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
128 | SEPTEMBER 2021
Inside this issue ISSUE 128 | SEPTEMBER 2021
Want to know more? Find our latest resources and information on the ASMS website www.asms.org.nz or follow us on Facebook and Twitter. Also look out for our ASMS Direct email updates. This magazine is published by the Association of Salaried Medical Specialists and distributed by post and email to union members. Executive Director: Sarah Dalton Magazine Editor: Elizabeth Brown Designer: Dink Design Cartoon p10: Emma Cook If you have any feedback on the magazine or contribution ideas, please get in touch at firstname.lastname@example.org.
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The Stopwork Diaries Leading into the future Uncertainty and frustrationover residency rights Are our Emergency Departments Covid fit? Health equity 2040 Stopworks and surveys – the fight for a fair MECA Thumbs up for non-DHB members Flooding serves up pub-based healthcare Mental health on the line The highs and lows of clinical innovation New faces welcomed at branch officers’ workshop Five minutes with Dr Carol Chan Drug driving and evidentiary blood samples Missed opportunity to consider funding in PHARMAC Review Readying for legalised euthanasia Noticeboard Pivoting to stop Covid Did you know?
The Stopwork Diaries Dr Julian Vyas | ASMS President
ia ora ta-tou. The recent series of stopwork meetings held around the country were far from a regular occurrence for ASMS. Many of you will be aware that the last time stopworks were called was in August 2007, after some 14 months of MECA negotiations. Issues of concern were eerily familiar – recruitment and retention of senior medical and dental staff, adequate non-clinical time, and resisting managerial attempts to devalue members’ professionalism in their duty of care to patients. ‘Diplomatic avenues’ were explored for several months after these stopworks in an effort to reboot the negotiations before members were balloted on whether to take limited strike action 88% voted “yes”. This was an overwhelming mandate, and although industrial action never came to pass, the strength of resolve shown was enough to break the impasse. Even then, a settlement was not signed off until May 2008, and only after personal intervention from the then Minister of Health, David Cunliffe, to get an agreement across the line. Jump to early August 2021 when, in what was an impressive logistical and planning exercise, ASMS held 31 stopworks across New Zealand over a period of just nine days. The meetings were called to allow us to discuss directly with members the current position in our MECA negotiations with the DHBs (which have been conducted through their negotiating agents, TAS). As you heard at the meetings, the DHBs have repeatedly failed to put a meaningful claim on the table and members needed to signal how they want us to move forward.
“Over seven days, I attended 11 meetings, from Timaru to Thames. Not quite Goodbye Pork Pie, but a great opportunity for me to hear directly from members across the motu.” Thank you to all our members who gave up their time to attend a meeting. I am also very grateful to my colleagues on the National Executive for their
attendance at meetings, both locally or at other branches where possible, and for all the support from ASMS National Office staff. Over seven days, I attended 11 meetings, from Timaru to Thames. Not quite Goodbye Pork Pie, but a great opportunity for me to hear directly from members across the motu. Takeaway lessons What did I learn from these meetings? Not surprisingly, we are an organisation that encompasses a range of views. Some members expressed concern about industrial action harming our reputation in the eyes of the public or compromising patient care that is not classed as life preserving services. Others were very unhappy at the way that the DHBs/TAS had made counter-offers, which were generally seen as yet more prevarication rather than meaningful attempts to address the urgent problems of safe staffing, health and wellbeing, recruitment, and retention. Overall, the prevailing mood was that no matter where individuals stood on the question of preferred action to take going forward, there was a general consensus that the goodwill, professionalism, and sense of duty that senior dentists and doctors routinely exhibit has been taken for granted again and again by DHBs. No doubt the recrudescence of Covid-19 will influence members’ thoughts both in terms of how the general public will be faring during a time of increased hardship, and also what added work and risk it brings due to chronic understaffing, and the fact that our health system was ‘on the edge’ long before Covid-19 arose. To add to the complexity of the next few months, we also have the
impending dissolution of DHBs and the commencement of a new national health employer, Health NZ.
“…there was a general consensus that the goodwill, professionalism and sense of duty that senior dentists and doctors routinely exhibit has been taken for granted again and again by DHBs.” It will be up to your National Executive to look carefully at what the post-stopworks membership survey said and deliberate on the best course of action. At this stage, the Executive has no a priori view on the precise next steps to take. I do know that whatever decisions we ultimately make, they will be considered with full cognisance of the risks and benefits to ASMS and to our members. ‘Primum non nocere’ is something all dentists and doctors have hard-wired into their collective psyche. The Executive’s decisions on the best way(s) to achieve our MECA claims will be underpinned by this tenet and will be applied just as equally to ourselves and our colleagues as to our patients. No doubt, whatever plan is ultimately decided on will not please everyone. Nonetheless, our decision will be made in good faith. I need to stress that if we are to have any chance of success, we need all members to support the plan. A union is only ever as effective as the willingness of its membership to act collectively, and in support of one another. Kia kaha.
WWW.ASMS.ORG.NZ | THE SPECIALIST
Leading into the future Sarah Dalton | Executive Director
s we inch towards Health New Zealand and a Ma-ori Health Authority, it’s important to keep talking about the critically important role of clinical leadership across our health system. In hospitals, this starts with the CMO and streams through to other formal leadership roles (CDs, HoDs, clinical leads), but actually includes all senior doctors and dentists. You are all clinical leaders in your services and your chosen field. We notice when we work with groups of SMOs on service sizing, rosters, call arrangements and the like that where the CMO has a strong clinical voice, we tend to get better outcomes. Having senior clinical leaders role-modelling the primacy of clinically led decision-making is key to a successful health system. This is something we will continue to strongly speak up for.
“If Health New Zealand is to succeed it will need to recognise and promote clinically led decisionmaking at every level of our health system.”
As we’ve previously noted in The Role of the Clinical Director: A practical guide (which is available on our website), clinical leadership is critical in setting the tone and culture of our health services: “The [clinical leader] has a pivotal role in determining departmental culture. This includes transparency, decision-making, inclusiveness, and equity. ASMS research has shown high levels of burnout and bullying among New Zealand SMOs, which needs to be addressed urgently. There is often heavy pressure on [clinical leaders] to achieve patient-turnover targets for their department, but this should not be at the expense of staff well-being, and in fact employment legislation prohibits this. The ASMS MECA recommends 30% 4 THE SPECIALIST | SEPTEMBER 2021
non-clinical time as part of SMOs’ job-size. Advocating for adequate non-clinical time, documented and appropriate recovery time, regular service sizing and succession planning are key aspects of [the] role.” If Health New Zealand is to succeed it will need to recognise and promote clinically led decision-making at every level of our health system. A nasty hangover One of the key weaknesses of the current system is an over-reliance on bean-counting as the driver of planning and funding decisions. This is a nasty hangover from the neoliberal approach that pretended hospitals were businesses. They are not. Hospitals are critical public institutions, and only by placing people rather than balance sheets at the centre will we start to build a system that provides safe, sustainable work for its staff, and best care for all patients. This pseudo-business approach to running our health system has also fuelled a race to the bottom in terms of funding that sets DHB against DHB in a race for scarce resources. As Otago University’s Professor Robin Gauld recently observed in a Newsroom article, “The DHBs are providing more services than they’re funded for, so they wind up in this situation of being underfunded or having a so-called deficit".
gathering, proactive succession-planning, and use of staff wellbeing data as key metrics to determine clinical and support staffing FTE. We need Health NZ to be able to flex with surge and demand. It must provide a structure that gets ahead of future growth, and which builds in significantly enhanced workforce modelling, development, and investment functions. That means starting from zero, as few if any of these things are currently in place. Building on good practice There are a few existing pockets of good practice that will help us. A handful of DHBs have recognised the work individual SMOs are doing to develop better workplace practices around staff wellbeing. This work recognises that wellbeing is an organisational concern, requiring whole-of-system responses. It’s not asking staff to be resilient, drink kale smoothies and attend lunchtime yoga. We need to build on this isolated good practice and lobby for funded (and backfilled) SMO roles to develop and lead this work. ASMS is keen to establish a network of wellbeing champions to connect, support and nurture the research and implementation work they’re doing. I’ll be talking to the Transition Unit about the vital importance of roles like these. I hope you will too.
“One of the key weaknesses of the current system is an over-reliance on beancounting as the driver of planning and funding decisions.”
Staff from the Transition Unit have committed to attending several of our JCC pre-meetings over the coming months. It will provide an opportunity to speak directly with some of the people tasked with putting together the Health NZ Charter, which they tell us will underpin the whole healthcare workforce. I warmly encourage you to attend your next JCC.
Strategic and systematic underfunding of staffing and infrastructure has directly contributed to the DHBs’ preference for slight understaffing of services over a more considered, forward-looking approach, which would support good workforce data-
And finally, a big thank you to all of you who attended the recent stopworks. We know how precious your time is, so it was great to see so many of you actively participating. Nga- mihi
Uncertainty and frustration over residency rights Eileen Goodwin | Senior Communications Advisor
he long pause in processing permanent residence applications is causing stress for some doctors and adding pressure to an already stretched health care system.
Clare French is a general surgeon at Masterton Hospital. In a team of three, her caseload includes gallbladders, breast, thyroid, laparoscopic bowel cancer surgery, and endoscopy. It’s busy – she loves the role, describing her patients as “reasonable and practical” people. The working environment is much more “humane” than her former roles in the United States. She is frustrated by the lack of progress in reopening the applications track for New Zealand residency, without which she is unable to purchase a home or safely leave the country. Paused last April due to Covid-19, it was first subject to a hiatus, then extended in October, with no decision since about when applications will resume. Some doctors have already left jobs – and the country – because of the problem. This includes Otaki GP Harding Richards, who told RNZ his family had been unable to put down roots due to the uncertainty. Figures obtained by RNZ under the Official Information Act on 31 August, showed there were 675 doctors and just over 2,200 nurses waiting to apply for residence. Dr French says should she need to leave New Zealand to see family, she might be unable to return. “I’m at risk of being in position of being forced to leave. My dad has Parkinson’s. I’m not able to go and see them in a reliable way. If I need to decide between going and having to take months to get back in, then I will need to decide whether to end my tenure here.”
front, and she hopes to obtain vocational registration in the coming months. “As a group we are eager to have any concrete information that will allow us to plan our lives, especially when our plans involve staying in New Zealand.” Health Minister Andrew Little said in a statement to The Specialist the issue was under active consideration but gave no firm detail. ASMS Executive Director Sarah Dalton wrote to Immigration Minister Kris Faafoi about the problem in June, pointing out that New Zealand relies heavily on overseas-trained senior doctors and dentists to maintain our already stretched medical workforce. “International recruiting is a difficult and time-consuming process. Those who are employed here in NZ meet all the requirements of the skilled migrant category for immigration purposes. However, due to current restrictions on processing residency applications from the skilled migrant list we are losing actual and potential senior medical consultants who are unable to buy a house, enrol in a Kiwisaver scheme – in short, they are unable to settle their families and put down roots in Aotearoa.”
“If I need to decide between going and having to take months to get back in, then I will need to decide whether to end my tenure here.”
Her husband does not work in the health sector and would have even more difficulty re-entering.
However, Sarah Dalton says she was heartened by comments from Finance Minister Grant Robertson at a recent Council of Trade Unions affiliates meeting. “We hope that the Minister’s assurances to the CTU are correct about addressing residency applications, and that these issues for specialist doctors and dentists are a high priority. “We also expect improved communication around process and timeframes, which has been a massive problem to date.” Mr Robertson was also quizzed about difficulties experienced by some doctors obtaining spots in managed isolation, which he said the Government was working to address. MIQ frustrations Meghan Ryall, an emergency medicine specialist at Whakata-ne Hospital, travelled to see family in Canada in early August. It was a short trip – just over two weeks – taken for personal reasons to support her parents. For her return she tried to obtain a spot in emergency MIQ but was told she didn’t qualify. This surprised her, given her department was “down 50% of senior doctors”. She was then able to secure a regular MIQ spot due to “dumb luck”. She really felt for members of the public who had had huge trouble obtaining a spot. Dr Ryall believes doctors working in the public health system should be granted access to emergency MIQ spots, due to the pressure the health system is experiencing. With the youngest of her three children aged just 2, she is very pleased to be home. “I knew I was taking a chance, but I thought it was more important that I see my mother.”
“We would end up being like the separated families due to the border. We don’t want to separate.” Dr French and her husband arrived in the country in March 2020, their decision to move to New Zealand from Washington State made before the pandemic. She initially entered under a special purpose one-year locum visa. Her efforts to become vocationally registered have also been subject to a long delay due to hold-ups with that process which are indirectly related to the pandemic. It has been a frustrating wait, but there has been progress on this
Dr Clare French
Dr Meghan Ryall
WWW.ASMS.ORG.NZ | THE SPECIALIST
Are our Emergency Departments Covid fit? Elizabeth Brown | Senior Communications Advisor
survey of emergency specialists highlighted significant gaps in the preparedness of our EDs to deal with a re-emergence of Covid-19. With the arrival of the highly transmissible Delta variant, it provides some timely insights and lessons.
Emergency departments and their staff are stationed on the frontline of the Covid-19 pandemic. They triage cases through their doors, some obviously infected with SARSCoV-2, but others still presenting with heart attacks or sprained ankles who might also be. That puts them at the sharp end of exposure and transmission risk. In the first Covid-19 outbreak last year, Ministry of Health figures showed that one in every ten cases of Covid-19 were health workers. Unfortunately, there is no public information on whether they had become infected on the job or in the community. About a year ago, Northland emergency medicine specialist Dr Michael Howard looked across the Tasman and watched as Melbourne struggled with a Covid-19 outbreak in which half the cases initially were among healthcare workers.
therefore the ability of the system to care for people, so it’s like a vicious circle.” He adds that it was no secret that New Zealand’s health system risked collapse in the event of a major Covid-19 outbreak, so anything to shore up our defences would benefit everyone. Identifying and addressing weaknesses Dr Howard wanted to identify and address weaknesses in local hospital infection control in terms of department policies, PPE use and hospital ventilation and space, to reduce the risk of transmission and be ready for a Covid-19 re-emergence. Drawing on US and Australian research, he put together the New Zealand Emergency Department Covid-19 Preparedness Survey, asking emergency specialists about the levels of Covid-19
protection in their workplaces. He enlisted co-author Dr Charlotte Chambers (Director of Policy and Research at ASMS) to help create and distribute the survey to 422 ED specialists across DHBs. It was sent out through October–November 2020. A colleague, Dr Nicholas Mohr, lent his expertise to the project even as Covid-19 surged through his ED at the University of Iowa last December. It included questions on negative flow isolation rooms, shared/cohorted patient areas, segregated patient flow, and physical distancing. It also asked about policies for rostering, workflow, and breaches, along with the supply, fit testing, use and re-use of PPE equipment. A total of 137 surveys were completed – a 32% response rate and with all 20 DHBs represented.
“Even if rapid antigen tests become available, the level of PPE used will have to be reconsidered in all areas if we want to halt the Delta variant.”
The outbreak revealed deficiencies in hospital-level infection prevention and control, prompting authorities there to look at a model to reduce risk in the system. “This was a health system similar to New Zealand’s so I thought I could see our potential future, what weaknesses were present and the improvements which may be needed to prevent future New Zealand healthcare worker infections,” Dr Howard says. “If you put staff at risk and they are exposed or infected, you then have to take them out of the work environment, decreasing the number of available personnel and 6 THE SPECIALIST | SEPTEMBER 2021
Dr Michael Howard outside Whanga-rei Hospital ED
Some of the key findings included: • more than 10% reported no access to negative pressure rooms • 83% reported four or fewer negative pressure rooms in their ED • 11% had not had N95 fit testing • 86% were working in EDs that cohort patients • 34% did not use spotters during PPE doffing. The survey results suggest that many hospitals need to upgrade or modify their ventilation systems and provide enough adequately ventilated negative pressure rooms, as a matter of priority. Negative directional airflow dilutes contaminated air breathed in by healthcare workers caring for patients with airborne transmissible infections such as Covid-19. Smaller hospitals are more likely to be affected by a lack of adequate facilities.
“Ensuring a manageable workload through adequate staffing ratios by anticipating the increased care required for these infectious respiratory failure patients is paramount.”
Dr Howard says cohorting of patients speaks to the space constraints and overcrowding in so many of our emergency departments. Most survey respondents worked in EDs where some beds are separated only by curtains with shared air circulation. He says that pushes up the risk of potentially infected patients sharing air circulation with non-infected patients. 92% of respondents said they did have the capacity to segregate patients with a high Covid-19 suspicion index from those with a low suspicion index if alert levels rose, but there is no good way to rapidly identify asymptomatic infectious patients.
“Even if rapid antigen tests become available, the level of PPE used will have to be reconsidered in all areas if we want to halt the Delta variant,” according to Dr Howard. The ability for ED staff to physically distance in non-clinical hospital environments is shown to be clearly problematic (Figure 1). In recent months the pressures and short staffing of our EDs have been making headlines, as they grapple with high volumes of RSV cases.
“I feel like we’ve resigned ourselves to suffer the same failures as our trans-Tasman neighbours, and no one can find the space to think about preparedness.”
Dr Howard points out that this winter’s RSV presented a real stress test. “With nearly twice the usual presentations of this respiratory virus, we were stretched to take care of the ‘business as usual’. Since EDs will not close their doors to people in need when the much- discussed ICU beds are at capacity, we are left wondering where the help will come from. There doesn’t seem to be a plan.”
Dr Howard believes that more value needs to be placed on ED preparedness rather than simply dealing with it when it comes roaring through the door. He says the survey highlights the proactive steps DHBs and the Ministry of Health could be taking to mitigate the Covid-19 risk to both patients and staff in the ED environment.
The lack of adequate staffing levels during the pandemic is cited as the greatest concern for two-thirds of respondents (Figure 2). The survey notes that “ensuring a manageable workload through adequate staffing ratios by anticipating the increased care required for these infectious respiratory failure patients is paramount”.
“I feel like we’ve resigned ourselves to suffer the same failures as our trans-Tasman neighbours, and no one can find the space to think about preparedness. But the examples in the recent literature of how they altered weak policies, elevated PPE levels and practice, and protected their staff by ‘decanting’ crowded wards and bringing in portable HEPA filters are like messages from our future.
Has anything changed? Dr Howard has no way to gauge how much has changed in the eight months since the survey was carried out. The survey report itself makes the point that while PPE training, simulation and segregating patients were initially widespread, those practices quickly seemed to drop away.
“We need to be as prepared as possible because Covid is not going away any time soon.” The New Zealand Emergency Department Covid-19 Preparedness Survey is currently being peer reviewed for an international medical journal and has not yet been accepted for publication.
“Because we relaxed, we don’t have the same practice, and keeping people’s skills up to date is hard when there’s a perception that there is no longer a threat.”
Have adequare staffing levels
Work stations on ED floor Break rooms
Be prepared for another wave of COVID-19
Have adequate supplies of PPE
Changing rooms Canteens/Cafeteria
To rapidly test/diagnose COVID-19
Bathrooms -100% -80% -60% -40% -20% 0% Strongly disagree/disagree
Overall, the survey findings show that “engineering upgrades to respiratory pandemic standards are not prevalent, administrative Covid-19 policy has not adapted to scientific advances seen in policy from other healthcare systems (i.e., Australia), and PPE current practice reveals high variability suggesting poor dissemination of guidelines, low confidence in recommendations, or little practice because of low prevalence”.
Neither agree nor disagree
20% 40% 60% 80% Strongly agree/agree
Figure 1: Do you feel able to meet minimum physical distancing requirements in the non-clinical staff areas of your ED?
-80% -60% -40% -20% Strongly disagree/disagree
Neither agree nor disagree
Figure 2: If there were another wave of COVID-19 in NZ, what are your views regarding your ability to do the following?
WWW.ASMS.ORG.NZ | THE SPECIALIST
Health equity 2040 Lyndon Keene | Health Policy Analyst
n July, ASMS and the Canterbury Charity Hospital Trust joined forces to host a virtual conference – Creating Solutions: Towards health equity outcomes for all. Drawing on the discussions, we have produced a report titled Creating Solutions – Te Ara Whai Tika – A roadmap to health equity 2040. It will be submitted to Government for achieving an underlying goal of health for all by 2040. Lyndon Keene details some of its sobering trends.
The aim of the conference was to take a hard look at the stark and growing health inequities in Aotearoa New Zealand along with the social determinants which feed into them. It encouraged participants to reflect on their own practice in relation to health equity and come up with solutions. It featured presentations from health and social sector leaders, Health Minister Andrew Little, and prominent experts in their fields, including one of the world’s leading authorities on health equity, Sir Michael Marmot.
22nd century – taking approximately 127 years and 134 years, respectively. Pasifika females would need to wait approximately 220 years.
In the period 2005–07 (when data first became available in four ethnic groups: Ma-ori, Pasifika, Asian and European/ other), average life expectancy at birth for Ma-ori males was 8.6 years less than for European/other males; for females the gap was 8.1 years. By the period 2017–19 the gaps had narrowed only by 1.3 years and 0.7 years.
Comparisons of life expectancy between the poorest and wealthiest New Zealanders over the same 12-year period show a widening gap. In the period 2005–07, males in the wealthiest decile could expect to live 7.2 years longer than those in the poorest decile. By the period 2017–19 the gap had widened to 10.6 years. Life expectancy gaps for females were 5.4 years during 2005–07, increasing to 9 years during 2017–19 (Figure 1).
The life expectancy gap between Pasifika and European/other during 2017–19 was 5.6 years for males and 5.5 years for females – an improvement of 0.5 years and 0.3 years respectively over the 12year period. At this rate of progress, Ma-ori males
The widening gaps are owing to a life expectancy increase in the wealthiest groups – especially over recent years – and a drop in the life expectancy of the poorest groups.
would achieve equity in life expectancy with European/other males by around 2090 – taking approximately 70 years. For Ma-ori females and Pasifika males, equity with European/other would not be achieved until well into the
There are multiple reasons for this failure to address health inequities, which are discussed in Creating Solutions – Te Ara Whai Tika – A roadmap to health equity 2040.
The conference brought together more than 200 health professionals from throughout the health workforce. People dialled in from Australia, Fiji, India and even as far away as Afghanistan.
Health Strategy of 2000 and part of a broader policy to address social and economic inequalities between Ma-ori and Pasifika and other New Zealanders.
Closing the gaps? Attempts to close the long-standing gaps in health inequalities in New Zealand have a dismal record. Closing the gaps in health inequality was a priority of the New Zealand
8 THE SPECIALIST | SEPTEMBER 2021
Decile 1 males (least deprived)
Decile 10 males (most deprived)
Decile 1 females (least deprived)
Decile 10 females (most deprived)
Figure 1: Life expectancy at birth deprivation deciles 1 & 10, 2005–2007 to 2017–2019
Wellbeing economics A major shortcoming is an apparent mindset among policymakers to view health and social services in narrow financial terms, as an expenditure that needs to be controlled, rather than with a broader social and economic perspective which recognises the overwhelming evidence for investment for potentially substantial social and economic gains.
“At this rate of progress, Ma-ori males would achieve equity in life expectancy with European/other males by around 2090.”
While the Government improved social spending after its ‘Wellbeing Budget’ in 2019, it has yet to demonstrate genuine transformational change. This is needed to truly implement wellbeing economics where priorities for public spending are guided by the extent to which a programme can improve population wellbeing given its expenditure requirements. The need to adopt a stronger and more urgent commitment to addressing poverty is among the most urgent issues. Creating Solutions – Te Ara Whai Tika – A roadmap to health equity 2040 recommends specifically that: • the minimum wage be set at the same level as the voluntary ‘living wage’ • the current policy of 20 hours of free early childhood education (ECE) for 3–5-year-olds is extended to 1–2-year
olds as a first step towards addressing the cost barriers to accessing ECE • benefits are set so people who depend on them are not living in poverty. Cultural bias and racism Cultural bias and racism are also key barriers to achieving health equity, as illustrated in our relatively recent political history. Initiatives introduced by the Labour-led Government in 2000 to ‘close the gaps’ generated such a public and political backlash amid claims that Ma-ori were receiving privileged treatment that the catch-phrase was soon abandoned and the policy re-branded by the Government as ‘reducing inequalities’, in an attempt to make the policy more popular with the public. A few years later, the then National Party leader Don Brash’s infamous ‘Orewa speech’ attacking what he saw as special privileges for Ma-ori resulted in a major surge for the National Party in public opinion polls. Recent attempts by the current National Party leader to use similar tactics in a ‘Demand the Debate’ campaign on what she calls separatist policies has so far not had the same effect. However, if the task facing the Ma-ori Health Authority to help bring about health equity were not challenging enough, the opposition to its existence from the National and ACT parties has made it a lot tougher. As speakers at the conference reasoned, to succeed, the Ma-ori Health Authority will need strong support from everyone working in the health sector, and medical specialists are in an especially influential position to lead the way. To improve cultural safety and address racism, Creating Solutions – Te Ara Whai
Tika – A roadmap to health equity 2040 recommends that: • the Government has policies in place requiring public health and social organisations to demonstrate how they are supporting health professionals to achieve culturally safe practice and address racism • adequate resources are provided for all government services to achieve cultural safety at every level, including sufficient staffing to allow time for learning and self-reflection • the collection, monitoring, analysis, and reporting of quality ethnicity data – both from an organisational performance and workforce perspective – is substantially improved.
“The Ma-ori Health Authority will need strong support from everyone working in the health sector, and medical specialists are in an especially influential position to lead the way.”
Creating Solutions – Te Ara Whai Tika – A roadmap to health equity 2040 is available on the ASMS and Canterbury Charity Hospital Trust websites. It features 27 recommendations that cover 13 themes to improve policies on the determinants of health as well as on improving the health and disability system. ASMS will continue to monitor these issues and report on how they develop.
Behind the scenes
osting a virtual conference was uncharted territory for ASMS and posed a formidable challenge.
ASMS’ Manager of Support Services Sharlene Lawrence says she went into it “slightly naive”. “I’ve run numerous large-scale, face-toface conferences so was expecting this to be a lot easier – it definitely wasn’t. There were so many moving parts and it ended up being a huge job logistically”. She says the biggest challenge was coordinating the number of presenters nationally and internationally along with the mix between pre-recorded and live presentations.
Managed by the company Vidcom, the scale of the technical operation needed to support the smooth-running of the conference was impressive. For two days ASMS’ Wellington office was transformed into a fully operational recording studio, awash in wires, cords, and equipment, not to mention about a dozen separate laptops, used to host the virtual breakout groups. Sharlene says there were very few hiccups, and everyone felt a huge sense of achievement once it was over.
WWW.ASMS.ORG.NZ | THE SPECIALIST
10 THE SPECIALIST | SEPTEMBER 2021
Drs Adele Melton and Anurag Sekra at the Middlemore Hospital stopwork meeting
Stopworks and surveys – the fight for a fair MECA F
or the first time in 14 years ASMS members in DHBs across the country attended stopwork meetings in response to the stalled MECA negotiations.
Over nine days, 32 meetings were held across all 20 DHBs, along with two special Zoom meetings – one for those in rural hospitals and another two ‘mop-up’ meetings for those who couldn’t attend the meeting in their area on the day.
one-off payment, and to earmark $15 million dollars to be spent on a working group to look at the senior medical and dental workforce. The ASMS negotiating team believes these are unacceptable options.
At the time of the stopworks there had been ten days of MECA negotiations but the DHBs had failed to come up with an acceptable offer.
To add to the frustration, the DHB decisionmakers are almost never anywhere near the table.
A handful of ASMS’ claims had been accepted but nothing that would make any difference to pay or the current staffing crisis. ASMS’ revised pay claim is a very reasonable 1.5% for the first year and 2% or CPI for the second if a two-year term was agreed. DHBs continue to refuse to consider CPI adjustments, or any salary increases in the first year of a settlement and reject ASMS’ claims aimed at improving working conditions, doctor wellbeing, burnout, and safer staffing. What they have offered is to convert $5,000 from individual CME funds as a
There were very good size turnouts at the stopworks and some lively discussions. While a wide range of views were expressed, common themes stood out. Members across all DHBs outlined their personal frustrations over workload, staffing shortages, working conditions and exhaustion, not to mention the temptation to move to Australia or shift to private practice. There were also significant concerns expressed about our ability to recruit and retain younger SMOs. Disappointment and disillusionment also came through over what was considered the failure of DHBs and the Government to value senior medical staff, while at the
same time expecting them to go the extra mile and do more with less. Survey results Following on from the stopworks, ASMS sought members’ views via a survey to help the National Executive decide on priorities for next steps, and what actions members would consider in support of reaching a fair settlement. The level of participation in the survey was higher than any other member-wide survey ASMS has ever conducted with a 65% response rate. Thanks again to all those who took part. When The Specialist went to print the results from the survey were still being considered along with the large amount of valuable qualitative information shared by members in the form of wide-ranging views and comments. It’s been well-publicised that the Government has signalled zero pay increases for public servants, except those in the lowest pay brackets. This is a key driver in the DHBs’ negotiating position with ASMS. WWW.ASMS.ORG.NZ | THE SPECIALIST
Messages for the Government In the survey, members were asked to leave a message for the Government and more than 2,000 responded. Here’s a taste.
Ultimately patients suffer if we are exhausted day on day and the Department less likely to reap the benefits of new protocol and treatment developments.
THE CURRENT ROSTERS ARE OFTEN VERY UNSAFE. GAPS IN STAFFING ARE DANGEROUS.
Look after us so that we can look after others.
We increasingly struggle to provide first world nation quality of care and patient safety.
Staff are strained and drained. I am afraid we are heading to a point of no return: nobody wants to stay on or join a sinking ship.
OVERWORKED, DEMOTIVATED, BURNT-OUT SMOS CANNOT DELIVER QUALITY SERVICES TO PEOPLE WHICH GOVERNMENT OFTEN BOASTS OF!
It’s not about becoming rich but being able to do a good job safely year after year.
PLEASE ACKNOWLEDGE THE WORK WE DO. VALUE YOUR WORKFORCE DURING THIS CHALLENGING TIME.
WORK PRESSURES INCREASE YEAR AFTER YEAR. WE NEED TO RETAIN A HEALTHY AND EXPERIENCED WORKFORCE.
Something which wasn’t expected, but which has changed the MECA negotiating landscape is the outbreak of the Delta variant of Covid-19. The stopwork meetings and the survey happened well ahead of the latest lockdowns. The outbreak highlights the need for a resilient, dedicated and valued senior medical workforce, but also places extra demands on our hospitals and health system. This will factor into the National Executive discussions. The National Executive will also be meeting with the wider ASMS negotiating team as it considers next steps. In the last month, ASMS President Dr Julian Vyas and Executive Director Sarah Dalton have been able to hold separate meetings with the Minister of Health Andrew Little, the DHB Chief Executive in charge of the MECA negotiations Kevin Snee, and Andrew Norton from the Health and Disability Review Transition Unit. Following the stopworks, ASMS has also received a formal invitation from the DHBs’ advocates to enter into mediation. All these steps add potential ways forward in achieving a fair settlement. ASMS will share more specific information about the MECA negotiations through the MECA Matters newsletter. 12 THE SPECIALIST | SEPTEMBER 2021
Messages to the Government in key words
Keep an eye out for the MECA Matters newsletter that will keep you updated on any further negotiations, and next steps in this important industrial campaign. You are welcome to write to us firstname.lastname@example.org
ASMS Hospice negotiation team: (L–R) Dr Simon Allan (Arohanui Hospice), Dr Di Winstanley (Mercy Hospice) and Julia Holyoake (Nurse Maude Hospice).
Thumbs up for non-DHB members W
hile most ASMS members work for DHBs, we also have almost 300 who work in the ‘non-DHB’ area. They work across a broad range of services, including mental health, general practice, ACC, sexual health, ESR, hospices, the Ministry of Health and in rural hospitals. Over the past few months, new collective agreements have been successfully negotiated in several nonDHB organisations. One of those was at Hokianga Health, where senior industrial officer Lloyd Woods said, “It was time for a serious catch up for members.” There are seven
ASMS members at the Northland Ma-ori health provider.
MECA has 13 employers and covers 54 ASMS members.
The three-year agreement brings specialists at Hokianga Health in line with those employed in other rural hospitals.
Lloyd Woods praised the input from the ASMS representatives.
ASMS representative Dr Steve Main says the talks were respectful and collegial, and he welcomed the approach of Hokianga Health’s new Chief Executive (and former Ministry of Health Chief Nursing Officer), Margareth Broodkoorn, who has been a strong advocate for the health workforce. Members at Hospice New Zealand were also pleased to have recently settled their MECA. The Hospice New Zealand
“All of our non-DHB negotiations are heavily reliant on member input, and our representatives are key to obtaining good outcomes as we have in all of our non-DHB negotiations this year.” ASMS is negotiating 18 non-DHB collective agreements this year. Others that have been settled include Golden Bay Community Health, Family Planning, Clutha Health, Waitaki Health, Otara Wha-nau Medical Centre, and Ministry of Health.
WWW.ASMS.ORG.NZ | THE SPECIALIST
Hospital bar staff. Sally (2nd left) with the team – Michelle, Sharon, Priya and Denise
Flooding serves up pub-based healthcare Elizabeth Brown | Senior Communications Advisor
ospitals don’t normally have pool tables, a jukebox, and a fully stocked bar, but during the record-breaking floods in Westport, doctors and nurses found themselves caring for patients out of the local pub.
On 17 July the Buller River was flowing almost 13 metres above normal – the largest flood flow on any New Zealand river in almost 100 years, according to NIWA. The unprecedented flooding inundated large parts of Westport, leaving hundreds of red and yellow stickered homes in its wake. Formerly a rural hospital, Buller Health is now an integrated family health centre, but still the only place to get emergency health care for miles around. The floodwaters filled the building’s basement, taking out the boiler, affecting electrical systems and spilling sewage. Time to evacuate With a civil defence emergency already declared, the decision was made to evacuate to the only suitable building on higher ground – Club Buller, a community bar and restaurant. 14 THE SPECIALIST | SEPTEMBER 2021
According to Rural Generalist and Emergency Medicine specialist Dr Sally Peet, the health centre was especially busy at the time. With flooding imminent, many households had been evacuated to the local school, but elderly and disabled people were brought to the health centre. So instead of the usual 2–6 inpatients, there were 15. “They tried to send ambulances up from Greymouth to retrieve patients, but they became stuck in the floodwaters and couldn’t go back. The bonus for us was that we had additional paramedics in town, which was invaluable,” Sally says. Evacuating patients out of the floodaffected building was no easy task. Pushing beds along the street was impossible, and with the flooding too much for the ambulances, the Army transferred patients in Unimogs.
Once they reached the club, patients were cared for on mattresses on the floor. “That meant nurses getting down on their hands and knees to roll patients and help them to the toilet etc. One nurse couldn’t get home so stayed and worked for nearly 30 hours. She said her back was terrible by the end.” There were personal challenges for some of the staff as well as they worked through, knowing their own homes were being flooded. Many others wanted to come in and help but simply couldn’t get there. M*A*S*H* in a bar Once all the patients and equipment were transported, Club Buller was quickly transformed into a makeshift hospital. Dr Peet says fortunately none of the patients who had been evacuated was too sick. A few were able to be taken to
the local rest home, and by the end of the weekend others had been choppered out to Greymouth, leaving just three inpatients behind. “A colleague called it ‘M*A*S*H in a bar’ – it was a spot-on description!” Dr Peet says. Staff quickly renamed it ‘Club Med’. “It was a great big room with a bar and three beds in it. One was a resuscitation bed which personally terrified me because I was looking at the set-up and thought wow, this is real basic stuff.
“There we were, working out of a good old Kiwi workingman’s club with the bar behind us, so there were a lot of jokes”
“We were having to borrow a defibrillator from the ambulance rather than have our own because there was too much interference from the games and the TVs and stuff. We also had a lot of equipment laid out on the pool table.” In one corner a birthing suite was set up with a mattress on the floor with a neonatal Resuscitaire in case a woman went into labour. In the slightly separate dining room, an inpatient ward was set up. For the first few days, staff spent time running back to the old hospital building to fetch equipment and supplies they realised they’d left behind, and eventually the beds were pushed across.
M*A*S*H* in a bar
Whole households out on the road
Dr Peet says while it all felt very rudimentary and there was some anxiety about the possibility of a patient coming through the door needing resuscitation, they were comforted by the amount of backup they had.
She describes entire households piled up outside houses – carpets, drawers with clothes coming out, teddy bears, kids’ toys – all ruined by floodwater containing sewage and farm runoff.
“Because of the state of emergency, the Army was there, and we had lots more paramedics than we normally have. “I had a guy come in with pneumonia who was looking pretty rough. The ambulance crew would normally have to dump and run because they are just so busy, but they were able to stay and help and then we made the decision to send him down to Greymouth, so the turnaround was very quick,” Dr Peet says. There was also a lot of team spirit. “There we were, working out of a good old Kiwi workingman’s club with the bar behind us, so there were a lot of jokes, and we were inundated with care packages and cakes from the community and other DHBs.” And then there were the extra-special moments. Dr Peet says a young medical student who was in a rural medicine immersion programme opted to stay during the civil defence emergency. Not only was he invaluable when it came to moving equipment but during a bit of downtime, he found a piano in the corner of the club. “Turned out he was the most beautiful piano player, and that was such a nice experience for everyone.” Devastating scenes One thing Dr Peet won’t forget is the devastation she saw.
“You could smell it as you walked around.” “What makes it worse is that Westport is a poor area where houses were either uninsurable because they are in the flood plain or people just can’t afford insurance,” she says. Dr Peet works at Buller Health Hospital every other week for 2–3 days, rotating between there and Te Ni-kau Hospital further south in Greymouth, as part of a rural health medical team. She says while the community spirit and support has been amazing, medical staff are preparing to see patients coming in needing treatment for depression, anxiety, and social problems.
“A colleague called it ‘M*A*S*H in a bar’ – it was a spot-on description!”
“Initially people just get on with it and there’s a bit of an adrenalin rush, but now nearly every patient is stressed and sad.” After a novel and challenging two weeks of treating patients from the inside of a pub, the staff at Buller Health were given the all-clear to return to their original building. Dr Peet says while it was a perversely enjoyable experience, it’s one they hope never to have to repeat. WWW.ASMS.ORG.NZ | THE SPECIALIST
Mental health on the line Lyndon Keene | Health Policy Analyst
n June 2018 the Stuff news website published a letter from a psychiatrist describing their working conditions – how referrals had doubled over the previous eight years while the size of the mental health team remained unchanged, and how patients who needed hospital care were often sent home because of a lack of beds. The psychiatrist wrote: “When I leave at the end of the day, I worry about whether everyone I have seen will be safe ... If they do harm themselves, my life won’t be the same for a while – but I will still need to see my patients, one every 30 minutes.” In November that year the Government’s Mental Health Inquiry report found specialist services were under “severe pressure and unsustainable”. Today, nearly three years later, the ongoing parlous state of the country’s mental health services is outlined in the recent ASMS report What price mental health? The report found: Workforce shortages • The prevalence of anxiety disorder and depression is increasing well above the population growth rate. • The use of mental health and addiction (MHA) services is increasing well above the staff growth rate, whether it be psychiatrists, nurses, or allied health staff. • The number of psychiatric beds per head of population in New Zealand is among the lowest in the OECD. • The number of inpatient MHA beds per population has fallen by nearly 10% in the past five years. • DHBs frequently exceed 100% occupancy levels for MHA inpatient beds – well above the 85% occupancy considered clinically safe. • For more than a quarter of a century, specialist MHA service funding has been designated to cover 3% of the population, deemed to be those with the most severe need. But the latest evidence – now 15 years old with no evident plans for an update – indicates that closer to 5% of the population has a severe need.
16 THE SPECIALIST | SEPTEMBER 2021
The report also found New Zealand has the lowest number of practising psychiatrists per capita among 11 comparable countries, some of which are reporting workforce shortages. Unpublished workforce forecasts obtained from the Ministry of Health show the pressures could become even more challenging in the coming decade unless recruitment and retention improve significantly. The forecasts in Figure 1 are projected from workforce entry and exit trends, in five-year age bands, over the last five years. Similar forecasts have been produced based on trends over the last three years, producing a steeper decline to 12.0 psychiatrists per 100,000 population.
These forecasts may have been affected by the drop in practising psychiatrists over the past year (an estimated 1.2% drop per capita), which may be in part due to Covid-19 travel restrictions and quarantine requirements in a speciality that heavily relies on overseas-trained doctors. On the other hand, the forecasts do not account for the increasing complexity of cases. This data highlights the need for a comprehensive workforce investment plan, as ASMS has called for in its report Building the workforce pipeline, stopping the drain. This must include a regular medical workforce census to support independent expert advice to the Ministry of Health on all aspects of workforce policy, education, training and development, planning, and purchasing. Targets for medical training are needed that will address equity and diversity of our medical workforce as well as distribution by geography, rurality, and specialty. For psychiatrists, the New South Wales Ministry of Health’s Psychiatry Workforce Plan 2020–2025 provides a model consistent with ASMS’ recommendations. It comprises nine strategies listed below, each with a set of specific actions and timelines, and identifies the agencies responsible for implementing them:
• Align the workforce with forecast demand and delivery requirements. • Monitor the psychiatry workforce. • Attract and support the future psychiatry workforce. • Support the psychiatry workforce to grow its management and leadership capability. • Provide effective working arrangements. • Support academic psychiatry to strengthen the workforce and the NSW psychiatry knowledge base. • Support development and growth of the rural psychiatry workforce. • Embed innovative approaches to attract and retain psychiatrists to outer metropolitan, rural and regional areas. • Strengthen connections between rural and metropolitan psychiatric services.
Health Minister Andrew Little told last year’s ASMS annual conference that the idea that there is no plan for workforce renewal and development “seems criminal” to him. So, it may be reasonably assumed a plan is on the way. For MHA services specifically, it will need to be substantially better than the MHA Workforce Action Plan 2017–2021, which appears to have made little headway. If the urgency for a more detailed (and properly resourced) plan is not already clear from the current data, it will be reinforced in a forthcoming ASMS publication analysing the results of a national survey of DHB-employed psychiatrists. This will describe the state of wellbeing of our psychiatry workforce, the degree to which they feel supported at work, the demands they are facing in terms of workload pressures and acuity, and the possible consequences of this in terms of their intentions to leave. It’s not a pretty picture. The full What price mental health? report is on the publications page of the ASMS website.
Number of Workforce per 100,000 population - HC
Number of Workforce per 100,000 population - FTE
Figure 1: Forecast number of psychiatrists (headcounts and full-time equivalents) practising in New Zealand per 100,000 population Source: Ministry of Health 2021
WWW.ASMS.ORG.NZ | THE SPECIALIST
The highs and lows of clinical innovation Elizabeth Brown | Senior Communications Advisor
hen it comes to reducing the cost burden of cardiovascular medicine on our health system and improving equity, Auckland cardiologist Dr Patrick Gladding is all about finding solutions.
An estimated 170,000 New Zealanders are living with cardiovascular disease, and it is responsible for about one in three deaths. Dr Gladding works for Waitemata- DHB, which serves a growing but ageing population on Auckland’s North Shore and a more disadvantaged and highneeds population in the city’s west. It adds up to a lot of people needing to be seen. The key tools in any cardiologist’s toolkit are ECG, echo-cardiography or cardiac ultrasound, and Holter monitoring to detect arrhythmia. “In most hospitals the waiting list for an echocardiogram is anywhere between nine months to a year unless there is an urgent problem. We are not meeting the needs of tomorrow at all, we are just getting by today, but the wait list is long,” Dr Gladding says. He explains that under current standards of care, a patient gets referred by a GP, then most likely waits months to see a specialist. When they finally see the specialist, they get a blood test and an ECG on the day, then get referred on later for an echocardiogram or Holter. Once that’s done the specialist sees the result and the patients gets rebooked to a clinic, which can also be months away. “It just seemed daft to have someone come back time and time again, disrupting their employment, making them travel repeatedly and adding stress,” Dr Gladding says.
18 THE SPECIALIST | SEPTEMBER 2021
AI technology Using AI technology, he has introduced the Rapid Cardiac Screening Clinic, which he is piloting out of Waitakere Hospital. The aim is to speed up the patient management process, make treatment more accessible and improve outcomes. Dr Gladding says patients can get things done “in one hit”. When they turn up, they have their height and blood pressure taken, have an ECG and a short echocardiogram, and then see the specialist. The AI tool analyses the data using a probability-based system.
“We’ve shortened the whole experience for patients down to about 75 minutes as opposed to hours of to and fro and waiting – or sometimes days or months waiting for these things.”
“Ultimately, I’m still the one who makes the call on the need for any further investigation or treatment because I look at the disease probability after looking at the patient and talking to them. The machine learning probabilities either get disregarded or acted on based on augmented decision making – so I still do all the same things. “We’ve shortened the whole experience for patients down to about 75 minutes
as opposed to hours of to and fro and waiting – or sometimes days or months waiting for these things.” Six pilot clinics have been run in the past year involving around 60 patients. In that time the number of cardiac ultrasounds has been reduced by 25%, twice the number of patients have been discharged, and feedback has been very positive. “One of the cool things about this is you can introduce a technology and run it side by side against your current system and compare it. If it’s as good, you can say I’m going to go with that now. The clinic also has modularity so you can just plug in or out different things depending on their value add.” Frustrations and challenges A self-confessed early adapter, Dr Gladding is driven by a desire to do things differently. “It’s frustrating to be a doctor in this era when it’s the same as when you were at medical school. Things are printed out for you on paper, we just got rid of fax machines last year. There’s a gap where we are still doing the same things, yet we could be introducing some new ideas.” There is also frustration over what he sees as the lack of investment in clinical innovation from a Ministerial level and the fact he gets pretty much ‘zero nonclinical time’, despite the requirement of the MECA. “When I have my admin time, I fill that with trying to get this clinic off the ground along with my usual paperwork.
Dr Patrick Gladding in a clinic room at Waitakere Hospital
This isn’t the fault of our hospital management, which has been very supportive. DHBs are only given so much to work with, and it’s all focused on service delivery. The problem is higher up at a governmental level." “Investment doesn’t necessarily have to be monetary – it can be time and being able to remove yourself from clinical commitments,” he adds. Other staff have also given their time, support, and commitment to getting the clinic going. “It’s the people in the hospital who are crying out for FTE who are helping this clinic. Everyone is crying out for more FTEs to cut down these wait lists.” Another challenge to clinical innovation that Dr Gladding points to is that the DHB has no budget for research and development, and New Zealand’s R&D healthcare budget is tiny compared to other similar countries.
He says fostering clinical concept in New Zealand is important but clinicians face difficulties getting funding through the Health Research Council because it tends to fund incremental academic and scientific research rather than projects at the delivery end of health or transformational change projects.
“Investment doesn’t necessarily have to be monetary – it can be time and being able to remove yourself from clinical commitments.”
In saying that, he is grateful for the support he has had from Waitakere Hospital’s own internal innovation group – i3 – and its focus on digital infrastructure.
Engagement with local Ma-ori and bringing in Ma-ori advisors has been key. They have raised particular concerns around data privacy and sovereignty in relation to AI technology. “We have really valued that input because we know AI is starting to be used in multiple areas like radiology and ophthalmology. How you govern data and establishing social contracts for its use needs to be discussed with the public.” Once a few hundred people have been through the clinic, Dr Gladding is hoping they will be at a point where the clinic can be a sustainable tool that can be rolled out in other hospitals. “In two years, I would want recognition of the clinic and the idea, and for the Ministry of Health and people higher up to actually see that instead of expecting it to work on some laughable budget, to actually fund it properly.”
WWW.ASMS.ORG.NZ | THE SPECIALIST
New faces welcomed at branch officers’ workshop
New branch officers meet in Wellington
his year’s ASMS branch officers’ workshop in July was marked by a raft of new faces, following elections earlier in the year.
Each region is represented by a President and a Vice President. They are key representatives in your workplace and are elected for three-year terms. They officially took up office on 1 July. Every year ASMS brings our branch officers together in Wellington for a day of discussions, presentations, and information-sharing to support them in their roles. Last year many branch officers had to join virtually due to Level 3 Covid-19 restrictions in Auckland. Unsurprisingly, a key focus of this year’s meeting was the lack of progress in the MECA negotiations, including briefings on the planned stopwork meetings. The Council of Trade Unions’ new economist Craig Renney brought macro-economics to life as he gave his analysis of the Government’s last Budget. Craig, who spent five years in Finance Minister Grant Robertson’s office, said Covid-19 is a mere blip that won’t have a long-term structural effect on the economy. He also pointed out that New Zealand has comparatively very low debt levels, and in his view the Government has “significant fiscal headroom for expenditure”. Other big themes of the day were burnout and wellbeing. ASMS Policy and Research head Dr Charlotte Chambers presented the findings of the recent member burnout survey, while Northland SMO Dr Lucille Wilkinson spoke about the research she has been doing on wellbeing during her sabbatical. It included looking into the need for wellbeing measurement tools for health workers and the obligation for employers to provide safe working environments.
Dr Clare French
Dr thomas carter
Dr nigel giles
Dr Clare French is the new Vice President of the Wairarapa branch. The general surgeon is not only new to ASMS but also to New Zealand, having arrived last March, right before lockdown. As an American she says being an SMO in a union is new and different.
Dr Thomas Carter is the new President for the MidCentral region. As an emergency doctor he was keen to step up some of the advocacy work he has already been doing within his DHB.
The new Vice President for Whakata-ne, Dr Nigel Giles,
“We don’t unionise in this way in the States, and I was interested to see what goes on behind the scenes and wanted to be a part of it.” She found the branch officers’ workshop worthwhile. “I work in a small workplace and will go back with more details and knowledge to share. I definitely feel more confident about fielding questions from colleagues and equipped to represent the union.”
20 THE SPECIALIST | SEPTEMBER 2021
“It’s another avenue to combat the problems we face front on. “I feel the public and politicians are disconnected from individual hardship. The branch officer role will let me communicate with my colleagues more often and act as a sounding board for them.”
also put his hand up to help his fellow SMOs. “Many SMOs are feeling vulnerable, not represented and largely ignored by senior management of the DHB. The meeting was exceptional and great to know ASMS is working so hard to help us do the clinical work we love to do.”
You can find out who your branch officers are on our website www.asms.org.nz by searching “branch officers’.
Standing in support of midwives We were out supporting midwives as they marched on Parliament during their recent industrial action. Midwives had rejected the latest pay offer from their DHBs but were also highlighting critical staffing shortages. It’s important for health unions to stand together and send a strong message about health workforce shortages across the board and the need to value the staff we do have.
Support for ASMS remit on user charges An ASMS remit to the Council of Trade Unions women’s conference has been adopted unanimously and will now go to CTU delegates at their annual conference for consideration later this year. The remit stated: That the CTU advocates that user charges for primary health services (including dental) are abolished, starting with free dental care. ASMS’ recommendation comes directly from our Health Matters publication from last year and is also part of our Creating Solutions agenda for change. We firmly believe that any aspirations towards health equity will fail while New Zealand continues to impose user charges for primary care. If the remit is passed at the full CTU conference, it will become an official CTU policy position which it will lobby Government on.
CTU Women’s conference passes ASMS remit
WWW.ASMS.ORG.NZ | THE SPECIALIST
Tandem hobbies of travel and photography
At July’s branch officers’ meeting in Wellington
Dr Carol Chan
Dr Carol Chan works as a paediatrician at Gisborne Hospital. She is also Vice President of ASMS’ Tairawhiti branch. What inspired you to get into your field of medicine? My grandmother was a nurse and I used to spend time with her when she worked at a school. I particularly liked watching her give injections! Growing up I always liked science and helping people, but never actually thought about medicine until university application. During medical school, I was reassured that I do like dealing with people and not just science. I also became unwell as a medical student, and my journey as a patient not only strengthened my resolve to continue but more importantly shaped how I am as a practitioner. What are some of the challenging aspects of your job? What I did not fully appreciate before I started my career, was how significantly sleep deprivation affects me. Unfortunately, regional paediatrics go hand-in-hand with interrupted nights! By far the most challenging aspect in my work is dealing (or rather, being powerless) with the determinants of health, most of which the secondary health sector has no direct influence over. Challenging families, disagreements in 22 THE SPECIALIST | SEPTEMBER 2021
management approaches and difficulties adhering to treatment are frequently encountered in our work, but generally, in a therapeutic relationship there are gains to be made. Poverty and lack of livelihoods, poor housing, drug and alcohol and violence are underlying causes of illness that we cannot effectively “treat” in the hospital. While we can continue to provide advocacy when clinical duties allow, they continue to drive presentations. What do you find rewarding about your job? One of the best aspects of paediatric medicine is that most parents and caregivers care about the wellbeing of their children. Another is that most of them get better. Seeing children recover, or at least have the best experience they could have through their encounter with us, are probably the most powerful rewards. What keeps you happy outside of work? It is fortunate that we’ve had the freedom of travelling within New Zealand (until recently), but I cannot wait until it is safe to go further! This year I committed on the journey into the bottomless pit that is photography and bought an actual camera. It is refreshing
to engage a different part of the brain. Photography and Camera Club also force me to do more walks and look at things I don’t routinely pay attention to. Eating and taking photographs of food combine two things I enjoy. People who know me would know I love food. I make a point of going out from time to time with friends to eat, and this helps me stay connected with the world outside the hospital. I adopted a stray kitten last year. He was born in the first Level 4 Lockdown and was named Ricky Wildercat as he was left behind by his mother! He has provided me with entertainment, company, therapy, a few unwanted presents, and a lot of photographs! Also did I mention sleep? I love sleep. Why did you become involved with ASMS? I always believe in the collective voice being more powerful than the individual voice. The wellbeing of each of us is vital in providing the best service we can, and the wellbeing of the workforce is vital to scaffold its practitioners. I wanted to be part of this and have been fortunate to have many experienced colleagues support my involvement in the advocacy for our needs.
Drug driving and evidentiary blood samples By Dr Mark Burns (Medicolegal Consultant, Medical Protection) and Adam Holloway (Partner, Wotton Kearney)
t is well established that the risk of being involved in a motor vehicle accident increases as a driver’s blood alcohol level increases. There has recently been an increased focus on the role that recreational and prescribed drugs can also have. Waka Kotahi NZ Transport Agency’s ‘Drug-affected driving’ advertising campaign highlights that driving is greatly impaired by substances that affect cognitive processing, reaction times and the perception of reality. Most injuries from motor vehicle accidents are seen in hospital emergency departments, although some may present elsewhere such as after-hours medical clinics. Doctors working in these areas may not be aware of their obligations and options regarding taking evidentiary blood samples. Medical Protection has received enquiries from members contemplating a more pro-active approach to screen for potential drug driving. The legality of a pro-active approach The legal framework under the Land Transport Act 1998 (LTA) for taking evidentiary samples and providing them to police is the same for drugs as for alcohol. Section 73 of the LTA deals with who must give blood specimens when in hospital or at a medical centre. The doctor must take an evidentiary blood sample when requested by an enforcement officer under s73(3) (b) but may also do so at their own volition under s73(3)(a), provided in both instances that certain requirements of s73(5) are met. These requirements include that the doctor has a reasonable suspicion that the patient has been involved in a motor vehicle crash, that taking the sample wouldn’t prejudice their care, and that they inform the patient (either in person or, if the patient is unconscious, by telling them in writing as soon as practicable). If the circumstances of s73(5) above are met, then a doctor may, at their discretion, choose to take an evidentiary blood sample. No request from police is required and no consent from the patient is needed. If such a sample is collected, it must be sent to an approved laboratory and a certificate should be completed (s75). Section 73 provides the power to take a blood sample without a patient’s consent, but in practice a doctor may be unable to do so due to the patient’s refusal or behaviour. Notably, s60 of the LTA states that a person commits an offence if they refuse to allow such a blood sample. What are the potential criminal charges related to drug driving?
A blood sample will be important evidence under a charge of being under the influence of a drug to such an extent as to be incapable of having proper control
of the vehicle (s58); driving or driving and causing injury with evidence of using any schedule 1 drug (s58 & s61), which includes methamphetamine, LSD, cocaine and heroin; and finally, driving or driving and causing injury using ‘qualifying drugs’ in combination with failing an impairment test (s57A & s61). Qualifying drugs include controlled drugs in the Misuse of Drugs Act 1975 such as cannabis and benzodiazepines. Evidentiary blood samples taken under s73 cannot be used to prove use of a controlled drug in a prosecution under the Misuse of Drugs Act. They relate specifically to charges under the LTA. If doctors philosophically want to start taking evidentiary blood samples from every patient who presents because of a motor vehicle accident, they may do so provided they have followed the criteria set out above. It will remain a decision for police as to whether they wish to bring charges. In cases where police have not been at the accident scene, the charge of driving using schedule 1 drugs, for example, is likely to be more easily proved through such doctor-initiated sampling. It is a legal requirement under s22(3) of the LTA for drivers to report any motor vehicle accident causing injury within 24 hours to police, so most cases should already be known to them. However, not all drivers will be aware of this requirement, or they may choose not to report. Establishing whether this has occurred may assist the doctor in their ethical consideration of the merits of initiating a blood test of their own volition.
Broader ethical considerations The health and wellbeing of patients as the doctor’s first consideration is a basic tenet of medical care; however, there are many examples of where a doctor’s actions are for the protection of society more widely, overriding the interests of individual patients. Doctor-initiated evidentiary blood samples may not necessarily lead to treatment of the substance misuse health problem, merely to criminalisation. This of itself might be an objective for some who wish to see recidivist drug-drivers removed from the road. However, social disadvantage and marginalisation are strong predictors of drug use, and such an approach could conceivably criminalise an already disadvantaged sector of society. Some might argue that removing those who present a risk on the roads and to others is justifiable from a utilitarian perspective, but this would need to be underpinned by evidence that such an approach would actually reduce drug driving deaths and harm. Otherwise, there is potential for doctors to be acting merely as agents of the state, and what might be legal for doctors to do is not necessarily the right thing for doctors to do. While the legality of doctor-initiated evidential blood tests is clear, there is an ethical dilemma that every doctor involved in these processes needs to consider. Each clinical presentation would need to be taken on its own merit, and doctors may want to call their indemnifier to discuss the pros and cons of how to act in a particular case.
Taking an evidentiary blood sample, sending it to a police-approved lab with completion of an s75 certificate, with police accessing the results, delivers protection from civil or criminal proceedings. Furthermore, the Health Information Privacy Code (HIPC) is subservient to other legislation, so if the doctor is complying with these LTA sections, the HIPC cannot overrule the exercise of these powers. Importantly, this applies narrowly only for blood samples from patients involved in motor vehicle accidents. The LTA would not, for example, provide protection for taking urine samples without consent or passing on other information to police such as a patient’s verbal disclosure of drug use. WWW.ASMS.ORG.NZ | THE SPECIALIST
Missed opportunity to consider funding in PHARMAC Review Mary Harvey | Policy advisor
ack in March, Minister of Health Andrew Little announced that the Government’s drug-buying agency PHARMAC would be the subject of an independent review. It came in response to public concern about PHARMAC’s priorities and calls for the Government to follow through on its promise of a review during the last election campaign. The review panel was expected to issue an interim report to the Minister by 20 August and a final report by 10 December 2021. One key aspect that was signalled by the Minister as being out of scope for review was the fixed nature of PHARMAC’s budget and the total amount allocated to pharmaceuticals “as these quite rightly are for the Government of the day to determine”. ASMS made an early submission to the review panel. We argued that funding should be included as part of the review. Problems with the PHARMAC model stem from its statutory objective to stay within a fixed budget each year that is insufficient to fund the medicines New Zealanders need. We also raised concerns around the lack of transparency of PHARMAC’s funding decisions, the long delays in approving funding for new medicines, and the fraught process clinicians face when applying for medicines not listed on the Pharmaceutical Schedule. We highlighted that each time a funded drug is switched to another drug to save money, around 20% of patients lose effect from the new drug or get side effects due to the nocebo effect. The consequences for patients are not appropriately considered by PHARMAC in its decision-making. We also pointed out that to achieve more equitable health outcomes, PHARMAC needs to understand the health needs of Ma-ori, Pacific people, and other vulnerable groups, including disabled and rural communities, and reflect informed advice in its funding decisions. This includes understanding unmet health need in New Zealand, which affects many groups disproportionately.
ASMS considers there is enough headroom in the Government’s coffers for it to increase the pharmaceutical budget so that PHARMAC can address unmet need and support all New Zealanders to live longer and have improved quality of life. ASMS’ submission can be found on our website: www.asms.org.nz/publications
Readying for legalised euthanasia T
wo specialists have been appointed to a new statutory body that has been established as New Zealand prepares for the legalisation of euthanasia.
From 7 November this year, people who experience unbearable suffering from a terminal illness will be able to legally ask for medical assistance to end their lives. It comes a year after the 2020 referendum on the End of Life Choice Act 2019. The Act sets out the legal framework and a high-level process for accessing assisted dying, including strict eligibility criteria and safeguards. Assisted dying will be an entirely new service within the health and disability system. Two doctors must deem a person eligible before the assisted dying process is allowed to go ahead. Under the Act, if either doctor is unsure of the person’s ability to make an informed decision, a third opinion from a psychiatrist is required. The Support and Consultation for End of Life in New Zealand group (SCENZ) has been appointed by the Director General of Health. The 11-person group is charged with maintaining and providing a list of medical practitioners and psychiatrists involved in providing assisted dying services. It will also support the development of the standards of care for medicines as part of the implementation of the new law. The members are all currently practising health professionals. The two specialists on the group are Dr Michael Austen, a Wellington-based physician in occupational and environmental medicine and urgent care, and Dr Gary Cheung, who is currently a specialist old age psychiatrist working at the University of Auckland and Auckland DHB. Another statutory body, the End of Life Review Committee, which will report on compliance with the Act, is expected to be appointed by the Minister of Health around October. 24 THE SPECIALIST | SEPTEMBER 2021
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Conference remits If you have any items, you would like formally cons idered or voted on at annual confer ence, please get them in by 24 O ctober. All remits must be in writing and can be sent to conference@ asms.org.nz
Annual Conference going virtual vid outbreak and the Sadly, due to the latest Co , the 33rd ASMS Annual risk of further disruption ual event. Disappointing Conference will be a virt we know! eting on 25 November. There will be a one-day me address by the Health It will include an AGM, and speakers. Minister, along with guest istration forms are The programme and reg Those who have te. bsi we available on our rest will automatically already expressed an inte . be sent a registration link
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d Bs has prevente ail security in DH y of an m s, te da A tightening of em up S M from receiving AS ange some members s because of a ch er ld fo k jun in up ng di e en th e r ar te which curred af s. The problem oc in firewall setting ne. Ju in B DH Waikato cyber-attack at lve IT teams to reso rking with DHB at is wh ow kn rs We have been wo ensure membe to nt wa we ns as negotiatio . the issues with the MECA lly cia pe es g, in happen ur junk folder r emails, check yo ou ng tti ge t no If you’re ate. Another fix essages as legitim m e es al th pt ce ac and using your person unicate with you m m se co ea to pl us is, r th fo e is provid you’re happy to rial email address. If or let your indust z .n rg s.o m as p@ hi rs be em email m officer know.
WWW.ASMS.ORG.NZ | THE SPECIALIST
Volunteer vaccinator Dr Julian Fuller
Mass vaccination at Trusts Arena in west Auckland
Pivoting to stop Covid W
ith the outbreak of the Delta strain of Covid-19, New Zealand’s vaccination rollout stepped into high gear, particularly in Auckland.
The call went out to any willing and able health worker who could pick up a syringe and volunteer their time. ASMS Executive member and North Shore Hospital anaesthetist Dr Julian Fuller was one of those who answered the call. He joined the mass vaccination effort by Te Wha- nau O Waipareira at Trusts Arena in West Auckland, where in just one day during the Level 4 lockdown, 1730 people received their Covid vaccine.
The ASMS MECA requires that job descriptions include a comprehensive list of non-clinical 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.
Access to non-clinical time is a MECA requirement. If you do not have scheduled non-clinical time, or that time is eaten up with clinical tasks, your employer is not complying with your MECA entitlements. 26 THE SPECIALIST | SEPTEMBER 2021
A recent survey of ASMS members found 69% have some rostered nonclinical time, but over a quarter do not. Of those who do have non-clinical time, the majority access less than the recommended 30%. Clinical administration also often swamps clinical time.
ASMS staff Executive Director Sarah Dalton Communications Senior Communications Advisor Elizabeth Brown Senior Communications Advisor Eileen Goodwin Industrial Senior Industrial Officer Steve Hurring Senior Industrial Officer Lloyd Woods Senior Industrial Officer Henry Stubbs
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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.
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