Letter Of Expectations To The Minister Of Health
Address to the Hospital And Community Dentistry Conference
NAPIER, 27 JULY 2012
IAN POWELL
EXECUTIVE DIRECTOR
ASSOCIATION OF SALARIED MEDICAL SPECIALISTS
Thank you for the opportunity to address you again. As always my comments are personal observations although in broad
terms at least I believe they are consistent with the Association’s view on the matters discussed. In this address I
would like to do two things – discuss whether we still have a public hospital specialist workforce crisis and outline a
variation to the Minister of Health’s letter of expectations to district health boards – that is, instead of a letter
from him, a letter to him.
Before this I would like to tell an amusing story about innovation in the American penal system. The health system is
riddled with one-off gains but we need longer-term sustainable gains. This story is about the former:
An old Italian lived alone in New Jersey. He wanted to plant his annual tomato garden, but it was very difficult work as
the ground was hard. His only son, Vincent, who used to help him, was in prison. The old man wrote a letter to his son
and described his predicament:
Dear Vincent
I am feeling pretty sad, because it looks like I won't be able to plant my tomato garden this year. I'm just getting too
old to be digging up a garden plot. I know if you were here my troubles would be over. I know you would be happy to dig
the plot for me, like in the old days.
Love
Papa
A few days later he received a letter from his son.
Dear Pop
Don't dig up that garden. That's where the bodies are buried.
Love
Vinnie
At 4 a.m. the next morning, FBI agents and local police arrived and dug up the entire area without finding any bodies.
They apologized to the old man and left.
That same day the old man received another letter from his son.
Dear Pop
Go ahead and plant the tomatoes now. That's the best I could do under the circumstances.
Love you
Vinnie
This was innovative, it worked but it would not work a second time. If Vinnie could pull something off like this each
year for his Pop now that would be sustainable. But I don’t think so.
Do we have a public hospital specialist workforce crisis?
In opposition, Tony Ryall declared that there was a specialist workforce crisis in public hospitals. He reaffirmed this
when, as Minister of Health, he met our National Executive in 2009. Then, on 3 October 2010, he reiterated this
declaring that:
“We have a workforce crisis in New Zealand because we need to maintain more of our hospital specialists, I say yes we
do, it’s our number one priority.”
In November 2010 the blueprint document, ‘Securing a sustainable senior medical and dental officer workforce in New Zealand: The business case’, jointly developed by the DHBs and ASMS, reaffirmed that there was a specialist workforce crisis, that it was causing
serious risks for the public health system (including standards of patient care and financial wastage), and set out
actions to address the crisis.
Description of a crisis
The Business Case based its work on the best ‘health intelligence’ available and its observations included the following:
• New Zealand has the second-highest emigration rate of doctors in the OECD. New Zealand has in effect become a
medical training ground for other countries, especially Australia.
•
• The New Zealand specialist workforce has the highest dependency on international medical graduates (IMGs -
primary degree gained in a country other than New Zealand) in the OECD, averaging 41% across all specialties. Further,
it is trending upwards. Over recent years IMGs have comprised approximately half of new specialist registrations.
•
• Employment of IMGs in both specialist and resident medical officer (RMO) positions is essential to the running
of our health service, and the international “brain exchange” of hospital specialists facilitates the sharing of
knowledge and experience. However, New Zealand’s excessive reliance on IMGs often adds further to specialists’ workloads
and further worsens our systemic instability.
•
• Retention rates of IMG specialists are poorer than those of New Zealand-trained specialists. While Medical
Council data show that around 16% of a cohort of New Zealand specialists are lost to New Zealand nine years-post
vocational registration, about a third of vocationally registered IMGs are lost over the same period.
•
• The high turnover of IMGs contributes to the reduction of the capacity to develop strong clinical leadership,
bring cohesiveness to medical services generally, and increases specialists’ supervisory load.
•
• Our high dependence on IMGs puts services in a vulnerable position in view of the increasing international
competition to attract health professionals. Any change in migration flows outside the control of New Zealand
authorities could have a dramatic impact on our health services.
•
• Our growing and ageing population requires a significantly larger specialist workforce to serve it. Currently
about 13% of New Zealanders are aged 65 or over; by 2021 that figure is projected to increase to 17%.
•
• The Government requires specialists to play a greater role in RMO training and education. However, increasing
clinical demands have meant that many specialists are not able to find adequate time for training and supervision on
current workloads.
•
• There is a growing imbalance between specialists and RMOs which not only increases the inability of specialists
to provide the necessary training and support for RMOs, but also is likely to worsen New Zealand’s already poor
retention rates of specialists and RMOs. The substantial government investment in boosting the RMO workforce could
continue to be lost offshore.
•
• A Ministerial Review Group report in 2009 estimated that up to $800 million is spent annually on potentially
preventable adverse events in public hospitals. Research indicates the majority of these events are from subsequent
admissions, not incurred in the original admission. While a range of factors contribute to this, there are many examples
indicating specialist staffing levels are an important one (for example, an external review of clinical quality at
Whanganui Hospital in 2007).
•
• Staff shortages and heavy workloads mean that quality improvement activities such as clinical audit are not
sufficiently emphasised. But a key practical measure for reducing adverse events in hospitals is improving the
supervision and support of RMOs.
•
• Shortages, combined with increasing clinical demands, are preventing many specialists from finding adequate time
for training and supervision. This situation will worsen as the Government is requiring specialists to play a greater
role in RMO training and education, and medical workforce data indicate the RMO workforce is increasing at a much more
rapid rate than the specialist workforce.
•
• Specialists’ lack of adequate time to enable quality supervision of RMOs is contributing to job dissatisfaction
and poor RMO retention rates.
•
• Specialist shortages and heavy dependence on short-term locum positions severely limits the ability to implement
government policy to develop clinical leadership in our hospitals.
•
• DHBs spent more than $50 million in 2009-10 to employ short-term specialist locums (mostly to cover vacancies)
the cost of whose services are significantly greater than those of permanent salaried specialists.
•
• Significant growth in the trainee doctor workforce is set to continue as the increases in medical school
entrants flow on to the medical workforce. Intakes into medical schools increased in 2004 (from 285 to 325) for the
first time since 1982. Intakes rose again, to 365, in 2007. The Government’s plan to increase the number of medical
school places by a further 200 over the next five years will mean that between 2004 and 2015 the number of medical
school entrants will double. Poor retention rates of RMOs means much of this financial and professional investment may
be lost to New Zealand but the training they receive before they go must still be given by our stretched hospital
specialist workforce.
•
• Implementation of the RMO Commission’s (2009) recommendations adopted by the Government requires specialists to
both spend more time in RMO training and supervision and undertake more clinical duties in order to allow RMOs protected
time to receive their training.
•
• Of the medical graduates that first registered in the year 2000, only 60% held a New Zealand practising
certificate 10 years later. Allowing for fluctuations, the losses in each year’s graduation class are not improving.
Further, around 13–15 years post-graduation, about only two-thirds of the original cohort of doctors hold a New Zealand
annual practising certificate (and some of those may not necessarily be practising in New Zealand).
•
• The loss to New Zealand of a relatively small number of New Zealand-trained specialists represents a loss of
tens of millions of dollars of government investment – and leads to even further costs of tens of millions of dollars
each year. Those costs are incurred in recruiting specialists from overseas, who tend to have very poor retention rates
(about two-thirds are gone in three years), which in turn creates further costs in recruitment. In the meantime many of
the resulting service gaps are filled by employing locums on high-paying short-term contracts.
•
• Inability to secure a stable and cohesive specialist workforce inevitably leads to still further, less tangible,
costs resulting from poor workforce satisfaction levels and the inability to develop effective clinical leadership to
drive innovative changes in service delivery.
•
• A lack of mentoring, training, support, oversight, professional interest and recognition contributes to RMOs
feeling unvalued and, in some cases, leaving the country or leaving the profession.
•
• A number of factors impacted adversely on the availability of specialists to teach RMOs, including an increasing
clinical workload (reducing the time available to teach); changes to RMO working hours and rosters which reduce contact
(and therefore teaching opportunities) between specialists and RMOs; and an increase in RMO numbers and the associated
additional teaching and training workload.
•
• The specialist workforce must grow at a faster rate than the RMO workforce to develop the capacity to respond
effectively to RMOs’ training and support needs.
•
• Large financial debts incurred by doctors during the course of their education played a part in “increasing the
focus on future income”. In 2010 student debt influenced 36% of medical student surveyed in their choice of vocation,
and 64% in their choice of locality of work in the world.
•
• An ASMS national survey and telephone interviews with training directors across four major specialties
(psychiatry, anaesthesia, surgery, general medicine and intensive care), undertaken at the end of 2009, found that half
of New Zealand’s registrars in their final year leave to take up their first specialist positions with overseas
employers and that the most common reason for leaving, according to the training directors, was for better salaries and
conditions.
•
• In order to keep our own graduates in New Zealand, measures must first be introduced to fix the specialist
recruitment and retention crisis. Until that is done, a substantial part of the huge government investments going into
specialist training each year will continue to be lost offshore.
•
If we continue as we are
The Business Case concluded that if we continue as we are:
• We will continue to lose many specialists and RMOs overseas.
•
• We will continue to rely heavily on IMGs and locums to maintain services, exacerbating the high medical staff
turnover rates.
•
• Some services will not be clinically and financially viable.
•
• Some of the Government’s key health targets will not be achievable in the coming years.
•
• The ability to build a health service to meet future needs, including the development of clinical leadership,
integration of services, regional and sub-regional service networks and integration, and improved efficiencies through
innovative models of service will be seriously limited.
•
Do we still have a specialist workforce crisis
It is timely to consider what the word ‘crisis’ actually means as there is a temptation to throw it at every
circumstance of uncertainty. In the passion and heat of the moment it risks being overused. Crisis is of Greek origin
and means an event that is, or expected to lead to, an unstable and dangerous situation affecting an individual, group,
community or whole society. It has also been described as a process of transformation where the old system can no longer
be maintained.
Certainly the situation of the DHB-employed specialist workforce confirms the assessment of the Minister of Health, DHBs
and ASMS in late 2010 that there was a specialist workforce crisis in DHBs.
This then begs the question of whether the situation between late 2010 and now has changed to the extent that the crisis
has been averted. The government and some ideological hanger-ons and appendages are claiming it has. They point to three
assertions – hospital doctor numbers have significantly increased; specialists will be flooding from England; and
resident doctors will be flooding from Australia.
Before commenting on these assertions, two points should be noted. First, the assessment that there was a crisis by the
DHBs and ASMS in the Business Case was not based on vacancy data. It was based on the points discussed earlier. Vacancy data was referred to but it was
accepted, as it was by the SMO Commission in 2009, as being unreliable. Vacancies are a significant understatement of
shortages. Based on DHB surveys of specific DHBs by the ASMS, we concluded that the official formal vacancies understate
shortages by between one-half and two-thirds.
Second, there are signs that the situation in 2012 is a little better than 2010. Much of this is due to DHBs, through
specialists, improving on ‘growing their own’ by smartly ‘shoulder tapping’ senior registrars to accept specialist
appointments in their departments before they leave. This appears to have been assisted by the dropping off of the three
bottom salary steps of the specialist salary scale in our last MECA negotiations. However, this does not change at all
the underlying factors discussed above that provide the basis of the crisis assessment. It is a change of degree rather
than kind.
So what about the claims of significant growth in public hospital doctor numbers over the past three years, what the
ASMS has described as ‘spread-sheet doctors’. When we have drilled down into the data, despite the best obstructive
efforts of the National Health Board to prevent this, what has emerged is that over the last three years if anything
there has been a decline in the rate of specialist increases. The reported high figures are due to highly suspect
resident doctor numbers.
What about a flood of specialists from England? With the destructive radical restructuring of the National Health
Service in England, including the expected loss of consultant positions, some predict a flood. However, caution is
required. There have been similar predictions over many years that have not materialised. As two experienced and
pragmatic chief executives have said to the ASMS recently, we have heard this before and we will believe it when we see
it. Those consultants who might leave England have to get past the greater financial temptations of North America and
Australia first. A quick observation of a cohort analysis of medical graduates by the British Medical Association
suggests a possible figure of 85 doctors (including GPs and RMOs) per annum considering coming to New Zealand
permanently. It is also worth noting periods of reducing specialist numbers invariably leads to a need to increase them
because of the consequences of the reduction. Depending on a flood of English specialists is speculative and also risks
further increasing our excessive dependence on international medical graduates with its associated financial risks.
What about Australia? Again we need to drill down below the headlines. Through a flawed analysis in the 1990s that
Australia had too many doctors, rather than too few, massive shortages developed. The consequential crisis that
developed, including Bundaberg, led to the federal government significantly increasing the number of medical students
and medical school. Unfortunately they did not make sufficient investment, despite advice from the Australian Medical
Association, to the capacity of public hospitals to train these students once they became house surgeons and registrars.
But this does not automatically mean an ongoing flood of RMOs to New Zealand who then stay on to become specialists.
First, efforts to improve this capacity problem will affect any possible flood. Second, the specialist shortages still
remain and the temptation for any Australian RMOs who come across to return home to considerably higher remuneration and
other conditions will be high.
A reality check is required. In The Business Case the ASMS and DHBs agreed that in order to secure a sustainable specialist workforce for New Zealand, we would need to
match Australia’s projected specialist-to-population ratio by 2021, the average net growth for the next 10 years would
need to be an estimated 232 specialists per year. According to DHB provided data we continue to perform considerably
less than that. In the three years to 2008 the average annual specialist increase was 167. In the subsequent three years
(to 2011) it reduced to 124 (a 25% decline). We are falling further and further behind in achieving this important
objective.
Our decision-makers need to focus on addressing the underlying causes of the crisis and not get diverted by searching
for magic bullets that they can then put in their CVs.
‘Letter of Expectations’ to the Minister of Health
Each year the Minister of Health sends DHBs an annual ‘Letter of Expectations’ about what he expects from them in the
forthcoming financial year. I thought it appropriate to, for a change, pen an unofficial ‘Letter of Expectations’ to Mr
Ryall. It would go like this:
Dear Minister (or Tony if you would prefer)
This letter outlines our expectations of you for the coming 12 months. We would first like to congratulate you for
improvements that have been made under your ‘watch’ to date. These include the provision for some elected medical
practitioners on the Medical Council (the Dental Council remains unchanged although there are some complications there
which you have inherited); the In Good Hands policy statement on clinical leadership; the more operational focus of the Ministry of Health (through the National
Health Board); the formation of the Health Quality & Safety Council; the increased recognition of the important positive role of public hospitals; and, with qualification,
the targets.
In respect of targets they have the value of sharpening focus on important matters. But care is required. Much clinical
work provided by DHBs is not covered by the targets, including chronic illnesses, intensive care, and mental health. Our
caution is that the more the targets are over-emphasised, the more likely the risk is that performance of the targets is
that’s all you will get.
We have several specific requirements below.
Financial Pressures
We appreciate the serious financial challenges faced by the government. But the continuing reduction in the level of
increased funding to DHBs is now risking serious harms. You periodically compare health funding in New Zealand with
other countries but unfortunately these are selective. Your comparisons are with poorer performing economies.
Comparative work by Rand Europe on European health systems under the global economic recession suggest that many
European countries would have been envious of New Zealand’s financial position in 2008 when the recession fully hit,
with particular reference to debt levels and unemployment.
Public hospitals have not been well funded for some time, even during the period of significant funding increases in the
2000s. Greater priority was given to primary care, new initiatives and capital works. The situation has been made worse
by increasing demands on what they are expected to do and the revision to the ‘efficiency adjuster’ which was changed to
a ‘contribution’ towards cost pressures. The combined effect is increased demands and funding increases below the level
of costs. It has been made worse by the failure to invest in distributive clinical leadership which provides the basis
for significantly improved fiscal effectiveness.
We note that in the Budget advice recently released by the Ministry of Health major financial shortfalls are revealed
(coded as ‘required efficiency and reprioritisation’) - $376 million in 2012-13; $719 million in 2013-14; $1,087 million
in 2014-15; and $2,136 million in 2015-16.
The ‘rubber is now hitting the road’ as DHBs and health professionals struggle to cope. There are too many unproductive
creaks and strains in the system and the workforce is being over-stretched. Without corrective action the situation will
only further deteriorate and consequential risks to clinical and financial performance escalate.
One of the negative effects of these pressures is the adoption of petty short-sighted decision-making in some DHBs. The
Auckland District Health Board is an example with what is now widely popularised as the ‘$5.47 stapler’. One of the
largest departments required a stapler costing $5.47. The service manager ordered it in the normal manner only to
unexpectedly be advised that she did not have the delegated authority to make this decision. The clinical director then
ordered it but only to receive the same response (to someone who has the delegated authority to save lives). This then
led to some blunt internal discussions including the obvious observation that the time taken to debate it cost well in
excess of $5.47. The eventual outcome was the purchase of the stapler and a highly embarrassed DHB as more and more
staff became aware of the fiasco. There are other stories on the subject of pens but there is not enough time to
describe them.
Consequently we require you to review health funding in order to ensure that it is able to meet both cost pressures and
increased government and demographic demands as well as invest in distributive clinical leadership.
Health Benefits Ltd
We welcome the initiative of utilising Health Benefits Ltd to improve efficiencies although we decry the derogatory
connotation of the artificial divide between ‘back office’ and ‘front line’. They are in fact highly integrated and
inter-dependent. The latter can’t function without the former. Try telling surgeons and anaesthetists working in
Christchurch Hospital during and immediately after the devastating February 2011 earthquake that boilermakers are not
integral to the front line.
Unfortunately there are serious problems with the expectations of HBL and its process. The required five-year cumulated
savings of $700 million is an arbitrary figure not derived from any robust analysis. It was a plucked figure which, some
might say, leads to a similar sounding word aptly describing the outcome. HBL is not resourced to meet its expectations.
Instead it is forced to engage external consultants without sufficient experience in the issues they advise on, leading
to advice based on tenuous assumptions.
While on paper there is a good change management framework agreed between HBL, DHBs and the health unions, it is likely
to be rendered ineffective for three main reasons. First, the sheer volume of work risks overloading it. Particularly
within the tight time framework the combination of procurement, finance & supply chain, facilities, and human resources is too much.
Second, almost inevitably, the consultation with the workforces represented by the health unions will be constrained to
the application of what the DHBs and HBL agree to rather than the merits or otherwise of the proposals.
Third, it is disingenuous to say that it is for each DHB to decide whether to accept HBL’s recommended business case on
‘procurement, finance & supply chains’ due later this year and then to require each DHB to have the business plan approval linked to the Annual
Plan that you require. This is setting up conflict between the DHBs and the health unions arising out of a process not
of their making.
DHBs are forced to make a considerable financial payment of around $85 million, through the top-slicing mechanism, to
fund HBL with the financial benefits arising out of this investment being both speculative and well down the track.
It is disappointing that the positive initiative of the alliance of the South Island DHBs appears to be side-lined. They
have already made promising advances, including savings, in procurement through a virtual share services framework which
does not require the same financial set-up costs that HBL requires. It is important to note that this initiative is
based on collaborative clinical and financial/procurement expertise from within the five DHBs. What was HBL’s response?
They used external consultants without comparable experience and expertise to evaluate the work of those with
considerably more relevant experience and expertise. The net result was a report that had a ‘bob’ both ways. Unless
something changes it is likely that the South Island DHBs will have to make further savings, without factoring in the
savings they have already made through their own process.
Consequently we require you to slow down the time frame HBL and narrow its scope of work to what is realistic and
manageable in order to avoid serious risks, ultimately to patient care. Further, we require you to ensure that HBL
seconds relevant financial, procurement and clinical expertise to advise it rather than use external business
consultants. Finally we require you to embrace the initiative of the South Island DHBs and ensure that HBL adopts a
supportive attitude towards it.
Distributive Clinical Leadership
Despite the excellent In Good Hands policy (2009) advice to DHBs distributive clinical leadership has not advanced in the manner outlined in that document
or, for that matter, the Ministerial Review Group Report (2009). While there have been encouraging developments in some
DHBs, others have barely progressed. Overall the situation has not advanced substantially since the publication of these
two documents.
While cultural issues (prevalence of managerialism) are a factor behind the lack of progress, the main problem is the
specialist workforce capacity in DHBs. In general because of shortages specialists do not have enough time to engage in
distributive clinical leadership to the level envisaged by In Good Hands. As clinical pressures increase they are affected by what is known as ‘clinical creep’. This means that time for other
activities including core process improvement is either non-existent or very limited.
This is a tragedy because the failure to utilise a workforce that is, by virtue of its training and experience, natural
and effective problem-solvers is a wasted opportunity to achieve both enhanced quality improvement and fiscal
effectiveness. Failing to invest in this workforce is a strategic failure.
The DHBs unprincipled U-turn and unprofessional behaviour over the Business Case last year was a major set-back for those proponents of distributive clinical leadership, including yourself.
Subsequently the ASMS and DHBs did agree on a document called the Quality Improvement & Patient Safety Plan which was based on the Business Case but, aside from sharpening the focus a little, has made no substantive difference and is likely to wither away.
Earlier this week the ASMS sponsored with the MidCentral and Whanganui DHBs a successful engagement workshop focussed on
clinical collaboration between the two DHBs. Had you been fortunate enough to have the opportunity to attend you would
have been very excited with the positive attitudes. It would have made your shirts glow even brighter. However, it
became clear that the current specialist workforce capacity was only likely to sustain much of the collaboration to the
level of clinical standards and professional development rather than to the next step of service configuration which is
what we all need.
Consequently we require you to ensure the right investment is made in specialist workforce capacity to achieve
comprehensive distributive clinical leadership in and between DHBs consistent with In Good Hands.
Claims of Increased Hospital Doctor Numbers
You will be aware that the ASMS has been critical of your assertions of increased hospital doctor numbers since you
became Minister (from 500 to 800 to 1,000). This first occurred from delegates at our Annual Conference when you
addressed it last year and has continued in the public arena in response to your media releases. We have endeavoured to
seek clarity from the National Health Board but this has proven to be very difficult.
However, it is clear that the NHB has been giving you very unreliable data despite them being emphatically advised of
this. The data you have been using in respect of specialists is, in fact, consistent with what we have been saying.
Given that the data to both the NHB and ASMS comes from the same source (DHBs) this is hardly surprising. The
differences are because the former is full-time equivalents and the latter is headcount but the trends are very similar.
Essentially the annual specialist increases from 2009 are averaging 25% less than what they were over the previous three
years. They continue to be well short of the increases recommended by the Business Case.
The much higher figures quoted by you are explained by highly suspect and dodgy resident medical officer numbers due to
changes in the locum market and the reclassification of several of them from casuals (coded no fte) to employees (actual
ftes, usually coded 1.0).
It is also disappointing that the NHB has opted to report to you in a misleading manner. It advises you that senior
medical and dental officers have had the greatest increase among the categories of hospital doctors. However, this is
only achieved by dividing resident doctors and dentists into two – house surgeons and registrars.
We require you not to make public statements based on unreliable misleading information from the NHB. Giving NHB
officials a jolly good spanking for giving poor quality advice would also not go astray.
Private Public Partnerships
The decision to require Canterbury DHB to explore a possible Private Public Partnership for the hospital redevelopment
arising out of the earthquake damage was unwise. At best it is a serious distraction for very busy people. The only
potential benefit is that it removes the cost of the rebuild from the government’s balance sheet. It is very risky to
insert profit maximisation in the running of hospital and clinical support facilities which is so interwoven in the
provision of patient care. It also creates confused accountabilities between the PPP consortium and the DHB for staff
whose work directly or indirectly affects both. As reported in the British Medical Journal and Lancet the experience of PPPs in the United Kingdom has been alarming. After all the people of Canterbury have been through
they don’t need to be exposed to this as well.
Consequently we require you to cease going down this PPP path because of the high level of risk, disruptive impact and
resultant destabilisation. There would be more logic in asking a panel beater to design a traffic intersection.
Proposed Amendments to Employment Relations Act
While this is not your Ministerial portfolio proposed government changes to the Employment Relations Act are of serious
concern in terms of the implications for the health system. The proposal to remove the application of the duty of good
faith on the parties to a collective agreement to conclude a settlement will give health employers too much power and
incentivise the potential for abusing this imbalance.
The proposal to remove the 30-day protection for new employees to be covered by the provisions of the applicable
collective agreement incentivises health employers to try to impose inferior conditions on those at the most vulnerable
part of their employment relationship and less aware of the implications.
National and other multi-employer collective agreements (MECAs) are particularly appropriate in the health system given
its industry and vocational nature. They bring major benefits to all parties, including reduced transaction costs and
the opportunity to focus on sector-wide issues. The proposal to allow employers to opt out of MECA negotiations is an
incentive for poor disruptive behaviour and undermining the benefits MECAs can bring.
DHB chief executives rely on their human resources advisers for advice on these matters. Despite DHBs usually being the
largest employer in their location this is not reflected in the calibre of human resource management. The standard is
mixed and overall not strong.
Consequently we require you to recommend to the Minister of Labour that these and other proposals that introduce
unfairness and increased imbalance into employment relations be withdrawn.
Trans Pacific Partnership Agreement
The secrecy, coupled with the inevitable leaks that arise as a consequence, associated with the Trans Pacific
Partnership Agreement negotiations is raising major concerns. This includes the future effectiveness of Pharmac and the
ability of overseas tobacco companies to take legal action against anti-smoking measures in New Zealand
We require you to persuade the Prime Minister and Minister of Foreign Affairs & Trade that these negotiations do not lead to a reduction of Pharmac’s effectiveness in negotiating with the
international pharmaceutical companies and that public health initiatives (such as anti-smoking) are not able to be
legally threatened by overseas companies. New Zealand’s sovereignty in these matters should be retained.
Workforce Development and Planning
The achievement of improved workforce development and planning has been a major disappointment. The formation of Health
Workforce New Zealand seemed like a good idea at the time. But it has failed to develop a strategic direction and get
‘runs on the board’. There is too much focus on looking for magic bullets instead of sustainable longer term solutions
and too much of a scattergun approach.
We require you to improve the performance of health workforce development and planning through much more collaborative
and practical engagement with the health sector.
Critics and Spivs
Finally we are disappointed that you at times can be oversensitive to the issues raised by critics while having no
apparent problem in listening to spivs. We require that you disregard the advice of Spiv-like elements and regard the
advice of critics as coming from your best friends because they will tell you what you may not want to know but need to
hear. Critics are critics, not opponents. Spivs are something else. They are like seagulls; they fly over, deposit
everywhere and fly off leaving others to clean up the mess.
Thank you for the opportunity to make these observations. I will leave it to you to mail the letter. But I will put on
my back shield to protect myself from the inevitable knives that will be thrown. Perhaps I should contact Vinnie
somewhere in a New Jersey prison. He’s good at one-off innovations.
Ian Powell
EXECUTIVE DIRECTOR
ends