THE MAGAZINE OF THE ASSOCIATION OF SALARIED MEDICAL SPECIALISTS 123 | JUNE 2020

CAN WE FIX IT... INSIDE THIS ISSUE ISSUE 123 | JUNE 2020

WANT TO KNOW MORE? Find our latest resources and COVID-19: PUBLIC HEALTH LAID BARE information on the ASMS website 03 www.asms.org.nz or follow us on HEALTH CARE POST-COVID Facebook and Twitter. 05 Also look out for our ASMS Direct email updates. 06 COVID LESSONS AND INFRASTRUCTURE ‘HUNGER GAMES’ This magazine is published by the Association of Salaried Medical 07 MECA 2020: NEGOTIATING, BUT NOT AS WE KNOW IT Specialists and distributed by post and email to union members. 08 COVID-19: UNFORSEEN CIRCUMSTANCES Executive Director: Sarah Dalton Magazine Editors: Elizabeth Brown HEALTH BUDGET 2020: THE GOOD, THE BAD AND THE ‘BUTS’ and Lydia Schumacher 10 Designer: Dink Design 12 NEW FACE AT THE CTU If you have any feedback on the magazine or contribution ideas, please A KIWI IN LONDON: INSIDE BRITAIN’S COVID CRISIS get in touch at [email protected]. 13 LOSING SLEEP: THE FIGHT FOR BETTER ON-CALL 14 ACCOMMODATION 16 DOCTORS IN THE HOUSE

A MAY DAY FAREWELL Cover 18 cartoon: Sharon CALLING TIME ON AN ACCOMPLISHED CAREER Murdoch 19 20 TALKING TELEHEALTH POST-COVID 21 MY SABBATICAL The Specialist is produced with the generous THE MENTAL HEALTH CRISIS INSIDE OUR PRISONS support of MAS. 23

WILL THE DOCTOR-PATIENT RELATIONSHIP BE CHANGED FOREVER? ISSN (Print) 1174-9261 24 ISSN (Online) 2324-2787 26 THINKING OF BECOMING A CLINICAL DIRECTOR? The Specialist is printed on Forestry WOMEN IN MEDICINE Stewardship Council approved paper 27 WELCOMING NEW POLICY ANALYST

28 DID YOU KNOW? 29 FEEDBACK 30 NOTICEBOARD

2 THE SPECIALIST | JUNE 2020 COVID-19: PUBLIC HEALTH LAID BARE ELIZABETH BROWN | SENIOR COMMUNCIATIONS ADVISOR

legacy of underinvestment in public health has left the virtual fence at the top of the cliff in desperate need of repair. Will the Alessons of Covid-19 turn things around? And what do ASMS members at the centre of the pandemic response have to say? “Health care is vital to all of us some of public health services. Ten years later the “We’ve actually had to turn highly the time, but public health is vital to all budget is $469 million. competent applicants away just on the of us all of the time.” So said American basis that we weren’t getting sufficient paediatrician and health administrator funding to be able to train them,” she says. Charles Everett at the turn of last century. “It’s really important that That lack of capacity was highlighted in It’s no secret that the Covid-19 pandemic has a rapid audit of contact tracing carried exposed a lack of capacity and investment in this investment is ongoing out by infectious diseases specialist and New Zealand’s public health service. and sustainable, so that ASMS member Dr Ayesha Verrall in April. Our lack of pandemic preparedness it’s not just a kneejerk It stated: showed up as recently as last October response.” “The capacity of the 12 public health units when the Global Health Security Index in New Zealand is the primary factor gave New Zealand a score of just 54 out of limiting New Zealand’s ability to scale up 100 points and ranked us 30th among the its case management and contact tracing Looking it at another way – public health 60 high-income countries reviewed. New response to Covid-19.” Zealand scored poorly in early detection services had a budget of about $140 per and reporting of epidemics, along with the capita in 2010/11 compared with $94 per It also described expansion of the availability of doctors and hospital beds. capita in 2020/21 – a 33% drop in real workforce as an ‘urgent need’ and warned per capita funding. DHBs could not keep plugging the holes The New Zealand College of Public by seconding staff from other areas once Health Medicine has repeatedly sounded In terms of overall Vote Health, public alert level 4 was lifted. warnings, most recently in a hard-hitting health funding in the 2010/11 Budget editorial in the New Zealand Medical represented 3.8% of the vote, compared Journal last month: to 2.3% in the Budget for the coming year. “The Covid-19 response has exposed an CAPACITY HOLES “We’ve actually had to turn extremely concerning reality – that there is highly competent applicants Currently, several public health units and a massive and hugely problematic shortfall away just on the basis that in New Zealand’s public health investment. DHBs do not provide guaranteed training posts for public health registrars, despite we weren’t getting sufficient “It is also evident in the number of lobbying by the College for more positions. funding to be able to train public health events over the past few years, including the Havelock North It is a situation which College President, them” campylobacter outbreak and the 2019 Waikato DHB Medical Officer of Health, measles epidemic – both of which were and ASMS member Dr Felicity Dumble preventable had the health system had finds deeply frustrating. Dr Verrall, who has become a household capacity to manage upstream risks.” “We have an excellent, highly skilled name during the Covid crisis, says, “I knew Government figures show that $517 million workforce which has done an amazing job, the people whose work I was reviewing was budgeted in 2010/11 directly for but there just isn’t enough. were working extremely hard, that they

WWW.ASMS.ORG.NZ | THE SPECIALIST 3 Dr Felicity Dumble Dr Ayesha Verrall Dr Caroline McElnay

were already exhausted and that what I primarily on contact tracing and paying the health challenges which “will require a recommended went against established hundreds of people temporarily brought in really good look at how we as a country consensus around how the Ministry and to help boost the workforce. both fund and deliver services to help public health units interact with each other.” address these.” Dr Dumble warns while the extra money is The legacy of underinvestment stretches welcome, it cannot make up for more than to IT systems and contact tracing tools, a decade of underinvestment. which were shown to be unfit for purpose. “It’s really important that this investment “I hope that what we see Dr Felicity Dumble points to the need for is ongoing and sustainable, so that it’s not now is the unique challenge information systems that can capture all just a kneejerk response. We need to see of planning for infectious data needs, from clinical and laboratory better resourcing going forward. It’s not diseases, and it’s not a notification through to case and contact just how we respond to communicable management, as well as real-time disease but about preventing disease matter of planning for last monitoring and centralised reporting. and prolonging life, with a firm focus year’s demand” on improving Ma-ori health, achieving According to Dr Verrall, there are also health equity, reducing child poverty, and major gaps in our technical capacity to mitigating climate change.” analyse data. In Dr Ayesha Verrall’s view, data, There are currently about 171 public transparency and measurement drive health specialists in New Zealand. system improvement. She believes the According to the Ministry of Health, the Covid crisis has given us an opportunity “Public health is also about growth in the number of public health to build our public health units and effect policy and evidence and medical specialists holding a practising structural change. certificate between 2010 and 2019 was influencing” “I hope that what we see now is the 9.6%, compared to 38% across all medical unique challenge of planning for infectious specialities over the same period. The diseases, and it’s not a matter of planning incremental increase is outstripped by for last year’s demand. Infectious diseases “We do have excellent people in New population growth. can have exponential growth, and what Zealand, but mostly we sit in the wrong The Ministry says it is considering options we need to do now is ensure that we build place. A lot of the analytic expertise in to increase the funding available for new that out to include other aspects of public infectious diseases sits in universities. I am public health medicine registrars in 2021. health practice.” working now for the first time with modellers. Meanwhile, another ASMS member who Long before Covid-19 reared its head, “I’m more of a clinical epidemiologist, has found herself in the Covid media several public health experts have but clearly mathematicians like Sean spotlight is the Director for Public Health, argued for a strong national agency to Hendy are making a big contribution to Dr Caroline McElnay. She could often be consolidate public health activities and the modelling space. Why are we only seen fronting the Ministry’s now infamous take responsibility for our growing public meeting now?” she asks. 1pm briefings. She describes the past few health challenges. Dr Verrall also believes having technical months as a ‘rollercoaster’. Some are hoping that this will be a expertise sitting outside New Zealand’s She says it is important to point out that recommendation out of the Simpson policy-focused Health Ministry is the issues in public health are about much Health and Disability System Review. ‘catastrophic’, particularly in a pandemic. more than funding. Whatever lessons are learned from the FENCEPOSTS FOR THE FUTURE “Public health is also about policy and Covid-19 pandemic, Dr Felicity Dumble says There’s clear consensus that New Zealand evidence and influencing,” she says. future proofing our public health service will cannot afford to return to a system that take political commitment and leadership, She also points out that public health units was unable to prepare not only for a global strong governance, and a whole-of- are only one piece of the jigsaw and the pandemic, but the recent measles epidemic, government approach, not to mention workforce is broader than just specialists. increased and meaningful investment. rheumatic fever, TB, and even syphilis. “The public health workforce is an She says it also needs to be co-designed While national public health services interdisciplinary workforce with only a with the public health professionals who overall did receive a relatively modest 6.6% number being medical practitioners, so understand it intimately. increase in this year’s Budget, there has when we talk about the workforce pipeline been no increase to baseline funding for Ultimately, she believes we now have the we can’t just look at the medical workforce”. the country’s 12 public health units. They opportunity to move public health service have received an extra $30 million as part Dr McElnay agrees that New Zealand has design in New Zealand into the 21st of the Covid-19 response, which will focus a number of unique and complex public century which we cannot let slip away.

4 THE SPECIALIST | JUNE 2020 HEALTH CARE POST-COVID PROF MURRAY BARCLAY | ASMS NATIONAL PRESIDENT

ight now, I am very glad to be a doctor in New Zealand and not in the UK, Europe, or the US. As others have said, we dodged a Rlarge bullet by going into strict lockdown quickly and, fingers crossed, we can keep Covid-19 at bay and live relatively normally. Importantly, so far, we have had no health patients with symptoms, polyp and cancer Let’s hope the Ministry also responds care worker deaths. This could have been so surveillance, and colon cancer screening. appropriately. Until now it seems to different. Nurses in particular have had to The graphic shows the way Covid has have struggled to understand the real run the gauntlet in caring for infected aged exacerbated the gap between healthcare requirements for new hospital facilities. care facility residents. service delivery and health need. There are a growing number of new hospitals that will not be fit for purpose on So, what is the outlook for health care There are two main options to try and completion for several reasons, including services as we come out of lockdown and catch up with workload post-Covid. reassess health need? too few beds, and poor accommodation 1. Run health care teams ragged with for staff. The Covid-19 experience adds Before Covid, we were faced with: overwork. to the long list of reasons against large • 10 years of steadily reducing 2. Invest in more staff and hospital beds. open-plan office spaces and hot-desking. investment on health care as a The first option will obviously result in Even more important is the shortage percentage of GDP loss of health care staff from burnout, of health care staff, the most important • 25% shortage of hospital specialists including poor mental and physical well- determinant of health care capacity. The being, and worsen understaffing. • decaying and overburdened hospitals Ministry has long appeared to have its running up to and beyond 100% head in the sand regarding medical staff PATIENT bed occupancy NEED shortages in hospitals, and it does not seem • 50% burnout rate in hospital specialists to be moved by the high level of burnout (70% in younger female specialists) UNMET NEED in hospital specialists. After several years, Health Workforce New Zealand was finally • an estimated 448,000+ New DHB acknowledged to have failed to deal with Zealanders unable to access the hospital SERVICE specialist services they required. CAPACITY workforce issues, and a new entity called PANDEMIC the Health Workforce Advisory Board has Covid-19 highlighted very specific taken its place. There is hope this new entity deficiencies in our health system, including TIME - WITH COVID PANDEMIC will be more productive, but time will tell. a dangerous shortage of ICU beds compared with other similar countries, All DHBs and managers must know that SUMMARY and a depleted public health specialist the second option is really the only logical Now more than ever, spending on health workforce and occupational health choice for staff and patient well-being. care needs to be an investment in workforce at a time when we most needed However, until now their arms have been productivity and well-being for our society these people. However, similar deficiencies tied by the Ministry of Health and the exist in many, if not all, the medical and Government, with threats of ministerial and not as a financial drain. The positive surgical specialties across the country. intervention and/or dismissals of boards, financial flow-on effect from treating and chief executives, and other managers for improving mental and physical well- WHAT IS DIFFERENT NOW? questioning budget restraints. being is known to far outweigh the cost. Secondly, investing in the recruitment of We have the same number of medical staff HOW ARE THE GOVERNMENT AND health care staff to match patient need and same hospital capacity, but waiting lists MINISTRY RESPONDING? are two months longer. Efficiency is reduced should be the highest priority with the by the need for extra hygiene precautions This year’s Budget sees the largest extra investment the Government is now increase in spending in health care in and cleaning. As a gastroenterologist, the making. Additional recruitment won’t decades. You can find a Budget analysis example most clear for me is that endoscopy happen quickly due to the time it takes on page 10. patient turnover will be reduced by up to train, along with global competition to 30%. This has enormous implications The Government has recognised and for health care workers, but the correct for all endoscopy indications, including responded to the need for new hospitals. signals need to be sent to DHBs now.

WWW.ASMS.ORG.NZ | THE SPECIALIST 5 Television interview Covid-style

COVID LESSONS AND INFRASTRUCTURE ‘HUNGER GAMES’ SARAH DALTON | ASMS EXECUTIVE DIRECTOR

ne of these days I will write a column that does not start with the words ‘roller coaster’ or ‘crazy few months’ or ‘how time flies...’ Obut this is not one of those days. I am currently sitting at my other ‘desk’ think harder about the long-term failure to It is not acceptable that DHBs are – more accurately my dining room table resource our essential services and what required to develop convoluted, expensive, – although I have started venturing back that means in a crisis. I am glad some light business cases, which are then cut to the into the office on occasion. One of the cool has been shone on several crucial yet bone; nor is it tolerable that boards are things ASMS has learned from lockdown under-resourced specialties. I am nervous making massive capital works decisions is that we can function effectively from we are still in a position of robbing Pita to behind closed doors. Overseeing all this home, by Zooming into our case work pay Paul for healthcare. – the Capital Investment Committee - and meetings around the country. This is seems to be giving advice along the lines Speaking of crime - is it really ok for our something we will take into the new normal. of - you can have the baby, or the bath, or DHBs to be locked in a healthcare Hunger the water, but not all three. Personally, I have learned that you can give Games for capital works? Is it really ok physically distanced interviews via Zoom, that every new hospital bid is cut back, I cannot see any virtue in a bidding war Skype and even on the driveway! I have and that we’re hearing things like “we for major public buildings predicated on learned that lockdown hair is not fatal, and can’t include mental health in the new a sinking lid on capital spend. In 2018, that driving and flying less, walking more, build” or “most of the floors will be a Treasury estimated we would need to and spending more time with the person in shell, that we might furnish in the future” invest more than $14 billion in hospital my bubble, are lovely things. or “we can’t afford air conditioning now” development over the next decade. During the Covid emergency many of our or “our new building will be at maximum Yes, this government is putting its hand members led and contributed to flexible, occupancy the day it opens” or “everyone deeper into its pockets when it comes to responsive, focused actions in their DHBs, agrees our buildings are no longer fit for the health budget, but the prospect for informed by SMO/SDO advice. These purpose but our business case has been buildings is gloomy. rejected - again.” actions helped keep staff and patients We know you have suboptimal workspaces. safe. In JCC meetings around the motu I think it is time to centralise responsibility What is not entirely clear is why we are I am already hearing our members’ for planned provision and development putting up with it. In this issue you will see hopes that these examples of positive of key infrastructure. We need to make a sad article about what passes for SMO engagement and clinical decision-making it very clear, to health workers and sleeping accommodation in a number will stick. taxpayers alike, where the new buildings of our hospitals. I see it as symbolic of I hope we can hang on to the things that will go, in what order they will be provided, the larger struggle for decent hospital have worked well. Review them, consult and the timeframes. accommodation for everyone. We need with staff, and make sure that as hospital to move past the “sin of cheapness,” and The Auditor-General has repeatedly occupancy rates rise, and we resume make a serious long-term investment in commented on the fractured oversight elective services we do not lose the good hospital infrastructure across the country. of hospitals’ capital works. In 2016 she things we have put in place. questioned the DHBs’ ability to support Given how focused DHBs need to be on We need to think harder about future service delivery and noted that the here and now, maybe it’s time to hand travel, about telehealth and virtual “audit work since 2009 shows a sector the task of imagining our new hospitals communication. We also need to strongly focused on delivering short-term to a centralised agency that has the time, remember that face-to-face is often not results within a challenging operating clinical expertise, and resource to make a just better, but necessary. We need to environment and financial constraints.” proper job of it.

6 THE SPECIALIST | JUNE 2020 MECA 2020: SUMMARY OF NEW MECA NEGOTIATING, PROVISIONS

BUT NOT AS • 12-month term, 1 April 2020 to 31 March 2021. WE KNOW IT • In underlying principles, Clause 1.1 now reads: The parties acknowledge the LLOYD WOODS | SENIOR INDUSTRIAL OFFICER/LEAD MECA ADVOCATE fundamental importance of the need to promote and establish DISTRIBUTIVE clinical leadership within the workplace consistent with the principles of hen I think of MECA 2020, Star Trek jumps to mind and that iconic engagement in the Time for Quality Wline, “It’s life, Jim, but not as we know it.” The negotiations were agreement between the Association and certainly like none which had gone before, and it’s worth reflecting on how all District Health Boards (refer Clause it all played out. 2) and the associated need to establish We began in February, tabling our very full claim some two months before the effective employer-employee partnerships, MECA was due to expire. It became clear fairly quickly that we were in for a based on good faith, mutual respect and battle and that it would likely take quite some time, so by early March we had constructive engagement. agreed with the DHBs to 16 days of talks taking us through to the end of May. • All salaries adjusted per CPI (1.9%). The first six days saw us varying some of our claims and gaining agreement • Recovery time is to be applied to overall on five of them, but the big ones were still on the table, particularly shifts as well as to after-hours on-call those with a clear financial cost. arrangements. By the end of negotiations on 11 and 12 March, New Zealand (and indeed the • Safe access to car parking must be rest of the world) was staring down the barrel of what looked to be the biggest arranged during hours of darkness. medical challenge of the last 100 years with coronavirus rapidly spreading. We • A new clause enabling pregnant agreed to hold more face-to-face meetings in Wellington on 25 and 26 March, employees to reduce their hours of work but as everyone is aware, the situation ramped up quickly, and, within a few days (if they wish) from 28 weeks. it was becoming clear that talks would not be able to proceed as planned. Once • A new professional development clause the Government announced the one-month lockdown, we knew talks would be that provides for SMO/SDOs with clinical disrupted for at least two to three months. After hurried discussions between the leadership roles to undertake relevant ASMS team and the DHBs, it was agreed we would go ahead with one day of leadership training outside of CME time. negotiations on the Wednesday before the lockdown took effect, via Zoom. • The word “posting” has been added to the Negotiating ‘virtually’ was something neither side had ever experienced before. secondment clause, which will allow for charitable work to be undertaken under The ASMS team met ahead of the meeting to consider whether to either this provision. postpone the negotiations indefinitely or ‘go for it’. We decided on the latter, and by the time the DHBs joined the call we were in the position of offering a • The words “working (or volunteering) for package contingent on the DHBs agreeing to a settlement that day. After a lot a medical charity” have been added into of back and forth, an offer was left with the DHB team to take back for sign off. the terms of the sabbaticals clause. This required high-level agreement including both the Ministry and Government • An addition to the research and – but at the end of the day we found agreement. publications clause: “In addition to the right to use sabbatical leave, secondment Basically, this agreement was to ‘roll over’ the MECA with those clauses already agreed, plus three extra clauses agreed on the day, along with a salary increase leave or continuing medical education based on the consumers price index (CPI) of 1.9%. We agreed on a one-year term, leave for research purposes, special leave which is unusual, but considered the best option given the situation with Covid-19. and leave without pay may be used for such research activity.” The new MECA was ratified • Shift work is now included in the vacancies by the ASMS National and locums clause. “Notwithstanding any Executive after members of the above, an employee shall not be voted overwhelmingly in required to undertake additional duties favour in an online ballot. and responsibilities caused by an absence We want to thank the ASMS of an employee(s) on their on-call or shift team for their hard work roster beyond a reasonable period throughout, and in particular of time.” for the rapid acceptance of • There is a new clause dealing with life as we have never known domestic violence. it on the long, final day of the • The concept of an accord (or similar mass Zoom meeting. arrangement) was agreed over the We will be back in bargaining term of the MECA. Part of that would for the next MECA in include exploring the issues facing shift February 2021. workers, with a focus on looking at the underpinnings of the claim for alternative MECA 2020 is available on pay for after 5pm. our website: www.asms.org.nz ASMS bargaining team

WWW.ASMS.ORG.NZ | THE SPECIALIST 7 Dr Cheryl Johnson and her son Caleb

COVID-19: UNFORESEEN CIRCUMSTANCES ELIZABETH BROWN | SENIOR COMMUNCIATIONS ADVISOR

hen Dr Cheryl Johnson dropped her 10-year old son Caleb off to her ex-husband on 24 March, she drove away wondering if she Wwould ever see him again. While the country has given collective Waitemata- DHB’s older-adults service She knows she is not the only one who has thanks that Covid-19 spared our hospitals faced major disruption due to Covid-19, faced personal difficulty through Covid-19. the scenes witnessed overseas, it did take leading to a lot of reshuffling of staff Many of her colleagues, spooked by the a personal toll on some ASMS members, and resources. scenes coming out of Europe, moved forcing them into situations and decisions out of their homes or sent their families Dr Johnson was redeployed from North they never imagined. elsewhere. Shore Hospital to Waitakere Hospital, Rewind to the days leading up to the which had become one of the country’s She brings herself back to the night she Level 4 lockdown when there was so much flashpoints. She was looking after patients dropped Caleb off at his dad’s in March, uncertainty and fear that New Zealand who had been cared for by nurses who when she drove away not knowing what was about to be hit by a massive wave had unfortunately become infected on the future might hold. of sick people which would overwhelm the job, sparking a full-blown health and “What I have really struggled with hospitals and services. safety review. and questioned is when you take the That is when Dr Johnson and her ex- For her it not only brought home the Hippocratic Oath and take on this role as husband decided that Caleb, whom they dangers of contracting the virus but also a doctor, what is the extent of that oath? happily share responsibility for, should go meant at least another four weeks of What does one person have to give up to to his dad’s and stay there for the next separation from her son. fulfil that role? four weeks. “It felt like a real rollercoaster – not seeing “My workload was really ramping up him, then seeing him a bit, and then and we didn’t know what my exposure suddenly back to not seeing him at all.” “It felt like a real to Covid-19 was going to be,” says rollercoaster – not seeing While being separated from Caleb was the geriatrician and clinical leader at difficult, Dr Johnson was also cut off him, then seeing him a bit, Waitemata- DHB. from her parents, friends and the social and then suddenly back to “It was the right decision for us, but it was networks which are integral to her daily not seeing him at all.” a very difficult decision.” life. It has been an incredibly lonely experience she says. She kept in touch with Caleb regularly, and after almost four weeks she excitedly Often, she found herself working late “It’s been extremely hard that I’ve had to had him back for some weekends, but then at night or going into work just for the sacrifice my family and give up my social everything changed again. distraction and human interaction. networks for that oath I took.”

8 THE SPECIALIST | JUNE 2020 STOOD DOWN She also spent time reflecting on how As an anaesthetist Dr Pearce says it is she had ended up in the position she near on impossible to physically distance Dr Greta Pearce describes the surreal found herself in and questioned her own from patients and colleagues in closed moment when she was told she had work practices. been exposed to Covid-19 and had spaces such as the operating theatre. to stand down from her role as an When she did return to work, she was very mindful of social distancing. anaesthetist at North Shore Hospital. “I found myself noticing it a lot more “I got a phone call saying the week and general behaviour within the “People have changed a lot beforehand someone I had been in work setting. of ways they practice, so contact with at work had ended up symptomatic and had tested positive.” “People have changed a lot of the much of which is engrained ways they practice, so much of which is in what we do.” When she got the call her first thoughts engrained in what we do.” were for her colleagues and what her She gives the example of ward rounds stand-down would mean for them. where doctors move in groups and see patients behind their bed curtains to Looking back, this was not the scenario maintain privacy. through which she would have “It was stressful coming to “However, we still have to work within anticipated an exposure. Fortunately, that decision and thinking, the parameters of the services that there was no further infection and she am I putting my family at we provide.” returned to work after a week. risk?”

“I was on call that weekend, so it was a little stressful in terms of letting your team members down and other people having to quickly pick up your hours. It was at a time when we were on a Covid call system, so we were already working on additional call rosters.” Because she was asymptomatic, she did not have to trawl back through her contacts, but she did think about whether she may have infected patients and hospital staff. That phone call also prompted some big decisions for her family. After a discussion with her husband they decided they would self-isolate with their two young children as a group. “If I’d tried to separate myself at home or moved out, it would have caused major upset to the children. My three- year-old still climbs into my bed every night,” says Dr Pearce. “It was stressful coming to that decision and thinking, am I putting my family at risk?” During the stand-down period she received a phone call every day asking how she was. Dr Pearce gets hay fever and was suddenly paranoid about Dr Greta Pearce every sneeze.

WWW.ASMS.ORG.NZ | THE SPECIALIST 9 Stuff Limited

HEALTH BUDGET 2020: THE GOOD, THE BAD, AND THE ‘BUTS’ LYNDON KEENE | HEALTH POLICY ANALYST

The good news: Vote Health’s operating Supplementary Estimates are likely to be funding is unlikely to make real inroads budget for 2020/21 is an 8% increase on used more than usual to adjust funding into that unmet need while DHBs attempt last year’s Budget Day figures – well above as the year progresses, there is little to address the substantial backlog of forecast population growth and inflation doubt that the scale of the increase in cancelled treatments along with all the new and excluding the one-off pre-Budget Vote Health is of record levels, even when acute and ‘elective’ cases coming in during funding for the Covid-19 response. putting aside one-off spending related to the year. It should also be noted that part the pandemic. Table 1 compares the main The bad news: Funding for hospital of the DHBs’ new budget is to cover pay buildings and other capital needs are 2019 and 2020 Budget Day allocations. equity costs. As noted above, the increases must be well off track to meet the DHBs’ needs, In other examples, the 27% increase for estimated in 2018 to require $14 billion put into the context of many years of National Disability Support Services starts over 10 years. under-investment in the health system and its workforce. Last year’s Council to evaporate when funding for pay equity, The ‘buts’: This year’s Budget, significant of Trade Unions–ASMS Health Budget the ‘in-between travel’ settlement for though it is, follows years of funding analysis conservatively estimated this community support workers, and minimum shortfalls and amounts to a good start year’s Budget would need over $2.5 billion wage increases are considered. The New to catching up. If the real funding hike is extra for 2020/21 to restore the value of Zealand Disability Support Network, while unprecedented, so too are the service funding to 2009/10 levels, which even welcoming the funding increase, estimates challenges ahead. then were not ideal. a further $350 million is needed across Vote Health and Vote Social Development THE OPERATING BUDGET This accumulated funding shortfall has to maintain current service levels and contributed to a pre-Covid estimate of While Covid-19 has brought a lot of meet unmet need. uncertainty into this year’s forecast more than 440,000 people who are not population growth (1.8% pre-Covid) able to access timely hospital treatment. Continuing the incremental funding and inflation rate (0.8%), and the Even this year’s 9.3% increase in DHB increases for mental health and addiction

10 THE SPECIALIST | JUNE 2020 HEALTH VOTE 2020 – MAIN OPERATIONAL ITEMS Service Areas 2019/20 2020/21 % increase $m $m Ministry of Health 221 250 13.1 DHBs 13,980 15,274 9.3 National Services 3,221 3,760 16.7 Disability Support Services 1,345 1,707 26.9 Public Health Services 440 469 6.6 Planned Care (formerly ‘Electives’) 396 425 7. 3 Primary Health Care Strategy 331 367 10.9 Maternity Services 189 205 8.5 Emergency Services 150 148 -1.3 Mental Health Services 141 208 47. 5 Child Health Services 113 112 0.9 Personal Health Services 67 67 0.0 Other 49 52 6.1 Misc Training & Development 212 219 3.3 Supporting Pay Equity 414 0 See notes Monitoring/Protection 32 26 -18.8 Other 32 34 6.3 Provider Development & ‘Other’ 46 55 4.7 TOTAL OPERATING BUDGET 18,157 19,618 8

NOTES: • 2019/20 figures are 2019 Budget Day figures. • National Services are those funded at a national level and managed by the Ministry. • The National Disability Support Services increase includes funding for pay equity, ‘in-between travel’ for home and community support workers, and funding for expected minimum wage increases. • National Mental Health Services includes a transfer of $15.3 million from Expanding Access & Choice of Primary MHA Support. • National Emergency Services refers to air and road ambulance services. • Pay equity funding was devolved to DHBs and National Disability Support Services in 2020/21.

(MHA) services following the MHA inquiry, over the following 10 years. Again, this on construction work, but the forecast National Mental Health Services received, is in large part an outcome of long-term for the next few years is not encouraging. on the face of it, a healthy looking $67 under-investment in the system which led This year’s Budget includes a five-year million boost for community-based services. to DHBs, as Treasury put it, “sweating ‘Health Capital Envelope 2020–2025’ Nearly $8 million of that was transferred their assets and under-funding repairs and totalling $3.115 billion, including the $583 from last year’s Budget however, which maintenance to help balance their books”. million allocated for 2020/21 and the coincidentally was also the shortfall to $755 million additional capital funding Tracking capital budgets is a messy pay for new and expanded MHA services announced on Budget Day. business as they often involve multi- estimated in the Council of Trade Unions– year allocations which are frequently Meeting a $14 billion need appears a long ASMS Budget 2019 analysis. That analysis underspent, overlap, and are adjusted way off. too estimated a conservative $55 million in various ways over time. With that cut in DHB ring-fenced services for MHA WHAT NEEDS TO HAPPEN NEXT? caveat, current and forecast capital clients with the most severe needs. (The funding for sector infrastructure does not At the time of writing, the release of the ring-fenced allocation for this year was appear to be tracking anywhere near Health and Disability System Review’s final not available at the time of publication. the earlier estimated funding need. This report was pending, but its ‘interim report’ ASMS has requested it under the Official year $583 million is budgeted for sector had suggested: Information Act.) infrastructure costs for 2020/21, though “If New Zealand is to develop a system THE CAPITAL BUDGET some of that is unlikely to be spent this that operates effectively with equitable year as it includes funding for multi-year In December 2017 Finance Minister Grant projects. outcomes throughout, it must first operate Robertson, in answer to a parliamentary as a cohesive, integrated system that question, revealed DHBs had signalled The Covid-19 lockdown restrictions will works in a collaborative, collective, a required capital spend of $14 billion of course have had an immediate impact and cooperative way. Behavioural and

WWW.ASMS.ORG.NZ | THE SPECIALIST 11 attitudinal changes are needed. These described in the ASMS’ Hospitals on the This requires a mind shift away from an changes need to be led from the centre Edge report. It made recommendations adversarial style of politics to one that and applied consistently throughout to the Government aiming to bring about is more collaborative and constructive, the system.” the kind of working environment outlined which has been more evident during above. Now, with even greater challenges the pandemic because that is what the Reports of the pandemic abound public has wanted to see. But as one with examples of this. When health ahead, it is more urgent than ever to get this going. commentator said, “Some politicians have professionals have an opportunity to lead, proved more able to do that than others” to make the best use of their knowledge As the Health and Disability System – which may be something for voters to and experience, to collaborate, and Review says, attitudinal changes are consider in September. to form alliances, with support from needed throughout the system. That managers and quality leadership from the A vital part of a more constructive, must include the politicians and those long-term approach to policymaking centre, they can work wonders. There is a who advise them. Transforming the wealth of international evidence showing concerns future funding. This year’s health system will not happen through Budget is a job well started after many this. The pandemic has put it in the policies focused on three-yearly election spotlight, and, critically, underlying it all years of under-investment. The job now cycles. It requires long-term timeframes, has been a strong sense of mutual trust. is to continue on a track to build service unified values among policymakers, and capacity, in real per capita terms, to help Before the pandemic, the health system constancy of policy approaches for both secure not only a strong health system but was already well over-stretched, as operational and capital planning. also a stronger economy.

NEW FACE AT THE CTU DR CHARLOTTE CHAMBERS | ASMS HEAD OF POLICY & RESEARCH

ndrea Black has recently taken over from Bill Rosenburg as Policy Director and Economist at the Council of Trade AUnions (CTU). Originally a tax and policy specialist working at Inland Revenue and Treasury, Andrea has also worked on criminal justice reform as Policy Coordinator for JustSpeak (JS) and with Yoga Education in Prisons. Andrea took time out of her busy schedule to share some thoughts on Budget 2020 and priorities in a post-Covid future. What were you hoping to see in this year’s further increase in benefits, no move What are your future work priorities? Budget, and how did it measure up? to individualise them and that the in-work tax credit is still lost if people Looking at our immigration settings in I was hoping to see measures that lose paid work. a world where the borders are closed. I looked to address the past and current believe immigration in the past has been challenges – low wage etc – but at What do you think are the main issues used as an alternative to training and the same time looking to mitigate facing New Zealand in a post-Covid investment in the people already in New unemployment and have our public environment? Zealand and/or investing in capital. This services recover. Unfortunately, they are exactly the is starker with rising unemployment. There was a lot to like in the issues we were facing pre-Covid but Looking at ways the Government can Budget – increased health spending, are now more urgent. New Zealand is fund the recovery. There is an automatic conservation work, trades training, a low-wage, low-productivity, high-rent, assumption this will need to be paid for increased funding for domestic violence high-carbon economy, with decayed with future taxation. While this will play and Ko- hanga Reo. public services but now has rising a part, there are tools the Government unemployment as well. can use, as the Bank of England is I would have liked to see a greater currently, where it is paid for by the emphasis on the ‘Future of Work’, which The risk is that – like post-GFC – we Reserve Bank creating money. It’s also Bill Rosenberg is leading for the CTU. return to a less good version of the known as Modern Monetary Theory and That is all about moving to a high-wage economy and society we had when we I really want path for the country and giving much went into lockdown. Also, recessions better support to working people to help don’t hit everyone evenly. Those at the to understand them through the changes along the way. bottom tend to get hit much worse it properly. than those at the top. For example, I would also have liked to see more I also want even though we are about to get 9.8% emphasis on housing, particularly to explore unemployment – which will probably be affordable rentals. There is a large why, when the about 20% underutilisation when you cohort earning too much for a social gender pay include those who want more work and house but paying large amounts of gap is falling those that are discouraged – the stock disposable income in rent. generally, it is market, while it has fallen, is currently rising in the I was also disappointed that at a time at much the same levels as November public sector. Andrea Black of rising unemployment there is no last year.

12 THE SPECIALIST | JUNE 2020 A KIWI IN LONDON: INSIDE BRITAIN’S COVID CRISIS DR WILLIAM RUSH

e all saw the horrifying pictures of overwhelmed hospitals and health care workers in the UK as Covid-19 swept through. Dr WWilliam Rush is a Kiwi doctor in London. He shares his experiences and observations of working in a busy hospital during the crisis. Two and a half years ago, we moved to suspect that the early community spread surgical masks, bore the brunt of the London with our three young children. I was far greater than imagined. Many of us surge. The hospital emptied out behind us, left my job as an emergency consultant in went off sick, to isolate, protect the NHS, and finally, we were not bed blocked. Now south Auckland, exchanging it for a post and return to work after our 7–14 days the threat of corridor patients carried real at a busy major trauma centre in East were complete. consequence and weight. London. Far, innit? We will probably never know if that Do I feel proud? No. I feel fortunate. The I was told the NHS was a juggernaut, that headache, runny nose, and bout of team that I am with is excellent. I would it was unsinkable, perhaps because it was diarrhoea were from Covid-19 or not. I encourage them to move to New Zealand already sitting on the bottom? A complex have three children who regularly supply if it did not adversely affect my chances of system of bespoke solutions compounded me with new germs. There was not re-employment. by the British dependence on bureaucracy, enough testing for frontline health care queuing, and the fax-machine. professionals when I fell ill. As we all know, Covid-19 arrived, ignoring The science was lacking, and the systems “We were left gut wrenched Brexit, and crossing into the UK rapidly, were new. We endeavoured to maintain and angry that our patient easily, as if it were just another part of business-as-usual standards of care. Just Europe. Undoubtedly, the virus had a clear because this was ‘unprecedented’ did not had died before we could intent to Remain. mean we could redraw the line a little ‘throw the kitchen sink at Like everywhere else in the world, we bit lower and deny people ventilation or them’.” dropped everything to ready ourselves a hospital bed. The government could for the hordes of patients dying from artificially lower the PPE requirements, Covid-19. Within a week the National but redefining hypoxia just was not going The NHS is full of saints, working selflessly. Health Service had become the National to work for our patients. Every so often Too many have died or been admitted to Coronavirus Service. House officers and someone would say something like, ‘In intensive care during the pandemic. The registrars did not rotate as planned; most times like this, we need to be pragmatic.’ weekly clap (8pm Thursdays) is nice but will were redeployed. Some juniors, bless them, I thought we should always be pragmatic, soon be forgotten as it fades into tokenism. actively volunteered to switch into ED. Extra but the official line was to not alter Perhaps now the UK will value its health consultant shifts were created, non-clinical thresholds of care until NHS England said care professionals and bail them out like time was halved, daily Zoom meetings were we must. the bankers in 2008? Rounds of applause instigated. The preferred debriefing venue – Our own ICU capacity increased six- do not make up for over 10 years of fixed the local pub – shut its doors. fold, and ventilation mega centres were wages or compensate for the increased There were one or two ‘horror nights’ back opened but thankfully were never used. personal risk of intubation or death. in March where the ED was almost overrun, Despite our best efforts, some patients There will be a national inquiry, closed- but the nurses, doctors, and other health did not receive all the care we wanted to door decisions uncovered and critiqued. care workers stepped up and weathered provide. System errors, which led to delays Outrage will come and pass. The clapping the storm just as they would have in any caused by newly derived bottlenecks, and free food will stop, but I am confident New Zealand ED. I thought of heading combined with a nastier and more the controlled chaos of emergency back home to New Zealand, deserting aggressive disease than initially expected. medicine, and the wider NHS, will carry on. my adoptive, dysfunctional country of We were left gut wrenched and angry residence. But my Stockholm syndrome that our patient had died before we could took over, I signed up for extra shifts, ‘throw the kitchen sink at them’. dialled into the next Zoom meeting, turned my camera and mic off, and bought better life insurance online at my wife’s insistence. “Just because this was For us, PPE was consistently available. My ‘unprecedented’ did not clinical lead was brilliant at sourcing kit for the department, though it pains me to think mean we could redraw the how much he spent at Amazon. line a little bit lower and Nevertheless, the near-complete lack of deny people ventilation or a testing meant Captain Boris was sailing hospital bed.” with all his usual bluster through a fog. Thanks to the UK being slow to lock down, a large proportion of the health workforce I suspect that the London Ambulance was subject to a de facto, dumb, short- Service, those knights in forest green, Dr William Rush lived ‘herd immunity’ experiment. I strongly complete with flimsy plastic aprons and

WWW.ASMS.ORG.NZ | THE SPECIALIST 13 Shared office which doubles as an on-call sleep room at Waitemata- DHB

LOSING SLEEP: THE FIGHT FOR BETTER ON-CALL ACCOMMODATION ELIZABETH BROWN | SENIOR COMMUNCIATIONS ADVISOR

or SMOs who work overnight and weekend on-call, having somewhere comfortable to catch some decent shuteye is crucial, but Funfortunately it is something many can only dream about. The ASMS–DHB MECA states that Dr Charlotte Farrant is one of six O&G by the midwives’ station and is noisy and employers should provide sufficient good consultants at Wha-nga-rei Hospital who brightly lit. do 1-2 calls per week and a 48-hour quality overnight accommodation. “We just need somewhere quiet and dark weekend shift every six weeks. She says but close to the ward where when you’ve “This accommodation should be secure, some of her colleagues were bringing in got the opportunity to have a sleep you can private, quiet and self-contained. It should squabs and a sleeping bag to put on the just get into a bed and sleep. I get there are be within reasonable walking distance training room floor before they asked the bigger things in the world, but this is part of of the workplace, having regard to any DHB for a bed. emergency and other duties the employee the contract, and it’s just a little bit sad that may be required to attend to overnight.” “What appeared was this fold-up thing. It the provision isn’t there for us.” is quite narrow, very thin, and rickety when It also specifies that the accommodation you’re on it. There are no sheets provided, should include at least: so you have got to go find some sheets, make up the bed, and find a pillow. When “What appeared was this “a bedroom or bed-sitting room; private you might only have an hour to catch up on fold-up thing. It is quite bathroom with toilet and shower facilities, a bit of sleep, that all takes time,” she says. access to basic kitchen facilities for narrow, very thin, and rickety cooking or heating food, a television set, The prefab is also designated office space, when you’re on it.” a comfortable lounge chair and a work- so technically no one is supposed to sleep station or desk with telephone, computer in it. Dr Farrant adds that it is cold, and you must walk outside to get to it. terminal and internet access”. What she would like to see is a room Earlier this year members caused a stir at The hospital does have two houses within the building, not having to go the Northland DHB JCC meeting, when which provide SMO accommodation for outside, and somewhere which is just a they wheeled in a fold-up bed to highlight paediatrics, anaesthetics, ICU and ED, but short run back to the ward. A bed with the inadequate SMO accommodation in they are too far away from the O&G ward sheets which are changed each day would to safely walk to in the middle of the night. be the icing on the cake. the Obstetrics and Gynaecology (O&G) Department. The bed is available in a Dr Farrant says she personally goes into a The Northland DHB had promised to do prefab used as a shared training room. clinic room and sleeps on a couch, but it is something about the situation by this

14 THE SPECIALIST | JUNE 2020 Dr Andrew Robinson and the cold, Fold out bed for O&G SMOs echoey, faraway accommodation at Accommodation at Lakes DHB at Northland Lakes DHB

month’s JCC meeting. Dr Farrant has no salubrious. They are rudimentary, cold and has slowed things down a bit but we hope doubt there is a will to address the problem, noisy, and the toilet is a bit of trek down to to continue plans in the near future.” but that was before Covid came along, and the end of the corridor.” now she says, “We’ll wait and see.” Where he works in ICU, he shares an office If I were a house surgeon, I probably with another consultant, and it has a bed ADEQUATE WITH A SMALL ‘a’ wouldn’t mind, but I’m getting towards the in it. He describes it as a shared office- end of my working years and I’m getting a At Rotorua Hospital, where there is overnight cum-sleep room which is pretty basic but little fussy.” accommodation provision, the focus of at least close to the ward. complaint is around the standard of it. Ideally, he would like to see a room with Lakes DHB ASMS Branch President a bed, a table, a chair and an ensuite and anaesthetist Dr Andrew Robinson “I’ve done a few night bathroom, like a bedsit unit. describes them as a row of rooms on shifts and it’s reminded Arrangements for SMOs in other one side of an echoey, cold corridor me that the rooms are less with no ensuite or lounge facilities and departments vary, but Dr Casement points desperately out of the way. than salubrious. They are out none meet the MECA standard. He rudimentary, cold and noisy, says the situation is worse at Waitakere “Very basic really,” he says. Hospital which is also managed by the and the toilet is a bit of - “I don’t use them much because they are trek down to the end of the Waitemata DHB with anaesthetists known to sleep on an old sofa in the admin office. such a long way away from intensive care, corridor.” and if I’m worried about a patient in ICU, I just go and find a sheet, find a spare bed and bunk down in it. If I can, I prefer to go home.” Lakes DHB Human Resources carried “I get there are bigger things in the world, but this is part His colleague and fellow anaesthetist out an investigation and found the Dr Murray Williams says the rooms are accommodation to be adequate. However, of the contract, and it’s ASMS Executive Director Sarah Dalton, adequate with a small ‘a’. just a little bit sad that the who had a tour of the rooms in March, says they are far from MECA compliant. provision isn’t there for us.” It was raised at the JCC meeting, and the “Most of us appreciate it is DHB has promised to take another look. hard to find accommodation AN ESTIMATED $1 MILLION ON The lack of accommodation means the areas in an active busy MOTEL ROOMS DHB does allow and pay for nearby motel rooms to be hired out by on call and hospital, and many SMOs at North Shore Hospital in emergency staff. Auckland have been wrangling with consultants don’t want to - make a fuss or be accused of the Waitemata DHB over workplace “We haven’t seen the receipts and we’ve accommodation for years, with meeting done a bit of maths on the back of an elitism, so they just make do.” notes dating back to 2008. envelope, but we reckon they (the DHB) ASMS Branch President and intensivist has paid over $1 million in motel rooms over Dr Jonathan Casement says the DHB has the past ten years,” says Dr Casement. When he does an overnight on-call shift, now set up a working group with a budget “Most of us appreciate it is hard to find he prefers to stay at the nearby Ibis Hotel, set aside for planning. accommodation areas in an active acute which he pays for himself, but with the hospital and many consultants don’t want Covid emergency he was forced back in “It’s a major gain for us as we’d never had to make a fuss, so they just make do, but the rooms due to the hotel closure. any scoping money assigned to project plans. It’s been a really frustrating past ten providing good SMO accommodation is “I’ve done a few night shifts and it’s years, but I think with persistence we’ve one part of the MECA which DHBs have reminded me that the rooms are less than now created some momentum. Covid-19, not taken seriously enough.” he adds.

WWW.ASMS.ORG.NZ | THE SPECIALIST 15 DOCTORS IN THE HOUSE ELIZABETH BROWN | SENIOR COMMUNCIATIONS ADVISOR

here are just two MPs in the New Zealand Parliament who are medical doctors – one in the red corner and one in the blue. TThey both sit on Parliament’s Health Select Committee and both were on the Epidemic Response Committee, formed to assess the impact of the Covid-19 crisis. What leads a doctor into the bear pit of politics, and what contribution do they feel they can make?

DR LIZ CRAIG candidate in 2014 and then got into incorporated in political decision making, Parliament at the last election,” she says. not to mention the additional investment Dr Liz Craig is a first-term Labour list in the country’s public health units. MP from Invercargill – a job she likens As a new MP her life is now split between to a first-year house surgeon. Invercargill and Wellington. The hours Dr Craig does not deny that parts of the are long, especially when Parliament is health system are struggling but argues She entered Parliament after a career sitting and it is a travel day. the Government has inherited a decade as a public health physician. of underinvestment and realistically “There is no training manual, so you’re Her interest in public health developed has only had two budgets to address it, very much working from your own when, following two years as a house with the first two focusing on primary experience but liaising with senior surgeon at Taranaki Base Hospital, care access, mental health, where colleagues. It just feels very like those she headed to Australia, first working there has been huge unmet need, and first few years in medicine where the infrastructure development. in Canberra, where she earned a learning curve is steep, the hours are Diploma in Paediatrics, before spending long, yet it’s really rewarding.” “This year the Government has moved four years training Aboriginal and to significantly expand our public health Torres Strait Island health workers A lot of Dr Craig’s time is taken up with capacity in response to Covid-19, with in Queensland. Returning to New select committee work. She sits on the this month’s budget also investing a Zealand she entered the public health Environment Committee, where she record amount in DHBs to relieve basic training scheme, completed a PhD in takes a keen interest in zero carbon cost pressures and help them catch up epidemiology and went on to establish initiatives and climate change. As a on the backlog created by Covid-19. the New Zealand Child and Youth member of the Health Committee she “But it’s not just about what’s in this Epidemiology Service, monitoring and likes the overview she gets of district year’s budget, you have to take a collating data on the health of the health boards and the Ministry of longer, strategic approach. You have country’s children and young people. Health, and her background helps her to look over three, seven, ten years in understand some of the complexities terms of what is the broader investment The move to politics seemed like a and policy interface. strategy and asset management plan.” logical step. Workforce training and retention also “I’d seen during the course of my work requires “some strategic thinking,” that we had high rates of children “It just feels very like those she adds. coming into hospital for poverty-related conditions. Tracking back, I could see child first few years in medicine What really spins Dr Craig’s MP wheels poverty rates surged in the early 90s, where the learning curve is is that on any given day she can be with the Mother of All Budgets, benefit steep, the hours are long, looking at water issues, employment issues, community development, cuts, market rates for state houses and yet it’s really rewarding.” housing, employment, or health. the Employment Contracts Act. For now, politics is very much in her “Children are looked after well in future. She has been selected again hospital but then they go home to She appreciated the opportunity to to stand as Labour’s candidate for the damp, cold houses and I thought about be part of the Epidemic Response Invercargill electorate. how to make a bigger impact on that, Committee on the Covid crisis, hearing so I joined the Labour Party in 2010 from the range of health professionals “It would be good to be able to with a view to helping them write and groups which appeared before it. continue. In the first term you focus children’s policy. on the basics of being an MP, and the For the long-time public health next step is being available where you “From there I got more involved in advocate, it was heartening to see the are needed. Given my background, the thinking through the broader social value of epidemiological modelling and health sector is definitely where I’d like policies we might need and became a public health advice recognised and to make a bigger political contribution.”

16 THE SPECIALIST | JUNE 2020 Dr Liz Craig Dr Shane Reti

DR SHANE RETI responsible for an electorate of 85,000, so unmet need, which New Zealanders need I can reach and help more people.” to accept. The solution he believes is to Dr Shane Reti is in his second term as the make the most of the resources we have - - Dr Reti keeps up his medical registration, National MP for Whangarei. He is a GP and improve the system through better and during parliamentary recesses and and dermatologist and served three terms measurement and public service targets. on the Northland District Health Board. the summer break he dons his stethoscope He worked at Harvard University in the and sees patients. He also keeps in close Fundamentally, he believes New Zealand US, where he specialised in informatics, contact with medical colleagues by boxes above its weight in terms of what helping foreign governments fix their running a Maintenance of Professional we do with the resources available and broken health systems. Standards (MOPS) group once a month. in relation to the percentage of GDP spent. He adds however, there is room It is his firm view that doctors and politics to do better and sitting on the Epidemic are inextricably linked. Response Committee to Covid-19 has ”Medicine always has a “If politics is the ability to persuade brought some of that into sharp focus. towards a point of view, that’s what political interface because we are the advocate for our “Coronavirus has pushed and stretched our doctors do day in and day out with our system and made more evident some of the patients, especially around patients. Medicine always has a political holes we have, especially in public health. interface because we are the advocate funding and servicing.” What I’m hoping we may get out of Covid-19 for our patients, especially around funding is greater resourcing and funding of public and servicing.” health and maybe even more people “I don’t think you can be a doctor without He believes “staying on the tools” adds value interested in it as a career specialty.” having political engagement,” he says. to his role as an MP and as the Deputy He believes the beauty of the Epidemic On a personal level, his time on the Chair of the Health Select Committee. Response Committee was that it allowed Northland DHB, along with his work with “I bring technical expertise and I bring the professionals to tell their stories and overseas governments during his time at coalface to Wellington. Officials will tell highlight the issues. Harvard, consolidated a long-held interest me about some great policy and great Dr Reti has no plans to quit politics at this in politics. When five-term Wha-nga-rei MP programme in one ear, and then I go stage. He is currently National’s associate Phil Heatley announced his retirement and find the truth to that by speaking to spokesperson on health and would be up in 2014, Dr Reti was enticed home and patients and my doctor colleagues. I find for a larger role, though he is quick to add successfully campaigned to retain the seat out exactly what is and isn’t working. “that would be up to the leadership.” for National. “That’s not to diminish the advice and As to whether he’s a future health minister He says he often hears from voters that hard work that officials do, but there’s a in the making, again he reiterates that New Zealand needs more doctors than difference between the blackboard and would be the decision of the National Party politicians. He has a ready response. the patient bedside.” leader, but says, “I keep my head down and “In general practice I can service maybe Dr Reti says health systems everywhere are work hard and my observation over several 1500 to 2000 patients, but in this role I’m a challenge. He says there will always be careers is that good things happen.”

WWW.ASMS.ORG.NZ | THE SPECIALIST 17 Angela Belich Virtual farewell party

A MAY DAY FAREWELL SARAH DALTON | ASMS EXECUTIVE DIRECTOR

ay Day marked ASMS Deputy Director Angela Belich’s last day in the paid workforce. It was strangely fitting that these two Mevents coincided. Angela has spent her working life in the encountering someone from the public around her are nurtured and cared for. pursuit of better pay and conditions for service, it is not uncommon for Angela As her daughters noted at her farewell, working people. In particular, she has to remark that she knows that person, Angela has always role-modelled what it been a fierce and persistent leader in whether they were a PSA delegate, a is to be a working parent and has inspired the pursuit of equal pay and fair and public service manager, or someone them to grow up as feminists and activists equitable entitlements for working women. she’d advised or advocated for at some in their own right. She is a proud and staunch feminist, not to point in the past. Angela’s networks are Angela’s decades of commitment to the mention a passionate and utterly reliable broad and strong, and her institutional working people of Aotearoa cannot be friend, colleague, and comrade. And she is knowledge will be truly missed. We know encompassed in a short farewell. Her always kind. that the whole point of union endeavour is to ensure that whole systems support service to the PSA and ASMS has been If you dip into New Zealand’s electronic people, and that we do not need to rely on significant both in quantity and quality, archives you will find glimpses of her one person. Together we are stronger, but and her leadership and mentorship student activism in the 1970s and people like Angela also remind us that our of many union activists, organisers, reference to her contribution to New union movement is enriched, strengthened delegates, and members means that her Zealand’s left-wing political struggles, and nourished by individuals of her legacy is much more than the work of a including a visit to China in 1974. She calibre. And we celebrate that. single person. Her contribution is marked has been a strong and effective voice by a network of women and men engaged She also leaves numerous collective on various gender pay and pay equity and enriched through her intellect, agreements that bear the hallmarks of her inquiries and taskforces and has fought leadership, and support. for the betterment of New Zealand’s shrewd advocacy and intelligent approach public service. to negotiation. Most recently our members We were proud to achieve further at Family Planning, and those in a range gains for women in our recent MECA Angela’s working knowledge of the state of rural hospital and urban primary health negotiations, along with an assurance sector legislation in all its myriad forms is care settings, have reason to be grateful from the DHBs that they will address the such that she is the acknowledged expert for her tenacity in securing improvements gender pay gap across the SMO/SDO in this field, and who knows what poor to their conditions of work. workforce. These initiatives will continue, souls (because it will surely be more than It would not be proper to mark Angela’s and as we continue to tackle equity issues one person needed) will have to try and fill retirement without commenting on her across the health sector we will do so this gap. love and care for her wha-nau, be they strengthened and encouraged by the As noted at her virtual Zoom farewell on immediate, extended, or adopted. Angela legacy of Angela’s commitment to the May Day (actual party pending), when always makes time to ensure the people labour movement.

18 THE SPECIALIST | JUNE 2020 COLLEAGUES PAY TRIBUTE TO ANGELA “I thank Angela for her mahi, for being “Angela and I first met at CTU a great comrade in arms and for being I PAY TRIBUTE TO meetings and I was in awe of her a generous person and colleague. ANGELA BELICH AND THE obvious intellect and the high Angela played a significant role in the COMMITMENT OF OVER 40 esteem that people held her in. YEARS OF HER WORKING development and roll-out of the Health LIFE TO THE ADVANCEMENT It was not until starting work Professionals Competency Assurance OF WORKING PEOPLE with ASMS that I realised that Bill (now Act) in the early 2000s, AND THEIR UNIONS. SHE alongside that intellect and Angela bringing together health professional WAS AN ACTIVIST AND being a deeply committed union EMPLOYEE OF THE PSA and health trade union groups. She AND WAS ONE OF THE KEY activist, she was also one of the worked relentlessly, effectively and PEOPLE IN THE BUILDING kindest and most generous people determinedly to make sure that the OF ASMS INTO THE STRONG I have ever met and would become legislation was based on respect and ORGANISATION IT IS TODAY. the best boss I have ever had. Her recognition of health professionals and ANGELA IS A GOOD FRIEND, vision and strategic thinking has AND I WISH HER ALL THE their needs and concerns. Angela – you BEST FOR HER RETIREMENT.” been invaluable, but it is the kind - are appreciated, you are hugely valued, – JOHN RYALL, FORMER E TU colleague that we are going to and you will be much missed.” – EILEEN ASSISTANT NATIONAL SECRETARY miss the most.” – LLOYD WOODS, ASMS BROWN, CTU SENIOR POLICY ANALYST SENIOR INDUSTRIAL OFFICER

CALLING TIME ON AN ACCOMPLISHED CAREER DR CHARLOTTE CHAMBERS | ASMS HEAD OF POLICY & RESEARCH

SMS’ former head of policy and research Lyndon Keene has formally retired from his role at the union. He is well known to Amembers for his insight and deep understanding of the health sector, along with his sharp analyses of health policy and politics. When Lyndon arrived in New Zealand in (then Minister of Labour). After his time in As a successful painter and printmaker, the mid-1970s from Britain, little could he Parliament, Lyndon once again undertook Lyndon is planning to use his retirement to imagine the contribution he would make to contracts for ASMS before joining its staff pursue his passion for art. He also plans the country’s public health system. Despite as a part-time researcher in 2012. to keep hitting the waves south of Sydney a stint at art college in the UK, Lyndon where he has been based for the past Dr Peter Roberts, a former ASMS few years. went on to forge a career in journalism in president, has had a long association New Zealand, working for The Listener with Lyndon that began in 1991 with the The good news for ASMS members is that before freelancing. It was at the New Coalition for Public Health as it battled Lyndon will continue to do some contract Zealand Nurses Organisation (NZNO) privatisation of the health sector. work and articles for The Specialist. You where Lyndon first delved into the health can read his latest contribution – an union sector, first editing Kai Tiaki Nursing He says the Coalition became a real analysis of the Budget on page 10. New Zealand and then taking on the role force thanks to Lyndon’s tenacity and as public relations officer. journalistic know-how. Lyndon left NZNO to act as coordinator “Through Lyndon we came to understand of the New Zealand Coalition for Public exactly what we needed to say. Lyndon Health through most of the 1990s. During was the primary writer and developer this time, he also began work for ASMS on of a huge series of press releases. There a contract basis, as well as campaigning was always more data and detail in his alongside former CTU president Ross releases to back up our arguments.” Wilson against the privatisation of ACC. He describes Lyndon as one of the most From 2000, Lyndon moved to the insightful and logical thinkers he has ever known. corridors of power at the Beehive, working for eight years as a ministerial advisor and ASMS wants to acknowledge the occasional press secretary in the Clark contribution Lyndon has made to the shape Government. He continued with stints as of New Zealand’s health system, along with a press secretary for Annette King (then his personal commitment to fairness, and Lyndon Keene Minister of Health) and Margaret Wilson the values of unionism and equity.

WWW.ASMS.ORG.NZ | THE SPECIALIST 19 TALKING TELEHEALTH POST-COVID DR JULIAN VYAS | ASMS NATIONAL EXECUTIVE MEMBER

he Covid-19 pandemic has meant a rapid increase in the use of IT to support distance consultation through telehealth. ASMS TNational Executive member and Auckland paediatrician Dr Julian Vyas has been thinking about the implications for members. The current coronavirus pandemic has with the recently updated Medical Council telehealth, although many of the clauses highlighted that ongoing distant contact statement, as well as respective College relating to workplace equipment provision with patients is inevitable and can guidance and your DHB’s policy guidelines. will encompass it. Whether there is a need generally be thought of as a desirable for a specific clause will be discussed by In addition, the New Zealand Telehealth adjunct to health care services. Where ASMS’ leadership in the future. geographical or financial constraints Project website (www.telehealth.org.nz) disadvantage some patients, telehealth can links to many relevant documents and Nonetheless, aspects of care provision and help address areas of inequity of patient guidelines for clinical practise as well as ultimate consequences of virtual clinics access. However, the disparate nature technical requirements. may need to be agreed upon by services and their DHBs, before embarking on a of clinical work and patient complexity Looking at other peer-reviewed literature long-term change in service provision. The means that each service must assess on telehealth relating to your specific area how telehealth might be implemented for MECA is very clear that DHB’s cannot of practise would also be useful. patient groups within its case mix. introduce or increase service delivery via There are several platforms via telehealth without adequate consultation We would encourage members who downloadable apps and online that can and engagement, and ultimately are considering expanding their clinical host video or audio meetings. At present agreement, with clinical staff. support for patients through telehealth Zoom seems to be the platform of choice to take a circumspect approach to the Telehealth is not a panacea for problems in New Zealand and globally. Members numerous implications and ramifications of ensuring patient contact with clinical who wish to use other platforms (e.g. doxy. for their usual practise before committing services. Ultimately, use of telehealth must me) are advised to clarify if their DHB to this. Where necessary, clarification from be the patient or carers’ choice, and not be will support the use of alternative video the employing DHB should be obtained insisted upon by the clinician, or DHB. beforehand, on issues such as liability, conferencing platforms rather than just equipment purchase and maintenance, using them. Look out for further ASMS research and advice on the issue and if have any along with funding and workforce ASMS is reviewing the industrial aspects of consequences of telehealth contact. concerns around telehealth get in touch telehealth. These have not yet had much with your ASMS industrial officer. If you are contemplating initiating or consideration from health unions, either increasing the use of telehealth in your within New Zealand, or internationally. The A fuller discussion document on telehealth clinical work, it pays to get acquainted ASMS MECA has no specific reference to by Dr Vyas is on the ASMS website.

20 THE SPECIALIST | JUNE 2020 Dr Genevieve Ostring A wintry walk to work in Vancouver

MY SABBATICAL DR GENEVIEVE OSTRING

arly this year Auckland paediatrician and paediatric rheumatologist Dr Genevieve Ostring spent time in Vancouver, Canada, as Epart of her sabbatical. She took some time to share her experience. I am probably one of the few people What I had not realised was how similar “Our consideration of the who managed to take (part) of my British Columbia’s medical system is to our inequalities in health care sabbatical in early 2020. I work in a own here in Aotearoa New Zealand, at outcomes for Ma-ori and small national team of four paediatric least in terms of paediatrics. Similarities rheumatologists, and in a larger team include population (5 million in New Pacific Islanders in New of general paediatricians. For the first Zealand, 5.1 million in British Columbia), Zealand is echoed by their half of my sabbatical I chose to spend a predominately public health system emphasis on ensuring equity time with the paediatric rheumatology (no private paediatric rheumatologists in team at the British Columbia Children’s for the indigenous First either), and a small team covering a large Hospital (BCCH) in Vancouver, Canada. I Nations population.” geographical area. Our consideration of chose BCCH for many reasons, but a key the inequalities in health care outcomes one was that Professor Ross Petty, who - is widely considered the grandfather of for Maori and Pacific Islanders in New The BCCH team culture was enlightening. paediatric rheumatology, still spends 1–2 Zealand is echoed by their emphasis on days a week in the hospital with the team, ensuring equity for the indigenous First There were diverse ideas, nationalities despite being officially ‘retired’. I had met Nations population. So there were many and backgrounds, but despite the Ross several times over the years and issues, other than specific management of difference, it was a highly functional team was impressed with his extensive clinical clinical conditions, which I found directly and a very positive environment to work in. expertise, combined with a very kindly, applicable to my role and teams back in Due to shortages of space in the hospital gentle, humble personality. New Zealand. (another similarity to my workplace in

WWW.ASMS.ORG.NZ | THE SPECIALIST 21 New Zealand), I ended up sharing an Vancouverites. The news videos poking fun times as much FTE for medical staff and office with the fellows (juniors in training) at themselves for their lack of ability to 5 times as much FTE for nursing staff and and was able to explore quietly some cope with ‘real snow’ (something the rest physiotherapy staffing, as well as access of the team dynamics. They verified my of Canada does on an annual basis) were to other staff such as a psychologist. This impression that it was a positive place to hilarious. I had the appropriate gear as we all could have been depressing, but I came both work and learn. I believe the concept did some skiing while in Canada, however, back to New Zealand with a sense of of ‘psychological safety’ was what made getting to and from work involved more pride in our team here in terms of what we things work so well. It was fascinating to than an hour’s walk each way (in my ski achieve for our patients despite the very watch fairly vigorous discussions regarding gear) as no public transport was running. small current FTE available. patient investigations and management Those that did try and catch buses to work between the more ‘grey-haired’ members found themselves in lines of up to 15 buses of the consultant team, who tended to which had all become stuck in snow! These rely on clinical experience, versus the walks provided me with some spectacular “There were diverse more recently trained consultants, who photo opportunities. ideas, nationalities and relied more on the latest ‘consensus backgrounds, but despite the protocol’. Many of the diseases we difference, it was a highly treat in paediatric rheumatology are “These vigorous but functional team and a very rare, and therefore randomised trials of positive environment to management are not available. However, respectful discussions I believe these vigorous but respectful resulted in better patient work in.” discussions resulted in better patient outcomes, as well as outcomes, as well as development of a development of a very very healthy team culture. healthy team culture.” The sabbatical time has given me I found Canadians to be friendly, practical increased knowledge and expertise and inclusive and instantly felt at home in regard to paediatric rheumatology while exploring beautiful Vancouver conditions, an opportunity to create links and its surrounds. We were there for a The biggest difference between the with a wonderful team overseas, renewed record-breaking snowstorm, which brought paediatric rheumatology team in BCCH admiration for my colleagues and the work the most snow since records began in and here in Starship is resourcing. they do back home, and an ongoing love 1899 and the coldest weather in over 50 Although access to drugs and treatments affair with the spectacular natural beauty years! As a visitor I was thrilled, but the were similar, the resource of ‘time’ was far that snow creates. I would recommend a huge dump certainly caused havoc for in excess in BCCH. They literally had 10 sabbatical to anyone.

22 THE SPECIALIST | JUNE 2020 THE MENTAL HEALTH CRISIS INSIDE OUR PRISONS DR CHARLOTTE CHAMBERS | ASMS HEAD OF POLICY & RESEARCH

hortly before Covid-19 dominated world headlines, Dr Erik Monasterio and other clinical directors from New Zealand’s forensic Sservices co-wrote a powerful editorial for the New Zealand Medical Journal. Entitled ‘Mentally ill people in our prisons are suffering human rights violations’, it followed on from other articles he and his colleagues have written, highlighting the grim plight of forensic psychiatry patients in our country’s prisons. Forensic psychiatrists deal with the pointy in custody who have serious mental Lack of adequate resources to provide end of the mental health spectrum. Many illness. In particular, having limited care to persons with mental illness in patients with the most acute mental access to treatment for serious mental custody also increases the risk of re- health needs are in custody. Unfortunately, illness, especially when they are too offending and is inconsistent with the services available to treat prisoners with unwell to accept treatment by consent. Government’s priority to decrease the serious mental health issues have not As highlighted in the editorial, those on prison population number and to target benefitted from the increase in funding urgent waiting lists can spend extended improved treatment for mental illness. announced by the Government for mental periods of time in Intervention and What do you want the Government to do? health services in relation to the growing Support Units (ISUs) in conditions of demand and growing prison population. solitary confinement without receiving We believe that this needs to be As Dr Monasterio and his colleagues treatment and while continuing to considered a health crisis, and in the detail, much of the prison population experience considerable disability and short-term, focus on health solutions, falls between the cracks of the system. distress. The conditions of ISUs breach while in the longer term, political Many require mental health treatment national and international standards for approaches need to decrease systematic - yet cannot access the services that would minimal care of prisoners and is in breach bias against Maori, inequality, poverty, benefit their own health and wellbeing of human rights, Te Tiriti o Waitangi, the lack of affordable housing and stable and bring down reoffending rates. Mandela Rules for prisoners, the Bill of employment. There is an urgent need for additional psychiatric hospital resources It is a problem which Dr Monasterio says is Rights and the United Nations Convention to manage those who have acute not only pressing, but likely to get worse. on the Rights of Persons with Disabilities, along with other international agreements and severe mental illness, particularly He took the time to respond to a written to which New Zealand is a signatory. those with high and complex mental interview during the Covid lockdown health issues. An extension of culturally and is interested in the views of ASMS Why does this matter? appropriate treatment interventions members on the subject. There has been rapid growth in the is crucial. Specialist mental health courts and diversion initiatives to avoid Why have you and the other clinical New Zealand prison population over incarceration of the seriously mentally directors of the New Zealand Forensic the past decade which is not explained unwell, particularly when associated with Service written this editorial? What are by changing patterns of recorded low-risk offending, need to be considered. the main arguments you are making? crime, particularly violent crime. The incarceration rate in New Zealand is Extension of drug courts, which have been The editorial looks at the substantial very high (per capita 30% higher than successfully piloted in New Zealand, and disadvantage faced by persons detained Australia, with a rate of 220/100,000 increased access to additional drug and cf. 167/100,000) and the prevalence of alcohol treatment would relieve pressure mental illness continues to increase in on the prison system and provide early prisons. intervention. It is not rare for persons with serious Prior to Covid-19 restrictions, work on a mental illness, social disadvantage and number of initiatives between Forensic low-risk offending to be detained in Mental Health Services, the Ministry of Health, Corrections and Mental Health custody, as there is insufficient general and Addiction Services for improved adult mental health service support and access and flexibility for the provision services. Those persons can then end up of mental health care in New Zealand in the ISU in unacceptable conditions (for prisons commenced. The aim of these example, persons with serious untreated initiatives was greater flexibility and schizophrenia remanded to custody interagency integration in the provision of with minor charges such as breach of services, including culturally appropriate court conditions, shoplifting or theft). interventions in custody. However, while This affects some of the most vulnerable these initiatives are likely to relieve and disabled persons in our community, pressure within New Zealand prisons, particularly Ma-ori. they will not adequately deal with the use Given the high prevalence of Ma-ori in of ISUs for those inmates with acute and prison, this is also a breach of Te Tiriti o serious mental illness requiring inpatient Dr Erik Monasterio Waitangi. hospital care.

WWW.ASMS.ORG.NZ | THE SPECIALIST 23 WILL THE DOCTOR-PATIENT RELATIONSHIP BE CHANGED FOREVER? DR PALLAVI BRADSHAW | MEDICOLEGAL LEAD, RISK PREVENTION AT MEDICAL PROTECTION SOCIETY (MPS) FOREWORD BY DR TIM COOKSON | MEDICOLEGAL CONSULTANT, MPS (NEW ZEALAND)

FOREWORD

he following is a transcript of a talk Dr Bradshaw gave at the recent UK ‘Risky Business’ virtual conference on lessons Tlearned from Covid-19, and it is very instructive to see the pressures and medicolegal implications from the Covid-19 crisis in the UK compared with New Zealand. In New Zealand, the Medical Council significantly changed the wording of the statement on telehealth in a way that provides additional protection for doctors conducting remote consultations. The Health and Disability Commissioner also stated to the RNZCGP just prior to level 4 commencement that any complaints during this time would be assessed taking into consideration the changed circumstances. The extent of complaints relating to delays in treatment or issues relating to remote consultations is not yet known, but each will be considered according to the particular situation, and also taking into consideration the Medical Council statement on safe practice in an environment of resource limitation. Thankfully, due to the low numbers of Covid-19 cases in New Zealand, we are not likely to see many cases directly relating to care provided to infected individuals. The estimated 78 billion NHS liability for claims already existing prior to Covid-19 does put things into perspective compared with New Zealand.

24 THE SPECIALIST | JUNE 2020 Dr Pallavi Bradshaw Dr Tim Cookson

The relationship between the doctor and the utilitarian ideals advocated by some The New York State Governor has granted patient is crucial, and it is influenced by the to act for the greater good, and is this legal immunity to health care workers practice of medicine, ethics and the law – all compatible with our sense of empathy or during the pandemic. of which have been disrupted by Covid-19. indeed the criminal law? In the UK, MPS has called for emergency Patients have been physically and Consent is fundamental to the trust laws to protect health care workers from emotionally separated from doctors by and respect within the doctor–patient criminal and regulatory investigation – a use of PPE, remote consulting and fear relationship and relies on there being a call supported by two thirds of the public, of accessing health care, leading to competent patient in receipt of sufficient according to a YouGov survey of over an imbalance between the art and the information, free of coercion. I do question 2,000 adults in Britain.1 science of medicine. whether informed consent is always If immunity from criminal and regulatory Empathic and clear communication is possible in the current climate when hearing of patients receiving letters investigations is not offered, then we must seen by patients as a proxy indicator look to judges to interpret the current of competence and skill. In fact, poor regarding their DNR status and ED staff discussing options with elderly, vulnerable law and reflect the attitudes of society. communication is often the differentiating They must question whether it is fair that factor between those doctors who are patients attending alone. I also wonder what unintentional influence society has a psychiatry trainee asked to cover an sued and those who are not, even if acute ward in the pandemic be judged at clinical incident rates are equitable. had on those patients’ decisions in our unremitting focus to save the NHS. the same level as a medical registrar, as Telemedicine relies heavily on per the Bolam test. Does Bolitho [Bolitho communication, which is impaired by HOW HAS OUR LEGAL RELATIONSHIP v. City and Hackney Health Authority] loss of verbal and non-verbal cues and CHANGED? allow them to overlay the Covid-19 our impatience. The need for full and While we normally enjoy the right of context to a logical interpretation of open dialogue at this time is highlighted self-determination, the Coronavirus Act negligence? Should the legal test be what from claims experienced during SARS 2020 saw the UK Government assuming a ‘reasonable society’ expects rather than and MERS. In some cases, physicians responsibility for managing our risk. Most the ‘reasonable’ patient? Will the judiciary were unduly influenced by the pervading settled into this passive role without who have upheld patient rights for so context and incorrectly attributed patients’ resistance, with many now unwilling to long intervene to protect our health care symptoms to those diseases. These risks assess or assume the hazards posed and system and its workers? are heightened if examination is limited seeking direction from authority. Does but can be mitigated to some degree by There is also fear that a tsunami of claims this mean that we will not tolerate risks in altering our consultation style – listening may be approaching, particularly owing actively and checking back information health care either or expect guarantees to delayed and missed non-Covid-19 and warmth of tone. Cost, convenience and absolutes before accepting diagnoses. With outstanding NHS and risk means telemedicine will remain treatment? Or will patients look to us to liabilities estimated at £78 billion,2 this a fundamental tool but potentially to the make a judgement call and tell them what again raises the challenging question as detriment of the protective connection we to do – a return to paternalism maybe? to whether patients should be prevented have with patients. I wonder if the respect and empathy being from seeking compensation at this time. TURNING TO THE ETHICAL ASPECT OF shown by the public and press towards The crisis may have escalated the break- THE RELATIONSHIP. health care workers will translate to up with our patients but perhaps there is greater tolerance of medical error. Can a new love affair between the profession We see the interests of our patient we now accept that stretched staff and and society. Covid-19 has brought as paramount, and yet in the time of resources will not always deliver high disruption to the practice of medicine, our Covid-19 many have received less care quality care and that on occasion patients ethics and even the law – it is no surprise due to constraints, or no care at all due will be harmed? then that it has changed the doctor– to many patients opting to stay away from hospitals. We have struggled to Even in a country which takes pride in its patient relationship forever. agree on fundamental issues of resource citizens’ constitutional rights and freedoms, allocation and withdrawal of treatment, the US Senate Majority Leader recently REFERENCES though at this stage we have been stated, “We are going to protect the 1 https://www.medicalprotection.org/uk/ mercifully saved from having to decide healthcare workers who have been locked articles/covid-19-public-support-for-doctors- whether to withdraw ventilation from in combat with this mysterious new disease. legal-protection-overwhelming one Covid-19 patient to benefit another We are not going to let healthcare heroes 2 https://resolution.nhs.uk/wp-content/ as worries about ventilator shortages emerge from this crisis facing a tidal wave uploads/2019/08/NHS-Resolution-Annual- have not materialised. Should we accept of medical malpractice lawsuits.” Report-2018-19.pdf

WWW.ASMS.ORG.NZ | THE SPECIALIST 25 THINKING OF BECOMING A CLINICAL DIRECTOR?

SMS has created a new document about the role of the clinical director. Many of you will hold this role at some stage of your Acareer but may not receive specific training in what’s involved. The document covers the ins and outs of what to expect from the role, the reasons you might choose to do it and some of the duties involved. There are also useful tips about decision making, information sharing and some of the relationships involved as clinical director. Our aim is to help you better understand and tackle this important role, and to support better outcomes for patients, improve staff cultures and increase your job satisfaction. Search ‘The role of the Clinical Director’ on our website to read the whole document and let us know what you think. We’re interested in your feedback and intend to update it on a regular basis.

WHAT MAKES A GOOD CLINICAL DIRECTOR?

• Decision-making through consultative • Utilises skills and talents of staff and • Actively guards against gender bias, processes, based around providing is not threatened by this ethnicity bias and ageism best possible patient care and Knows and understands staff contracts Supports staff requirement for non- enabling staff to flourish • • clinical time to protect staff well- • Seeks department consensus for all • Accurately analyses service being important decisions requirements to provide best • Informs themself and staff of bullying possible patient care Questions themself and reassesses if • behaviours so these can be actively their view is clearly at variance with • Makes these requirements known discouraged most colleagues to management to enable good • Gives regular positive feedback to decision-making Puts the department team before • staff themselves • Considers cost-effectiveness of tests • Ensures adequate time for the role and treatment in decisions • Recognises that all department members are equally important • Accepts others’ points of view • Shares information freely and frequently with department staff • Enables contribution, without • Welcomes constructive feedback interruption, from all team members and advice • Encourages staff to develop in meetings

26 THE SPECIALIST | JUNE 2020 WWW.ASMS.ORG.NZ | THE SPECIALIST 27 WELCOMING NEW POLICY ANALYST

ASMS has welcomed Mary Harvey to its Policy and Research team. Mary comes to ASMS from the Australian committees on key issues. and New Zealand College of Anaesthetists The Covid-19 emergency meant an unusual (ANZCA) where she had been working as start to her new role at ASMS. Mary had senior policy analyst. only been in the office a day or two when the Before that she had built an impressive career country went into lockdown and has had to rely working across government. In particular, on Zoom to get to know the team. she worked at the Ministry of Health, and “The team has made me feel very welcome. the Office of the Auditor-General where she I’m looking forward to working with ASMS managed a portfolio of central government and shining a light on relevant issues in the Mary Harvey agencies, advising Parliamentary select health sector” Mary says.

remuneration schedule, particularly if you are reducing your hours/FTE or duties. Be aware that reductions in hours of work and job size may also affect other entitlements e.g. superannuation, on-call and availability arrangements, CME and existing and future leave entitlements. If you’re thinking of reducing your hours of work, we encourage you to contact your ASMS industrial officer for advice. CHANGES TO JOB DESCRIPTION – CLAUSE 48.1 Your job description must also be mutually agreed. Again, this means if the DHB wants to introduce any changes they are obliged to seek and obtain your prior agreement. If your employer wishes to discuss changes to your job description, we strongly advise you to read MECA clause 48. This clause ABOUT WORKPLACE CHANGES AND our members. The consultation clause sets out what should be in a job description THE NEED FOR CONSULTATION AND requires DHBs to first consult and seek the and observes that the Council of Medical AGREEMENT endorsement of ASMS as to the purpose, Colleges of New Zealand endorses that extent, process and terms of reference of non-clinical activities should make up at ASMS is aware that Covid-19 has meant such review. Only after that first stage least 30% of the total job size, not counting changes to work practices around the average after hours on-call rosters. country, and District Health Boards are of consultations should DHBs begin to beginning to consider what business as consult affected members. WORKPLACE FACILITIES & EQUIPMENT – CLAUSE 53.1 unusual might look like in the short to CHANGES TO WORK HOURS OR JOB medium term. It is important to remember SIZE – CLAUSE 13.1 Finally, if your work or office space is being that the DHB Collective Agreement contains ’redesigned’ to meet Covid occupational multiple provisions which protect members’ Your hours of work and job size must be health requirements, it is important interests when change is being considered. mutually agreed. This means that your to remember that you are entitled to employer may not make changes to your facilities that are of good quality, safe, CONSULTATION – CLAUSE 43 hours of work or job size without your suitable for your needs and generally ’fit Where a DHB proposes a review that may express and prior agreement. ASMS for purpose’. If you do not feel they are result in significant changes for members, advice is that any changes should be adequate, you should seek advice from the DHB must consult both ASMS and in writing, together with an amended your ASMS industrial officer.

28 THE SPECIALIST | JUNE 2020 FEEDBACK

Dear Dr Fuller, Re: Your Article “Not Unwell Enough” We agree entirely with the views you expressed in the March 2020 edition of The Specialist. The Canterbury Charity Hospital Trust (CCHT) has treated thousands of patients with unmet secondary elective healthcare needs (USEHN) of the types you describe since 2007 (NZMJ 2010; 123:58-66. & 2013; 126:31-42). Such unmet needs are not life-threatening but are never- the-less very serious correctable disabilities for the sufferers. It is inhumane and makes no economic sense to frequently defer or deny treatment. It has been clear to us at CCHT since 2014 that vital datasets not measured in New Zealand are the amount and nature of this USEHN. These data are measured by some countries in Europe, North America, Asia and Africa. They are commonly viewed as important for effective health service planning and as excellent overall indices of how well any national health service is functioning. In order to fill the gap in our New Zealand health service data, we got together a national group of experts. They defined a 23 question population questionnaire for the purpose. Then, with funding contributions from ASMS, Canterbury Medical Research Foundation and other benefactors, we conducted a pilot study in Auckland and Christchurch. These relatively small samples we used demonstrated that our questionnaire was externally valid and estimated the overall USEHN to be about 9% for the adult population (NZMJ 2017;130;23-38). We then applied twice to the New Zealand Health Research Committee for funding for a national survey. These applications were turned down on the erroneous grounds that the data were not important and were available from other sources! However, with support from the current Minister of Health, the Ministry of Health agreed to help with the acquisition of these vital data. Unfortunately, at the time of writing this letter, they have only agreed to include one of our survey questions in next year’s National Health Survey and perhaps six questions in the 2022 survey. Furthermore, next year they will only ask about USEHN in the previous year. This will produce a large underestimate of the prevalence of USEHN; our pilot showed only 39% of the total eventuated in the previous year. In conclusion Dr Fuller, we totally appreciate your concerns about the large group of patients with USEHN, whose plight is chronicled by no one and heralded by few of us. We contend that the first step to addressing this muffled issue is to measure its size and nature. Please help us to convince the Ministry of Health to work with our expert group to do the job properly. We’d be eternally grateful if you and all your like-minded colleagues would support us to do so. Yours sincerely,

Phil Bagshaw Chair, CCHT To read “Not Unwell Enough” see page 14 of the March 2020 Specialist

WWW.ASMS.ORG.NZ | THE SPECIALIST 29 NOTICEBOARD

ASMS MEMBERS RECOGNISED IN QUEEN’S BIRTHDAY HONOURS Dr George Ngaei, a Southland surgeon, has become a companion of the New SIMPSON REVIEW Zealand Order of Merit (CNZM) for his services to health and the Pacific The Health Minister David Clark has community. reportedly received Heather Simpson’s long-awaited Health and Disability System Professor Alec Ekeroma, an Review but as The Specialist was going to obstetrician and gynaecologist who print, it had not been released. worked at Middlemore Hospital, has been made an Officer of the New The review was completed by its 30 Zealand Order of Merit (ONZM) for March deadline but has been delayed his services to health and the Pacific due to the government focus on the community. Covid-19 pandemic. ASMS is planning a comprehensive response and analysis Dr Garry Forgeson, a medical once it is made public. oncologist at Palmerston North Hospital, has been made an Officer of the New Zealand Order of Merit (ONZM) for his services to oncology. Dr Janet Catherine Turnbull, a Wellington consultant geriatrician, has become a Member of the New Zealand ON THE MOVE OR CHANGING HOURS Order of Merit (MNZM) for her services – GET IN TOUCH! to health. When you move DHBs or change your hours it is important to let us know so your membership doesn’t lapse and you are paying the right amount. Most members pay by salary deduction, and when you move DHBs your deduction stops, indicating to us that you no longer wish to be a member. If that is not the case, it is best to let us know so we can make sure it doesn’t happen. PREFER TO READ ONLINE? It is also important to tell us if your THE SPECIALIST contact details or hours have changed. We have listened to your feedback and are aware that some members It’s easy to get in touch, by emailing prefer not to receive hard copies [email protected] or calling of the magazine. If you want to

04 499 1271. opt out of the hard copy, just email [email protected] and we can let you know via email when the next issue is available to read online.

30 THE SPECIALIST | JUNE 2020 ASMS STAFF Executive Director Sarah Dalton COMMUNICATIONS Senior Communications Advisor Elizabeth Brown Communications Advisor Lydia Schumacher INDUSTRIAL Senior Industrial Officer Steve Hurring Senior Industrial Officer Lloyd Woods ASMS SERVICES TO MEMBERS Senior Industrial Officer As a professional association, we promote: OTHER SERVICES Henry Stubbs Industrial Officer • the right of equal access for all ASMS job vacancies online Ian Weir-Smith New Zealanders to high quality health Check out jobs.asms.org.nz a services Industrial Officer comprehensive source of job vacancies Phil Dyhrberg • professional interests of salaried for senior medical and dental specialists/ doctors and dentists consultants within New Zealand hospitals Industrial Officer and health services. Miriam Long • policies sought in legislation and Industrial Officer government by salaried doctors and Contact us George Collins dentists. Association of Salaried Medical Specialists Industrial Officer As a union of professionals, we: Level 11, The Bayleys Building, Georgia Choveaux 36 Brandon St, Wellington • provide advice to salaried doctors and POLICY & RESEARCH dentists who receive a job offer from a Postal address: PO Box 10763, New Zealand employer The Terrace, Wellington 6143 Director of Policy and Research Charlotte Chambers • negotiate effective and enforceable P 04 499 1271 Policy Advisor collective employment agreements F 04 499 4500 Mary Harvey with employers. This includes the E [email protected] collective agreement (MECA) covering W www.asms.org.nz SUPPORT SERVICES employment of senior medical and Follow us Manager Support Services dental staff in DHBs, which ensures Sharlene Lawrence minimum terms and conditions for more facebook.com/asms.nz Senior Support Officer than 5,000 doctors and dentists, nearly twitter.com/ASMSNZ Vanessa Wratt 90% of this workforce Have you changed address or phone Membership Officer • advise and represent members when number recently? Saasha Everiss necessary Please email any changes to your contact Support Services Administrator • support workplace empowerment and details to: [email protected] Angela Randall clinical leadership. If you have reason or need to seek a reduction or waiver to your annual subscription, please write to us. Our PO Box 10763, The Terrace constitution allows for this in certain Wellington 6143, New Zealand circumstances. Emails should be addressed +64 4 499 1271 [email protected] to [email protected]

WWW.ASMS.ORG.NZ | THE SPECIALIST 31 We’re here to help.

COVID-19 Response

If you use MAS for your insurance or investments, then we have a number of ways we can help you and your loved ones at this time. Your mental, physical and financial wellbeing is important to us.

To learn more about our response to COVID-19, options for financial support, and the free wellbeing and counselling resources available to all Members and their families, please visit mas.co.nz

And if you’re one of our nation’s frontline heroes in this crisis, you and your families have our deepest gratitude.