Public Health : The Silent Crisis

How the public health system is being driven into the ground
by Gordon Campbell

The first of a two part series on the health system

New Zealand’s public health system has been in crisis for so long that its failings – and deteriorating performance vis a vis other developed countries – now tend to be treated as its normal mode of being. Unmet needs are rife. In 2013, a major survey of the health system’s unmet needs reported that some 170,000 Kiwis are being turned down every year from getting onto public health waiting lists. While 280,000 Kiwis a year met the clinical threshold for elective surgery, only 110,000 were being placed on the waiting list.

To function at all, the public health system has become increasingly reliant on internationally trained medical graduates (IMGs) to cope with senior doctor shortages, while also proving increasingly unable to retain them here. (New Zealand’s dependency on IMGs to meet its health needs is the highest in the OECD.) As the Association of Salaried Medical Specialists (ASMS) pointed out in a major report released in August, overseas trained senior doctors had comprised 35% of the public health workforce in 2000 (already a high proportion by international standards) and this has risen to 42%, on 2012 figures. Even so, these foreign doctors and specialists are leaving at an accelerating rate – apparently in response to the toxic combination of high clinical workloads, relatively poor wages and conditions, and chronic delays in the provision of essential equipment. Judging by the ASMS figures, of those IMGs who first registered in 2011, nearly 40% were no longer practising in New Zealand one year later, which is more than double the percentage loss of five years earlier.

Much of the disturbing trends charted in the ASMS report – and more on them later – are a reflection of the funding shortages imposed by central government through the DHB system, under both Labour-led and National-led governments. The current shortages are also a reflection of the current government’s ideologically-driven goal of getting the books into surplus, come what may. The result is a DHB managerial culture that places a high value on short-term cost-cutting and the deferral of investment – with a reluctance to plan long term, despite the efficiencies this could deliver.

There are few signs of improvement on the horizon. Quite the contrary. The staffing levels in New Zealand’s public health system are set to deteriorate, via a vis Australia. To take just one example : Australia is on track to meet its target of 1.5 specialists per 1,000 people by 2021. As the ASMS report indicates (p.31) to do likewise in New Zealand would require a net increase of 300 specialists a year, or roughly 80 a year above what New Zealand has managed over the past three years. “Unless the current growth rate improves significantly, New Zealand’s total (public and private) specialist workforce target for 2021 will fall short by a headcount of approximately 560 specialists. “ While the ambit and precision of some of these figures are still in dispute, the ASMS confirmed to Werewolf that the specialist workforce in the DHB system is currently running at around 100 a year below what would be needed to reach parity with Australia by 2021.

One reason why the state of public health is not a bigger political issue is that an informal level of bi-partisan agreement exists between National and Labour about some of the public health system’s worst features. For example : the current six month waiting list system – implemented by the Clark government, and tightened under National – is a major reason for the levels of unmet need. Getting sick people onto the waiting list forces everyone (patients, GPs and specialists alike) to game the system and exaggerate the symptoms, in order to ascend the priority ladder and gain access to treatment. Routinely, the old and the sick are being forced into competition with each other, in a bid for attention.

The other reasons why the state of the public health system is rarely in the headlines is due to (a) the professionalism of healthcare staff and (b) the internalisation by the public of the view that their public hospitals are chronically in crisis, so they shouldn’t ask for very much. As the ASMS report concludes, health professionals can be their own worst enemies in that respect :

…While the consequences of senior medical officer (SMO) shortages are far reaching, they go largely unnoticed by the public, in part because the shortages are so entrenched. They have become the ‘norm’ in many areas. Incursion of clinical workloads into important non-clinical [teaching and training] time has become an accepted and unavoidable fact of life for many SMOs. This, and the high use of locums [a short-term and significantly more expensive fix] to fill service gaps temporarily, have saved many services from becoming dysfunctional – have largely kept the negative effects of shortages out of the newspapers.

Ignoring the issue, however, simply means the issue grows and the consequences become more severe further down the track.

Signs of the underlying malaise do occasionally become apparent. Every now and then, highly trained and capable clinicians will throw up their hands and leave New Zealand, generating newspaper headlines such as “Top Specialist Quits in Disgust.”

In mid-November, one such departure highlighted some of the issues behind the negative trends. Wellington Hospital lost its leading cardio-electrophysiologist, Dr Alejandro Jimenez Restrepo. Born in Colombia and trained in the US, Jimenez had arrived here in 2012 with his wife and young family, intending to settle permanently in New Zealand. Within two and a half years, he was gone. In late November, Werewolf contacted Jimenez at his new post in Abu Dhabi, to discuss the reasons for his departure.

The service that Jimenez arrived to set up – basically, it would enable the effective diagnosis and treatment of serious electro-cardiac conditions – had been totally absent from Wellington Hospital for five years, since 2007. “It took a lot of effort in those two years [since 2012] to get the service re-established,” Jimenez told me, “and to make sure that when people referred the patients, that we were providing adequate care. Because its not about just getting the patients and doing the procedures ; its about getting results that were comparable to more established electro-physiology services..”

Essentially, what Jimenez encountered at Capital & Coast DHB was a nominal commitment that chronically needed to be augmented by the inputs of un-compensated time and effort by him and his colleagues. “In my personal opinion I think the DHB was committed in word, but not in action. They said yes, we were supporting the service, we will support the service, but there wasn’t a financial support to provide the service with the needs to cope with the demands for the service. If you think of the electro-physiology service, you’re looking at a catchment area where the population of the central region is a million people. When I arrived in May 2012, there was not a single electro-physiologist between Hamilton and Christchurch.” Until earlier this year, one electro-cardial specialist [ie. Jimenez] was treating a catchment area of 1.1 million people.

Pay was not the reason why Jimenez had come to New Zealand. “If I’d wanted to make $600,000 a year in private practice, I’d have stayed in the United States.” Instead, he’d wanted to work within public health amid the collegial work environment that this entailed. When he left, a job-sizing exercise within the cardiology department had been in train at Wellington Hospital for 18 months. “It measures how many hours per week you work, what sort of work you do, are you able to cope with the demands of the service, are you working more than you supposed to be working. How many hours beyond your contracted hours, and so on. By the time I left, we had still not gotten to an agreement. Some details remain confidential, but I can say that the cardiology department in general – including myself, but not just me – were working at about 150% of what was contracted. There was a 50% of extra workload that was not being recognised by the hospital in terms of remuneration, or in terms of acknowledging that extra workload.”

That extra workload, he continues, was being carried out of necessity, to maintain the level of service required. “In other words, the patients demanded the care, they needed the care, and cardiology, as you know is a very critical area where you can’t deny patients access to certain services for certain procedures, even if its after-hours. So we were trying to get some recognition from the hospital with regards to the remuneration because we were all working above and beyond the contracted hours ..It was a very protracted negotiation and at some point it became very clear that they were not going to honour the extra work we were carrying on for a very long time. “

Essentially, this lack of remuneration for the chronic overtime being worked went hand in hand with protracted delays in acquiring essential equipment – eg, a mapping system that measures and tracks how the heart’s electrical impulses are functioning was eventually acquired with the help of a third party. Cumulatively, the situation eroded the reasons that had attracted Jimenez to New Zealand in the first place.

His case is merely indicative of the wider problem. As mentioned, the NZ system is becoming more dependent on foreign doctors and on foreign specialists whom it seems increasingly unable to attract, and retain. In his experience, is this retention problem mainly to do with pay levels, or with work conditions?

“I think its both…” Compare the salaries of senior consultants in New Zealand, he says, with those in other countries – such as Australia – and the salaries are far inferior in New Zealand. His decision to come here, he repeats, was on other grounds. “You make it on the basis that you are going to get a balance between work and family life. But when you start working and you start seeing all these issues with patient workload, wait lists, and see that the ratio of physicians to cope with the patient demands is insufficient, you start working extra hours…”

Most physicians, he says, will do the extra work because even though they’re not being paid or recognised for it, they feel the call of duty and owe it to the patients to do the best they can. “If I’m being paid to work 8 to 5 and I’m at the hospital and ready to go home, and somebody calls me because there’s a patient on the ward that has a complex arhythmiation, I’m not going to turn my back and say ‘Sorry guys but I‘m not on call, my clinical hours have ended.’ You’re not going to do that, and the hospital administrators know that. And they feel very grateful for it, but they don’t recognise it.”

Surely those extra calls come with the job? Yes, he agrees. “But when it becomes s recurring problem or becomes the norm then you look at yes, I came here because I wanted a better lifestyle – but because of all this extra work, that’s not happening. And on top of I’m not being remunerated equitably. So I might as well go somewhere else where yes, you will still have the workload, but you know its being recognised.”

Typically, he says, the role of an electro-physiological specialist will have an agreed flexible structure. “They’ll say you’re going to work say, 38 clinical hours and then you will work 12 non-clinical hours, and then have 4 on-call hours…and they say OK your job size is 54 hours. But in reality you’re not working 38 [clinical] hours. You’re working 50-55 clinical hours, so you have to do your non-clinical hours at home, and so your job size inflates, and it is not being recognised.”

That aspect aside, were there extensions to the quality of care to the patients that the DHB’s emphasis on cost-cutting and related bureaucratic delays were affecting ? “Oh yes, absolutely.” Inevitably, he says, there will be a delay whenever a service starts up again, as it accumulates a steady growth of referrals. “But after two years, you reach a point where you have to draw the line and say : ‘Do we have a service that meets the demands of the population we serve ? And the answer [at Wellington Hospital] was ‘No.’ Do we have a service that provides a quality of service that is comparable to other DHBs in the country? The answer was ‘Yes’ in terms of the quality of the service, but the answer was ‘No’ in terms of the time it takes for the patients to access the service. Because obviously, we didn’t have enough manpower to cope with all the patient volume. “

That next step brought Jimenez and his colleagues into conflict with management. “ So the next step was OK, we need to hire another physician, we need to increase the number of sessions, we need to increase the number of technicians and nurses available. And yes, they did – eventually – hire the second electro-physiologist but no, they didn’t hire any additional staff, nor did they provide additional sessions until we basically pushed it to the point where…” He sighs. “When they hired the second electro-physiologist, they did not plan to increase the number of sessions for him. So basically they were hiring a highly skilled sub-specialist to sit at a desk and do office visits and the clinics. Because they hadn’t really organised for him to have his theatre sessions, to do his procedures, and to cut down the wait lists. It was just another example of a lack of planning and forward thinking, in my view. “

Inevitably, a tension will always exist between the wishlists of specialists and the resources that are affordable. That reality, Jimenez says, was acknowledged and accepted. However, the electro-cardial mapping capability was an essential part of the service : “It was not a want-to have, it was a need-to have.” That aside, did he have plans to enhance and expand the quality of service available in his specialty that the funding constraints prevented him from pursuing ? “Absolutely,” Jimenez replies. “We had many areas where we could have increased the access of patients to procedures like atrial fibrillation ablation, ventricular tachycardial ablation, ICD implants ..”

Across all the DHBs in New Zealand, he says, there has been a steady growth in the availability of cardiac device implants. “But it is still way, way behind other comparable healthcare systems like Canada, the United States, and even Australia. This basically means that a lot of patients in New Zealand are not getting devices, because they don’t have access to those services. Obviously, those were areas where the service would continue to grow, and without the appropriate resources, it was not going to happen. Or if it happens, it will happen very slowly. There was a lot of talk about committing to the service, but there wasn’t really an expansion plan…or a serious commitment to say OK, how are we going to put this into action…”

In its August report, the ASMS touches on a number of the issues relevant to such concerns. One of the symptoms of under-resourcing that it raises (page 29) is the thorny issue of “sickness presentee-ism” – whereby due to under-resourcing and the lack of sufficient back-up, the available specialists feel obliged to turn up for work even when unwell themselves. A Capital & Coast DHB survey published in the NZ Medical Journal in August 2014 and followed up by Ben Heather in the Dominion-Post found that over a 12-month period 82% of respondents (55% of whom were specialists) were turning up to work when they were sick :

Of those who went to work sick, 75% knew they were too ill to perform to their usual standards, and 49% reported going to work with an infectious illness. 
The DHB’s Chief Medical Officer, Geoff Robinson, a co-author of the study, said the result would be similar in any hospital and could be an even bigger problem in provincial centres, where fewer staff were available to cover.

As the sole cardio electro-physiologist at CCDHB for much of his time there, Jimenez inevitably came under that pressure. Sometimes with device implants, his recently appointed colleague could help cover for him. “But if it was electro-physiologically specific ablation work…If I called in sick on a Wednesday – which was my ablation day, all day – those cases would be cancelled, and these might be patients waiting for over a year for the procedure. Oftentimes, I felt the service needs were so high and the waiting lists were so onerous that even if was sick I would go to work. Obviously, if I felt I was so incapacitated when it came to a procedure I wouldn’t do it, but if I was moderately ill but felt able to cope with a few hours of surgery, I would do it.”

If ‘sickness presentee-ism’ is one of the surface signs of the underlying stresses on the health system, the ASMS report identifies deeper structural problems as well. For the best part of a decade, there have been supply problems with insufficient New Zealand born medical graduates being trained and retained here, despite a looming situation of scarcity that is evident in the fact that 40% of our current doctors are over 50 years of age. As the ASMS report indicates (p.8) many New Zealand medical graduates are departing for greener shores :

On average more than 10% of medical school graduates are not registering after their final class year. Of those that do register, about 37% are no longer practising in New Zealand a decade later, when they would usually be in training to become a specialist or GP. Of the New Zealand graduates who gain vocational registration (ie, become
a specialist or GP), 10%-12% are lost to New Zealand long-term – and the situation is worsening. Of those who first registered as a specialist in 2011, 18.9% were no longer practising in New Zealand one year later.

For now, the gaps are being plugged (a) by those foreign doctors and specialists who being churned through at increasing rates, and (b) by short term (and expensive) contracts with locums. These stop-gap measures are indicative of the deeper problems :

In the DHB’s general surgery services, for example, 38% of the specialist/medical officer workforce are in temporary positions. In the Emergency Department, 42% of specialists (child ED) and 31% (adult ED) are on short-term contracts….On the face of it the figures suggest DHBs are simply unable to attract sufficient staff other than on a temporary basis.

The prospects for the future are equally grim. In 2010, the ASMS and DHBs had jointly agreed on a road ahead. As mentioned earlier, the required growth rate would be based on a Business Case proposition that New Zealand’s total (public and private) specialist workforce per population should match that of Australia’s by 2021, and that the DHB specialist full-time equivalent (FTE) workforce would grow at a parallel rate. Right now, that isn’t happening :

To reach that benchmark by 2021 requires a net growth rate of approximately 260 FTE Senior Medical Officers per year (approximately 230 FTE specialists and 30 FTE medical officers). In the three years to March 2014, the average SMO growth rate was 164 FTEs per year (180 headcount). Unless the current growth rate improves, New Zealand’s DHB workforce target for 2021 will fall short by about 670 SMO FTEs.

And the consequences if this trajectory is maintained, and the under-supply of specialists and senior medical officers continues at the current rate ? The ASMS report sets it out :

increased wasteful expenditure

reduced cost-effectiveness of hospital services overall

decreasing ability to improve safety and quality of services

reduced capacity to develop more innovative and efficient services

continuing heavy dependence of overseas recruitment, escalating specialist turnover rates

reduced capacity to train new specialists, with far-reaching negative flow-on effect for the whole medical workforce.

In recent years, Alejandro Jimenez has not been the only specialist to abandon Wellington Hospital with good reason. In 2007, Liz Hesketh (one of the hospital’s two child cancer specialists at the time) left for overseas because, in her view, “dwindling resources and a [paediatric oncology] unit moving toward unsafe clinical practice.” In 2011, British specialist Gerry McGonigal left, citing his frustration with the delays in setting up a dedicated stroke unit.

For Jimenez, it took some time for him to realise that the delays were a consequence of bureaucratic mechanisms for deliberately postponing expenditure. “There are so many layers of bureaucracy in the DHBs. I mean, for a consultant to identify a clinical situation and for that decision to reach the level of decision-makers, it can take months. There are a lot of mid-level administratives who will filter and delay and postpone things. In my view, if you look at their jobs…. the executive directors have these operational managers whose role is basically to contain the problems. They don’t want to hear the problem, they just want to contain the solutions.”

Oftentimes, he adds, the “solutions” being put to him would have meant decreasing the patients being seen. “One of the advices I got was ‘You guys are seeing too many patients. You can’t put more patients on the list, because you don’t have capacity.’ Our response was – well, if we see a patient with a cardiac condition, and the patient has been referred and hasn’t been seen by an electro-physiologist in years, and they come with a condition that has an indication for a procedure, I can’t deny [them] the procedure. We’re not talking just about emergency procedures, but those with a substantial impact on the quality of life of patients, who potentially run the risk of hospitalisation, heart failures and other problems…”

In the end, Jimenez was contacted by the US Cleveland Clinic in Ohio, to join a new hospital it was opening in Abu Dhabi. Some sense of the esteem in which Jimenez – and the Cleveland Clinic – is held is that when Cleveland Clinic began hiring for the new facility, 5500 thousand medical staff from around the world applied for the 175 positions on offer.

Reportedly, some 40 interviews were conducted with each person finally selected. By contrast Jimenez was, in effect, asked to apply to be interviewed.

In other words, CCDHB has managed to drive away someone who is evidently regarded as one of the world’s best cardio – electrophysiologists. This loss will be to the detriment of the New Zealand patients who could have benefitted from his care. Does Jimenez think that – as word gets around – the New Zealand health system is running a reputational risk when it comes to its ability to recruit and retain specialist staff ?

“That’s a very interesting question,” he replies. “The New Zealand market for physicians is very small, because the number of positions available is very limited. So you’re not looking at something like the US or Australia where new hospitals are being built, and there’s an expansion of service with a lot of opportunities for physicians.” And when he says the number of positions available here is small…..again, isn’t that a sign of cost-cutting measures, rather than an indication of the extent of patient need?

“Yes. It hasn’t anything to do with need,” Jimenez says. “It simply means the DHBs have decided not to advertise, or not to fill that position. it doesn’t mean that there isn’t a patient need. If you count the number of physicians per capita on a given DHB, there are a lot of DHBs who could recruit more physicians but who decide not to do so, on the basis of cutting costs. You can’t measure the need for physicians in New Zealand by the number of jobs available.”

Jimenez points to an example. “Pediatric oncology [child cancer services] is non-existent [in the Wellington region.] Yet if you look at the CCDHB website, I don’t think you’ll find they’re looking for a paediatric oncologist – because basically, that service has gone. So, the true measure of the workforce need is not in the number of jobs that are vacant. In terms of the reputation issue…New Zealand physicians are highly trained, highly specialized, and hard working. The quality of the physicians in my environment – cardiology, critical care, cardio-thoracic surgery, vascular surgery and some of these subspecialties – is very good, second to none. And that’s true of both the foreign specialists, and of the New Zealand trained or overseas trained specialists who have returned to work in New Zealand. ”

The wider problem? “ It is that a lot of good physicians will come to New Zealand, spend a few years there, and realize ‘This healthcare model is not helping me develop myself professionally.’ Some people may leave because of the lack of service growth, some may leave because of the lack of professional opportunity, or they may leave for financial reasons. I didn’t feel burned out. I just felt uncomfortable with the situation. The DHBs were not the only reason I left New Zealand, but it was a big reason.”

Towards the end, Jimenez had started doing private practice to improve his financial situation “But it is not what I wanted to do. I’d wanted to do research and to teach [but] under the work conditions it was all clinical work, all clinical work – and there wasn’t an opportunity to do anything else. So I was sacrificing financial stability and I was sacrificing the things I wanted to do. And for what? There wasn‘t much of a light at the end of the tunnel. In my view, it wasn’t what I’d envisaged initially. I knew there would be limitations, but I don’t think there was an attitude from the hospital to model the service with a view to growing in that direction. I think they were trying to reach a level of viability and a basic provision of services, but without [fostering] an exemplary provision of services. For me, that was probably a breaking point. I realized these guys don’t really want a service that is an example of quality to other services. That wasn’t their intention. And I didn’t want to end up 5, 10 years down the track where I had only got to this point in my career, and this was as far as I could go. Not when I could go somewhere else, and really make a difference.”