Politicians want to choose who treats you

Last week, I attended the launch of Health Coalition Aotearoa’s Level the Lobbying Playing Field campaign, a worthy initiative by public health experts seeking law change to limit the influence of lobbyists on Ministerial decisions about health.

It was an interesting night, full of compelling arguments, but to me the most telling part was question time. A GP stood up to ask the mostly political panel whether health policy could be built on advice from health experts, with a plan that lasts beyond one election cycle. All three politicians – Helen Clark, Chris Finlayson, and Ann Tolley – were unanimous: ‘No. WE are the ones who make the decisions.’

I know. Health experts designing the system they work in – what a silly, naive hope.

But hey, we’re resigned to it. Health has always been a political football. Every time a new government comes in, health workers grit their teeth, knowing that the policy they have worked for decades to bring to the attention of those-who-make-the-decisions might be shredded before it can even begin to save lives. (Goodbye, Smokefree Act which was a lost opportunity to save 5,000 lives per year and dramatically reduce the life expectancy gap between Māori and non-Māori.) Unfortunately, the current Coalition government has exceeded our expectations and is on track to be the most heath-ignorant leadership ever.

And now we have the latest: a ‘consultation’ from the Ministry of Health which is misleadingly titled “Putting Patients First: Modernising Health Workforce regulation”. The misleading part is the up-front labelling, selling the idea that what they propose ‘puts patients first’ – when in fact, what it really does is ‘put politicians first’ – giving them the power to decide who can and can’t work as a health practitioner in New Zealand and taking that power away from the clinicians and lay people who make up our current health regulation boards. I also think it’s a bit of a Trojan Horse for the real agenda. But more on that later.

Before I go into the proposed changes, a quick primer on how healthcare is regulated in Aotearoa NZ. Why regulate? To protect patients from the risk of harm.

The core purpose of health practitioner regulation is to make sure that patients are treated by people who are properly qualified, competent, and fit to practice. No-one wants to be operated on by a surgeon who doesn’t have the skills to do the job, to be picking up medications from a pharmacist who has made a string of dispensing errors, or to be under the care of a nurse who is coming to work intoxicated by drugs or alcohol. Regulation makes sure that clinicians wanting to work in NZ meet the standards for safe practice, whether they trained locally or are moving to New Zealand from overseas. Regulators also seek to identify clinicians who are causing patient harm – and support them back into safe practice or, in rare instances, limit or cancel their ability to practice.

Historically, doctors, nurses, and allied health professions were “self-regulating” which meant that a body of their peers would make these decisions. This changed in 2003 with the introduction of the Health Practitioner Competence Assurance Act, which recognised the importance of community voice in these decisions. So, for example, the Medical Council of New Zealand has twelve members – four community members appointed by the Minister, four medical practitioner members also appointed by the Minister, and four medical practitioner members elected by the medical profession. Similarly, the Nursing Council regulates nurses, and the New Zealand Psychologists Board regulates psychologists. In addition, medical specialists – such as paediatricians or radiologists – belong to a “College” which is like a professional guild, training the next generation of doctors, making sure specialists stay current through ongoing education, and updating professional standards as healthcare changes over time. Doctors pay hefty membership fees for the privilege of belonging to a College, and over time the number of hoops doctors must jump to keep practicing has increased – often in response to a serious instance of patient harm.

So what changes are the Ministry proposing? At first glance, they seem reasonable enough: firstly, that people who use healthcare have a say on the standards clinicians are held to; secondly that regulation is streamlined so it is cost-effective; thirdly that the regulation hits the right balance between protecting patients while not getting in the way of practitioners doing their work; and finally, that new ways of providing healthcare are considered, for example new roles that might augment or replace the existing workforce.  But hidden in the reassuring language are some not so benign possibilities.

I’ve been talking to my colleagues, including those in nursing and allied health, and we’re all worried that this government’s proposals may open a Pandora’s box that would irrevocably change our health system. We’re worried that policy makers are ignoring the potential costs of these changes in favour of easy political point-scoring. We’re worried that dumb decisions might be made with the ‘mandate’ provided by the straight-to-public consultation, with only a month to feed back. We’re worried about the document itself containing seriously leading questions, insulting insinuations, and strange inferences, for example that doctors only serve their own interests and that cultural knowledge is not part of having good clinical skills. We’re worried that the politicians and the Ministry seem spectacularly disinterested in talking to us, the people with expertise in delivering safe healthcare. And we’re worried most of all that this will lead to patients not receiving the care they need.

The government says they are trying to put patients first. But when you read the fine print, it sounds suspiciously as though the government views health professions as “cartels” and that their aim is to break the ability of professions to set and uphold high standards of care. Because upholding standards of care requires meaningful investment in healthcare – so why do that when you could simply lower standards?

First up. No one is disputing that the current regulatory system is ungainly, and that streamlining and more collaboration would be helpful. But let’s look at the idea that over-regulation is getting in the way of New Zealanders having enough doctors.

The Medical Council registers over 1,300 overseas trained doctors each year. After two years 60 percent of these doctors have left NZ again. This strongly suggests that the registration pipeline is working well, but the NZ healthcare system struggles to retain doctors once they are here. Because Health NZ doesn’t routinely offer “exit interviews” to doctors who are leaving, we don’t know exactly where or why they go. But a quick poll of my colleagues – which turned into an avalanche of correspondence – suggests that overseas-trained doctors leave for very many life reasons. Many are junior doctors who wanted to work and travel in NZ for a year or two, and leaving was always the plan. Those that stay fall in love with either the NZ lifestyle or a New Zealander.

It’s worth reflecting on the reasons why the longer-stayer doctors leave, however. The current migration wave is mostly from the US, UK, and South Africa, but we also have many doctors from Sri Lanka, India, Malaysia, and Hong Kong. These overseas-trained doctors are propping up our health services, particularly in rural and regional areas. Many of them consider themselves New Zealanders and they are valued and respected by the communities they live in and look after.

NZ’s distance from home countries is a big factor, especially as parents age and families need to make tough decisions. Some doctors pointed out that NZ’s tight family reunion laws mean they can’t easily bring family members here, so they have to leave. 

Many cited the ever-worsening work conditions in NZ tipping the decision tree for them:

“People come to NZ rather than Oz or stay home because we are the most beautiful and nicest…..until we aren’t.

“If you are going to be overworked and underpaid, why wouldn’t you either a)go back to where your family and friends are or b) go to Oz and get paid more. (A lot, lot more, especially when pension contributions etc are included).

“NZ has traditionally been less litigious [but] that is changing too … unreachable expectations that are the system’s fault rather than ours [leading to] lengthy and utterly horrible HDC (Health Disability Commissioner) complaints or MCNZ (Medical Council of NZ) investigations with limited or no support from the workplace.”

In the short-staffed services I’ve covered, even after finding an overseas-trained doctor who wants to work with us, we wait six  to 12 months before that doctor arrives and is able to work. I’m told that this is rarely a delay in the medical registration process (though this is inconsistent: waits up to 18 months have been reported); more due to delays in Health NZ recruitment processes, immigration visas, and the other nuts and bolts of moving countries.

Poor communication on timelines causes a lot of extra work. Most departments receive little information on when a doctor is arriving: meanwhile rosters are being written and rewritten and people are cancelling their holidays to cover. I can only imagine how much worse it is for the doctor trying to come here.

Regulation could definitely be streamlined, hitting the right balance between safety and workflow. Many international medical graduates will be asked to complete a period of supervised medical practice when they arrive while they become familiar with the NZ healthcare system and the required standard of practice. Doctors who come from senior roles in their home country are sometimes supervised by local peers with less experience, making for embarrassment on both sides. These supervision requirements take time, and can slow down a clinic, leading some overseas trained doctors to feel like they’re an imposition.

“Leaving your home requires a lot of sacrifice. When you’ve trained for years, became a specialist in your field, left your home and your family, and then are faced with a system that keeps telling you that you’re not good enough for NZ, it really takes the wind out of your sails. Needing to jump through endless hoops to get recognition, vocational registration, paying outrageous amounts for these processes is really discouraging, while at the same time expected to work at full capacity, do unpaid work and work above and beyond your scope.

“If NZ wants to keep their overseas trained doctors, the system needs to stop making them feel like they are incredibly lucky to be able to practice here, and start making them feel valued and wanted.”

I agree in part with the Ministry’s position that the medical profession has been too slow to change. But I don’t think the government taking over regulation is the first step needed. It’s a wider issue of culture. We have a xenophobia and racism problem in our medical community that is still foolhardy to bring up in conversation, let alone confront – just like in wider NZ society.

“The politics here within the hospital are so toxic that unless you are part of the white boys club you are out. Being one of the few women in my field also doesn’t help as men don’t understand that I am not less skilled because I am a mum and a doctor.”

There are many things the government could do to retain our medical workforce: ensuring services are adequately staffed so that people have time to enjoy life in NZ, streamlining immigration, supports to help doctors find jobs for their partners and settle kids into school, and looking at tax settings – currently after four years immigrants have to pay tax on their overseas assets. 

There’s also the matter of hiring biases. Many overseas trained colleagues, when interviewing for positions or promotions, were openly told that they would be the last to be picked. This is obviously a brilliant way to encourage people to stay. But look at the reason – the Government offers financial incentives to hospitals for employing NZ trainees. This rule is about ’jobs for New Zealanders’ (with a narrow definition of who is a ‘New Zealander’). It is not about ‘quality’ or even ‘cultural competency.’ Newly qualified doctors who have been fully trained in NZ medical schools but are not NZ residents also have difficulty getting jobs here.

But is the Ministry using the idea of streamlining regulation as a handy-dandy excuse for a different agenda? What they are calling ‘future-proofed regulation’ is explained as “enabling new models of care; for example, utilising professional groups like physician associates and nurse practitioners.”

This is not a brilliant new idea: in all healthcare settings, a mix of differently trained clinicians work together. Senior doctors already spend a lot of time supervising, and taking responsibility for, less experienced doctors. In my experience, supervising a junior doctor to see a patient takes twice as much time as me just seeing them directly, but training is vital to sustaining our workforce. 

Conversely, nurse practitioners are already highly trained colleagues who have a lot of autonomy and specialist skills; there are other roles, such as accredited nurses who take on roles that in other places junior doctors would fill. They tend to work alongside doctors as part of a team rather than be directly supervised by them.

Physician associates are a little different in that they are ‘helpers’ for the doctors so while not actually doctors, they take on a wide array of medical tasks, like assessing and diagnosing patients, writing medical notes, and doing procedures including minor operations (gulp).

There are currently fewer than 50 physician associates in NZ, but they are common in the UK. Serious concerns have been raised in the UK about patients feeling misled into thinking they were seeing a doctor when they were seeing a physician associate (posters with words like “the cancer specialist will see you now” certainly didn’t help), and having conditions misdiagnosed (for example, a life-threatening lung clot being treated as anxiety) when a physician associate didn’t know what they didn’t know.

There is no training program currently in NZ for physician associates, but training from other countries varies widely: typically it is an undergraduate degree, not necessarily in health,  plus two years postgraduate ‘clinical experience’ towards a diploma. Specialist doctors do six years of medical school, two to three years general experience as a house officer, and then spend at least six years (usually more) working as a registrar while also doing written and clinical exams and research projects. Only then do they earn the title of ‘physician’ or ‘surgeon’.

The idea of having healthcare workers who require shorter training times (read: cheaper) and are paid less is, of course, like catnip to politicians. What a wonderful way of solving the healthcare worker shortage and showing those pesky senior clinicians that they’re not really needed. The problem is that less training also means less experience and therefore more need for supervision. Who does this supervision? The senior clinicians of course. Who takes ultimate responsibility if there are any failures, or please-don’t-think-about-it, deaths? You can bet it’s not the politicians.

You know the saying ‘a little knowledge is a dangerous thing’? That’s the worry here. Someone with a two-year diploma is nowhere near ready to practice medicine unless there is someone closely supervising them. But the government wants to replace more and more roles cheaply.

Take the already-announced ‘associate psychologist’ role. Again, note the name – it’s hard not to conclude that these titles are meant to deliberately mislead as to experience and training. Like the physician associates, their training is vastly less rigorous than that of the professions they seek to replace. Associate psychologists do a one-year postgraduate diploma (two NZ universities have already signed on to develop these courses). By contrast, Clinical Psychologists complete a minimum of six years at university, including a Master’s degree and a professional doctorate or postgraduate diploma with 1500-plus hours spent under supervision.

One psychologist writes:

“(Associate psychologists) may possess some of the ‘tools’ of psychology, such as knowledge of cognitive behavioural therapy techniques for example, but they will lack the foundational scaffolding to know when and how to use them safely and effectively.”

The fact is that these invented roles (their proposed scope of work and qualifications are literally being made up right now), far from taking pressure off existing workloads, may actually add to them. This is due to the need for supervision and damage control for rash decisions made due to inexperience.

When I spoke to a group of psychologists, many of their concerns echoed those of doctors. Like doctors, they feel blindsided by the government making decisions without consulting them. They’re also baffled as to why the real issues are being ignored. Like doctors, they have stats to prove that the ‘pipeline’ delivering new clinicians isn’t the issue; it’s the retention that is the problem, and that is by and large due to feeling unsupported and pushed into unsafe clinical loads by the current health system.

The pipeline also isn’t the issue because those coming out can’t even get jobs. The loudly denied – but obvious – hiring freeze at Te Whatu Ora is reaching the realms of ridiculousness. I’ve heard so many hospital leads express frustration that they are unable to offer newly qualified (and definitely Kiwi) psychologists, nurses, doctors, and others jobs. Meanwhile they are bleeding experienced staff who can no longer justify the cost to their families and themselves, of working under stress and with no control over their hours.

Dr Kumari Valentine, Clinical Psychologist, points out the many actions the government could take that would be more effective:

“We need to increase and expand resource to support existing workforce. New Zealand already has a range of registered health professionals – counsellors, social workers, occupational therapists, and mental health nurses – who undergo additional training to deliver therapeutic interventions. Rather than introducing a new, undertrained workforce, greater investment should be made into expanding postgraduate psychology training programmes and clinical placements. Increasing funding for psychologist training would allow more qualified practitioners to enter the workforce while maintaining professional integrity and high standards of care. There are current issues with the retention of psychologists that can be addressed.”

Māori clinical psychologist Clive Banks worries also that introducing the associate psychologist role would create a two-tier system:

“I have concerns that this new workforce will be sold as the solution to a lack of psychological support for those in under-served communities such as rural populations, which are predominantly Māori. They will not have the skill set required for managing the levels of risk and complexity that a registered psychologist can and if they have insufficient support this is not good for anyone. Not the clinician or the community they are working in.”

As I write this, my fellow senior doctors have announced they will strike after unsafe workloads are once again ignored by those-who-make-the-decisions. So, what do you think? Is our government being disingenuous in declaring that it’s time for them to take over regulation of health professionals, while ignoring all the other issues they could fix? Are these proposed reforms really “putting patients first” or are they a disingenuous way to cut healthcare cuts while undermining the ability of regulatory boards, composed of experienced clinicians and community members, to set and uphold safe standards of care?