At a Tipping Point in New Zealand’s Public Health System?

At a Tipping Point in New Zealand’s Public Health System?

PAPER TO
AUSTRALIAN MEDICAL ASSOCIATION
INDUSTRIAL COORDINATION MEETING
CANBERRA, 19-20 APRIL 2012

Ian Powell
Executive Director
Association of Salaried Medical Specialists
AT A TIPPING POINT IN NEW ZEALAND’S PUBLIC HEALTH SYSTEM
It seems that New Zealand’s public health system is reaching a tipping point in recent months, since the last Industrial Coordination Meeting and, more significantly, since the general election last November. The government is adopting a more assertive hard line position overall but also including in health. The Minister of Health Tony Ryall has a highly personalised manner of working and has his own inner circles (some more ‘inner’ than others). Those insiders are now noting a shift in the Minister’s style of working them. Instead of being asked by him what they know about or think about particular issues, it is now notification of what he intends to do. One of the dilemmas is the influence on the Minister of those who look to quick fixes for problems (sometimes magic bullets) when longer-term solutions are required if the fix is to be sustainable.

Among our members there are also discernible shifts. This Health Minister has now addressed four of our Annual Conferences (more than any other health minister). On the first occasion he went down very well. Although not to the same extent because of an increasing sense of blasé, he was also well received at the next two. But at the fourth, last November, there was rebellion in the ranks and he was heckled (largely over his inexplicable insistence that there were now 800 extra hospital doctors since he became minister which clashed with the understanding of the Conference delegates own practical frontline experience). He did not leave the Conference a happy minister.

There is increasingly a sense of growing frustration and resentment among more and more of our members. The serious specialist shortages continue (with the government now in denial mode); despite a promising start there has been a failure to progress clinical leadership overall; and health professionals are being required by government to do more (increasing demands) with relatively less (declining funding increases falling more and more below the level of actual costs).

Advances under National led Government, 2008-11

A significant number of improvements to the health system had been made by the previous Labour led government (1999-2008), including legislative reform removing the requirement for public hospitals to operate as if they were competing commercial businesses. Nevertheless, when he was in opposition the current Minister of Health Tony Ryall was still able to successfully identify some serious weaknesses. These included the precarious state of the workforce employed by district health boards (particularly hospital specialists), lack of progress in achieving extensive clinical leadership, the need for clinical networks, increasing inter-DHB clinical service collaboration, and enhancing primary-secondary integration.

Once becoming Minister after the 2008 general election he introduced several positive initiatives. In particular:

• He reinstated the right of the medical profession to elect a specified number of medical practitioners on the Medical Council (he also introduced for the first time a similar right for the nursing profession in respect of the Nursing Council).
• He established a clinically led working group on clinical leadership and then forwarded to DHBs with his endorsement their policy statement titled In Good Hands with its more explicit focus on ‘distributive clinical leadership’, of which formal positions of clinical leadership (eg, clinical directors, chief medical officers) were only a small part. More important was the involvement of the wider mass of senior medical staff in decision-making beyond their immediate clinical practice through the lens of quality improvement and what makes good clinical sense.
• The Ministry of Health was given a more operational focus in respect of DHBs with the creation within it of the National Health Board.
• A new more practically focussed health workforce body was established within the Health Ministry (Health Workforce New Zealand – HWNZ) but with its own board reporting directly to the Minister.
• The establishment of the Health Quality & Safety Commission as a separate crown agency.
• He revised the role of the National Health Committee (an existing statutory committee) to advise on new technologies, devices and models of care with some limited similarity to Pharmac, New Zealand’s state pharmaceutical purchaser.
•
2011 General Election

The general election (New Zealand has three year terms which usually run their full distance) in November last year saw the re-election of the National led government with its support parties – Maori Party, ACT and United. However, our electoral system is based on proportional representation (with a 50:50 mix of electorate and list MPs) unlike Australia. For example, had our system applied in the recent Queensland election Labour would have over 20 seats instead of less than 10 – still a landside but a more viable opposition.

In summary, National’s vote marginally increased but it won more seats because its proportion was higher than last time (partly due to a lower turn-out). However, its support parties lost seats which, overall, left it in the same position as in its previous term. The Maori Party has three MPs while the other two have one each.

On the opposition benches the biggest party is Labour who had a bad election with a declining proportion of votes and the loss of some seats. On the other hand, the Greens had a surge of support increasing their MPs while the economic nationalist NZ First Party made a triumphant return to Parliament by exceeding the 5% threshold for representation. The final party in opposition is Mana, largely a split from the Maori Party, with one electorate seat.

The net result is that the government has a governable but slight parliamentary majority. The prevalent view among political commentators is that the 2011 election result was the highpoint for support for National; it would not get any better. The parliamentary tightness was highlighted over the government’s response to a bill from Labour to extend the entitlement to paid parental leave. Two of National’s support parties advised of their support for the bill in the first reading stage at least and, with all the other opposition parties also supportive, the government lost its majority on this issue. However, National announced that it would, at the third reading stage, invoke the little used parliamentary provision of vetoing it because it involved finance.

The current political environment is best described as odd. Both main political parties – National and Labour – are in a race to see who can best lose the next election. On the one hand, National is displaying signs of arrogance, aggressiveness and bad judgment in a way that it largely avoided in its first term. Its political trajectory appears to have shifted more overtly to the right. It has been described as behaving like a third term government in its second term. This is also having ramifications for the public health system.

On the other hand, Labour’s new politically inexperienced parliamentary leader David Shearer has an approach of being as invisible as possible. When he did try to up his profile after a long delay he praised as a role model a former prime minister of Finland who hardly anyone had heard of, was of the opposite political persuasion, and was voted out after three years. In a word, it was perplexing.

It is a race between whether National can antagonise and aggravate its way to defeat or whether Labour can sleep-walk to defeat. Until the most recent reputable opinion poll (Roy Morgan), the odds favoured Labour to cross this line. However, due largely to a fall in support for National and a significant increase for the Greens in this poll the race may be neck-and-neck.

Industrial relations policy

The government’s industrial relations policy for this term involves a hardening position favouring the interests of employer positions, including in the rights of employees to collective bargaining, and is now in the context of increased employer militancy and aggression in the Auckland Port, one of the major freezing industry companies, and a major rest home chain. It is not inconceivable that the government may seek to amend the legislation to weaken the ability of unions to represent their members in these sorts of disputes, particularly the first two which have been very nasty. In the Port dispute the union has had a series of legal victories.

The proposals that could possibly have an effect on salaried senior doctors are the changes proposed for collective bargaining. The one that could have the most impact is a change that would remove the requirement for employers to offer the provisions of a collective agreement to a new employee for the first 30 days of their employment. If an employer and a new employee should wish to do so they will be able to negotiate, for instance, higher pay and less leave, for an employee who says that they do not intend to join the union and therefore be covered by the collective agreement.

The other main changes would be to remove the requirement that collective bargaining concludes unless there is good reason and allow employers to opt out of negotiations for a MECA before they begin.

DHB MECA negotiations

The acrimonious breakdown in our MECA negotiations last year has been previously reported, including in our publications. From a highpoint of constructively jointly developing with the DHBs a shared understanding of the state of the specialist workforce in DHBs, leading to the production of an agreed business case through a process that might reasonably be described as ‘interest based’, we suddenly plummeted to a low point mid last year. At the point where the ‘rubber was hitting the road’ and with a change of key personnel in the national leadership of the DHBs, the DHBs did a U-turn with a series of attacks designed to undermine the previously agreed principles of the Business Case, discredit the leadership of the ASMS, and misrepresent our position.

This led late last year to a short-fix settlement that does little to help address our specialist workforce crisis. The 15-step scale was reduced to 12 by removing the bottom three steps. The intent was to improve the attractiveness of the scale to New Zealand trained senior registrars seeking their first specialist appointments. Translations were not step number to step number but two steps lower than one’s current step. For the large majority of members the effective salary increase was 3% or a little above (there was an earlier 2% increase that took effect in January 2011).

There were two inherent problems with the settlement. First, it raised relativity frustrations with those who found themselves two step numbers lower. Second, it did nothing for the second group of specialists vulnerable to recruitment to Australia – those at the top of the scale (an increasingly large part of our members) who are largely free of immediate family obligations and are receptive to change at this stage of their career. The National Executive recommended the proposed settlement to members in an indicative postal ballot but explicitly identified these downsides in the accompanying background material. The ballot produced a strong majority in favour of ratification with a high turn-out.

The new MECA expires next year on 28 February with formal negotiations commencing earlier in the year. The National Executive has already commenced its preparation including the question of what sort of salary structure might be appropriate to help overcome our specialist workforce crisis in DHBs, particularly the threat from Australia. Part of this preparation will include holding a national workshop of our branch presidents and vice presidents next month.

Specialist workforce crisis and the Health Minister’s spreadsheet

Up until October 2010 the Minister of Health was still publicly accepting that there was a hospital specialist crisis and that it was his number one priority. But, in election year, we started hearing statements initially from HWNZ and then both the Prime Minister and Mr Ryall that there had been 500 more hospital doctors since 2008. Subsequently this increased to 800.

This was then cynically used to assert that because of an increase of 800 hospital doctors the hospital specialist crisis had been solved. But there is a problem with this narrative – the truth. In short a significant number of these doctors are ‘spreadsheet doctors’. For example:

• The alleged 800 extra hospital doctors include resident medical officers. However, the Health Ministry did not differentiate (or chose not to).
• It is a full-time equivalent figure described as ‘employed ftes’ which inflates numbers. In summary, an fte is a 40-hour week. Someone who works less than 40 hours for their DHB is pro rated under this approach (eg, someone who works 30 hours for the DHB is counted at 0.75). Someone who works more than 40 hours per week is, however, counted as 1.0 (eg, someone who works 50 hours for the DHB is counted as 1.0 instead of 1.25). The inflation occurs where job sizing reviews lead to increased paid hours to part-timers (eg, from 30 hours to 40 hours per week or above), the total fte increases but not the headcount; it is the same senior doctor. There has been a lot of job sizing over the past three years, particularly in the more populous three Auckland DHBs (nearly 40% of DHB employed senior doctors). Part of this is the greater recognition of time for non-clinical duties.
• In the past the three Auckland DHBs paid a higher rate of remuneration to locum resident medical officers than the other 17 DHBs. They were classified as “casuals” as they were not also employed as regular DHB employees. Subsequently, within the past three years, they shifted to the lower ‘national rate’. One effect was to dry up this pool of locum only RMOs. Many have moved or returned to regular employee status. Whereas the “casuals” were not counted by the Ministry in 2008, when they commenced their calculation for the 800 extra hospital doctors (because the three DHBs recorded casuals as ‘0 fte’; those who subsequently became regular employees were then counted). The DHBs’ regional RMO service has advised us that this number is over 200. In other words, the same doctors were not counted in 2008 but were in 2011.
• Based on figures provided to us by all DHBs, the number of employed specialists increased by only 373 over the three years from July 2008 to July 2011. Even an extra 373 specialists is inflated because it includes some short-term appointments.
The irony is that the Minister is claiming that under his three-year watch the recruitment of specialists has been much more successful than under the previous government. The facts are, however, based on DHB supplied data, that in the three year period before his watch (ending July 2008) the number of specialists increased by 501, nearly 130 more than on his watch.

Health Workforce New Zealand

HWNZ was a welcome creation. In the 1990s ‘market era’ the language of workforce planning or development was, in effect, forbidden. There was a positive change from 1999 with the encouragement to promote workforce planning but, in the main, this was largely analysis of the issues and scene-setting. The formation of HWNZ with its more practical orientation was seen as an advance.

While there has been some interesting work in primary care and some useful things might arise out of its commissioned service reviews, there is increasing dissatisfaction with the performance of HWNZ by professional bodies and also within DHBs. It is seen as scattergun in its approach, failed to get incremental ‘runs on the board’, has a ‘decree issuing’ rather than engagement approach, produces generic communications to explain specific issues, and is out-of-touch with how public hospitals work.

Late last year HWNZ produced an alarming proposal on the prioritisation of funding for postgraduate medical training. Its text (what there is of it) and conclusions ranged from difficult to understand to incomprehensible. It was been widely criticised by the various medical professional bodies for lack of robustness. The main flaw was the use of government health targets to the prioritisation of funding for training in the medical specialties. But the former has a short-term focus while the latter requires a much longer term approach. Further, the targets only cover a portion of the needs of the health system.

On the positive side HWNZ has noted the firm critical responses and convened a meeting in March of key organisations, including the ASMS, RDA and colleges. This meeting was a positive event although we are still awaiting the report back. But, in what appears to have been an organisational blunder, somehow DHBs were not invited to this meeting. Whether this is by accident or not, it has been damaging on HWNZ’s relations with DHBs.

HWNZ has overstated the significance of its physician assistant pilot/demonstration at Middlemore Hospital’s general surgery department. Its public comments have confused the contributions of two outstanding and experienced individuals sufficiently confident to work outside their comfort zone in another country with insights into the relevance and value of physician assistants in a New Zealand context. It has not led to further pilots in other hospitals. Instead the next pilots will be in general practices in the rural Waikato area in the upper North Island. Whatever the merits of these pilots, they do not logically flow from the Middlemore Hospital pilot. The evaluation of the Middlemore pilot has recently been released and has been forwarded separately for discussion. As a matter of interest the original evaluators had their contract terminated for reasons that are unclear.

Serious difficulties in working with DHBs nationally

If anything the ability of DHBs to work together nationally has declined after a period of frustratingly slow improvement, at least in the experience of the ASMS. This is evidenced by their unprofessional and inconsistent behaviour in our last MECA negotiations, and particularly over the jointly developed Business Case (discussed above). Even on a smaller issue of developing agreed guidelines for the engagement and employment of senior medical staff in regional service collaboration between DHBs, the DHBs through their chief executives have overturned an agreement between the ASMS and DHBs. Attempts are being made to resurrect it.

At a national level DHBs are polymorphous and very unreliable to work with. The calibre of chief executives is highly variable from the impressive and competent to the other sort. Too many of them struggle to see beyond a short-term local lens and to be more that a hospital manager when cast into a national context requiring a broader vision. They drag down the others.

The consequence of this is that adherence to agreements reached with their representatives can’t be relied on. There is a systemic dishonesty in the way in which they work together nationally because they can’t function in an integrated and functional manner. A change of personnel in the national chief executive leadership can make the world of difference. We experienced this in our MECA negotiations. The hostile attacks on the ASMS leadership and abandonment of the principles of the previously agreed Business Case coincided with the changes in the key positions of the chairs of the national chief executives group and the DHBs’ Employment Relations Strategy Group.

Health Benefits Ltd

Health Benefits Ltd (HBL) is a crown entity which, following the government’s restructuring of central agencies in 2009-10, is responsible for handling the rationalisation of so-called ‘back office’ functions of DHBs. Previously it had been responsible for the funding of general practitioner benefits but lost this function some years ago when it was devolved down to DHBs. HBL has its own board which reports directly to the Ministers of Health and Finance.

HBL is required by government to make savings in DHBs of $700m (cumulative) over five years. Its most recent action was the preparation of its first ‘indicative case for change’ (a business case without much business in it by another name) which is on ‘finance, procurement and supply chains.’

Each of the 20 DHBs has made a submission to HBL as has the national group of DHB chief operating officers and other organisations such as the ASMS (ours was necessarily brief). One difficulty facing the submitters is the ‘high level’ of the document.

The next stage is that HBL will prepare draft ‘business cases’ for each DHB in two phases. The first will look at possible pathways to go down (eg, scenarios) in order to identify what are ‘go’ and ‘no go’ areas while the second will be more specific. This process is expected to go right through to August at least.

In the meantime HBL will launch a second ‘indicative case’ into DHBs – this time on ‘facility management and support services’.

The ASMS has a reasonable working relationship with HBL staff, including the chief executive. It is positive that a good consultation process has been developed. Nevertheless, it is ironical that DHBs were able to use the various union negotiated consultation clauses (including in our MECA) as an argument for slowing HBL down even though some of them have not always been good adherents to compliance themselves. It is a funny world.

But even the best consultation process can be overwhelmed. Essentially the problem is:

1. The sheer scope and volume of what HBL has to address with DHBs is too large.
2. The pace required by government, through the Health Minister and HBL’s politically appointed board, is too fast.
3. HBL, as a small organisation, does not have the staff capacity to provide the expertise necessary to do its work. Consequently it has to engage external consultants who in the main lack the experience of the complexities of a universal public health system. They generate assumptions which at times are tenuous and then tie up DHBs resources and time in trying to sort them out (ie, high transaction costs).
4. The unsettled environment arising out of this potentially extensive restructuring is likely to lead to uncertainty among key non-clinical staff (eg, operational management, finance, IT) with skills that can be used outside the health sector. This inevitably risks encouraging some to leave DHB employment on their own terms rather than coping with the fear of being restructured out.
5.
It seems to be generally accepted that there are savings to be made in some of these areas. It would have been better, however, if government allowed HBL to narrow its scope (eg, procurement), give it more time flexibility, and allow it to second appropriate DHB staff with expertise in these areas (eg, clinical, IT, finance) to investigate and advise.

The ASMS has had several constructive discussions with individual DHBs through our Joint Consultation Committees and it is fair to say that we are broadly on the same page on these matters with shared concerns.

Those driving the HBL process forget what very large and highly complex 24/7 organisations DHBs are. The process creates risks by trying to put a simplified overlay over a large complex organisation. For some relatively less complex areas like banking, insurance and possibly big multiple purchases, it is reasonable to assume that there would be advantages through economy of scale. In terms of insurance it would also spread the risk across the country.

But for the likes of suggestions like a single rostering system across all DHBs it is simply impractical. There is confusion with HBL trying to force what they call ‘back office’ mergers. This is a demeaning and unhelpful term that disregards the highly integrative nature and complexity of a DHB. Orderlies and cleaners, for example, are all essential part of the clinical system and not some ‘back office’ non-entity. Nowhere is the value of ‘back office’ boilermakers appreciated more by clinicians than Canterbury as a result of their incredible work during the February 2011 earthquake in getting the hospital up and running again and maintaining its functioning.

The government is requiring $700 million cumulative over five years. It has been reported that in the first year $55 million has been saved which, on the surface given its cumulative nature, appears encouraging. But there are two qualifications – these savings have to be continued (they can’t be one-off) as well as increased and much of these savings have come from the DHBs’ own processes, not HBL’s. I have no doubt that the $700 million savings will be made; the only doubt is the proportion that is achieved ‘creatively’.

Partial Privatisation & Selective Personal Enhanced Remuneration to Drive Models of Care: Planned Elective Surgical Centre, North Shore Hospital

Coming from left field to us has been threats to the viability of a new ‘elective surgical centre’ (ESC) planned for North Shore Hospital at Waitemata DHB (Auckland).

Establishing a dedicated ESC as a ‘model of care’ for patients has wide support, including from specialists. The experience of both Counties-Manukau DHB with its Manukau ‘super clinic’ and Canterbury DHB’s use of Burwood Hospital demonstrate that significant benefits and efficiencies can be achieved (including for patients), particularly in larger population catchments, through a separation of acute and elective surgery and doing each set of procedures in different facilities. This ‘model of care’ is also well supported in the international literature.

But this excellent innovation is threatened by ideological agendas poorly grounded in practicality. They involve live options to partially privatise the ESC and also introduce divisive selective personal financial incentives to drive the ‘model of care’.

While the physical structure that houses the ESC will remain in public DHB ownership, there is a proposal to leave responsibility for the governance and operation of the ESC in the hands of a separate legal entity such as a joint venture, some lease-back arrangement with a private facility or operator, or some other form of allowing profit-driven private interests to have undue influence on this part of the public health service.

Such an arrangement would need to return a “profit” for the shareholders or owners of these private financial interests. There would be increased transaction costs, muddled accountabilities, and scope for confusion and tension in the necessary interactions between the ESC and other North Shore Hospital services.

The second threat is the proposed use of discriminatory personal remuneration incentives for selected specialists to ‘drive’ the model of care at the ESC. This raises some serious concerns and the real prospect of unintended consequences that need to be considered.

Why should elective surgery alone attract financial incentives to increase productivity? Ignoring for the moment how does one fairly measure productivity, why should other clinical services be discriminated against in the “productivity stakes” (e.g. acute surgery, diagnostic services, psychiatry, ED admissions and ICU) and be offered no incentives?

Why should specialists working diligently in these above services be paid less than their surgical colleagues undertaking “low risk” electives? There is no good answer to this question. Inevitably this unfairness and discrimination will result in a high level of specialist dissatisfaction across the organisation which will undermine the strong culture of collaboration and team work that is at the heart of the ethos of public hospital healthcare delivery.

Across the other side of Auckland, Counties Manukau’s dedicated facility for elective operations functions as effectively and efficiently as the planned ESC at North Shore aspires to. But it does not require personal financial incentives to make it happen. Professionalism and teamwork do the trick.

It raises the question that if one model of care in one DHB generates remuneration benefits for some specialists, why should it not for other employees in the same service and why should it not in other services (eg, internal medicine, paediatrics, psychiatry, diagnostic services) both in Waitemata and other DHBs. It would become professionally untenable not to and potentially industrially also. The ASMS could have a field day in this ‘law of the jungle’ but it would be corrosive and detrimental to the public system.

It is interesting that an evaluation of the “Waitakere Pilot” undertaken by Professor Toni Ashton does not do what the proponents of personal remuneration incentives claim they do, particularly the Board chair. This pilot involved examining the performance of using an operating theatre at Waitakere Hospital (the second and much smaller public hospital in Waitemata DHB) as an ESC and using financial incentives for selected specialists to drive the service.

Subsequently we received under the Official Information Act a copy of Professor Toni Ashton’s evaluation report.

But it does not say what the proponents of personal financial incentives claim it says about the claimed success of these incentives. Instead it highlights the divisiveness of this approach, particularly among those involved in the ‘pilot’ and gives weight to other factors leading the results that were achieved. The best one could say is that the report is equivocal. But arguably it could also be said that implicitly it is critical.

This proposed model also creates serious risks for the training of resident doctors. Much of the “service” requirements of resident doctors come from working with acute cases while their training is largely achieved with elective cases. The use of personal incentives linked to arbitrary ‘efficiency’ or ‘productivity’ targets will undermine the ability to provide quality training.

Public Private Partnerships

Following the virtual Christmas Eve announcement by the Minister of Health that Canterbury DHB would be required to explore the possibility of its rebuilding following the earthquake destruction being handled by a Public Private Partnership (PPP), the NHB has been working “collaboratively” with CDHB on “market sounding” which is a process to identify whether a PPP model is viable; specifically, are there businesses interested in being in a PPP. It would require a consortium of at least four parties – finance, operator, building and architecture.

The Minister’s intention is that other DHBs seeking significant capital works rebuilds will have to go through this process. The ‘trigger’ is the government’s intent to explore different ways of investing in health. One of the features of a PPP compared with the current system of contracting with the private sector for hospital redevelopment is that the private operator partner in the PPP has a lease on the new facilities for a specified period of time (eg, 20 years) and is responsible for their management, including support services. The DHB would continue to be responsible for the provision of clinical services in these premises. At the end of the specified period ownership would return to the crown.

This is raising many concerns including the effects of profit maximisation by private companies on the provision of a universal public good, the impracticality of divorcing support services from clinical services, and confusing accountabilities. The experience of the United Kingdom in these schemes has not been positive (controversial at the very least). Already specialists at Christchurch Hospital have commenced campaigning against this controversial initiative.

Regulatory Authorities

The government is moving to amalgamate the regulatory authorities’ secretariats (eg, Medical, Dental and Nursing Councils). In April last year Health Workforce New Zealand circulated options for decreasing the size of regulatory authorities and amalgamating their secretariats. We were surprised with the decision to give HWNZ this task as it did not seem to rest comfortably with its role and expertise. Subsequently, however, responsibility for this work shifted elsewhere in the Ministry of Health.

The formal objectives of the process and intended changes are:
1. Efficiencies in ‘back office’ staffing.
2. Quality of workforce information, especially doctors.
3. Improving quality of regulations.
The ASMS and other professional bodies reacted negatively to the proposals and the regulatory authorities did not agree to the proposals. Apparently the government concluded that it was unable to force amalgamation given the current legislation and brought forward the planned review of the Health Practitioners Competence Assurance Act (HPCAA) partly so the legislation could be amended to force such amalgamations. The review was expected last year but, to the best of our knowledge, has not commenced.

However, it has been reported to the ASMS that the Minister of Health summoned the regulatory authorities to a meeting on 26 January where they were told that unless they proceeded to amalgamate secretariats voluntarily the Minister would force them to do so. It is not clear whether this refers to a planned change in the HPCAA or whether he will use his power to appoint to the Councils to select individuals pledged to this course of action. The smaller authorities advise that he had already unilaterally started moving on another item flagged in the consultation paper and rejected largely by the sector, and started decreasing the size of the councils of various authorities by not appointing to vacancies.

The driver appears to be the cost to DHBs but regulation and, in particular, the Medical Council appeared to be targeted by National’s support ‘free market’ party ACT in 2008-11 government so this initiative may be able to be ‘spun’ as cutting down on regulatory bureaucracy.

The NZ Nurses Organisation also has serious concerns over the secretive proposed restructuring of the regulatory authorities. While they have had significant difficulties with the Nursing Council in the past, the Council’s performance had considerably improved over the past three years. NZNO was concerned about the risk of losing this improved performance by the Nursing Council and also increases to the cost of the nursing annual practice certificate which is much lower than some other regulated occupations (including doctors).

Where this ends up is unclear but the Ministry is aware of the concerns, particularly the secretive process. There appears to be some recognition that the earlier assumptions of large financial savings were overstated with expectations now lower. But the regulatory authorities (especially with a reported ‘gun to their heads’) are not the professions and without engagement with the latter a poor outcome is virtually assured.

It is unfortunate that a government which professed strong support for clinical leadership is now disempowering the health professions from engagement in the future of their regulatory authorities.

New Medical Council Recertification Programme for General Registrants

In December 2011 the Medical Council advised relevant organisations, including the Association, of new prescriptive recertification requirements for general registrants (with some exceptions). The changes followed an analysis of feedback received from a period of consultation during 2009 and 2010.

The ASMS had made a submission to the Medical Council in 2010 in which our main concerns related to the need for the proposed three-yearly practice visits and how the cost of those visits was to be paid for. Currently we have as members over 440 medical officers (who are general registrants), over 400 of whom are DHB employed.

The Medical Council also sought expressions of interest from organisations willing to develop and run mandatory and prescriptive recertification programmes for general registrants and subsequently selected ‘Best Practice Advocacy Service of Dunedin’ (bpacnz) to develop its programme (this can be downloaded from bpacnz website www.bpac.org.nz).

This change poses some important questions for ASMS general registrant members including who pays the $1,200 annual registration fee (for DHB employed medical officers it should be a reimbursable work-related expense as a fee for an accredited maintenance of professional standards or similar programme under the MECA); and the relationship with a member’s entitlement to regular non-clinical time; and the linkage with CME leave.

We have major concerns over the rigidity and inflexibility (‘one size fits all’) of the programme, especially where general registrants are involved with college programmes. These have been expressed to the Medical Council and we are awaiting the outcome.

Revitalised ASMS Branches

Last year the ASMS focussed on revitalising our branches including the holding of elections for the newly established position of branch president and vice president. Now, prior to each Executive meeting, members are invited to forward any issues they wanted raised to their Branch President or Vice President.

There will be another national meeting of branch officers to be held on 2 May in Wellington. The programme comprises:
• The direction and preparation for the next national DHB MECA negotiations.
• Success stories from branches on distributive clinical leadership and senior medical staff engagement.
• Branches reporting on burning issues for the senior medical staff workforce in DHBs.
Ian Powell
EXECUTIVE DIRECTOR

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