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T H E M AG A Z I N E O F T H E A S S O C I AT I O N O F S A L A R I E D M E D I C A L S P E C I A L I S T S   124 | SEPTEMBER 2020

      AND DELIVERY | P10
  ISSUE 124 | SEPTEMBER 2020

  Find our latest resources and
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                                                 03   WE NEED A STRONG UNIFIED VOICE ON HEALTH CARE

  This magazine is published by the
  Association of Salaried Medical
                                                 05   KINDNESS IS EASY TO SAY BUT HARD TO DO

  Specialists and distributed by post and
  email to union members.                             WALKING THE TALK ON SUSTAINABILITY

  Executive Director: Sarah Dalton
  Magazine Editors: Elizabeth Brown              09   HOW THE HEALTH SYSTEM IS BEING SHORT-CHANGED BY ACC
  and Lydia Schumacher
  Designer: Dink Design                          10   CLOSING THE GAP BETWEEN HEALTH POLICY AND DELIVERY

  If you have any feedback on the
  magazine or contribution ideas, please
  get in touch at asms@asms.org.nz.
                                                 12   SIMPSON REPORT: A DISSENTING VIEW - PETER CRAMPTON

  PREFER TO READ THE                             13   HOW THE PARTIES STACK UP

  We have listened to your feedback
                                                 14   A MULTI-MEDIA HUI FOR BRANCH OFFICERS

  and are aware that some members
  prefer not to receive hard copies              15   COVID-19 SHINES A LIGHT ON OCCUPATIONAL MEDICINE
  of the magazine. If you want to
  opt out of the hard copy, just email
  membership@asms.nz and we can
                                                 17   IMGS IN FOCUS

  let you know via email when the next
  issue is available to read online.             18   ASMS WORKING BRIEFS

                                                 19   WILL WE GO BACK TO OUR LOVE AFFAIR WITH JET TRAVEL?

                                                      BOOK REVIEW – THE BAREFOOT SURGEON
  The Specialist is produced with the generous
  support of MAS.
                                                      NEW FACE FOR THE SOUTH

  ISSN (Print) 1174-9261
  ISSN (Online) 2324-2787
                                                 21   WOMEN IN MEDICINE

                                                 22   FIVE MINUTES WITH DR ROGER WANDLESS
  The Specialist is printed on Forestry
  Stewardship Council® (FSC®) certified paper
                                                 24   INDEMNITY CLAUSES IN EMPLOYMENT CONTRACTS

                                                 25   ASMS HEALTH SOLIDARITY

                                                 26   BY THE NUMBERS

                                                      DR PETER STORMER

                                                      REMEMBERING A VISIONARY AND HIS GIFT


O     ne thing the Covid-19 pandemic has done is to sharpen the focus on our health system’s shortcomings. Most notable have been
      the dangerously low number of public health specialists and the shortage of ICU beds and ICU specialists compared to other
similar countries. There is little doubt our hospitals would have been overwhelmed without our Covid-19 elimination policy, and our
ability to deal with our usual patient demands would have suffered badly. However, the deficiencies highlighted by Covid-19 reflect
deficiencies across all specialist areas, resulting from more than 10 years of underinvestment in health care.
Another result of systemic                   mismanagement but by government and            staff/management culture at CDHB
underinvestment, and the Ministry            Ministry policy) has seen a tragic series of   developed over more than a decade.
ignoring clinician advice and placing        events culminating in the loss of arguably     This tragedy appears to be the result of
cost-cutting ahead of patient care, is the   the most highly regarded DHB executive         poor leadership at the highest levels, i.e.
situation now occurring at Canterbury        management team in the country. The            government and Ministry.
DHB (CDHB). The Ministry appointments        strident and unified support for this EMT      This poor leadership and underinvestment
of Crown Monitor Lester Levy and Board       by all CDHB staff and the public, and the      in health is also manifest in fragmentation
Chair John Hansen to slash the CDHB          disdain for the decisions of the Hansen-       and disunity at all levels of health care
deficit (which was generated not by CDHB     led Board, is a testament to the fantastic     around New Zealand. When everyone

                                                                                                                  WWW.ASMS.ORG.NZ | THE SPECIALIST   3
is fighting for the scraps, the natural                                                                                                                                       see exactly what needed to be done and                                                                                                strengthen the health voice nationally for
           tendency is to fend for oneself. DHB                                                                                                                                          his priorities were good. He was, however,                                                                                            our patients.
           chief executives seem not to have united                                                                                                                                      quickly derailed by Ministry officials with
                                                                                                                                                                                                                                                                                                                               You will have noted that ASMS recently
           views around the country; individual                                                                                                                                          faulty logic, plus the Labour Government’s
                                                                                                                                                                                                                                                                                                                               ran a survey to gauge members’ views
           departments are often having to fight for                                                                                                                                     imperative to display ‘fiscal responsibility’
                                                                                                                                                                                                                                                                                                                               on a range of important issues before
           their survival and for their own patient                                                                                                                                      for their political survival, leading to
                                                                                                                                                                                                                                                                                                                               the next MECA negotiations and also to
           group, at the expense of a unified voice;                                                                                                                                     under-correction of investment in health
                                                                                                                                                                                                                                                                                                                               reassess levels of member burnout to see
           and even at the union level, divisions are                                                                                                                                    and patients continuing to suffer.
                                                                                                                                                                                                                                                                                                                               whether this has improved or worsened
           being seen, with two unions now for junior                                                                                                                                    A strong clear voice for health in New                                                                                                since our previous similar survey in 2016.
           doctors and some divisions within the New                                                                                                                                     Zealand is urgently needed. This requires                                                                                             The response rate was 45%, which
           Zealand Nurses Organisation.                                                                                                                                                  intelligent, compassionate and mature                                                                                                 is fantastic when we know members
                                                                                                                                                                                         leadership. Leaders must recognise that                                                                                               are so extremely busy. The survey was
                                                                                                                                                                                         their primary responsibility is provision                                                                                             comprehensive, so analysis will take
                                                                                                                                                                                         of sufficient, high quality health care for                                                                                           time, but we hope to get results back to
                                      Another result of systemic                                                                                                                         all New Zealanders, rather than making                                                                                                members soon.
                                      underinvestment, and the                                                                                                                           budget-cutting the prime goal. They also
                                      Ministry ignoring clinician                                                                                                                        need to work together to reach agreement
                                        advice and placing cost-                                                                                                                         and present a unified voice at all levels,
                                                                                                                                                                                         especially when addressing the Ministry                                                                                                                       A strong clear voice for
                                    cutting ahead of patient care,                                                                                                                                                                                                                                                                                    health in New Zealand is
                                                                                                                                                                                         and government, who can easily blame lack
                                    is the situation now occurring                                                                                                                       of unity for their own faulty decisions.                                                                                                                         urgently needed.
                                          at Canterbury DHB.
                                                                                                                                                                                         Over many years, ASMS has worked hard
                                                                                                                                                                                         to ensure that we represent members’
                                                                                                                                                                                         views as accurately as possible, and                                                                                                  With the political and economic situation
           The most significant problem with this                                                                                                                                        to avoid divisions occurring. We have                                                                                                 in a state of flux, the MECA negotiations
           fragmentation is the lack of a strong                                                                                                                                         managed to keep membership levels at                                                                                                  are unlikely to be straightforward, and we
           unified voice in health care. This becomes                                                                                                                                    around 90% of eligible SMOs/SDOs,                                                                                                     need to portray member views accurately.
           an issue at government caucus where                                                                                                                                           and membership continues to grow                                                                                                      At this point, indicators suggest what
           the important funding allocations are                                                                                                                                         steadily. ASMS has earned respect from                                                                                                members need most right now is more
           debated. As I have discussed previously,                                                                                                                                      DHB management, media, and other                                                                                                      colleagues to share the patient load. This
           David Clark had the potential to be one of                                                                                                                                    organisations, and might have a growing                                                                                               would go a long way to resolving our
           our best Health Ministers. At first, he could                                                                                                                                 role in bringing together various parties to                                                                                          worst problems in health delivery.

                                                                    ESTIMATED SMO STAFFING SHORTFALL AS PERCENT OF CURRENT STAFFING ALLOCATIONS

                                                                                                                                                                                                               AVERAGE 24% STAFF SHORTAGE




                                           CAPITAL & COAST (2016)

                                                                     NELSON-MARLBOROUGH (2016/17)

                                                                                                    COUNTIES-MANUKAU (2016/17)

                                                                                                                                 CANTERBURY (2017)

                                                                                                                                                     WAITEMATA (2018)

                                                                                                                                                                        WAIKATO (2019)

                                                                                                                                                                                            NORTHLAND (2019)

                                                                                                                                                                                                                WHANGANUI (2019)

                                                                                                                                                                                                                                   TAIRAWHITI (2019)

                                                                                                                                                                                                                                                       AUCKLAND (2019)

                                                                                                                                                                                                                                                                         HUTT (2019)

                                                                                                                                                                                                                                                                                       WAIRARAPA (2019)

                                                                                                                                                                                                                                                                                                          SOUTHERN (2019)

                                                                                                                                                                                                                                                                                                                            LAKES (2019)

                                                                                                                                                                                                                                                                                                                                           WEST COAST (2019)

                                                                                                                                                                                                                                                                                                                                                                SOUTH CANTERBURY (2019)

                                                                                                                                                                                                                                                                                                                                                                                          TARANAKI (2019)

                                                                                                                                                                                                                                                                                                                                                                                                            BAY OF PLENTY (2020)

                                                                                                                                                                                                                                                                                                                                                                                                                                   HAWKES BAY (2020)

                                                                                                                                                                                                                                                                                                                                                                                                                                                       MIDCENTRAL (2020)

                                                                                                                                                                                                                                                                                                                                                               Data from ASMS staffing surveys

                    BUT HARD TO DO

Iam writing this in the last week of August – a huge week by any measure. We met with our branch officers for our annual workshop,
 in a mixed medium webinar. It was held as Auckland continued under Level 3 lockdown and Christchurch found some closure in the
sentencing of the terrorist responsible for the mosque shootings.
I want to take a moment to acknowledge          the next DHB, and the next, will not have     Canterbury DHB. We may not always
the terrible loss of so many lives at the       to pay the heavy price of losing an entire    have agreed with each other, and at times
Linwood and Al Noor mosques – including         leadership team? Here is some of what         we have shared difficult conversations. But
one of our people, Dr Amjad Hamid – and         I think.                                      we have never stopped the conversation.
the efforts of our friends and colleagues       • Innovating for integrated and timely
at Canterbury DHB who worked so                                                               We must only hope that those tasked with
                                                  patient care is not cheap and costs         governance in the future learn better
tirelessly in the service of those injured in     money up front – it is an investment.       than the current Board, Chair, and Crown
the attacks.
                                                • Sometimes longer-term benefits and          Monitor, who seem to have abandoned
                                                  savings do not show up on the balance       kindness, and whose eyes and ears are
                                                  sheets.                                     closed to the most important part of our
       It is galling that so many               • People are the most important thing         health system – our people.
      of those people who have                    about our health system, and we forget
                                                  this at our peril.
    sowed the seeds of kindness
                                                • Political cycles are not very compatible
    in Christchurch are reaping                                                                       People are the most
                                                  with long-term planning for best patient
      a very different outcome                    care. Wouldn’t it be great if we could           important thing about our
     from the one they deserve.                   agree some fundamentals and be given            health system, and we forget
                                                  time to put them in place?                            this at our peril.
                                                • Closed-door decision-making is
It makes me think about what being kind           unacceptable.
really looks like. As a team of five million    • Clinical good practice needs to             And to those of you tasked with leading
we grieved with the families of those             drive the work of the planners and          from the centre, we will be holding you
caught up in the mosque attacks. Now we           funders. Remember that doctors have         to account. Like our members, whose
are trying to remember to be kind as we           obligations that are wider and deeper       professional and ethical obligations require
navigate the restrictions and frustrations        than those of employees to employers.       that they speak up on issues of patient
of the various Covid-19 lockdown levels         • Being kind is easy to say and hard to do.   safety, health decision-making, and access
as weeks and months go by with closed                                                         to care, we will continue to advocate for
                                                It is galling that so many of those people
borders, limited travel, and tired hospital                                                   standards of health care that are sufficient,
                                                who have sowed the seeds of kindness in
and community buildings that make                                                             that are sustainable, and that are needed
                                                Christchurch are reaping a very different
infection prevention and control so             outcome from the one they deserve.            by our team of five million.
challenging, not to mention the massive
                                                I want to acknowledge the service and         He waka eke noa – te-na- koutou, te-na-
social and economic pressures on many of
                                                leadership of those who are leaving           koutou, te-na- ta-tau katoa.
our communities.
But I cannot help but wonder where that
sits in the minds of those charged with
overseeing hospital planning and funding.
Many of you will have been following the
unravelling of Canterbury DHB over the
last few weeks and will have seen many of
our members passionately taking protest
action to voice their concern about the
future of health care in the region.
And while money (or lack of it) is the
subject of this cautionary tale, it’s the
breakdown of key relationships, the
adversarial and dictatorial approaches
adopted by the DHB’s Board Chair and
the Crown Monitor (both appointed on
advice from the Ministry of Health) that
are its theme.
What can we learn? What crumbs can
we pick up and scatter in the hopes that                                                                       Cartoon: Sharon Murdoch

                                                                                                                    WWW.ASMS.ORG.NZ | THE SPECIALIST   5
Dr Rob Burrell with a single use intubation device                      Dr Marty Minehan munching a potato starch tray

                               WALKING THE TALK ON

      T   he Lancet has billed climate change as the greatest threat to human health in the 21st century. In many hospitals, specialists are
          at the forefront of sustainability initiatives, driving culture change with clinical expertise and a desire to make things better for
       patients, the planet, and the next generation.
       When it comes to climate change,                  millions of single-use plastic and plastic-     environmental steering group to measure
       sustainability and health care, Middlemore        wrapped items.                                  and reduce the DHB’s carbon emissions.
       Hospital anaesthetist Dr Rob Burrell
                                                         BRINGING CHANGE                                 At its last audit last year, it had reduced its
       describes what he sees as “cognitive
                                                                                                         carbon footprint by 26% through a number
       dissonance”.                                      But the worm is slowly turning, prodded         of initiatives, including the use of reusable
       “You are supposed to be here to help              along by clinicians and hospital staff          cups, rideshare programmes, reducing
       people, but we are creating so much havoc         concerned by the impact of climate change       anaesthetic gases, and better recycling.
       and mess around us by putting piles of crap       on human health and the environment.            It has been recognised as one of Toitu-
       into the atmosphere and the ground and                                                            Envirocare’s top carbon reducers for 2020.
       leaving it for future generations to sort. It’s
       not acceptable or sustainable.”                                                                   ICU specialist Dr David Galler was
                                                                “You are supposed to be                  involved from the start and describes it as
       It is estimated that New Zealand’s health              here to help people, but we                life changing.
       care sector contributes as much as 8%
       of New Zealand’s total greenhouse gas                  are creating so much havoc                 “We started off just doing carbon
       emissions, and according to the Energy                    and mess around us by                   reduction around waste, energy and
       Efficiency and Conservation Authority,                 putting piles of crap into the             travel, and it’s turned into a regenerative
       health is the largest emitter in the                                                              philosophy which has completely changed
                                                              atmosphere and the ground
       public sector.                                                                                    my world view.”
                                                                and leaving it for future
       Our hospitals generate a huge                                                                     Standing in a theatre next to recycling
                                                                  generations to sort.”
       environmental footprint as high-end users                                                         bins and cleaner anaesthetic gases, which
       of gas, electricity, water, and transport.                                                        he successfully lobbied for, Rob Burrell
       They churn out hundreds of thousands                                                              says a lot of progress has been made but
       of tonnes of waste each year, which are           In 2011 staff at Counties Manukau DHB           there is so much more to do, especially in
       dumped into our landfills. They consume           took a ground-breaking step and formed an       terms of procurement.

Auckland Renal Department recycling champions Drs David Semple and Jason Wei

A 2019 report by the Ministry of Health       popular worldwide for intubating Covid-19   his mind, not to mention the cost of
titled Sustainability and the Health Sector   patients, are made in Canada and cost       landfill disposal.
stated: “Procurement is responsible for       $30 each. Dr Burrell says the same
                                                                                          Thinking big, Dr Burrell says New Zealand
an estimated 61 percent of all carbon         company makes a reusable but much
                                              more expensive titanium option.             should be making compostable gowns or
emissions related to health care … This
                                                                                          investing in upcycling to turn the waste into
is the carbon emitted while extracting,
                                              “In the long run, buying five of the        items like combs, park benches or cabling.
manufacturing, packaging, storing,            expensive ones would be cheaper because
and transporting pharmaceuticals              we hoover through the disposable ones.
and supplies … Making sustainable             Plus, our environmental footprint would
procurement part of decision-making           be a tiny fraction. We wouldn’t have               “We tell the registrars if
processes across all health care sectors      thrown anything away, there’d almost be            they’re hungry, to grab a
will help signal a shift in demand toward a   no packaging, we’d be safe if Covid hit
more sustainable health care system.”                                                            bottle of sauce and start
                                              hard because the supply chain would be
                                              local, we’d be employing locals to clean                 eating them.”
                                              stuff and our carbon emissions would drop
                                              because we’re not constantly re-supplying
       “The system is set up to               from overseas.”                             PROVING A POINT
     consume. We need to keep
    pushing hospitals to change               Frustratingly, he says the disposable       Up the road at Auckland Hospital, Dr Marty
                                              items come out of the DHB’s operational     Minehan is another anaesthetist putting a
    the way they make decisions               budget, which is huge, while the reusable   sustainability lens on clinical practice with
     about what they purchase.”               devices would come out of the capital       some interesting results. Approximately
                                              budget, which is tightly held.              175,000 plastic drug trays annually were
                                              “The system is set up to consume. We        being used across Auckland DHB each
A DISPOSABLE CULTURE                          need to keep pushing hospitals to change    year. While the trays could be recycled,
                                              the way they make decisions about what      most were being sent directly to landfill.
Holding up a plastic packet with a single
                                              they purchase,” he says.
disposable intubation device, Dr Burrell                                                  Dr Minehan, who works in Women’s
says hospitals are great at throwing things   The volume of waste created by surgical     Health, took matters into his own hands.
away. The devices, which are currently        gowns and plastic drapes also weighs on     He conducted a life-cycle product

                                                                                                                WWW.ASMS.ORG.NZ | THE SPECIALIST   7
“We transport patients about 600,000
                                                                                                       kilometres a year to and from dialysis
                                                                                                       because we have a treatment model
                                                                                                       which is convenient for us, but often not
                                                                                                       for our patients. If we have units closer
                                                                                                       to where people are, that’s going to save
                                                                                                       travel time, carbon emissions and achieve
                                                                                                       equity goals and better patient care.”
                                                                                                       “When you’re a junior doctor you focus
                                                                                                       on the patient in front of you, but as I’ve
                                                                                                       moved through my SMO role I’ve realised
                                                                                                       my responsibility to the health of my
                                                                                                       population and my country as a whole and
                                                                                                       that health is more than the drugs I can
                                                                                                       prescribe,” Dr Semple says.
                                                                                                       ‘POCKETS OF BRILLIANCE’
                                                                                                       The number of clinical sustainability
                                                                                                       initiatives is steadily growing, but the reality
                                                                                                       is they require corporate sponsorship and
                                                                                                       partnerships so they can be cost neutral to
                                                                                                       the DHB. Many of the opportunities have
                                                                                                       been identified, followed through, and
                                                                                                       endorsed by senior doctors.
                                                                                                       They include a recycling pilot in which
                                                                                                       plastic syringes are being collected and
                                                                                                       repurposed into things like fenceposts, a
                                                                                                       programme in which single use medical
                                                                                                       instruments are converted back to their
                                                                          Surgical tool recycling      mineral content so they can enter the
                                                                                                       recycling chain, and the recycling of PVC
                                                                                                       products like fluid bags and oxygen masks
       analysis, and after a successful pilot, drug   by Clinical Director Dr David Semple.
                                                                                                       into playground matting.
       trays made from potato starch are now          They conducted a waste audit and have
       being rolled out across the hospital.          successfully decreased medical waste             SMOs have also been behind a push to
                                                      from each dialysis process by 40%.               get more charging stations for electric
       The trays are compostable and                                                                   vehicles in DHB carparks.
       biodegradable. He jokes, “We tell the          According to Dr Wei, “For our clinical related
       registrars if they’re hungry, to grab a        projects to be successful it was up to SMOs’     Auckland DHB has reduced its emissions by
       bottle of sauce and start eating them.”                                                         28% in four years, and the achievement has
                                                      support because if they are not on board,
                                                                                                       been recognised with several global and
       He took the project on to prove a point.       other staff won’t be confident to ensure all
                                                                                                       local awards. Like Counties Manukau DHB,
                                                      changes will be implemented properly.”           Auckland DHB has also been recognised
       “I rang each of the suppliers and sent
                                                      Green initiatives are now a standing             this year by Toitu- Envirocare as one of the
       them an email with 20–30 questions
                                                      item in the department’s regular service         country’s top carbon reducers.
       about their products. We did a
       spreadsheet of all the different products      management meetings. It is estimated             Deputy CMO and Director of Cancer and
       and how much they cost.                        four million litres of water a year could        Blood Services at Auckland DHB Dr Richard
                                                      be saved from water-heavy dialysis               Sullivan believes the challenge is to take the
       “We took it to the senior leadership           processes. As a result, staff are being          “pockets of brilliance” around sustainability
       team and what we’ve ended up with is           educated around simple ways to reduce            and embed them into the organisation’s
       a cheaper product, with a significantly        water use, and Dr Semple has been                culture and leadership structure.
       smaller footprint, something which is
                                                      in discussions with Watercare about              “Ideally, when we have our strategic
       easy to dispose of, has virtually zero
                                                      potential large-scale infrastructure             imperatives such as Te Tiriti, equity, and
       environmental impact, is locally made so
                                                      changes to help achieve that.                    digital enablement, in two to three years,
       the money goes back into the economy –
                                                                                                       there will be one around sustainability.
       and you can eat it.”
                                                                                                       “We are one of the biggest employers in
       His advice to his fellow SMOs is to                                                             New Zealand and we should be leading that
       question suppliers about their products.            “When you’re a junior doctor
                                                                                                       space, and the reality is that doctors have a
                                                             you focus on the patient in               major influence in those decisions,” he says.
       “Ask what their environmental credentials
       are, what makes their product better in            front of you, but as I’ve moved
       terms of its environmental footprint, how             through my SMO role I’ve
                                                                                                          The Specialist is distributed by a
       is their company engaged in terms of                realised my responsibility to                  marketing company which is Enviro-
       sustainability?”                                     the health of my population                   Mark Gold certified. The plastic
       WASTE AUDITING AND REDUCTION                        and my country as a whole.”                    wrapping is treated with EcoPure – an
                                                                                                          organic additive which helps plastic to
       A few floors down in the hospital’s Renal                                                          biodegrade. The magazine is printed
       Department, green initiatives began                                                                on Forestry Stewardship Council
       about two years ago, led by technical          Changing models of care are also being              approved paper.
       advisor Dr Jason Wei and supported             looked at.


  A                    CC appears to be under-paying its share of the cost of public hospital trauma care by hundreds of millions of dollars a year,
                       according to Ministry of Health and ACC data and modelling by one DHB.
    While ACC is responsible for funding the                                        indicated by official case-weight estimates.           INVISIBLE FUNDING SHORTFALL
    care for those injured in accidents, its                                        The study involved a relatively small
    funding for those who need acute care in                                        number of patients, so strong conclusions              This funding shortfall has most likely
    public hospitals, covering the first seven                                      cannot be drawn from it. However, if                   grown over many years but has remained
    days from injury, is not paid directly to                                       anything, it probably understates the                  invisible due to a lack of regular accurate
    DHBs. Instead, each year it bulk funds the                                      extent to which case-weight estimates fall             assessment and monitoring. Since the
    Crown for Public Hospital Acute Services                                        short of the true costs of care because                PHAS funding is absorbed into Vote
    (PHAS) costs, amounting to more than                                            it excluded patients who needed urgent                 Health’s general DHB funding, there is
    $500 million a year. The Crown in effect                                        transfer to a tertiary centre, who are                 no indication of how much of the PHAS
    purchases public hospital acute services                                        likely to be the most complex of patients              funding each DHB receives. The calculation
    on behalf of ACC. This is included as                                           requiring ICU care and surgery.                        of the value of the PHAS is equally opaque.
    an un-itemised part of DHBs’ budget                                                                                                    Accurate financial accounting of the true
    allocations in Vote Health.                                                     It also means the funding gap indicated in             costs of trauma – and therefore ACC
                                                                                    Figure 1 is conservative.                              patients – does not appear to occur in
    But while the PHAS funding increased by                                                                                                most DHBs. There is at best an antiquated
    15.5% in real terms between 2009/10                                             Recently, Canterbury DHB calculated
                                                                                    costings for injury patients that would come           classification system for injuries that in
    and 2018/19 (slightly higher than the                                                                                                  no way adequately represents current
    population 12.7% growth), accident-related                                      under the ACC umbrella and compared
                                                                                    this to their DHB share of PHAS funding                classification of surgical events. There
    hospital discharges are increasing at a
                                                                                    (estimated according to its share of                   appears to be no recognition of the extent
    much higher rate. Acute (case weighted)
                                                                                    national DHB population-based funding).                to which acute accident-related surgery
    discharges for injury or poisoning, for
                                                                                                                                           has grown in complexity over the years,
    example, increased by nearly 23% over the                                       Several models of costings were used
    same period (Figure 1). (The low number of                                                                                             often requiring the work to be done in
                                                                                    and resulted in estimates suggesting
    discharges prior to 2012/13 is due in part                                                                                             daylight hours – which means that as well
                                                                                    that PHAS funding is little more than
    to incomplete data up until that time.)                                                                                                as being under-funded, the work displaces
                                                                                    half of what the costs of ACC patients
                                                                                                                                           other elective surgery.
    Further, the indications that acute injury                                      would actually be. Given that PHAS
    related discharges are growing at a much                                        funding for the year of this study was in              The Ministry has explained that the
    higher rate than ACC funding are only                                           the order of $500 million, Canterbury                  PHAS funding has been calculated “after
    part of the story. A study on the costs of                                      DHB’s modelling suggests underfunding                  periodic reviews that require significant
    major trauma care in Northland found the                                        of trauma care provided by the DHBs                    resource yet have low levels of confidence”
    total actual cost was markedly higher than                                      nationwide is likely to be in the hundreds             (presumably related to accuracy). So,
                                                                                    of millions of dollars.                                it seems that both ACC and the DHBs
                                                                                                                                           have little idea as to the true cost of
                      FIGURE 1: CUMULATIVE PERCENTAGE GROWTH IN ACC FUNDING (DEFLATED)                                                     trauma and accident services. The PHAS
                                    AND ACUTE TRAUMA HOSPITAL DISCHARGES                                                                   contribution is simply based on the prior
                       25               Real ACC funding         Acute discharges (caseweighted)
                                                                                                                                           year’s contribution plus an increase in
                                                                                                                                           line with general DHB funding increases,

                       20                                                                                                                  thereby perpetuating a head-in-the-sand
                                                                                                                                           approach to trauma care funding.
                                                                                                                                           A prominent health advisor commented
                                                                                                                                           privately that “there is no appetite for
                        5                                                                                                                  change” on this issue. But given the
                                                                                                                                           evident gross underfunding of acute
                                                                                                                                           services and its flow-on effects for










                                                                                                                                           non-acute services, the New Zealand
                                                                                                                                           public will surely expect to see a more
                                                                                                                                           responsible attitude from government
    Sources: National Minimum Data Set, Ministry of Health; ACC annual reports; Stats NZ                                                   decision-makers.
    Notes: Acute trauma discharges include those categorised as ‘injury or poisoning’, including inpatients and day-
    patients. Data prior to 2012/13 are incomplete.                                                                                        Such funding neglect, to the detriment of
    Deflated in 2009 dollars using Reserve Bank of NZ inflation calculator.                                                                many patients, demands urgent attention.

                                                                                                                                                                WWW.ASMS.ORG.NZ | THE SPECIALIST   9

      A     striking feature of the Simpson Health and Disability System Review is the extent to which its recommendations resemble the
            policy intentions of the New Zealand Health Strategy of 20 years ago. Similarly, the Mental Health and Addiction Inquiry found
       that over the past couple of decades the mental health and addiction system ‘has not shifted’, despite the stated intentions of earlier
       strategies. It concluded that “a fundamental disconnect exists between stated strategic direction, funding and operational policy and
       ultimately service delivery”. Health policy analyst Lyndon Keene examines why such ‘disconnects’ occur and what is needed to close
       the gap, including the part that doctors have to play.
       A great irony in democracies is that the       their promises due to the coalition               the same results elsewhere. And those
       people entrusted to make them work tend        arrangements and negotiations. The                operating at higher levels cannot
       to be among the least trusted by their         literature on the policy-implementation           succeed without having some grasp of
       populations.                                   gap, or ‘policy failure’, identifies at least     what happens on the ground.
                                                      four broad contributors. In short:              • Inadequate collaborative policymaking:
       Prior to the last election in 2017, a Stuff/
       Massey University Election Survey found        • Over-optimism: Political party                  Policymaking has tended to be developed
       only 16% of nearly 40,000 respondents            policymakers underestimate the                  in silos. But good policy design requires
       were prepared to vouch that in general           complexity of the delivery challenges           continuous collaboration with a range of
       New Zealand’s politicians ‘keep their            and often lack the evidence base                stakeholders at different levels as well
       promises’, while 58% preferred the option        (insufficient objective, accurate and           as engagement with local communities
       that said they ‘only sometimes keep their        timely information on costs, timescales,        and the people who are critical to
       promises’, and 26% chose ‘usually break          benefits, and risks).                           implementing the policy on the front line.
       their promises’.
                                                      • The local context: In complex systems         • Vagaries of the political cycle – short-
       In New Zealand, under MMP, it can                an intervention that is successful in one       termism: Politicians are too easily
       be harder for candidates to keep all             location does not necessarily deliver           attracted to the prospect of short-term

results that suit the election cycle,         problems in the political system, not       But the public’s concerns about the
  rather than investing in policies which       just in terms of making government          effects of under-investment in our
  may take years to bear fruit. This            more transparent, but also improving        health system, as reflected in at least
  can lead to the pushing through of            its capacity to involve more public         one opinion poll before the pandemic
  policies as quickly as possible, often        participation.                              struck, further reinforced with reports
  half-baked, and the neglect of longer-                                                    on the system’s lack of capacity to
                                                Certainly, talk of engagement may
  term projects, which are usually more                                                     respond to pandemics, has raised public
                                                invite more cynicism among senior
  complex. Think health workforce                                                           awareness of just how precarious many
                                                doctors than a belief that it might make
  development, clinical leadership,                                                         parts of the system have become.
                                                a difference. The lack of meaningful
  integrated care and ‘health equity’,          engagement between doctors and              This, along with many of the findings of
  for starters – all of which have been         management in DHBs, let alone               the Health and Disability System Review,
  talked about for years by successive          between doctors and government, is a        highlights the need to develop with
  governments and are still being               long-standing sticking point. But that      urgency a strong health system fit for the
  talked about.                                 does not negate the critical need for       future with policies that are informed by
HOW TO ENSURE POLICIES ARE                      engagement if policy development is to      the best evidence and knowledge, and
IMPLEMENTED                                     be well informed and gets traction in       with accountability measures to ensure
                                                practice, especially where the policy is    those policies are implemented.
For solutions, there’s no shortage              complex and long term. If information
of ideas from policy think tanks and                                                        Policies must undergo regular and open
                                                flow and openness to engagement from
political commentators, ranging                                                             reviews to ensure they are working as
                                                the ‘top’ are weak, there is arguably
from strengthening the roles and                                                            intended, and modified as necessary,
                                                more reason that activity from the
functions of ombudsmen and                                                                  rather than quietly fading away as
                                                bottom-up must be strong.
parliamentary committees, to setting                                                        has often happened in the past. The
up policy ‘delivery units’ to track             Researchers suggest engagement              evidence shows this can work when
the implementation of policy, and               between the front line and centre may       governments are truly open and engage
establishing parliamentary policy               require some form of intermediary body      with the public and specifically those
costings units.                                 or bodies that work alongside and often     with the knowledge to provide the best
                                                at the direction of government to support   policy advice – and when parliamentary
Of the various themes running through,          effective policy implementation. Whether    debate is constructive rather than
one is worth a special mention for the          such arrangements are needed in New         destructive. These together have been a
critical role senior doctors could play         Zealand may be worth considering.           standout lesson from the pandemic.
concerning collaborative policymaking
                                                In the meantime, there is a lot that        The Simpson Review calls for the
and delivery.
                                                senior doctors can do to strengthen         development of a more positive culture
                                                current engagement avenues, such            and working conditions, improved
                                                as through ASMS branches and Joint          collaboration and integration, and
       The lack of meaningful                   Consultation Committees, simply by          clinically led service development. All
        engagement between                      participating in them. The information      are laudable, but these things do not
                                                flow from those forums then feeds into      happen just because you want them to.
     doctors and management                     the national forums involving ASMS,         They require deliberate strategies, hard
    in DHBs, let alone between                  as well supporting a range of national      work, and a commitment to change.
      doctors and government,                   advocacy work.
     is a long-standing sticking                When all else fails, particularly where
                point.                          there are specific local issues that               Policies must undergo
                                                remain unresolved due to poor policy
                                                or failure to implement good policy,
                                                                                                 regular and open reviews
                                                senior doctors have the right to speak          to ensure they are working
It’s well recognised that those who work
on the front line of the health system          out publicly, as outlined in Speaking up         as intended, and modified
know more about the challenges of               for patients and staff (ASMS website).           as necessary, rather than
delivery than national policymakers.            And the experience has been that when           quietly fading away as has
                                                doctors do speak up, people, including
A crucial part of developing and                                                                often happened in the past.
implementing policy, therefore, is to tap       those in government, tend to listen (The
into the experiences of those tasked with       Specialist, March 2020).
delivering it. It involves assessing existing   LESSONS FROM THE COVID-19
capacity to deliver, knowing what is                                                        Whatever the colour of the new
being done well, what needs improving,                                                      Government, 2021 is shaping up to be
and how best to build new capacity.             The public’s expectation for a strong       a significant year for developments in
                                                health system underpinned by good           health policy, whether it is putting the
The need for a bottom-up, top-down              health policy and delivery has been         meat onto the bones of the Simpson
flow of information in both directions          under the spotlight this year like no       Review recommendations or something
is emphasised in Max Rashbrooke’s               other. The extraordinary sacrifices made    entirely different. The participation
research report Bridge Both Ways                by the ‘team of five million’ to protect    of senior doctors, in whatever form it
about transforming the openness                 the country’s collective health, despite    takes, in shaping those developments
of New Zealand Government and                   the devastating effects on the economy,     could help to ensure that some of the
improving democracy. Rashbrooke puts            have underlined the high value people       much-needed policies identified 20
forward some key ideas about fixing             place on health above all else.             years ago are finally brought to life.

                                                                                                                   WWW.ASMS.ORG.NZ | THE SPECIALIST   11
       PETER CRAMPTON                                                                                                        Prof Peter Crampton

           O   ne of the most controversial recommendations of the Simpson Health and Disability System Review is around a new Ma-ori
               Health Authority (MHA). The final report proposes an advisory entity sitting alongside the Ministry of Health and the
           newly created Health New Zealand. It would be responsible for monitoring and reporting on Ma-ori health outcomes, managing
           Ma-ori workforce initiatives, controlling Ma-ori-specific innovation funds, and advising Health New Zealand, the Ministry and the
           Minister of Health on how to redress inequities in the system.
           However, four of the six panel members,     the implementation phase of any                 associated with integration of hospital
           along with the Ma-ori Expert Advisory       future changes. This matter was not             and community-based services. From
           Group, believe that for health outcomes     considered in detail by the panel and           a system design perspective, MHA
           for Ma-ori to improve, the MHA must         requires further work. Part of the              commissioning would bring focus to
           have the power to control both funding      challenge is the lack of knowledge              commissioning services for Ma-ori.
           and commissioning of services. In a         and understanding as to what is
           highly unusual step, that dissenting        currently spent on services in this             Your alternate view suggests
           position was included in a separate         domain. It is important to note that            the MHA “could more effectively
           chapter of the Simpson Report, known        costs associated with many of the               tackle institutional racism via its
           as the ‘alternate view’.                    report’s recommendations are yet to be          commissioning role”. Would there
                                                       quantified, including the entire change         be a risk that those services not
           Dr Peter Crampton, Professor of                                                             commissioned by the MHA may feel
           Public Health in Ko-hatu, the Centre        management budget. There is much
                                                       more work to be done to understand              that addressing institutional racism is
           for Hauora Ma-ori at the University of                                                      less of a priority?
           Otago, is one of the panel members          the financial implications of change.
           who favoured that view. We asked him        Would the MHA commission services               I agree that this is a risk, but it is a
           more about how it might work.               from hospitals as well as from                  risk that has been manifest within our
                                                       community service providers, and if so,         health system for a very long time. Our
           Given the new Health New Zealand                                                            hope is that a fully empowered Ma-ori
           agency would have “equal numbers            how would that work in practice?
                                                                                                       commissioning agency would model
           of Crown and Ma-ori members”, and           A fully empowered Ma-ori commissioning          approaches to commissioning that
           the MHA’s potentially powerful role of      agency could commission services from           would inspire change across the whole
           monitoring and reporting the system’s       hospital and community-based providers.         health system. We do not envisage
           performance for Ma-ori, why do you see      The commissioning process would                 that MHA commissioning would be
           a need for a fully empowered Ma-ori         be carried out in close consultation            undertaken in isolation of Health New
           funding and commissioning agency?           and partnership with Health New                 Zealand and DHBs.
           The proposal to have 50% Ma-ori             Zealand and relevant DHBs. Mixed
                                                       commissioning is already a well-                Could private health care providers be
           composition of the Board of Health
                                                       established model within the system             commissioned under either system?
           New Zealand is indeed a positive step.
           As a powerful addition to the leadership    (e.g. services funded by the Ministry           Yes, the existence of a Ma-ori
           and governance of the health system,        of Health, DHBs, ACC, Wha-nau Ora).             commissioning agency is entirely
           we believe a Ma-ori-led and controlled      Again, persistent inequities show us that       consistent with the ability to contract
           commissioning agency, with a                we need to do something differently in          with private health care providers.
           meaningful budget, would bring a focus      order to shift the trajectory of the system
           of expertise and strategic clarity to       from an equity perspective.                     Could there be public/private
           the task of commissioning services for                                                      partnerships, and if so, do you see
                                                       Integrating hospital and community-
           Ma-ori that has proven to be hard to        based services remains an important if
                                                                                                       potential for conflicts of interest which
           achieve in mainstream organisations.                                                        could be exacerbated with a separate,
                                                       elusive goal. Would a separate funding          empowered entity?
           History has clearly shown that it will
                                                       agency create additional challenges?
           take more than a seat at the table to                                                       Public–private partnerships are possible
           effect sustainable change.                  The role of service commissioners is to         within the proposed new system. I don’t
                                                       clarify expectations and outcomes, and          see any additional risks or potential
           If, as in your alternate view, the MHA
                                                       the role of health service leaders and
           was a budget-holder for commissioning                                                       conflicts arising as a result of a fully
                                                       clinicians at all levels of the health system
           services for Ma-ori, how would you                                                          empowered Ma-ori commissioning agency.
                                                       is to deliver on these expectations. The
           envisage that budget being set?
                                                       existence of a Ma-ori commissioning             ASMS has not yet formed a policy position
           This is an important question that          agency would not necessarily, in itself,        on whether it favours the MHA as laid out
           would need to be answered during            either amplify or diminish the challenges       in the report, or the alternate view.

    A    SMS reached out to the main political parties in the lead up to the 17 October general election to ask about their policies
         and priorities on health.
    Full responses and comments are on the ASMS website www.asms.org.nz

Research conducted by ASMS shows an average 24% shortfall
in the number of senior doctors working in DHBs nationwide.
Does your party agree that this shortage must be addressed
by increasing the workforce accordingly?
                                                                        ü               ü             ü             ü              ü               ü
According to the Health Coalition Aotearoa New Zealand has the
third highest rate of obesity within the OECD which is inextricably
linked to unhealthy diets. Does your party support self-regulation
by the food industry as an appropriate way to manage obesity
                                                                         û              ü             ü             û              ü               ü
rates and the wider impact of obesity on society?

Would your party ensure DHBs were sufficiently funded to
meet their communities’ health needs without clocking up huge
deficits every year?
                                                                                         only         ü             ü              ü               ü
Would your party be willing to commit to cross-party
agreements on longer term health investment and health
policies that require long time-frames for implementation, such
as workforce development, illness prevention and integration
                                                                        ü               ü             ü             ü              ü               ü
of services?

ASMS estimates there are nearly 450,000 people with
an unmet need for hospital care due largely to inadequate
hospital service capacity. Does your party agree that unmet
need is a significant issue for New Zealand; and would your
party increase hospital capacity to ensure unmet need is
                                                                        ü               ü             ü             ü           *Comment
                                                                                                                                   only            ü

* Full comments available on the ASMS website

                            • Equity of access for vulnerable populations and those in rural isolation.
                            • Future proof St John Ambulance funding.
                            • Reduce the number of DHBs.

                            • Sector capital, funding for district health boards to address demographic and cost pressures.
                            • Funding to implement recommendations from the Government Inquiry into Mental Health and Addiction.
                            • The Health and Disability System Review.

                            • Devolve primary health care services to allied staff.
                            • Ensure funding follow the patient not the practice.
                            • Increase the remuneration of our nursing workforce.

                            • Increasing public health funding to keep pace with need and the growing population.
                            • Ensure everyone can access healthcare services, regardless of their ability to pay, at the earliest stage possible. This
                              includes working towards providing adequate funding for community-based care and increased resources for wellness
                              and preventative health measures.
                            • Incorporate ma- tauranga Ma-ori into the health system, and fund a provision of primary healthcare through Ma-ori
                              organisations, overseen by a new Ma-ori health agency that focuses on remote areas with significant health disparities.

                            • Primary care funding.
                            • DHB infrastructure.
                            • Workforce development.

                            • Protecting public health in response to COVID-19.
                            • Mental Health.
                            • Addressing the shortfall of qualified medical professionals in the health sector.

                                                                                                                                  WWW.ASMS.ORG.NZ | THE SPECIALIST   13
Gaeline Phipps                      Drs Gareth Harris, Katie Ben, Anette van Zeist-Jongman, Alain Marcuse

                       Drs Lizi Thirsk, Tanya Wilton, Norman Gray, Neil Stephen                   Drs Kai Haidekker, Geoff Shaw, Roger Wandless


      I t was a multi-media affair when ASMS branch officers met for their annual hui at Te Papa in Wellington late last month.

       Level 3 Covid-19 restrictions in Auckland         and explained the rules for state sector       Lloyd Woods also discussed the initial
       meant branch officers in the northern             employees around political statements          bargaining strategy for MECA 2021 and
       region joined in virtually by webinar. For        during election time. Her message was          said planning is well underway.
       everyone else who was able to make it to          to use your union, and that speaking out
                                                         makes patients and colleagues safer.           A briefing was given by senior industrial
       Wellington, social distancing rules applied.
                                                                                                        officer Steve Hurring on the Holidays
       The annual hui provides branch officers           The current MECA and the bargaining            Act remediation so that branch
       with the opportunity to look at and discuss       process for the next MECA were also the        representatives are fully aware of the
       some of the big issues facing members.            focus of discussions.                          processes around rectification.
       “You can see what challenges are faced            ASMS senior industrial officer Lloyd
                                                                                                        There was much discussion about the
       by other DHBs and compare it to yours.            Woods detailed what had happened
                                                                                                        Simpson Health and Disability Review and
       It’s also an opportunity to discuss with          during this year’s negotiations with
                                                                                                        what the recommendations might mean
       the executive what the current issues are         Covid-19 resulting in an early settlement
                                                         and outlined some of the changes               for ASMS members.
       with health in New Zealand with an SMO
       focus,” said Waitemata- Branch President          included in the current MECA.                  Branch officers were also given a sneak
       Jonathan Casement.                                Canterbury Branch Vice-President               preview of the preliminary findings from
                                                         Siobhan Cross said finding out about the       our recent membership survey.
       Lawyer Gaeline Phipps delivered the key
                                                         changes to shift work and sabbatical was       Thanks to all the branch officers who took
       session of the day about the importance
                                                         particularly useful.                           part. The feedback we got was that the
       of senior doctors and dentists speaking
       out on issues of patient safety. She spoke        “I think most people are under the             webinar aspect of the meeting worked
       in depth about the provisions in the              impression that there was only the CPI         well, but here’s hoping that everyone can
       MECA which enable public comment                  pay rise,” she said.                           get together in person next year.

Dr Roderick Douglas out on the job


W     hile the Government and health officials have been working to keep the public safe during the Covid-19 pandemic, stretched
      occupational health teams have been focused on protecting the health workforce.
Hospitals have struggled to manage staff      of DHBs have occupational medical                to identify vulnerable staff. That meant
risk assessments and applications from        physicians employed directly on staff.           screening thousands of DHB employees.
workers with underlying health conditions,    There is no funding in hospital budgets to
                                                                                               Dr Kenny says at Waitemata- DHB alone
due to poorly resourced and understaffed      train occupational registrars.
                                                                                               about 1,000 people had an underlying
occupational medical services at DHBs
                                              During ASMS’ recent round of JCC                 condition who needed risk allocation and
across the country.
                                              meetings, occupational health was                a work plan. Insufficient PPE early on
Occupational medicine is about the            identified by most DHBs as a vulnerable          caused extra problems and anxiety.
effect of health on work and work on          service with serious training pipeline issues.   “We developed systems and protocols. We
health. Specialist occupational physicians
                                              GAPS EXPOSED                                     co-opted other doctors whose services
deal with a range of occupation-related
                                                                                               weren’t seeing patients along with GPs. We
health conditions and try and optimise a      The Covid-19 pandemic exposed the gaps.          had assistance from clerical, admin people,
person’s ability to work or return to work.
                                              Dr Courtenay Kenny is an occupational            and nurses, and some occupational health
They also look at a raft of work-related
                                              medicine physician at Waitemata- DHB in          specialists outside the hospital service were
risks such as heavy lifting, exposure to
                                              Auckland. He says, “While most specialists       able to come and help.”
chemicals, dusts and radiation, night duty,
and infectious diseases.                      in hospitals were quiet, we were incredibly      The workload at Waitemata- was
                                              busy. It was a stressful time as we had          compounded by a Covid-19 outbreak at
According to the Medical Council              to develop new understandings and                Waitakere Hospital involving
register, there are around 60 practising
                                              procedures as we went along.”                    several nurses.
occupational medicine specialists in
New Zealand. Most work in private             A National Occupational Health and Safety        “Covid told us that there is a great
companies, ACC or WorkSafe. Some are          Group was formed to look at Covid-19             need for the health and wellbeing of a
contracted by DHBs, but only a handful        and develop a mass screening strategy            workforce to be looked at and that health

                                                                                                                    WWW.ASMS.ORG.NZ | THE SPECIALIST   15
Dr Courtenay Kenny is concerned about the workforce pipeline

           workers are valued for what they do,”      Medicine, which sits within the Royal          according to the statistics, workplace
           Dr Kenny says.                             Australasian College of Physicians.            disease and illness is much more
                                                      There are currently only 11 occupational       significant in terms of morbidity
                                                      medicine specialist trainees, and only         and mortality.
           He explains that occupational medicine     one is working in a DHB setting.               He cites accelerated silicosis – a newly-
           as a specialty has had historically low
           numbers because many years ago             FUNDED TRAINING NEEDED                         identified, and very serious lung disease
           training was abandoned to industry.                                                       associated with artificial stone bench
                                                      In his view, what is needed is a funded
                                                      occupational medicine clinic within
                                                      each of the larger DHBs, which would
                                                      have a registrar working alongside an
                 “Covid told us that there            occupational physician. He would also
                                                                                                              “If you are a junior
                  is a great need for the             like to see better lines of communication
                 health and wellbeing of a            between occupational specialists and                 hospital doctor you can
                 workforce to be looked at            hospital specialists in general.                       go into orthopaedics,
                and that health workers are           “Having a regular presence within a                  rheumatology or public
                 valued for what they do.”            DHB would help improve this and bring                  health and remain in
                                                      us to mind when other specialists are                the hospital service and
                                                      considering their patients’ needs,” he says.
                                                                                                            vocationally register –
                                                      Dr Kenny has concerns about the                       but you can’t do that in
           “If you are a junior hospital doctor you   impact the lack of occupational health
           can go into orthopaedics, rheumatology     specialists in DHBs has on wider                     occupational medicine.”
           or public health and remain in the         community health.
           hospital service and vocationally
           register – but you can’t do that in        “People from the community who are in
                                                      hospital or are outpatients can’t access       He also says greater awareness of
           occupational medicine. You have to
                                                      an occupational medical assessment             workplace health and safety, along
           do all your own training, earn the
                                                      through the publicly funded system.”           with legislative changes, have driven
           income yourself by contracting with
                                                                                                     demand for occupational medicine
           organisations and then arrange to learn    “The only way people in the community
                                                      can be seen by an occupational                 services up, but the occupational
           everything for your exams and finally
                                                      medicine specialist and ensure they can        medicine workforce has not changed to
           become vocationally registered in
           occupational medicine.”                    go back to their job safely is generally       meet that demand.
                                                      to pay for it independently or do it           Both doctors agree that DHBs are
           Dr Roderick Douglas is an occupational     under ACC,” he says.
           physician in Tauranga and is the                                                          waking up to the value of occupational
           director of training for the New Zealand   Dr Douglas points out that the focus           medicine and are hopeful some
           division of the Australasian Faculty       of the government agency WorkSafe is           meaningful investment in funded
           of Occupational and Environmental          on accident and injury, prevention but         training programmes may follow.

FOCUS                                                                                           Erin and Michael with their three children


W     hen American couple Dr Erin Doherty and Dr Michael Howard packed up their three children and moved from New Mexico to
      New Zealand six years ago, they thought they knew what to expect, but there have been a lot of surprises along the way.
New Zealand is highly reliant on              make competent decisions that were               “To go back to a place where that doesn’t
international medical graduates (IMGs).       appropriate for the system here.”                happen would be a real crisis. I cannot
They make up about 40% of the specialist                                                       overstate it.”
                                              She felt disadvantaged having never worked
workforce, which is one of the highest
                                              in the NHS or a similar system. After feeding    MAKING A DIFFERENCE
proportions of IMGs among the 37 OECD
                                              back to her department, she is happy to say
nations. Dependency on IMGs is also                                                            Working in a place where they felt they
                                              changes have been made to the induction
greater in the provinces where SMO                                                             could make a difference was important.
                                              process to better support newcomers.
shortages and recruitment difficulties                                                         Both had worked in areas in the US
often bite hard.                              Her husband says working in a socialised,        with poverty and need, including Native
                                              universal health care system has been a          American reservations.
Dr Doherty is an acute general medicine
                                              revelation which has changed his practice.
specialist who also does outpatient                                                            “In New Zealand you get to practise
cardiology, while Dr Howard is an emergency   “The thing that really burns out a lot           medicine that is going to be more
medicine specialist. Finding a place where    of American doctors is the thought of            challenging,” says Dr Doherty.
they could each work was a priority.          bankrupting a patient or putting undue debt      “When you’re working in a provincial place
                                              on them because they don’t have adequate         with less specialists and speciality care,
                                              insurance and can’t get the equitable            you really get to practise at the top of
                                              outcomes that you get to see more often in       your licence. We get incredible diversity
     “It probably took me a year              New Zealand,” says Dr Howard.                    of patients with complex needs. I’ve seen
       to feel like I could make              He adds, “Even though I might sometimes          things here that I had only read about.”
      competent decisions that                feel that I can’t as easily access speciality
      were appropriate for the                services for my patients, I certainly see that
            system here.”                     outcomes are likely comparable, and the
                                              costs are much better controlled. It makes               “Even though I might
                                              my mental, spiritual and moral health better.”        sometimes feel that I can’t
                                              He also a big fan of ACC and believes any             as easily access speciality
After a two-week recce to check out
                                              IMG wanting to come to New Zealand                    services for my patients, I
a few job offers, Dr Howard (a California-
born surfie) landed firmly on Ngunguru
                                              should school themselves up on Te Tiriti.            certainly see that outcomes
in Northland, and it was not long             “I realise there are deficits, but trying to          are likely comparable, and
before they had taken up positions at         attempt to be faithful to a single treaty             the costs are much better
Wha-nga-rei Hospital.                         and bring it out through the health system              controlled. It makes my
                                              has been a remarkable thing to witness
FUNDAMENTAL DIFFERENCES                       and one of the best surprises that I
                                                                                                   mental, spiritual and moral
For Dr Doherty, the adjustment was more       wasn’t expecting.”                                           health better.”
difficult than she had expected due to what
she says are the fundamental differences
with the American health system.                                                               In turn, they believe having a diverse
                                                   “I’ve seen things here that I               IMG specialist workforce in New Zealand
“I had to unlearn some habits and                      had only read about.”                   enhances the system and means everyone
completely change how I approached                                                             benefits from what Michael describes
patients because the kind of practice                                                          as “the worldwide cross pollination of
I’d fallen into in the US involved a lot of                                                    expertise and information”.
defensive medicine where patients have        Having a union and collective bargaining
high expectations about getting tests and     has also been an eye-opener. He says the         Their advice to any IMG thinking of
having things done.”                          opportunity to sit in a JCC and “watch           coming to New Zealand is do your
                                              ASMS go toe-to-toe with the DHB and              homework, ask lots of questions, be
“You think medicine is a universal thing,     hold them accountable on issues of staff         humble, and approach it with an open
but it was apples and oranges. It probably    safety and welfare” is something he had          mind and an attitude of learning because
took me a year to feel like I could           never witnessed or experienced.                  the system can be full of surprises.

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