2018–19 year, CME travel contributed 10,000 tonnes of CO2, and the pattern is consistent across DHBs.

The role of specialists’ CME contribution to the health care carbon footprint will become increasingly conspicuous, and we risk being exposed as hypocritical.

With a Zero Carbon Act, motivated city councils, ministerial directives, and validated carbon reduction schemes (CEMARS – Toitu-), the lumbering behemoth that is health care will pivot away from its CO2-intensive ways. The role of specialists’ CME contribution to the health care carbon footprint will become increasingly conspicuous, and we risk being exposed as hypocritical. The issue has already been raised in the media. Knowing that the poor, the sick, the indigenous and the young are those who will suffer most from a changing climate, is it reasonable to continue to use our CME as a significant source of CO2? By 2030, we need to have largely shed our addiction to fossil fuels, and our

transportation and vacations and education need to be transformed. This is not going to be easy or pleasant, unless we are in charge of our destiny, taking the societal leadership role for which medicine is known. WHAT COULD THIS LEADERSHIP LOOK LIKE? Doctors are already advocates for health, for the public, and for climate action. We occupy a unique position in society: trusted, respected, and educated. ASMS is committed to a funded, equitable, accessible, and functional public health service. Its role in ensuring the Government of the day can meet these goals is deeply tied to its membership, and it must acknowledge that an effective response to the challenges of climate change will see alterations in how we work, what we work with, and how we learn. Either we lead, as doctors, as ASMS members, as a union, or we follow. The money we receive for CME activities is a contract with the state. We remain skilled and knowledgeable and safe, and the public purse pays. We decide how to spend it, and in most cases, the expenses are refunded. It is hard not to see CME money as ours, but it represents an investment by the country in us. We need to ask ourselves some rather uncomfortable questions: • Is it sensible to ask for CME money to spend on air travel? • Is it honest to think that we can all jet off to conferences, meetings and holidays, when the science is clear: humans need to rapidly draw away from fossil fuel consumption? • Should health care dollars be spent on that travel? • How can we untangle annual leave and CME and take adequate holidays, without relying on CME money to take us to exotic locations?

• How can we align public health goals with our own personal ones? • Can we move to a place where our profession can be proud of our climate response? • How can Zoom and other tools encourage virtual attendance? • If DHBs and other organisations can live within carbon budgets, can we as educated and up-to-date hospital specialists do the same? • Could we consider measures such as a personal carbon budget?

By 2030, we need to have largely shed our addiction to fossil fuels, and our transportation and vacations and education need to be transformed.

The only way we can dramatically respond to the challenges of climate change is with collective action, collective responsibility, and driving systemic change. As we did with removing cholera in the drinking water, campaigning for median barriers and seat belts, and championing vaccination to prevent disease, so must we act together as a profession to lead on the greatest challenge of our time. Can we start with how we spend the public’s money?

ASMS is looking at whether we can develop some guidelines specific to CME use through Covid-19. This is an important subject and one which we will address at our annual conference. We welcome your thoughts.

WWW.ASMS.ORG.NZ | THE SPECIALIST

BOOK REVIEW – THE BAREFOOT SURGEON DR LESLIE SNAPE

etired ASMS member and Christchurch oral and maxillofacial surgeon Dr Leslie Snape reviews The Barefoot Surgeon by Ali Gripper. It is the inspirational story of Nepalese eye surgeon Dr Sanduk Ruit.

Anyone with an affinity for Nepal will enjoy this amazing story of a boy born in a remote Himalayan village who went on to become one of the world’s greatest eye surgeons. As a seven-year-old boy, Sanduk Ruit became the first person in his village to go to school, walking two weeks with his father to a boarding school in Darjeeling. Instead of becoming a salt trader like so many in his village, he followed a career in medicine. Rather than take up a prestigious position in America or Europe, he chose to deal with the professional, political, and personal hardship in his own country, giving life-changing sight to thousands of the world’s poorest and most isolated people. Author Ali Gripper spent three years working closely with Dr Ruit and writes a fascinating biography of the personal life and professional journey of this modest man who overcomes the criticism of local and international ophthalmologists to give sight to people in remote areas of Nepal. He would regularly travel by horseback to such remote place as Mustang in the Annapurna region, laden with equipment to do assessments and surgery in outreach camps. Thousands of successful cataract operations were carried out in primitive conditions, as he proved to his detractors that intraocular lenses were preferable to ‘coke bottle glasses’. Mentored by the renowned New Zealand ophthalmologist Fred Hollows, together they made modern cataract surgery accessible and affordable for the poorest people in other countries, including India, Bhutan, Indonesia, Ethiopia, and northern China. Hundreds of thousands of intraocular lenses are now made each year at the factory Dr Ruit established in Kathmandu, at a fraction of the cost in the Western world, but his greatest satisfaction is restoring sight to his patients. Dr Sanduk Ruit says, “When you are right no one can prove you wrong … I took proving myself right as a challenge and I succeeded.” At under 300 pages, I found it difficult to put this book down.

NEW FACE FOR THE SOUTH

ASMS has welcomed Kris Smith to the team of industrial officers. Kris is covering members in the South Island DHBs, except for Nelson-Marlborough. She has taken over from George Collins who has joined our northern team. Kris comes to ASMS from the Tertiary Education Union (TEU) where she had a long career as an organiser. She had previously trained and worked as a psychiatric nurse. Kris lives in Port Chalmers and will be based out of Dunedin. She can be contacted at kris.smith@asms.org.nz

20 THE SPECIALIST | SEPTEMBER 2020

WWW.ASMS.ORG.NZ | THE SPECIALIST

MINUT

WITH

DR ROGER WANDLESS DR ROGER WANDLESS IS AN ANAESTHETIST AT SOUTHLAND HOSPITAL AND ASMS’ SOUTHLAND BRANCH PRESIDENT WHAT INSPIRED YOU TO STUDY MEDICINE?

WHAT DO YOU LIKE ABOUT YOUR JOB?

I think subconsciously it was my mother, who was a nurse but was smart enough to have been a doctor and was (and still is) fascinated by all things medical. At the end of school I remember weighing various career options and deciding on medicine because I felt that it had a combination of excitement, prestige and financial security, but ultimately I hoped that by doing a career where I could serve people in such a profound manner would be something that would be worthwhile and rewarding.

I am pragmatic about my job. There are many other ways I’d prefer to spend my time, but it is a combination of the fact that (between the periods of boredom and terror!) it is mainly interesting and rewarding. Every case is unique, and there are a series of decisions and judgements to be made in planning and executing a ‘good’ and ‘safe’ anaesthetic. Layered above this is the human aspect, both working as part of a team in the operating theatre, and teaching and mentoring registrars. The most important task is

22 THE SPECIALIST | SEPTEMBER 2020

quickly getting to know the patient on a human level and gaining their trust. I try to have all my patients go to sleep with a smile. If they wake up with one, then I’m happy too. WHAT ARE SOME OF THE MOST CHALLENGING ASPECTS IN THE CURRENT HEALTH ENVIRONMENT? In New Zealand I believe we have a health system that provides great results relative to the investment made into it. We are also lucky to have pretty good working conditions thanks to ASMS! But in terms of challenges, first and foremost in my

Dr Wandless’ passion is photography

mind is increased disease and demand and reduced funding relative to this. There are also issues around social media and misinformation and how it plays out in politics, artificial intelligence and what it means for our work and humanity. I think there needs to be a comprehensive vision around consistent and effective leadership and better discussions around quality in terms of the system and services. Matthew Syed’s book Black Box Thinking transformed my thinking around what was possible. WHAT KEEPS YOU HAPPY OUT OF WORK? My lovely wife Kara and my two boys. There is never a dull moment – from a hut built from sheets covering the room, to a full-on brotherly playfight or the dog has broken its leg. Beyond my family my main passion is photography. I am active in various national photographic organisations and have achieved qualifications and multiple awards over the past decade. I have successfully self-published two

coffee table books of New Zealand landscapes. The real joy is in being out in the wilderness. Along with skiing it is the closest to experiencing ‘flow’ (a state where you are totally immersed and engaged). It is a great antidote to my day job! WHY DO YOU LIKE LIVING WHERE YOU DO? I never dreamt I would end up in Invercargill. A town of wide streets and tatty facades braving the westerly winds at the end of the earth! I believe it’s one of New Zealand’s best kept secrets. It gives me a work–life balance and allows me to pursue my interests and spend time with my family and be able to go regularly to the southern lakes. I can swim, cycle or surf and enjoy outstanding coffee and food at one of the many eating places around town. Furthermore, it punches above its weight in many fields – local musical, theatrical and sporting events are world class. It has its fair share of wind and rain but there is more sunshine than you would expect.

WHAT ADVICE WOULD YOU GIVE TO YOUR TEENAGE SELF? Probably to take more risks. In the UK it was drummed into us to work hard and follow a career path. In retrospect, I would have benefitted from taking time off between school and college, as the ‘University of Life’ is an important teacher also. WHY DID YOU BECOME INVOLVED WITH ASMS? A colleague at Southland Hospital, Peter Christmas, shoulder-tapped me. I have remained in the organisation because of the combination of people involved, along with the unique role and influence that it has both at a local and national policy/political level. It seems to be the last effective structure that allows ordinary working doctors to have their voice effectively heard. I have enjoyed the opportunity to attend the annual conference and meet medics from all over New Zealand, plus hearing from various political figures gives me a greater insight into the health system as a whole. WWW.ASMS.ORG.NZ | THE SPECIALIST

INDEMNITY CLAUSES IN EMPLOYMENT CONTRACTS DR TIM COOKSON | MEDICOLEGAL CONSULTANT, MEDICAL PROTECTION

ait – don’t quickly move on to the next article. It could be an expensive move if you do.

I appreciate that reading about clauses in employment contracts could be better for getting you to sleep than any of the available sedatives on the market. Reading the contracts themselves is a pretty soporific exercise, so I will be concise. If your contract has the ‘wrong’ wording, and your employer suffers some kind of financial harm as a result of your actions, you personally would be responsible for that loss and you would not be able to request assistance from the Medical Protection Society (MPS). MPS indemnity protects you as an individual; it does not protect third parties, such as your employer. The type of clause you may encounter in an employment contract will have wording similar to: You accept liability, and will reimburse the (employer), for any loss, expense, damages or compensation which the practice incurs or is required to pay (including without limitation any legal fees or amount paid by way of settlement) in relation to any claim, which is threatened, notified or commenced against the (employer) and which: (a) arises directly or indirectly out of any act or omission by you in the course of your employment; and (b) alleges a breach of any duty owed by the practice or you in contract or tort. If you sign such a contract, MPS would be unable to assist with reimbursing your employer. The good news is that virtually all medical employers will accept an alternative wording such as: 24 THE SPECIALIST | SEPTEMBER 2020

The doctor (employee) will, during the term of this agreement, have and maintain professional liability cover from a recognised medical defence organisation or insurer. The doctor (contractor or employee) will, on request, provide evidence of his or her defence organisation membership or insurance cover.

It is a bit like walking across a narrow plank over a big drop – the chances of falling are small, but the consequences are not.

WHY MIGHT AN EMPLOYER HAVE SUCH A CLAUSE? Generally speaking, these contracts have been drawn up by lawyers who may be unfamiliar with the medical indemnity scene and may be more used to contracts for sub-contractors on building sites, for example such as the renovators of Notre Dame last year. The costs of reimbursement in that scenario do not bear thinking about. Some practices may also access generic employment contract templates from an uninformed source. Also, in the absence of a specific provision in an agreement an employer is liable for all acts and omissions of an employee when they are acting in the reasonable performance of their duties. Fortunately, most District Health Boards (DHBs) are aware of this and

the contracts are not problematic. However, we have experienced one DHB which refused to accept the suggested alternative wording, and as a result did not employ a much-needed locum. The phrase cutting off one’s nose to spite one’s face comes to mind. This is very unusual. Employed GPs are more likely to run into these contracts, however MPS is not aware of any practice that has not been happy to change the wording. What is the risk if you have already signed such a contract? Given the medico legal environment in New Zealand, it is unlikely that a claim would be made against a practice for which you would be liable. However, although the risk is low, the cost could be high. It is a bit like walking across a narrow plank over a big drop – the chances of falling are small, but the consequences are not. For those of you who now have a sinking feeling and are scrabbling about looking for your contracts, it is not too late. You are entitled to have your contract amended and should negotiate with your employer. MPS is happy to discuss this issue with any employer who is unwilling to change a problematic contract wording, on behalf of members. In summary, try to keep your eyes open as you are reading your employment contract and if you have any concerns about the indemnity clause, contact MPS or your indemnity provider for assistance. You can also find further information on the Fact Sheet on the subject on our website www.medicalprotection.org.nz

ASMS HEALTH SOLIDARITY

L-R: ASMS member Dr Rob Beaglehole, NZDA President Dr Katie Ayers, ASMS Executive Director Sarah Dalton and Associate Health Minister Julie-Anne Genter.

Sarah Dalton standing in support of striking primary health nurses during a rally at parliament.

WWW.ASMS.ORG.NZ | THE SPECIALIST

BY THE NUMBERS

DR PETER STORMER

SMS pays tribute to Dr Peter Stormer, who died in an accident at his home in Hastings last month.

Dr Stormer was a GP and had been a medical advisor at ACC in Hawke’s Bay for more than 20 years.

Male SMOs are the oldest occupation group in DHBs with a mean age of 51.4 years.

THE MEAN AGE OF FEMALE SMOS IS 47.8.

He was an active ASMS member at ACC and this year had joined the bargaining team negotiating a new employment contract for ACC members. His colleagues at ACC described him as a valued friend, colleague, medical advisor and GP who was well-respected throughout the organisation. ASMS Senior Industrial Officer Lloyd Woods, who led the ASMS-ACC bargaining team, says Dr Stormer was a kind, caring person. “He was a very nice guy who was always concerned for his colleagues and he was also obviously a very proud father and grandfather as he used to share many stories.” Dr Stormer was farewelled by friends and family in Hawke’s Bay.

SMOs have the longest length of service of all DHB occupation groups with a mean of 10.1 years.

SMOs take an average 34.5 hours annual sick leave – the lowest of any DHB occupational group.

REMEMBERING A VISIONARY AND HIS GIFT

K MA-ORI MAKE UP 1.9% OF THE SMO WORKFORCE.

West Coast DHB has the oldest overall DHB workforce with a mean age of 50.8 while Counties Manukau DHB has the youngest at 42.9.

* Information from TAS – DHB Employed Workforce Quarterly Report March 2020

26 THE SPECIALIST | SEPTEMBER 2020

awe mate or memorial ceremonies for the man who formally gifted ASMS its Ma-ori name have been disrupted by the Covid pandemic and have been postponed. Te Huirangi Waikerepuru (Nga-ti Ruanui, Nga-puhi) spent his life fighting for the preservation and revitalisation of te reo Ma-ori in both education and broadcasting. In 1985 he led the Wai 11 Ma-ori Language Claim which argued that te reo Ma-ori was a taonga and the Government was obliged to protect it under the Treaty of Waitangi. He was also an active trade unionist. In 2013 Dr Waikerepuru gifted ASMS the name Toi Mata Hauora. There is no literal translation, but the name expresses ideas around the pinnacle of health, the art of health, or the view from the top of health. It has become central to ASMS’ identity. Dr Waikerepuru died in April aged 91.

ANNUAL CONFERENCE – STILL TIME TO REGISTER! T

he 32nd ASMS Annual Conference will be held on 26-27 November at Te Papa in Wellington.

This year’s theme is “Building the workforce pipeline, stopping the drain”. We have an interesting line-up of guest speakers and of course it’s a great chance for members to actively take part in setting ASMS’ priorities and decision-making. Due to Covid-19 this year we will be offering a webinar option for anyone who wants to attend that way. If you are interested, please contact Cassey van Riel cvr@asms.nz. If you want to attend in person, you can find information and register on our website www.asms.org.nz

ASMS STAFF Executive Director Sarah Dalton COMMUNICATIONS

ASMS SERVICES TO MEMBERS As a professional association, we promote:

OTHER SERVICES

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

ASMS job vacancies online

• 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.

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 11, The Bayleys Building, 36 Brandon St, Wellington

Senior Communications Advisor Elizabeth Brown Communications Advisor Lydia Schumacher INDUSTRIAL Senior Industrial Officer Steve Hurring Senior Industrial Officer Lloyd Woods Senior Industrial Officer Henry Stubbs Industrial Officer Ian Weir-Smith

Postal address: PO Box 10763, The Terrace, Wellington 6143

Industrial Officer Phil Dyhrberg

P 04 499 1271 F 04 499 4500 E asms@asms.org.nz W www.asms.org.nz

Industrial Officer Miriam Long

Follow us facebook.com/asms.nz twitter.com/ASMSNZ Have you changed address or phone number recently? Please email any changes to your contact details to: asms@asms.org.nz If you have reason or need to seek a reduction or waiver to your annual subscription, please write to us. Our constitution allows for this in certain circumstances. Emails should be addressed to sarah.dalton@asms.org.nz

Industrial Officer George Collins Industrial Officer Kris Smith POLICY & RESEARCH Director of Policy and Research Charlotte Chambers Policy Advisor Mary Harvey SUPPORT SERVICES Manager Support Services Sharlene Lawrence Senior Support Officer Vanessa Wratt Membership Officer Saasha Everiss

CORRECTION In the June edition of The Specialist we mistakenly described the National Party MP Dr Shane Reti as a dermatologist. A member has written in to say that Dr Reti is not vocationally registered in dermatology and while he does hold a Diploma in Dermalogical Sciences from Wales, there is no legal basis for him to be described as a dermatologist. Our apologies.

Support Services Administrator Cassey van Riel

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

WWW.ASMS.ORG.NZ | THE SPECIALIST

“We’re with the insurer that’s started a foundation to fund health initiatives.” MAS has been busy doing good lately. We’ve established a foundation to fund health initiatives in our communities, we’ve been awarded Consumer NZ People’s Choice for house, contents, car and life insurance for four years running, and we’ve continued to deliver outstanding service to Members, like Kristine and Kris, especially at claims time.

Choose the insurer that invests in the health of Kiwis. Find out more at mas.co.nz

Kristine Gonzalez Videographer Kris Lewis-Fox Teacher and MAS Member

The Specialist - Issue 124

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The Specialist - Issue 124