More questions than answers

Source: Association of Salaried Medical Specialists

The Mental Health and Addiction inquiry report has laudable aims but lacks detail about implementation and side-lines those who work in the sector, says Lyndon Keene, Director of Policy and Research at the Association of Salaried Medical Specialists (ASMS)

Published in ASMS magazine The Specialist on page 17-18, Mr Keene’s analysis of the report can be read here: https://www.asms.org.nz/wp-content/uploads/2019/04/The-Specialist-Issue-118.pdf

Mr Keene takes issue with the inquiry panel’s decision to be (in the panel’s words) “guided by the needs of people and communities rather than the preferences of the various groups accustomed to the way the system is structured and services are delivered at present”.

Excluding workforce views might account, in part, for a lack of substance about how to deliver the recommendations. Mr Keene says notwithstanding the exclusion of workforce views, the conclusions are reasonable and will find consensus. An emphasis on wellbeing and community, prevention, expanded access to services, and more treatment options are laudable, if rather familiar, aims. The lack of specifics about how to achieve the desired outcomes allows the Government much wriggle-room.

The practicalities of what will change, and how, are no closer to being answered than before the panel was convened, Mr Keene writes.

While the report talks about a “workforce crisis” there is little recognition of issues in the psychiatrist workforce. Indeed, the report incorrectly states there was “a large jump in the number of registered psychiatrists in 2018”.

Trainee numbers have risen in recent years but are lower than in the early 2000s. There is a heavy reliance on international medical graduates (60% of the workforce).

In 2018 there were 492 full-time equivalent psychiatrists employed by DHBs, compared with 482 in 2017.  Caution is needed interpreting the figures because it could reflect an increase in registrations of doctors, including non-specialist medical officers, who were already practising.

District health board workforce figures do not show a large jump in full-time-equivalent psychiatrists.

The report calls for psychiatrists to provide more support for community-based workers. ASMS has long advocated for integrated services and patient-centred care. This approach requires a well-resourced specialist workforce.

Ultimately, it’s the Government – whose official response to the report is expected soon – which determines if the recommendations are transformed into actions.

“The extent to which the Government supports a well-resourced [Mental Health] Commission with teeth will be an early test of its commitment to addressing our mental health crisis,” Mr Keene writes.

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Acute hospital admissions grow despite increased use of GP services

Source: Association of Salaried Medical Specialists

Acute hospital admissions are increasing well above the population growth rate despite increased use of general practice (GP) services, says Lyndon Keene, Director of Policy and Research for the Association of Salaried Medical Specialists (ASMS).

This is one of the findings of an ASMS Research Brief looking at whether access to primary care, with a greater focus on health promotion and illness prevention, reduces pressure on hospitals, available online at: https://www.asms.org.nz/wp-content/uploads/2019/03/Research-Brief-on-primary-prevention_170857.2.pdf

“Evidence from New Zealand and overseas shows this approach has frequently not achieved what its advocates and governments hope and expect,” says Mr Keene.

He says primary care plays a vital role preventing illness and death, but it generally falls short of expectations in respect of keeping people out of hospitals. Reasons for this include a lack of clear evidence to determine the most effective approaches, lack of clinical time, lack of patient compliance, practitioner attitudes, and financial disincentives.

In New Zealand, barriers to accessing primary health care means the patients most likely to derive benefit often miss out on timely interventions, so recent moves to reduce cost barriers to accessing it are welcome. But it must be recognised this will identify previously unmet needs, which in turn will lead to more pressure on hospital services.

“With continuing tight funding, attempts to strengthen primary care at the expense of hospital care will lead to a greater bottle-neck to accessing hospital services which in turn will increase pressures on primary care.”

Mr Keene says reducing pressure on hospitals requires strong integration between hospitals, GPs, and social services and a cross-party political commitment to a long-term strategy. This not only requires a well-functioning and accessible primary health care system but also a well-functioning, accessible hospital system.

He says the evidence shows integration succeeds when it’s approached from the “bottom up”, and health practitioners are given adequate time to develop innovative practices. This cannot happen while hospitals, as well as primary care services, are struggling to cope from one day to the next.

Mr Keene argues the most effective measures for keeping people out of hospital lie outside the health system, in the form of taxes on unhealthy food, alcohol, and tobacco.

Housing and poverty are also big factors in health. “Without addressing the social and economic causes of poor health, it’s very difficult to improve the effectiveness of the health care system,” Mr Keene says.

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Hospital specialist among the victims of Christchurch shooting

Source: Association of Salaried Medical Specialists

ASMS is saddened to report that one of our members, Dr Amjad Hamid, died in Friday’s mass shooting in Christchurch.

Stuff website reports that Amjad Hamid, 57, was an SMO and rural hospital consultant at Hawera Hospital. Prior to that he was a senior doctor with a special interest in cardiology, and worked for Canterbury DHB and as a locum at other DHBs around the country. He lived in Christchurch with his wife and family but travelled to Hawera for work. He was well-liked for his kindness, compassion and sense of humour. He was a hard-working doctor, deeply committed to caring for his patients, and a thoughtful team member who was supportive of all staff. When he returned to Hawera Hospital he often brought fresh baklava from a bakery in Christchurch for everyone.

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Senior doctors’ union acknowledges contribution of Waikato’s interim health chief

Source: Association of Salaried Medical Specialists

The senior doctors’ union says departing Waikato District Health Board interim chief Derek Wright provided much-needed stability in the wake of the Nigel Murray scandal.

“The DHB desperately needed a steady pair of hands at the helm after former Chief Executive Nigel Murray left in disgrace,” says Ian Powell, Executive Director of the Association of Salaried Medical Specialists (ASMS).

“Staff were unsettled and morale was very low. Derek Wright’s job was to stabilise the ship so the DHB could get on with the task of providing health care to Waikato’s communities, as well as being a better place to work.”

Mr Powell was commenting on news that Waikato DHB’s interim Chief Executive Derek Wright is departing at the end of April (https://www.stuff.co.nz/national/health/111304317/waikatos-health-boss-derek-wright-to-leave).

He says Derek Wright made a significant contribution to turning around the DHB’s leadership culture.

“We wish him the best for the future, and hope that he will not be lost to the public health service.”

Mr Powell says the DHB’s new Chief Executive, when appointed, must be someone who understands the challenges facing the DHB’s vital health workforce, and who has vision and courage.

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Senior doctors urge Government to address chronic pain burden

Source: Association of Salaried Medical Specialists

“The Government needs to make sure the public health system has enough specialists to treat chronic pain to relieve the burden of suffering for patients and their families,” says Angela Belich, Deputy Executive Director of the Association of Salaried Medical Specialists (ASMS).

She was commenting on new research published today by the Faculty of Pain Medicine of the Australian and New Zealand College of Anaesthetists (http://www.scoop.co.nz/stories/GE1903/S00028/burden-of-chronic-pain-in-nz-worse-than-diabetes-dementia.htm and https://www.radionz.co.nz/news/national/384209/chronic-pain-widespread-with-too-few-specialists-clinics-report).

This research notes there are just 11 full-time pain medicine specialists in New Zealand and that the internationally recommended number for our population is more than four times that number.

“Chronic pain is very difficult to live with and affects so many aspects of people’s lives, including their ability to work, move around, socialise and choose suitable housing,” says Ms Belich.

“Senior doctors, like other front-line health professionals, see the consequences of chronic pain in their patients, and it can be very distressing.”

She called on the Government to develop a comprehensive plan to address the resourcing and treatment of chronic pain.

“Clearly we need more pain specialists and better access to pain services. Responsibility for addressing this rests with Health Minister David Clark.”

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Senior doctors welcome new Medical Council Chair

Source: Association of Salaried Medical Specialists

The senior doctors’ union welcomes the election of Dr Curtis Walker as the Medical Council’s new chair.

The Medical Council of New Zealand announced yesterday that Dr Walker, a renal and general physician at MidCentral District Health Board, is to take over the role from Auckland surgeon Andrew Connolly (https://www.mcnz.org.nz/news-and-publications/media-releases/dr-curtis-walker-elected-medical-council-chairperson/).

Ian Powell, Executive Director of the Association of Salaried Medical Specialists (ASMS), thanked Mr Connolly for his leadership of the Medical Council.

“His dedication to the medical profession coupled with a common sense approach to resolving issues has made him a superb leader, and ASMS has enjoyed working with him,” says Mr Powell.

“We are delighted to welcome Curtis Walker to the role and look forward to continuing our good relationship with the Council.”

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Opinion: Ian Powell – Leadership needed on safe staffing

Source: Association of Salaried Medical Specialists

When Health Minister David Clark was publicly criticised for dropping a requirement on his health ministry to publish the results of a set of narrow and misleading health targets in public hospitals, I defended him.

The Minister’s decision to drop this reporting showed a willingness to engage in a more thoughtful and effective fashion with his portfolio, which included exploring more robust alternatives.

Politically-driven targets cause potentially dangerous unintended consequences, especially in an environment of sustained underfunding. They are highly likely to have contributed to some patients going blind while waiting for eye-care appointments. It’s what can happen when DHBs are pressured to put crude surgery volumes ahead of monitoring patients with chronic conditions and necessary clinical follow-ups.

That is the legacy of the previous Government’s targets, particularly those in hospitals, and its overall approach to health. It tacitly encouraged poor decision-making, short-term thinking, and in some cases, neglect. The health system has too many moving parts and complex problems to distil into simplistic widget counts. The damage caused by the rigid application of targets was exacerbated by underfunding and short-staffing.

The false sense of productivity and transparency engendered by the targets (reinforced by financial retrenchment) papered over a workforce staffing crisis and poor service planning (within and between DHBs). It’s easy to see their attraction for publicity-sensitive politicians, so we admired Dr Clark for doing something brave and sensible.

We are less impressed by his attitude to an idea we put forward to combat the crisis in specialist staffing. We believe the specialist workforce is short by about 20%, an estimate derived from surveys of clinical leaders around the country. What more damning evidence is required than the shocking 50% burnout rate experienced by our highly qualified overworked hospital specialists.

Read more here: https://healthcentral.nz/opinion-ian-powell-leadership-needed-on-safe-staffing/

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Hospital specialists under increasing pressure due to under-estimated strength of strikes

Source: Association of Salaried Medical Specialists

“Health bosses have under-estimated both the level of support for the ongoing strikes by resident (junior) doctors and the impact on hospital specialists who are shouldering heavy workloads as a result,” says Ian Powell, Executive Director of the Association of Salaried Medical Specialists (ASMS).

Resident medical officers (RMOs) who belong to the Resident Doctors Association (RDA) have walked off the job twice over stalled negotiations on a new collective employment agreement, and plan to strike again for 48 hours from 12 February. Members are also being balloted on a potential fourth strike.

Mr Powell says the strikes have energised the RMO workforce, with doctors concerned by the DHBs’ strategy in the negotiations to roll back on earlier gains over safer working hours and to undermine the effectiveness of their union.  Instead RDA membership has increased.

Senior doctors, meanwhile, are challenging the message from health bosses that hospitals are coping well during the strikes.  “The reality is somewhat different for people on the clinical front line,” he says.

“Our members are telling us that they are under intense and increasing pressure as they shoulder heavier workloads during strikes caused by the DHBs’ failure to reach an agreement. Specialists are tired and frustrated, and they’re already seeing the effects on patient care and waiting times.”

A hospital specialist who is also a clinical leader and who did not wish to be named says:

“I have done nothing else for the whole of January other than contingency planning and begging favours. No quality improvement work, no winter planning, no RMO education.

“DHBs implying it’s business as usual is – at best – particularly disingenuous and also a slap in the face to those who are actually shouldering a heavy and increasing burden, while the ‘masters of industry’ sit in their offices making their battle plans.”

Mr Powell says other senior doctors have also communicated their frustration to ASMS with the DHBs’ lack of progress to settle the dispute.

“They are really under the pump to do more work and it’s obviously very frustrating and concerning for patients if clinics or surgery lists are cancelled or pushed back. DHBs need to urgently resolve this entirely avoidable situation.”

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MIL-OSI New Zealand: Solution to district health board financial deficits rests with the Government

Source: Association of Salaried Medical Specialists

“The solution to district health boards’ financial deficits rests with the Government.”

This was response to the published report that almost all DHBs were tracking towards financial deficits for the financial year ending 30 June from Ian Powell, Executive Director of the Association of Salaried Medical Specialists (ASMS). Read the New Zealand Herald story here: https://www.nzherald.co.nz/politics/news/article.cfm?c_id=280&objectid=12192429

“There are three main reasons for these deficits.  The first is the effects of eight successive years of underfunding that the current Government inherited.  The Labour led coalition improved funding in its first year, but one good year does not compensate for eight years of underfunding.  Underfunding leads to DHBs being forced to defer essential work such as building maintenance which only becomes more expensive when it eventually has to be paid for.”

Mr Powell added that the current Government is responsible for further increasing health funding to address this failure.

“The second reason is that the costs of treating acutely ill patients is continuing to increase due to factors such as the aging of the population, population growth and the effects of poverty.  Cost increases due to increased demand are greater than funding increases.

“The third reason is that there is a lot of waste and duplication in DHBs because of the lack of clinical leadership distributed through the senior medical workforce.  Genuine engagement with senior doctors would improve both the quality of patient-centred care and financial performance.

“Senior doctors are experts in complexity.  They are well placed to contribute to improving the financial performance of DHBs by improving complex systems.  But how can they when there is a lack of a sufficient engagement culture in their DHB.  Further, how can doctors who are overworked, burnt out, and working while sick (even infectious) make this contribution?”

Mr Powell said the Minister of Health had to take responsibility for requiring DHBs to genuinely support distributing clinical leadership throughout the specialist workforce and to address the crisis of specialist workforce shortages.

MIL OSI New Zealand