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The Importance Of Speaking Out (Voice) In Health Systems

Published: Sun 22 Oct 2023 06:03 AM
Voice is one of the most critical features of a robust health system. The experiences and concerns of patients and their families are often given voice. This is a good thing. Health systems learn from their voices.
Equally important is the voice of health professionals, including hospital specialists. They are the ones with the greatest relevant expertise and experience on how health systems are performing or under-performing (often concurrently given the level of system complexity).
Health system leaders need to listen and act on this health professional voice. The public, who both fund and depend on the health system, also need to know what this voice is saying.Brief historical context
Consequently it is essential for the public and their health system that these health professionals have the right to speak out, as part of this right, protected as an employment right.
When the Association of Salaried Medical Specialists (ASMS) was established in April 1989 as the union representing salaried senior doctors and dentists, I was its executive director.
At that time those employed by the newly established area health boards were covered by employment agreements called ‘determinations’. They were thin documents largely confined to ‘pay and rations – primarily salaries, leave and reimbursements.
‘Determinations’ were quickly replaced by more expansive ‘awards’ under the Labour Relations Act, then ‘collective contracts’ under the Employment Contracts Act from 1993, and finally ‘collective agreements’ under the Employment Relations Act from 2001.
Over the ‘post-Determination years’ ASMS was successful in increasingly expanding the scope of what was covered in these contractual documents. This included a range of process or procedural rights such as speaking out.
In the mid to late 1990s public hospitals were covered by the Commerce Act and expected to operate as competing businesses. This ‘external morality culture’ conflicted with the public good ‘internal morality culture’ of health professionals.
I discussed external and internal moralities in the context of culture in a previous Otaihanga Second Opinion post (20 September): External and internal moralities.Employment protection and encouragement for speaking out
This cultural conflict served as a catalyst for ASMS focussing on establishing employment protection for its members over speaking out; over voice.
Helpful was the fact that a form of protection had already been negotiated by the British Medical Association in the terms and conditions of consultants (specialists) in Britain.
From July 1993 to January 2001, under the then restrictive employment legislation, ASMS was precluded from negotiating a national agreement.
Nevertheless, by 2001, the right to speak out formed part of all the separate 23 public hospital based collective contracts. This right then formed part of the first national collective agreement and remains there unchanged today.
The right was described as the right to participate in “public debate and dialogue” relevant to one’s “professional expertise and experience”.
It was deliberately couched as a positive rather than just protective right that was in the interests of both the public and district health boards (DHBs) as the employers.
Where the issue at hand was relevant to the DHB, there was a responsibility to have first raised it with that DHB. This did not mean seeking approval to exercise the right or even when this right was to be exercised.
Rather the issue of contention should not come as a surprise to the DHB if and when the right was exercised.
The full clause is below:
40. Public Debate and Dialogue
40.1 In recognition of the rights and interests of the public in the health service, the employer respects and recognises the right of its employees to comment publicly and engage in public debate on matters relevant to their professional expertise and experience.
40.2 In exercising this provision employees shall, prior to entering into such public debate and dialogue, where this is relevant to the employer, have advised and/or discussed the issues to be raised with the employer.
Despite the culture clash of the 1990s environment, there was less need than now for senior doctors to exercise this speaking out right. This was also the case under the DHBs
Primarily this was because acute patient demand on hospitals was not out-of-control at least up to the early 2010s).
Further, workforce shortages were much less serious (although a crisis for senior doctors had emerged by 2008 driven by significant salary increases in Australia beginning with Queensland).
In general, on those occasions it was used, the speaking out right was respected by DHBs. There were moments, however.
Some human resource managers disingenuously referred to media policies which were either silent on this right or in conflict with it (provisions in a collective agreement trump those in a policy where there is a conflict).Today is different
But today is different. Workforce shortages are entrenched and across all the health professional occupational groups. They are beyond crisis point. Acute patient demand is rising higher than population growth which drives increasing workloads.
To make matters even worse, the massive restructuring of the health system into a highly centralised vertical one has led to the inevitable emergence of a ‘command and control’ leadership culture.
Hardly conducive to encouraging senior doctors to exercise their right to speak out!
Consequently senior doctors are speaking out about the terrible environment they have had politically imposed upon the. They live with daily angst over patients being denied timely quality care.
Never has their employment protection right been more important.Unsafe care
Christchurch surgeons have spoken out about unsafe care for patients, including being directed to cut cancer surgery lists and, further, to determine which patients have the worst cancers and won’t survive.
This was reported by Stuff journalist Kristie Boland (16 March): Unsafe care for Christchurch cancer patients highlighted. Needless to say this cancer crisis is nationwide. It’s not just Christchurch.
Subsequently (6 April) Radio New Zealand’s Checkpoint programme interviewed Christchurch colorectal surgeon Chris Wakeman on long waits for cancer patients: Christchurch surgeon speaks out on cancer patients’ long waits.
Wakeman revealed that “…some of his patients have waited close to a year for stomach operations that would complete their recoveries from cancer treatment.”
Further, “…others are being forced to go private for reconstruction surgeries because resources are so tight in the public system.”
He added that his employer, Health New Zealand (Te Whatu Ora), was trying to muzzle staff.Precarious safety in emergency departments
On 1 July NZ Herald investigative editor Alex Spence reported emergency medicine specialist Dr Anna Rosenberg at Auckland City Hospital.
She was speaking out about the precariousness of the safety risks at her emergency department: Burnt out and exhausted at Auckland City hospital emergency department.
Emergency medicine specialists at Palmerston North Hospital wrote to Te Whatu Ora outlining the healthcare plight they were experiencing and witnessing daily.
The response they received from the national bureaucracy was more than unhelpful. In their words it was “offensive’.
This led them to raise their concerns in public. On 28 August this was reported by experienced Stuff journalist Janine Rankin: Exasperated Palmerston North ED doctors speak out: Don’t blame the patients.Senior doctor strikes context
The frustrations of the health system crisis were also eloquently expressed in the context of the recent senior doctor strikes by Tauranga Hospital cardiologist, Dr Dean Boddington
Cardiologist Dean Boddington speaks out in context of senior doctor strikes
This was reported in the Bay of Plenty Times on 28 September (it was also reported in the NZ Herald): Tauranga Hospital cardiologist speaks out.
I have also discussed these strikes in Otaihanga Second Opinion on 15 September: What happens when senior doctors snap.Heading the wolf pack?
But the specialist who has attracted most recent attention for speaking out (and whistleblowing) is Hawke’s Bay radiologist Dr Bryan Wolf.
His concerns are most recently expressed in a measured, thoughtful and passionate manner in another Alex Spence investigative piece in the NZ Herald (30 September): Patients are at risk.
In his own words: “When you [health authorities] start misinforming the public and taking away their ability to advocate for themselves, that becomes very dangerous. It’s a slippery slope.”
These brave doctors are among the health system’s heroes. They are among those who the presumed next health minister, Dr Shane Reti, should be listening to.
Dr Reti’s acting on this listening should start hopefully on day one after he receives his ministerial warrant as he grapples with the health system crisis-plus he has inherited.
In the meantime, boy am I glad I negotiated that clause protecting senior doctors speaking out as an employment right so many years ago.
Ian Powell
Otaihanga Second Opinion is a regular health systems blog in New Zealand.
Ian Powell is the editor of the health systems blog 'Otaihanga Second Opinion.' He is also a columnist for New Zealand Doctor, occasional columnist for the Sunday Star Times, and contributor to the Victoria University hosted Democracy Project. For over 30 years , until December 2019, he was the Executive Director of Salaried Medical Salaried Medical Specialists, the union representing senior doctors and dentists in New Zealand.
Contact Ian Powell

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