KEY POINTS:
In the best tradition of medical dramas the senior doctors' industrial dispute has brought out plenty of rhetoric and some bloody metaphors. "We're haemorrhaging doctors and the sticking plaster we're using at the moment is extremely expensive locums," says Dr Jeff Brown.
"If our claim is accepted it will clamp the bleeders and stem some of the flow so we can sit down and make some reasonable longer term plans."
Brown, a paediatrician at Palmerston North Hospital, is president of the Association of Salaried Medical Specialists (ASMS), the doctors' union heading the call for a senior doctors' pay increase - an increase the ASMS insists is not just about money but about a crisis facing public health care in New Zealand.
"This crisis is not just being talked up, it's being ignored and if we continue to ignore it the consequences will be quite dire," Brown says. "There's not going to be enough specialists to give anything like the public health system New Zealand needs."
The senior doctors are backing their rhetoric with action: unprecedented stopwork meetings at District Health Boards (DHB) hospitals around the country and the prospect of the unthinkable - senior doctors going on strike.
The meetings are passing resolutions with alarming messages too: "If significant intervention at DHB and government level does not occur, patient safety will be compromised as a consequence of the current and escalating workforce crisis in New Zealand hospitals."
The doctors have agreed to hold a postal ballot to decide on strike action if the 12-month impasse can't be broken.
If the union position seems dramatic, the response from the other side is steadfast rejection. "This debate from the ASMS appears to be all about money - 'pay us more and we'll get more doctors'. That logic is not true," says Dr Nigel Murray, lead negotiator for the DHBs. "Putting wages above what we can afford as a country and thereby cutting back on health services is not a good use of taxpayers' money."
Murray, who is interim chief executive officer of Southland DHB, points out that the number of specialist doctors has actually increased by 300 since 2000. And he provides data that shows doctors are well paid. Since 1998 inflation has totalled 20.5 per cent while the pay of senior doctors over the same period has gone up 38.6 per cent.
Murray is dismissive of a key plank in the union's argument.
"There is no indicator that there is a sudden surge of New Zealand doctors going to Australia. There has been no significant change in the drift to Australia over the past 10 years." Murray is referring to 2005 Medical Council figures which show that about 25 per cent of medical graduates leave New Zealand after three years - a trend that's not changed over a decade.
The union begs to differ, pointing to the lag in Medical Council data and an informal survey of members which shows that at least 80 senior doctors have packed their bags and crossed the ditch in the past year.
What is attracting them, says Brown, is aggressive recruiting by Australian hospitals dealing with their own shortages, and attractive pay packages of between A$27,000 to A$50,000 more than they get in New Zealand.
"Those who go tell us they see fewer patients, are paid more, looked after better, and are more involved in the running of the hospitals - all round it's a better deal," says Brown.
John Campbell, chairman of the Medical Council, agrees that any increase in departures to Australia would take a year or so to show up. What is clear is that 60 to 70 per cent of those graduates who leave are going to Australia, which Campbell says is significant because Australia's proximity tends to work against those doctors returning.
The other trend is that while Australia has increased its level of medical graduates - from about 1400 to 3500 - only 3 per cent of overseas-trained doctors coming to New Zealand are from Australia.
Another concern is the increased use of locums in hospitals. Murray agrees that DHBs are using a higher percentage than they would like. He says that in the year to September senior doctor locums accounted for 8.5 per cent of the payroll, adding up to $51 million and amounting to 140 to 170 fulltime equivalent positions, not including fee-for-service contract doctors.
But like growing doctor shortages, and a greater reliance on overseas-trained doctors, using more locums to fill the gaps is an international trend Murray says we have to cope with like everyone else.
The union says that while it accepts locums are always necessary in a hospital system, in the context of their pay dispute the situation has become farcical.
"Some newly qualified junior doctors are staying on as locums on rates that start at $75 an hour [equivalent to $156,000 a year and going considerably higher] rather than accept employment at our starting rates. We are also aware of annualised locum salaries of up to $185,000," said Brown in a letter to the DHBs. The senior doctor salary steps proposed by the DHBs would, from June, begin at $119,863, rising to $172,666 in a 13-year progression.
The union says to halt the leak of newly qualified specialists overseas, and to tempt back those who went overseas on a temporary basis, the starting point should be $125,500.
The details of the dispute and doctors' pay structures are complex, but in broad terms, as well as percentage increases over two years, the union is seeking improvements to conditions, including double-time penal rates, a doubling of expenses for continuing medical education, and more progression steps.
The DHBs' offer is largely percentage increases over four years, but includes a $5000 lump-sum payment.
Such is the acrimony in the dispute that neither side can agree on how to calculate costings and what the other is offering.
The DHBs say their offer is 5 per cent a year. The union says it is 3.8 per cent.
And the union says its claim adds up to about 14 per cent over two years, but the DHBs say it's 22 per cent.
While senior doctors and DHB management are at loggerheads, the public looks on at what appears to be an increasingly dysfunctional public hospital system. Several hospitals last week declared Code Red - that they don't have the capacity to meet expected demand.
Doctor shortages have also affected some services, including North Shore's obstetrics and gynaecology wards. Most recently, Wellington Children's Hospital closed its doors to further cancer patients because a paediatric oncologist is resigning to move to Australia.
The problem was stated succinctly in March in a workforce taskforce report to the ministers of Health and Tertiary Education. It pointed out that 41 per cent of all doctors registered in New Zealand received their primary medical qualification overseas. "There is a significant gap between the overall numbers we train and the requirements of the New Zealand health system. Although for a small country the brain exchange that results from a significant influx and efflux of doctors has benefits for the system, the size of this long-term net deficit is unsustainable."
The report also says the overall shortage of medical practitioners, evidenced by the use of locums and reliance on overseas-trained doctors, will be exacerbated in the future as the population ages and competition for medical practitioners increases in the international market.
It concludes that New Zealand needs to train more medical practitioners locally to meet the demand.
But as Medical Workforce Strategy Group chairman David Meates points out, even with more doctors being trained, it takes 12 to 14 years before they become a consultant and make an impact on the senior specialist workforce.
There are other problems on the way too. In five to six years about 60 general surgeons will be retiring. Surgeons are now trained as specialists in various fields, so filling the gaps left by the retiring general surgeons is far more complicated.
"We have to change how we configure hospitals to deliver those services," says Meates.
Also worrying is that under 50 per cent of internationally trained doctors remain here one year after they are registered. By the third year just under 33 per cent remain.
As the Medical Council points out, short-term and locum appointments to meet workforce needs are extremely costly to the health sector and offer no long-term benefits.
"It exposes the whole system to risk because it's a global market," Campbell says. "If we're so heavily dependent on overseas-trained doctors then any shift leaves us with shortages."
Campbell is also concerned that with more internationally trained graduates arriving the risk increases that misleading information will slip through the vetting process.
The cost on senior doctors' time is considerable too. "When anyone with an overseas qualification comes into the country, they have to be under a period of supervision. That puts quite an additional burden on the person providing the supervision."
He says too many foreign-trained doctors arriving over a short time increases the burden. "People find on top of their other job it's becoming too much - not only because of the time commitment involved, but also because there is a certain risk. They carry a responsibility."
It's a responsibility that becomes frustrated when the whole process has to be repeated because of high turnover.
Campbell says it's necessary to recognise more clearly our critical dependence on overseas trained doctors. "We need to invest in them, look after them when they arrive, look at how we involve them in post graduate programmes and in the colleges.
"We need to put some resources into ensuring they're up and functioning effectively and their conditions are such that they don't want to move on."
Meanwhile the DHBs insist the pay increases the senior doctors are seeking aren't going to deal with the problem. Quite what will remains unclear.
"Meaningful discussion is getting subsumed in debates about pay," says Meates.
The DHBs talk about the need to reconfigure services to meet demand and to adjust professional boundaries, but they hold back from giving specific examples.
Both sides appear to agree that having experienced senior doctors leading the process is a trend that should continue.
But as Meates points out, there remains a paradox: "There are more clinical leadership roles, more opportunities for medical staff to be involved in the shaping of services and yet there is still a sense of disenfranchisement and a sense of disempowerment."
Brown cites managerialism raising its ugly head as the reason why some senior doctors are feeling disempowered.
He says that's why doctors - even though they are bound by the Hippocratic ethic of "never do harm to anyone" - are considering strike action.
For Brown it comes down to what results in the greatest good for the greatest number of people.
"Frankly, if I don't have somebody beside me to help share the load, if I have a department that should be six but there are only three of us, it is actually harming patients."
