Predictable Smear On Senior Doctors
During my lengthy stint as Executive Director of the Association of Salaried Medical Specialists (ASMS) one of my most important functions was to negotiate the collective agreements covering salaried senior doctors and dentists employed in public hospitals.
From 1989 to 1991 these were national negotiations; until 2000 negotiations were conducted separately with each main public hospital; and then, until 2019, they were national again with all the district health boards.
On occasions these negotiations were protracted and somewhat tetchy (or tetchy plus!). It became quite predictable that, when this occurred, at some point the employers would engage in a public misrepresentation or smear in an endeavour to undermine our credibility.
To the best of my recollection these public actions never came from health ministers (a few private grumblings notwithstanding) or bloggers (although I can't dismiss the possibility that far-right blogger Cameron Slater didn't hold back; he didn't towards me on other issues).
Health Minister Simeon Brown broke the practice with his public attack on ASMS over the recent senior doctors one day strike.
This was caused by the impasse in negotiations over the national collective agreement with Health New Zealand. He began by badly misrepresenting basic salary levels.
He also claimed that the strike was causing delayed access to planned (elective) surgery. This was more than a tad rich. Under his leadership and that of his predecessors, access was already being increasingly delayed every other day of each year.
Joining in on misrepresentation and smearing
Now right-wing blogger David Farrar has jumped in support of Brown with his own smear on his Kiwiblog site (7 May): Perks smear. He alleges that salaried senior doctors employed by Health New Zealand and the Ministry of Health received 'huge perks'.
It is important to understand what perks are (and what they are not). They are additional benefits to enhance the employment package such as health insurance or a company car. They don't involve reimbursement of actual and reasonable work-related expenses.
The problem with Farrar's argument is that it is based on major errors and sloppy homework. This is not new territory for him.
I have previously called him out (11 December) for erroneous claims about resident (junior) doctors leaving for Australia: Farrar's incomplete health workforce analysis.
Farrar's hearsay evidence
On this second occasion his evidence is based on a reader writing to him claiming that salaried senior doctors employed by:
… Health NZ and the Ministry of Health get generous leave and expenses for so-called professional development – which is often an overseas conference in an exotic location – flying business class and staying in a premium hotel. I have this on good authority from someone who processes the claims! This leave and generous allowance which can accumulated for two or more years.
This is hardly robust investigation. At best it is hearsay. To begin with, Health Ministry employed senior doctors are not covered by the collective agreement covering Health New Zealand employed senior doctors.
Farrar is discussing something that applies to the latter, not the former. Further, claims to the two different employers would not be processed by the same person
By referring only to one part of the entitlement and then incorrectly calling it an allowance, he is both selective and factually wrong.
Getting to the facts
The entitlement (I was the advocate who first negotiated it) is spelt out in Clause 36.2 of the national agreement. Its first subclause (a) begins with:
The employer [Health New Zealand] requires employees [senior doctors and dentists] to be fully informed, and where possible, practised in developments within their profession. To facilitate this, employees will be entitled to leave for 10 working days (pro rata for part-time employees) continuing medical education each financial year (1 July – 30 June), plus any agreed reasonable travelling time.
This is what Farrar ignores. Continuing medical education (CME) leave is something the employer requires of this particular occupational group. This is in order to help ensure that they can perform their duties and responsibilities to the level of competence, quality and patient safety required.
The rest of sub-clause covers administrative matters, including accruals. Farrar's focus is primarily on the next sub-clause (b). He does not ignore it. Instead, he gets it badly wrong. The sub-clause reads:
Employees shall be reimbursed actual and reasonable expenses of up to $16,000 per annum (GST exclusive) and accumulated on the same basis as the working days (a) above. This reimbursement is pro-rata for part-time employees except that part-time employees whose only income from medical or dental practice is derived from their employment with one employer shall be entitled to the full reimbursement.
The fundamental distortion (or mistake if one is in a generous frame of mind) by Farrar is to call the monetary amount an allowance. It is not. It is a capped reimbursement of work-related expenses.
Furthermore, it is not an absolute $16,000. It is up to this amount subject to claims being actual and reasonable.
The specification of a specific dollar amount serves the interests of both employer and employees even though, for the latter, it is capped (potentially it could cost Health New Zealand more if there was no cap). However, the cap better enables planning and budgeting for both parties.
While use of the leave and associated reimbursements is often used for medical or dental conferences, they have to be relevant to duties and responsibilities. Further, it can also be for other approved options such as working at another location or study.
Fringe benefits tax sideshow
Farrar's distortion (or mistake) leads him to then argue that the fringe benefits tax must apply and has to be paid by Health New Zealand. Somehow, he estimates the total additional cost to be least $23,880 (presumably per annum).
But it does not attract this tax because the entitlement is not an allowance. Perks apply to allowances, not work-related reimbursements. Much of the CME expenses are spent on consumables such as travel and accommodation. Where conferences are involved there also registration costs.
While some of these costs are close to home (Australia), our relative geographic isolation means that greater distances are required to exercise the full benefits of this necessary form of professional development and education.
The one exception where the fringe benefits tax might impact (it might instead be PAYE) is that the entitlement can be used for the personal purchase of laptops (that is, a personal capital product) for the express purpose of professional development and education. However, this requires specific employer approval and, to the extent that it happens is only a small component of the costs of the entitlement.
Farrar goes further to falsely imply that the two weeks CME itself, which is required by Health New Zealand, is also a perk.
Let me be very clear. Based on my experience in the health system, I would not want to be treated or diagnosed by a senior doctor who was not sufficiently utilising their CME leave entitlement. Patient safety has been compromised as a consequence.
Sloppy mistakes or deliberate distortion?
Finally, Farrar proceeds to make an astonishing attack on the credibility of senior doctors. He refers to something he had 'heard' (further hearsay). One employed by the health ministry had allegedly used the 'allowance' to a global conference on air pollution and health.
First, the entitlement is for Health New Zealand employed senior doctors. Second, if the person nevertheless was able to receive the same provision, it is not an allowance.
Third, a health ministry employed senior doctor able to attend this event is most likely to be a public health specialist.
If so, giving the relationship between air pollution and poor health, it would be up there among the most valuable events to attend if the health ministry were to properly perform its stewardship role for the health of New Zealand's population.
Is David Farrar's smear due to sloppy mistakes or deliberate? Readers can be the judge of that.
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The divisional leadership team had "significant concerns" about the number of staff vacancies and the "relatively junior nature" of the clinical staff in some areas. When the inspection took place the impact of Covid-19 was a "significant exacerbating factor". "While the effects were different across the various disciplines, it was evident that all disciplines … were affected. In addition, it was clear that not all disciplines felt heard and involved in clinical decisions. "There were reports of impacts on clinical care. Forensic mental health services were particularly challenged. Not only were there issues in maintaining minimum safe staffing levels, there were issues associated with the experience and seniority of staff." There were "critical shortages" of staff in many areas of the service, particularly inpatient units. "Clinicians frequently used the phrase 'on numbers', referring to being deployed to an inpatient unit to bring up the numbers of staff on a roster to a perceived safe capacity. "The inspection team heard concerns that people were working overtime and double shifts, to meet the 'on numbers' expectation. While the magnitude of the issue was unclear, it was raised repeatedly by staff in interviews. Some staff stated that they no longer wished to do overtime and double shifts due to the level of personal stress and strain it caused them." Dr Crawshaw said in some interviews a "palpable level of distress was evident". The staffing shortages appeared to particularly impact forensic mental health services, he said. "The clinicians seemed tired. There was a sense that many of them were no longer putting in discretionary effort, due to fatigue and burnout. Many clinicians spoke of the 'moral injury' they experienced by being obliged to provide suboptimal care to tāngata whaiora." 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There, staff described how a number of senior staff had recently left, particularly from the acute medium secure unit. "This had left both a gap in staff numbers and a gap in expertise. Some staff appeared to be distressed by and angry at the situation; particularly those working in the acute medium secure forensic ward." The service capped inpatient beds to ensure minimum staffing levels, with 193 beds. At the time of the inspection there were 178 in use or available. Dr Crawshaw said the response, while "understandable" from the desire to maintain minimum safe staffing levels, had "brought challenges". Some staff said there were occasions when patients needed to be managed overnight in a unit or ward different to the one they were admitted to, and others felt there was "general pressure" for early discharge or delayed admission. "Community staff raised concerns regarding the perceived risks they were holding and managing as a result. Some expressed concern that this was resulting in suboptimal care for tāngata whaiora." The bed number caps also meant that sometimes people with serious mental illness who had not entered treatment through the justice system "fell out of care or were unable to be admitted". Frontline forensic mental health staff expressed "significant concern" about their safety and ability to provide a service. "The inspection team heard there was a particular difficulty in the acute medium-secure unit. Apparently, a significant number of senior staff had retired or left that unit, affecting both staff numbers and experience levels." Of the staff in the unit 50 percent had less than three years' experience working in health services. 'Culture of blame' Dr Crawshaw said that on numerous occasions, the forensic mental health clinical governance team raised concerns to senior management about shortages of staff in the service. The inspection team also heard there was a tendency to blame individuals. "Interviewees used the term 'a culture of blame' and described situations where bullying had occurred and staff had been prevented from escalating issues due to a fear of repercussions." He said overall the staff appeared "dedicated to providing the best care they were able to". However, they felt care was compromised in several ways including staff limitations, and the increased pressure for early discharge. "In some cases, people required readmission following discharge, or, where they were not readmitted, their mental state and care deteriorated in the community. "Sometimes, staffing and bed capacity issues meant admission was delayed for people who required care." Dr Crawshaw said the observations were similar to what he had heard from other services around the country. "However, staff in Canterbury - Waitaha were particularly stressed." There were also concerns about how the service was incorporating te ao Māori into their model of care. "This was of particular concern to the inspection team given the cultural needs of the people accessing the forensic mental health services at the time of the inspection." The inspection team had "significant concerns" about the functioning of operational and clinical governance within the service. He was also told that clinical governance at a district level was not working effectively and that an emergency framework had been put in place. Dr Crawshaw did not receive a draft clinical governance structure at a level above the service until March 2024. "Staff reported difficulties in the escalation and consultation processes and gave examples of issues that had not been effectively resolved." He said there was an "overall reactive mode of governance". "Senior leadership was aware of the impact of staffing issues and had been putting reactive plans in place under urgency to address this (often daily). However, this very short-term focus compounded governance and communication issues." He said nationally all mental health, addiction and intellectual disability services are "under pressure". Several common challenges included mental health services struggling to improve access for Māori, the need for mental health services being greater than available sources and a "shortage" of suitably qualified mental health clinicians as well as a need for investment in facilities. "When things go wrong during the delivery of mental health services, service providers are subject to intense scrutiny and criticism. As a result, many mental health clinicians practice in a risk-averse manner. This also affects staff recruitment and retention." Dr Crawshaw's 18 recommendations looked at three of the main concerns raised: governance, care model and resourcing. "The uniting thread across these recommendations is the need for better cooperation between leadership and service delivery to prioritise these services, enable staff to do their best, improve the models of care and plan for the future." His recommendations included prioritising and focusing on mental health service performance, implementing clear pathways of decision-making and governance, and reviewing the care model. He also recommended the organisation focus "maximum effort" on staff recruitment, retention, supervision, training and mentoring. There also needed to be strategies developed long-term management, budget, staffing and facilities as well as establishing and investing in a Māori mental health service. 'Significant failings' HNZ national director of mental health and addictions Phil Grady acknowledged the "significant failings" identified in the report. HNZ was "committed" to implementing the recommendations to "prevent the tragic events of 2022 and 2024 from happening again". "We recognise the loss and grief these families have and continue to experience and express our sincere condolences to them. We are deeply sorry for the failings in our systems. "We have reached out to these families to apologise and discuss Dr Crawshaw's report, and will remain in contact, if that is their choice, to update them on progress to implement actions from the report." HNZ accepted all of Dr Crawshaw's findings and had an action plan in place to implement the recommendations, which focused on the underlying issues related to governance, the care model, and resourcing. "We are focused on continuing to provide senior leadership oversight of planning for the service, building a framework, and ensuring there is sufficient staff with the right level of training and experience to safely and effectively deliver services." Grady said there had been "demonstrable progress" on key recommendations including establishing a clinical governance framework and increasing clinical staffing by 11 per cent since 2022. Clinical decision making on patient leave was "consistent with policies" and there were weekly audits of compliance in place. "There are clear pathways both within the service and nationally within Health New Zealand to escalate and manage risk. " In addition to recommendations identified in the report, HNZ had already made improvements to embed regional planning, decision making and information flow, increase staff recruitment, upskilling and training across the service, develop a cultural narrative to include a te ao Māori perspective, and upgrade a range of facilities. "To ensure progress of the recommendations continue, we welcome Dr Crawshaw's increased oversight of the service over the next 12 months. "We are committed to improving the service and our actions will be closely measured against this report, and two other event reviews conducted by Health New Zealand." 'A very broken mental health system' In June another Hillmorton mental health patient, Elliot Cameron was sentenced in the High Court at Christchurch to life imprisonment with a minimum term of 10 years for murdering 83-year-old Frances Anne Phelps, known as Faye in October last year. Phelps' daughter, Karen Phelps, told RNZ that while the report did not specifically address her mother's case there were "many serious issues" identified that had "negatively impacted the ability to deliver services". "Most of these issues are no surprise as they were blatantly apparent in my mother's case namely staff shortages, communication and governance issues, pressure for early discharge and not enough funding to provide adequate services and care. "It's no surprise that Elliot Cameron was encouraged to move out of Hillmorton, that he was not being supervised or under treatment and his aggravated symptoms were not addressed. This report confirms a very broken mental health system. "So now the question remains will this be remedied, which will require significant funding, and that doesn't seem to be a priority for this government, or will another member of the public be killed? I think it's a tragedy this report has taken so long to be finalised and released as I can see numerous aspects in it that, if they had been remedied earlier, could have prevented the death of my mother. It's a timely reminder that every day counts when serious mental health service issues are identified and every day they are not remedied puts the public at risk." Following his sentencing a suppression order was lifted allowing RNZ to report Cameron killed his brother Jeffrey Cameron in 1975. A jury found him not guilty of murder by reason of insanity and he was detained as a special patient. Cameron was made a voluntary patient at Hillmorton Hospital in 2016, and then in October last year murdered Phelps, striking her with an axe. RNZ exclusively obtained emails from Cameron to his cousin Alan Cameron sent over more than a decade, detailing his concerns that he might kill again. In response to the revelations, Chief Victims Advisor Ruth Money said it was hard to see Phelps' death as "anything other than preventable". RNZ earlier revealed another case involving a man who was made a special patient under the Mental Health Act after his first killing was recently found not guilty of murder by reason of insanity for a second time, after killing someone he believed was possessed. After that article, Money called for a Royal Commission of Inquiry into forensic mental health facilities. After Cameron's first killing was revealed, Money said she stood by her recommendation. "The public deserves an inquiry that can give actionable expert recommendations, as opposed to multiple Coroners' inquests and recommendations that do not have the same binding influence. The patients themselves, and the public will be best served by an independent inquiry, not another internal review that changes nothing."
