WHICH WAY, MINISTER CLARK? | P3 - ASMS
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
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 I S S U E 1 1 5 | J U LY 2 0 1 8
WHICH WAY, MINISTER CLARK? | P3
THE DR BAWA-GARBA CASE: CRIMINAL LAW AND
HOW IT SHOULD BE APPLIED IN HEALTH CARE | P7
YOUR NATIONAL EXECUTIVE AND
BRANCH OFFICERS | P10 TO I M ATA H AU O R A
INSIDE
THIS
ISSUE
ISSUE 115 | JULY 2018
MORE WAYS TO GET
YOUR ASMS NEWS
You can find news and views
relevant to your work as a specialist
at www.asms.nz. The website is
updated daily so please add it to
your favourites or online bookmarks
to remain up to date. 03 WHICH WAY, MINISTER CLARK?
07
We’re also on Facebook, Twitter THE DR BAWAGARBA CASE: CRIMINAL LAW AND HOW IT SHOULD BE
and LinkedIn, and links to those APPLIED IN HEALTH CARE
pages are at the top of the ASMS
website homepage.
10 YOUR NATIONAL EXECUTIVE AND BRANCH OFFICERS
USING QR CODES
12 RESPONDING TO THE CHALLENGES AHEAD
WHICH WAY,
You’ll notice QR codes are
used throughout this issue of
The Specialist. They will take you 14 PREPARING FOR A TOUGH WINTER IN HOSPITAL
EMERGENCY DEPARTMENTS
MINISTER CLARK?
to the websites or online articles
mentioned in the magazine without
manually having to type in a
website address.
15 THE RISE IN ACUTES
If you don’t already have a QR
reader/scanner on your smart phone,
16 THIS YEAR’S BUDGET HAS STOPPED THE BLEEDING, BUT WHAT NEXT?
IAN POWELL | ASMS EXECUTIVE DIRECTOR
you can download one for free from
your phone’s app store (eg, Google
Play on Android or the App Store on
18 WAGE-LED GROWTH: HOW LOW WAGES HOLD BACK PROGRESS
N ew Health Minister Dr David Clark
has announced a highly significant
But it must be remembered that in a
previous life she was an academic health
The review deserves to be welcomed,
but with caution, depending on which
Apple phones). It’s simply a matter
then of pointing the QR reader at
the QR code on the page of the
21 CHILLING IMPACT OF POVERTY ON CHILD HEALTH
and wide-ranging review of health and
disability services. It includes district
economist. Further, she was centrally
involved in the construction of the current
way the review and the Health Minister’s
expectations go (hence the cover cartoon
health boards but goes beyond them to legislation that created DHBs and in this issue of The Specialist).
magazine and then clicking through
to the website link that appears. 24 FIVE MINUTES WITH JUSTIN BARRY-WALSH include primary health organisations
(PHOs) and the wider primary sector.
replaced the commercial business model
that had previously governed our public
New Zealand’s public health system,
compared with universal systems around
The draft terms of reference are broad health service. She knows the principles
The Specialist is produced with the generous
support of MAS.
26 BREASTFEEDING AND RETURNING TO PAID WORK; ISSUES FOR
ASMS MEMBERS and open to public consultation, a
positive approach which compares well
our current Act is based on more than
most, and no one, including political
the globe, performs very well. It punches
above its weight. But there are difficulties,
much of which are due to sustained under-
28
with past government initiatives. opponents, criticises the quality of her
THE CAPITAL CHARGE: A FUNDING GIVE-AND-TAKE funding in a sector affected by continuing
brain cells.
ISSN (Print) 1174-9261 The Chair is Heather Simpson (the rest of and increasing demand (especially acute
ISSN (Online) 2324-2787 the review group is yet to be appointed). This doesn’t mean ASMS will not have and chronic). The Government advises us
31 SPECIAL CIRCULAR 2018/6 Given her role as the highly influential
senior adviser to Helen Clark in her
differences with some of the things her
taskforce proposes. We may well do.
that it intends to address this during its
occupancy of the Treasury benches. It is
The Specialist is printed on Forestry
Stewardship Council approved paper 32 ASMS SUBMISSIONS different roles, especially as a three-term
Prime Minister, this appointment is open to
But whatever that might be, it is likely
to be considered, and not lacking in
off to an encouraging start, but one year
of reasonable funding does not make up
political attack. intellectual grunt. for eight previous years of under-funding.
32 VITAL STATISTICS
33 DID YOU KNOW?
New Zealand’s public health system punches above its weight but there are difficulties, mostly
34 HISTORIC MOMENTS due to sustained under-funding.
2 THE SPECIALIST | JULY 2018 WWW.ASMS.NZ | THE SPECIALIST 3
The review should consider making explicit in the legislation an obligation on DHBs to ensure
workforce empowerment and the well-being and health of those they employ.
RELATIONAL COMMUNITY AND led networks between public hospitals There are several problems with this
HOSPITAL CONTINUUM OF CARE have achieved proven success in Scotland approach. DHBs are responsible
and New South Wales. We have made for defined populations. These four
There are processes and leadership
some progress in New Zealand but are populations are too big and dispersed for
culture that also constrain the
way short of realising the potential. a DHB to have an effective operational
effectiveness of our system. There is too
focus in both community and hospital
much focus on primary and secondary For this to happen, however, we need
care. It is too big an ask. Look at how
care as somehow something being to increase the capacity of the health
organically separate, leading to narrow professional workforce. This includes difficult the relatively new Southern
constructs of ‘primary-led’ and ‘shifting specialists who face (through leadership DHB (the result of a top-down driven
services’ from the former to the latter. The neglect from government to DHB) a crisis merger between Otago and Southland)
focus is structural, rather than relational. as they suffer worsening chronic shortages, is finding addressing the health needs of
Instead, the emphasis should be relational burnout, presenteeism and retention loss. the most geographical dispersed defined
based on the continuum of care between The review should consider making explicit population of all our 20 DHBs.
community and hospital. in the legislation an obligation on DHBs to If the objective is to improve integration in
ensure workforce empowerment and the the continuum of care between community
The most mature example of this is
well-being and health of those they employ (why would it not be otherwise), then
the several hundred health pathways
(https://www.odt.co.nz/news/dunedin/ smaller is better. Where there is more than
between community and hospital (broader
campus/university-of-otago/crampton- one general practice voice or PHO in our
than just primary and secondary) at
protect-nz-health-staff). 20 DHBs, it has proven very difficult to
Canterbury DHB. These have been
developed and agreed through effective achieve the gains that have been made in
AVOID THE STRUCTURAL FOCUS
clinical leadership (not just doctors) in the Canterbury DHB (which has the added
PLEASE, MINISTER
both community and hospital. As a result, advantage of one GP voice to engage
the outcomes are much more robust, But there are some alarm bells. Dr Clark with; Pegasus). Creating four mammoths Our current four regional boundaries are and medium-sized ones, even greater than of a Northland health system. Conversely,
despite serious workforce capacity issues has intimated in a couple of public will severely impede this objective. somewhat artificial. Largely historical, the poorly judged Health Benefits Ltd it is illogical to speak of a northern health
(shortages) amongst specialists at least. utterances on a more structural approach; they do not neatly capture natural clinical initiative of the former Government. The system comprising the three quite diverse
Structure is not the determinant of synergies between DHBs. For example, political risk of such an approach, with the metro Auckland DHBs and Northland.
specifically, the number of DHBs. Further,
Centred on distributed clinical leadership, clinical collaboration between DHBs. while Whanganui DHB has a need to next election in 2020, is high. Only policy
medical sociologist Professor Peter In this context, the review would be better
good relationship-based networking and Davis has argued in the New Zealand There are already good examples of this consider a close relationship with its wonks with their heads in the clouds and
patient-centred care, they have led to happening now. One that hits me in the placed to consider how the operational
Herald (https://www.stuff.co.nz/national/ near neighbour MidCentral, particularly their feet well away from the clinical front
considerable gains both in the quality eye is the very small West Coast DHB role of the Ministry of Health might be
health/104612468/health-review-should- vulnerable smaller services and sharing line would contemplate going down such a
and accessibility of patient care and and the very large Canterbury DHB, better refined to facilitate (perhaps
consider-making-doctors-visits-free-to-all) critical mass, in respect of patient referrals short-sighted direction.
financial performance. This includes the separated by a huge mountain range. even direct) DHBs to focus on clinically-
that we should go back to the short- its clinical synergies are further north in led relational-based networking within
unparalleled experience of bending the There are longstanding historical roots NATIONAL AND LOCAL HEALTH
lived structures of four regional health Auckland and further south in Wellington. and between DHBs, and across the
curve of increasing acute demand. to this collaboration but in recent years SYSTEMS
authorities of the mid-1990s when the community-hospital continuum.
government of the day tried to run our it has qualitatively advanced beyond Merging DHBs does not of itself save
This doesn’t mean that we don’t have A feature of all universal health systems
public hospitals as commercial businesses Canterbury specialists doing lists or clinics money, or at least not enough to be worth
disagreements with Canterbury DHB over is the tension between their internal REVIEW MUST NOT BECOME
competing with themselves and the on the Coast. Services on both sides of the considerable hassle and disruption.
engagement; we do. But this experience local and national systems. All health RATIONALE FOR PROCRASTINATION
confirms the importance of this low private sector. These four authorities the Alps function in a more integrative Didn’t the top-down driven merger of systems struggle with getting the balance OR DELAY
transaction cost relational approach instead controlled the funding for this competitive way than before, with an encouraging the former Otago and Southland DHBs right between what works best locally,
Transalpine feel emerging. A big brother- into the new Southern DHB work well There is also a risk of the Government
of the high transaction cost contractual and model that subsequently collapsed under regionally and nationally. Arguably,
small brother relationship would not have financially with its sustained high level of allowing shorter term exigencies to either
structural approach. Critical to its success its own ideological absurdity. universal health systems are too dynamic
allowed this. debt? The politically driven failed attempt be dumped in the bucket of the review’s
is the leadership culture developing these to get the balance right. But it is not the
I suspect Professor Davis is not proposing to merge by stealth the three lower North scope or continuing to be ignored. These
pathways (distributed clinical leadership), This is still a journey but the road map struggle that is the issue. Instead it is the
a return to this failed business model. It Island DHBs – Wairarapa, Hutt Valley and include the crisis facing the DHB specialist
its networking approach and the focus on is good. But it is being achieved under quality and robustness of the struggle;
would be contrary to his own previously Capital & Coast – led only to uncertainty workforce referred to above, and the lost
patient-centred care. two DHBs rather than through a merger the better this quality and robustness, the
articulated views on this failed attempt to and a level of havoc. opportunities caused by the failure to
(although they share some senior better for our system overall.
The Minister’s review needs to focus on create a commercial market in a universal advance distributed clinical leadership.
improving processes through a relational public health service. But, simplistically, management functions). If it had been a The practical outcome of this review The reality is that we have defined Both of these were glaring omissions from
lens (sometimes called alliancing). This is he seems to be advocating for reducing merger, it most likely would have fallen focusing on the number of DHBs will be a geographic populations with variable David Clark’s first Letter of Expectations
not just through the networking approach our 20 DHBs to four, presumably based short. What has been important is that by distraction from what is really needed to diversity of needs as part of a national to DHBs in April. It is imperative that if
between community and hospital, but also on the four regional groupings of DHBs having its own DHB, the West Coast and improve our public system. It would create system. Each depends on and interacts the Minister is to be genuinely rather than
between DHBs sub-regionally, regionally we currently know as Northern, Midland, its SMOs have had a greater voice which uncertainty over the future for many with the other. It is logical, given its rhetorically transformational, that he
and nationally. Clinically developed and Central and South Island. has benefited all. working in DHBs, particularly the smaller defined population, for example, to speak focuses on addressing them post haste.
4 THE SPECIALIST | JULY 2018 WWW.ASMS.NZ | THE SPECIALIST 5
The review deserves to be welcomed, but with caution, depending on which way the review and
the Health Minister’s expectations go.
THE DR BAWA-GARBA
CASE: CRIMINAL
LAW AND HOW IT
SHOULD BE APPLIED
A positive aspect of the Minister’s
Letter of Expectations to DHBs was
the strong, unambiguous commitment
not wait until the Minister’s review. There
is general acceptance that a population
based funding system (with appropriate
could be done immediately is significantly
increasing the decades old absurdly low
threshold ($10 million) for capital works
IN HEALTH CARE
to public provision of hospital services qualifiers) is sound, especially when spending for triggering Government
DR ROB HENDRY | MEDICAL DIRECTOR AT MEDICAL PROTECTION SOCIETY (MPS)
(and by direct contrast, his opposition to compared with activity-driven alternatives. approval and Treasury monitoring.
privatisation). This is also evident from But some sharply focused work is required
his abandonment late last year of Public POSITIVELY TRANSFORMATIONAL OR
T
by those with expertise in this area on NEGATIVELY ‘DESTRUCTIONAL’ he case of Dr Bawa-Garba in England given a two year suspended sentence The collision that followed between the
Private Partnerships in the South Island. fine-tuning the qualifiers, reviewing whether has created concern amongst the and was subsequently suspended from medical community and the criminal
It took a long time for the penny to drop PHO enrolments might be a more robust If the Minister of Health and his review
medical community worldwide. Doctors the UK medical register for one year justice system has sent shock-waves
but Taranaki DHB eventually realised the method of assessing population than is going to lead to something positively
are afraid that if their care of a patient by the Medical Practitioners Tribunal around the world. ‘Could it happen here?’
obvious and reversed its plan to privatise the five-yearly census based on smaller transformational, it needs to steer away Service (MPTS). The UK General Medical
is judged to be seriously deficient, this and ‘Is a career in a high risk speciality
its hospital laboratory. But there is much numbers, recognising that PBF is unreliable from structural change. Instead, it should Council (GMC) appealed the Tribunal’s
could result in them being the subject wise?’ are questions many health care
more for Dr Clark to front foot on this. for addressing unexpected cost increases focus on improving clinically-led networking decision and sought agreement from
of a criminal prosecution and even professionals in New Zealand are asking
With the various services, clinical and due to natural disasters, and making the processes between community and the High Court to instead erase her
imprisonment. This concern is shared by themselves.
diagnostic, that have been privatised whole process transparent instead of the hospital, and between DHBs at all levels, from the medical register. The appeal
New Zealand doctors. A large degree of the outrage within
over the years, there is a need to plan for current secrecy. on explicitly directing DHBs to be enabling was supported by the High Court. MPS
returning these to public provision as each workforce empowerment (distributed Dr Bawa-Garba was convicted of gross instructed a number of the country’s top the profession in the UK was triggered
Major capital works funding could also be negligence manslaughter (GNM) in 2015, QCs to represent Dr Bawa-Garba in by the GMC’s decision to appeal the
contract comes up for renewal. But this clinical leadership for much of what they
addressed more immediately instead of following her part in the death of six these hearings, and we were extremely MPTS’ determination and seek to have
should not have to wait until the Simpson are responsible for), and explicitly requiring
waiting until the review is completed. Its year old Jack Adcock in 2011. She was disappointed at the outcome. the doctor struck off. It underscored that
review has concluded. It does not need to DHBs to be responsible for the health and
impact on the operational budgets of DHBs
be part of this review because the policy well-being of their workforce.
is profound and distortionary. Why not use
direction is already established. It should If they allow themselves to divert down the
the expertise that already exists in DHBs,
start now. particularly through the chief finance structural dead-end pathway, then, rather
officers, to advise on this? They could look than being positively transformational, the
FUNDING MECHANISMS
at a national risk pooling system of funding predictable outcome will be negatively The Dr Bawa-Garba case has been something of a watershed in the history of professional
The Population Based Funding formula is major capital works that takes the pressure “destructional’ (no such word, I know, but accountability.
a matter that deserves attention but need off operational funding. One thing that it fits).
6 THE SPECIALIST | JULY 2018 WWW.ASMS.NZ | THE SPECIALIST 7
“‘Could it happen here?’ and ‘Is a career in a high risk speciality wise?’ - questions many health care
professionals in New Zealand are asking themselves.“
those who hold doctors to account are far The Accident Compensation Corporation offender, the other is to serve as an So what gives rise to such cases The other crucial difference in Scotland is for the legal bar for a GNM conviction in
from developing the open, learning culture (ACC) example in order to minimise the risk of appearing in front of a criminal court? that if a charge of culpable homicide was England and Wales to be raised; moving
promoted as essential to patient safety. In When the ACC was set up in the recurrence. In New Zealand, the MCNZ There are two essential components which considered against a medical practitioner, towards the Scottish position where
New Zealand, it has also understandably 1970s it introduced a form of no-fault and the HDC effectively fulfil both theses lead from the death of a patient, to the the country’s most senior law officer who charges are only brought against doctors
prompted the question of what the purposes as they are afforded broad criminal court. Firstly, those investigating sits on the Scottish Cabinet is required if an act is proved to be intentional,
compensation for personal injury and
Medical Council of New Zealand (MCNZ) discretion in investigating, prosecuting the death are required to obtain an to approve it. It is possible therefore that reckless or grossly careless and is shown
since then an adversarial approach to
would do in the same situation. independent medical expert opinion on they would take a wider view regarding to be in the public interest. Many other
medical error has not developed. Due to and disciplining medical professionals
the actions of the doctor. If, in the opinion public interest than in England and Wales.
Many are also concerned by the decision to the scheme’s statutory ban on bringing accused of negligence. Hence, while the recommendations are aimed at improving
prosecute Dr Bawa-Garba for GNM in the civil proceedings against medical ACC does not afford medical practitioners of the expert, the care was not just sub- It is widely accepted that a culture of the way in which GNM cases are handled
first place, and here it is worth reflecting practitioners for injury, injured parties immunity from criminal proceedings, standard but a serious departure from openness and low blame should be by the police, courts and the UK GMC1. The
on some of the issues this case has brought can instead seek compensation through criminal prosecution in the absence of ill the proper standard of care, the question promoted in the health service, in order to outcome of the UK Government’s review is
into focus, how this area of criminal law of the doctor being blameworthy to a learn from mistakes. Is it then in the public
a bureaucratic process. This means intent is seen as purposeless. due to be published in the coming months
has developed in different ways in different criminal extent may arise. It is important interest to pursue criminal prosecutions of
there are fewer barriers to doctors being and I know it will be closely scrutinised
countries, and how (for some) it may THE POSITION IN ENGLAND AND WALES to stress that the standard the doctor is individual healthcare professionals? While
entirely candid with patients when things across the New Zealand medical
develop in the wake of this case. being measured against at this stage is such prosecutions are rare, their effect
go wrong. That said, if the ACC identifies GNM is a common law offence in England community and beyond.
one set by another doctor, not by a lawyer on staff perception and morale is greatly
a risk to the public health and safety, they and Wales and has evolved from the magnified. MPS has a wealth of experience in
THE POSITION IN NEW ZEALAND or the police. Without a very critical
may refer the matter to the MCNZ to same set of tests that apply to the civil supporting doctors faced with GNM
In New Zealand there is a statutory consider a doctor’s competence. independent medical report, criminal The culpable homicide law, and its
definition of GNM that mirrors the test for negligence. In order to secure a prosecution will not get off the ground. application in Scotland, has seen one charges. Though it seems unlikely due
The Health and Disability Commissioner conviction, firstly it must be shown that attempted prosecution resulting in to the differences between the New
English legal test. Manslaughter by gross
Health care professionals may not be the individual doctor in question owed Next, when the matter has been fully acquittal. Zealand system and the England/Wales
negligence is a statutory offence under
accountable through the Civil Courts the patient a duty of care; secondly, investigated and such medical expert equivalent, if a doctor in New Zealand
the Crimes Act 1961 making it possible
in New Zealand but they can be held that the doctor breached that duty of opinion is forthcoming the case may CONCLUSION was to be charged with GNM as a result
for New Zealand courts to treat the
to account by the Health and Disability care and thirdly, that the breach of duty be referred by the police or Coroner The Dr Bawa-Garba case has been of an adverse patient outcome, MPS has
circumstances giving rise to the Dr Bawa-
Commissioner (HDC) if it is thought that caused the patient harm. In civil cases to the Crown Prosecution Service. The something of a watershed in the history access to the most experienced lawyers
Garba case in a similar fashion to the
they have infringed patient rights, as set these tests are used to establish whether prosecutor must decide whether or not a and barristers in the country to instruct in
English courts. However, for over 20 years of professional accountability. It has
out by the Code of Patient’s Rights. Where compensation is payable to redress the prosecution is in the public interest and defence of our members.
there have been no GNM prosecutions in highlighted the tension between the open,
the HDC has serious concerns about an harm. In the criminal arena, if the harm if there is a reasonable prospect of
New Zealand and the system for holding learning culture we wish to see and an In addition, MPS is constantly monitoring
individual’s conduct or performance they caused was the patient’s death then the a conviction.
doctors to account has developed in a adversarial and punitive approach to the New Zealand medicolegal environment,
very different way. Two distinct bodies can refer them to the Health Practitioners possibility of a GNM prosecution arises. medical errors.
THE POSITION IN SCOTLAND and if we noticed a change in how the
unique to New Zealand, are worth Disciplinary Tribunal and the MCNZ. The final hurdle that needs to be cleared
Interestingly, the criminal law in Scotland The few health care professionals who general public and relevant authorities
considering because their influence, in Professional failings are therefore usually to secure a conviction is that the jury approach the question of criminal
has developed rather differently to that wilfully set out to harm patients, or are
my opinion, significantly reduces the regarded as a regulatory, rather than must be satisfied beyond reasonable prosecution against medical practitioners,
in England and Wales. Scotland has a reckless, should face criminal charges.
likelihood of such prosecutions occurring criminal matter. The main purpose of doubt that the level of negligence separate legal system; manslaughter is we will use our influence and resources to
However, the vast majority of health
in New Zealand. criminal prosecution is to punish the is ‘gross’. not a term that features and the nearest challenge those who blame and castigate
care professionals - who make mistakes
comparable offence is culpable homicide while working under difficult and complex hard-working doctors and we will continue
which is defined as the killing of a person conditions – should not be labelled as to protect the interests of members.
in circumstances which are neither criminals.
accidental nor justified but where the REFERENCE
wicked intent to kill required for murder, In England and Wales, MPS has provided
“This case has highlighted the tension between the open, learning culture we wish to see and an is absent. In short, the unlawful act giving evidence to the UK Government’s rapid 1. https://www.medicalprotection.org/uk/about-
mps/our-policy-work/consultation-responses/
adversarial and punitive approach to medical errors.” rise to the death must be intentional or, at review into GNM in healthcare. At the consultation-responses/evidence-to-the-
least, reckless and/or grossly careless. heart of our recommendations, is a call professor-sir-norman-williams-review
8 THE SPECIALIST | JULY 2018 WWW.ASMS.NZ | THE SPECIALIST 9
L-R, Back: Drs Julian Vyas, Paul Wilson, Seton Henderson, Julian Fuller, Tim Frendin.
Front: Andrew Ewens, Angela Freschini, Murray Barclay, Katie Ben, Annette van Zeist-Jongman, Hein Stander.
YOUR NATIONAL EXECUTIVE
YOUR ASMS BRANCH OFFICERS FOR THE SAME PERIOD ARE:
AND BRANCH OFFICERS
REGION PRESIDENT VICE-PRESIDENT REGION PRESIDENT VICE-PRESIDENT
Northland Jenny Henry Ian Page Whanganui Bernd Kraus Mark Van De Vyver
Waitemata Jonathan Keat Lee Palmerston North Andrew Spiers John Bourke
Casement Wairarapa Norman Gray Nicholas Pascoe
THE ASMS NATIONAL EXECUTIVE • Hein Stander, Immediate Past • Tim Frendin, geriatric medicine, Auckland Helen Pilmore Susan Farrelly Hutt Valley Neil Stephen Tanya Wilton
FOR THE THREE YEARS TO 2021 IS: President, paediatrician, Tairawhiti Hawke’s Bay Counties Manukau Sylvia Boys VACANT Wellington Justin Barry-Walsh Alain Marcuse
• Murray Barclay, National President, • Julian Vyas, paediatrics, Auckland • Angela Freschini, anaesthesia, Waikato Dara Las Heras Alison Stearn
gastroenterologist, Canterbury Tairawhiti Marlborough Jeremy Stevens Graeme French
• Andrew Ewens, emergency medicine,
Tauranga Rod Gouldson William McAuley Nelson Katie Ben Gareth Harris
• Julian Fuller, Vice-President, Waitemata • Seton Henderson, intensive care,
anaesthetist, Waitemata • Annette van Zeist-Jongman, Canterbury Taranaki Allister Williams Allan Binnie West Coast Stuart Mologne VACANT
• Paul Wilson, National Secretary, psychiatry, Waikato • Katie Ben, anaesthesia, Nelson Rotorua Andrew Robinson Philip Gartland Canterbury Geoff Shaw Siobhan Cross
anaesthetist, Bay of Plenty Marlborough.
Whakatane Richard Forster Kathy Sutton South Canterbury Matthew Hills Peter Doran
Tairawhiti Mary Stonehouse William Weiderman Otago Chris Wisely John Chambers
Hawke’s Bay Kai Haidekker Debra Chalmers Southland Roger Wandless Leonard Chia
Thank you to everyone who put their hand up for either the National Executive or Branch Officer positions. We appreciate your
willingness to advocate and support your medical colleagues, and this shows the Association is in good heart. We would also like to
acknowledge those members of the National Executive and Branch Officers who decided not to stand for re-election, and thank you for
your efforts and ongoing commitment.
10 THE SPECIALIST | JULY 2018 WWW.ASMS.NZ | THE SPECIALIST 11
80%
ASMS needs to take a strong role in advocating 70%
for the quality and equity of health care for
Prevalence of personal burnout
60%
patients in New Zealand. Female
50%
40%
Greece 30% Male
Italy
Czech Republic 20%
Austria
Latvia 10%
Estonia
Spain
Germany 0%
Switzerland 30-39 40-49 50-59 60 or
United States over
Age group
Portugal
Sweden Figure 2: Prevalence of burnout related to
Iceland
Israel age group and gender
United Kingdom
RESPONDING
Slovenia
Luxembourg 80%
Poland
70%
TO THE
Netherlands
% Reporting weekly/daily bullying
Finland
Belgium 60%
France
CHALLENGES
Norway 50%
Denmark
Ireland 40%
Australia
AHEAD
Korea
Mexico 30%
Canada
New Zealand 20%
Turkey
PROF MURRAY BARCLAY | ASMS NATIONAL PRESIDENT Chile 10%
0 1 2 3 4 5 0%
Practising specialists per 1000 Low Average High
B ecoming President of ASMS is not
something I imagined when I was
approached six years ago to join the
being President of the New Zealand
societies of gastroenterology and clinical
pharmacology, and clinical directorship.
WHAT WE KNOW
In 2013, New Zealand ranked near the
population in OECD countries
Figure 1: Practising specialists per 1000 population
Level of workplace demand
Figure 3: Bullying prevalence related to
bottom of OECD countries for number in OECD countries in 2013 workload demands
National Executive. As I came to grips of medical specialists per head of
What is apparent from the ASMS
with the Executive functions, I became research and member feedback is population (figure 1). Updated data is
increasingly involved in the research that the New Zealand senior medical being sought but requires validation.
activities of ASMS, particularly senior workforce has some major problems
doctor understaffing, and the well- Medical staff burnout is topical globally (figure 3) along with reduced support The ongoing series of DHB clinical ASMS is a mature organisation, almost
that need addressing urgently to enable but in New Zealand our frankly tragic from peers or non-clinical managers. director surveys on workload and FTE 30 years in existence, and its activities
being issues of burnout, bullying, and New Zealanders to get the medical care burnout rate of 50% (figure 2) looks requirements appears to be showing have grown beyond contract negotation.
presenteeism. My research background they deserve. When asked to be ASMS Disturbingly, burnout and bullying are
to be higher than in other countries consistently that New Zealand needs We now deal with issues around health
meant that I was keen to see good data President, it was the findings of the clearly even more of a problem for female 25% more senior doctors per head of
where burnout has been studied. The advocacy, climate change, healthy eating,
on these important issues to help drive research that convinced me this might consequences of burnout are serious senior medical staff (figure 2) with, in population just to deal with current doctor well-being, gender inequity and
improvement. I was therefore very be worthwhile as it was clear that further for these senior doctors and for their particular, a burnout rate 20% higher workload expectations, let alone to others. Feedback from members has
supportive of increasing the research work needed to be done to both define patients who fail to get the health than males at each age band (70% provide optimal health care following full been positive in respect of these ASMS
capacity of ASMS with highly competent these problems, but more importantly to care benefits that result from proper in young female senior doctors) and a consideration of unmet need.
directions but it is probably a good time
staff. We certainly have those now. attempt to bring about improvements. engagement with their doctor. High bullying rate of 40% versus 32%.
Our current best tool in the MECA to reflect on priorities. ASMS will therefore
For those who don’t know me, I work I have found that the ASMS team and workload is at least one of the factors WHAT FOR THE NEXT THREE YEARS? for addressing departmental FTE be seeking views from members within the
as a gastroenterologist and clinical national executive are exceptional in their predicting burnout. requirements is regular job-sizing. In next year to help fine-tune priorities.
At the time of MECA negotiations, the role parallel, it may be that service-sizing that
pharmacologist at CDHB. I am also a approach and passion. All are dedicated More recently, we have documented high
of ASMS needs to be to negotiate for the takes into consideration unmet health So there is plenty to do, but also some very
Clinical Professor with the University to improving the lot of senior medical rates of bullying in the New Zealand
staff in New Zealand, and improving the best possible conditions for members. In need may further define and address good people doing it at ASMS. During my
of Otago. I grew up in small town New senior medical workforce, including 38%
Zealand, Balclutha, went through Otago quality and equity of health care in NZ. between MECA negotiations, however, it requirements. Service and job-sizing time on the Executive so far I have been
experiencing this at least weekly and
Medical School, have a grown family and This makes working with them a pleasure seems clear that ASMS needs to take a requires significant resourcing from DHBs fortunate to observe the great leadership
67% witnessing bullying at least weekly.
live on the rural edge of Christchurch. that generates enthusiasm and hope that Again, high workplace demand was strong role in advocating for the quality and and ASMS but the outcomes should more styles of Drs Jeff Brown and Hein Stander
My leadership experience includes positive changes can be made. strongly associated with risk of bullying equity of health care for patients in New than compensate. ASMS will be helping who have brought a solidity, good humour
Zealand. In relation to senior medical staff, to drive these initiatives whenever and and strength of purpose to the role that I
the most obvious thing that needs to occur wherever possible. hope I can, at least partly, replicate. And I
is a sharp increase in senior doctor numbers The gender inequity highlighted in our look forward to the next three years with
to combat unmanageable and dangerous surveys over the past two years requires the hope that we can help bring about
workloads. Senior staff also need adequate further exploration and definition with a some significant improvements in health
The New Zealand senior medical workforce has some major problems that need addressing time to consider service reconfiguration that view to providing some solutions for our care in New Zealand, and in particular,
urgently to enable New Zealanders to get the medical care they deserve. provides better, more manageable health female senior medical staff. I believe this is better working conditions and job
care for patients. now a high priority for ASMS. satisfaction for members.
12 THE SPECIALIST | JULY 2018 WWW.ASMS.NZ | THE SPECIALIST 13
When pressure goes on ED,
every part of the hospital
THE RISE IN
ACUTES
system becomes stressed.
ANGELA BELICH | ASMS DEPUTY EXECUTIVE DIRECTOR
At many of our Joint Consultation numbers insufficient for the level of
Committees, where ASMS members acuity, primary care presentations
met with DHB management, members greater than the degree of
raised the issue of the rise in acute population growth
presentation which had not showed
the usual summer lull but continued • Wairarapa – higher than average
to be high. The bad flu season in the demand, shortfalls have meant the
northern hemisphere also contributed cancelation of electives
to a gathering sense of doom. The • Hutt Valley - hospital already
following issues were noted (some
full on a number of occasions as
meetings did not discuss the issue):
of February, optimistic that full
• Northland – acute demand complement of nurses this year,
increasing, no summer decline in
looking at an escalation plan for ED
presentations, theatres stretched,
ED under pressure due to bed block • West Coast – pressure on primary
• Waitemata – winter planning care meant overflow pressure
to minimise the impact of flu, on ED.
vaccinations a big emphasis
PREPARING FOR A TOUGH particularly of staff WHAT SHOULD ASMS MEMBERS
• Auckland - little room to DO?
WINTER IN HOSPITAL
accommodate surges as serves as 1. Get vaccinated and make sure your
acute hospital for the rest of the colleagues get vaccinated too
country; some services very vulnerable
2. Participate as fully as you can in
EMERGENCY DEPARTMENTS
• Counties Manukau - hospital at planning for this winter
nearly full capacity with 21 lists
being cancelled at the date of the 3. If you are too tired or sick, or you
JCC, 14% growth in acute demand see colleagues who are too tired or
DR JOHN BONNING over the last five years without sick to work, take leave or take a
corresponding increase in beds, break. If you cannot work safely, you
resilience is complicated by low cannot give patients safe care
morale among staff, many of whom
In New Zealand, the summer months are historically a time of relative quiet but not this year, with a number of emergency
departments feeling under pressure even over summer (https://www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=12004291).
Whilst there is usually a 4-6% increase in presentations year on year in Waikato Hospital, there was a 19% increase in presentations in
“Ambulance ramping (being unable to
unload patients from ambulances due to
no physical space being available in ED
perceive the DHBs problems as
management’s fault
4. Make sure you are familiar with
the Medical Council Statement on
managing in a situation of resource
February/March compared to 2017. to put them) will happen again this year • Waikato - see accompanying article
constraint https://www.mcnz.org.
(having happened in NZ for the first time for John Bonning’s assessment
“It’s going to be pretty torrid this winter,” “At Waikato Hospital’s emergency roads, older people living longer, more nz/assets/News-and-Publications/
in 2017 and happening in Australia for a • Lakes – very busy, higher number of
says Waikato Hospital emergency department, there’s been a nearly 50% falls, and higher levels of unmet health decade) and we’ll see people languishing Statements/Safe-practice-in-
presentations compared with last
physician John Bonning, who’s also increase in presentations between April need. We’d arrive at work at 8 o’clock in in ED corridors again. It will be tough to an-environment-of-resource-
year; at the time of the meeting, four
the New Zealand faculty chair of the 2011 and April 2018. We’re talking over the morning and there would be over 20 find a bed and people will end up staying limitation.pdf
patients in ED under the influence of
58,000 presentations pa to Waikato patients waiting for inpatient bed spaces many hours in ED.
Australasian College for Emergency methamphetamine 5. Schedule breaks, weekends, leave
ED in 2010, increasing to over 63,000 which were not available. And that was just
Medicine (ACEM). in April before winter had started.” “When pressure goes on ED, every part of • Bay of Plenty - surge in and keep to them, and support your
in 2011 (8% increase) after the new ED
the hospital system becomes stressed, and presentations at Whakatane, colleagues to do so
“We’re going to be flooded in particular opened, to well over 85,000 in 2017. He says people with minor complaints
EDs are not the place to manage patients unanticipated number of patients
with older people, particularly with chronic are not the cause of the clogged 6. Reiterate to your managers, your
“That is a nearly 70% increase over 7 ongoing health needs for hours on end using hospitals
illness, as well as children. Not just at hospital system. Chief Executive, your Board, the
years. At the same time, the population once their acute needs have been met.” • Tairawhiti - stress on services due to
Waikato – hospitals all around the country hasn’t grown by anywhere near that Minister and the Government that
“We’re not busy because patients can’t understaffing
are in a similar situation. Hospitals have proportion over that period so the increase He says patients can help by taking the solution is adequate staffing and
see their GP for something minor or • Taranaki - long-term consistent
been operating well above 80% inpatient is really due to increased burden of chronic because they’d stood on some Lego. We’re some responsibility for their own health decent accommodation, and that
care, ensuring that they are vaccinated, increase in demand, DHB blindsided
bed capacity and demand has gone disease, diabetes, heart and respiratory dealing with a lot of very sick people, and today’s situation is the result of the
don’t smoke, that they drink alcohol in by rise in demand over Christmas,
right up. illness, more trauma, more cars on the it’s going to increase. under-resourcing of the past. Job
moderation, and are aware of their sugar number of nurses the critical factor;
intake. Clinicians and patients also need bed block had a negative effect sizing should be adequate to cope
to be aware of the Choosing Wisely on electives with surges, and this for many DHBs
initiative (www.choosingwisely.org.nz) to • Hawkes Bay - second year in a is the second or third year where
ensure limited health care resources are row with no summer drop off, ED acutes have risen faster than the
We’re not busy because patients can’t see their GP for something minor or because they’d used rationally. designed to take 27,000 patients in population and there has been no
2021 now seeing 46,000, nursing summer lull.
stood on some Lego. We’re dealing with a lot of very sick people, and it’s going to increase. “We all need to help to manage our limited
health care resource as best we can.”
14 THE SPECIALIST | JULY 2018 WWW.ASMS.NZ | THE SPECIALIST 15
You cannot run down health funding by $2 billion without consequences. Years of funding shortfalls merely shift the costs, both financially and socially, downstream.
increased by 1.8 million, though GPs are We want to make sure people get the would be an even tighter bottleneck to
still seeing about 80% of the patients. The health care they need to stay well. Early accessing non-acute hospital care, which
population grew by an estimated 11.4% intervention and prevention work can also in turn would create greater pressure
over the same period. help take pressure off our hospitals and on primary care and possibly, eventually,
THIS YEAR’S BUDGET HAS
specialist services.” acute services.
WHY THE INCREASE IN ‘ACUTES’?
However, the evidence from New Zealand The evidence indicates clearly that both
There will be many factors contributing and overseas indicates that while measures primary care and hospital care services
STOPPED THE BLEEDING,
to the rise in acute hospital admissions. to improve access to primary care are require significant boosts in resources.
Overseas studies indicate common much needed, they do not necessarily And studies looking at interventions to
patient factors are related to aging, low reduce the use or need of hospital care.
BUT WHAT NEXT?
reduce acute hospital admission suggest
socioeconomic status, lower educational The dynamics are more complex. a promising solution to reducing acute
attainment, chronic disease and
multimorbidity. In New Zealand, additional If, under continuing budget constraint, hospital admission is in improving the way
factors will be high levels of unmet need the ‘strong focus’ on primary care is code the two parts of the health system work
LYNDON KEENE | ASMS DIRECTOR OF POLICY AND RESEARCH for primary and secondary care and for a ‘rob Peter to pay Paul’ approach to together. These issues will be examined
mental health care, along with underlying health service funding, the likely outcome further in future articles.
inequalities. Poverty, poor housing, high
and growing rates of obesity are all well- ACUTE AND NON-ACUTE HOSPITAL DISCHARGES
C ouncil of Trade Unions (CTU) economist Bill Rosenberg described the Government’s 2018 Budget as a ‘stop the bleeding’
budget, but warned that the body of public services is still in dire straits: “While the bleeding may have stopped, we still have to
get the patient well again.”
documented issues.
Despite the increased use of primary
(ACTUAL AND CASE-WEIGHTED [CWD]), 2010/11 TO 2016/17
health care, many people continue to Acute actual Acute cwd Non-acute cwd Non-acute actual
The Health budget is a good example. You cannot run down health funding by acute service need. Hospital day cases
face barriers to those services. The
For the first time since at least 2010, $2 billion dollars without consequences. (non-overnight stays) are not included 700,000
New Zealand Health Survey 2015/16
Vote Health appears to have received The ASMS has long argued that years of in this data but other Ministry of Health
shows 29% of adults reported one or
sufficient funding ($863 million additional funding shortfalls merely shift the costs, reports indicate a 16.9% rise from 2010/11
more types of unmet need for primary
operational funding) to cover rising costs both financially and socially, downstream. to 2014/15 (the latest data published) –
health. The most common reasons for
and demographic pressures, compared with Those downstream effects are now again, well above the population increase
this unmet need were being unable to get 600,000
the previous year, as well as pay for new evident in the trends showing increasing of 4.8% for that period.
an appointment at their usual medical
initiatives such as reducing primary care fees health service use is far outstripping the
Increases in Emergency Department centre within 24 hours, and the cost of
for people on low incomes and extending rates of population growth, including
(ED) presentations and the use of Mental GP services. Cost barriers to primary
free general practitioner visits to children public hospital admissions. Health and Addiction Services (MHA) health services for children have been
under 14. At the time of writing there 500,000
The number of public hospital inpatients are also far exceeding the growth in reduced through increased subsidies
remains a number of unknowns, however,
(excluding mental health and addiction population. Waikato District Health to general practices. However, in
such as the outcome of pay negotiations
services) rose by 14.1% from 2010/11 Board’s ED, for example, has seen an 2015/16 nearly a quarter of children still
with nurses, allied health staff and others,
to 2016/17 (13.2% when adjusted for increase of presentations approaching experienced one or more access barriers,
and the pay equity settlements such as for
‘caseweights’), while the population grew by 70% in seven years (see separate article including difficulties in getting timely
mental health care and support workers. 400,000
9.3%. This growth is due largely to a 20.0% in this issue of The Specialist). And the appointments. The location of a primary
CTU-ASMS analyses of the Health number of unique ‘clients seen’ by MHA care practice (and the local ED), and the
increase in acute inpatients over that
budgets have estimated that years of service teams grew by 50% in the years ability to get a convenient appointment
period – more than twice the population
funding shortfalls have accumulated 2008/09 to 2015/16. Further, many of with a primary care practitioner are
growth. When adjusted by caseweight,
to the extent that if this year’s health those clients are seen more than once commonly cited barriers to primary care 300,000
acute inpatients increased by 14.2%.
funding was to be restored in real terms to in any given year, as indicated in data both here and overseas.
2010 levels (when CTU analyses began), The rapid growth in acute cases appears showing ‘new referrals’ to MHA triage
it would have needed an additional to have squeezed out non-acute patients, HOW WILL THE GOVERNMENT
teams increased by 62% over the five
$2.7 billion, so is nearly $2 billion short whose numbers grew by just 5.3% over years from 2010/11 to 2015/16 (earlier RESPOND? 200,000
of that mark. No one would expect a the same period. That becomes a 12.0% data is less robust). The data indicate growing pressure in
funding shortfall of such magnitude to increase, however, when adjusted by case- every part of the system. The question
be addressed in a single budget, but weight, indicating the non-acute cases The big increase in acute hospital service
now is how the Government will respond
whether the public health system is to are becoming more complex, possibly an needs has occurred as primary care
while it is highly constrained by ‘Budget
operate more efficiently and effectively, effect of the aging population. use is also growing ahead of population 100,000
Responsibility Rules’ limiting government
whether it is to provide timely responses growth. Between 2008/09 and 2016/17,
The headcount growth of non-acute spending and debt.
to New Zealand’s growing health needs primary care consultations increased by
and address unmet need, whether it is to patients being less than population 24.3%. Much of that is due to more nurse When Health Minister David Clark
provide staffing levels that are safe for growth suggests a growing but consultations, which grew by 115.1%, while announced a major review of the health
0
both patients and those providing the unmeasured level of unmet need for general practitioner consultations grew system recently, he stressed that the 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17
care, is all dependent on a restoration to people with non-acute conditions, which by 12.6%. GP consultations increased review would include “a strong focus
2010 funding levels – and more. may in turn be contributing to growing by 1.5 million, while nurse consultation on primary and community-based care. Source: Ministry of Health Caseload Monitoring Reports (data extracted from Excel spreadsheets)
The evidence indicates clearly that both primary care and hospital care services require significant Increasing health service use is far outstripping the rates of population growth, including public
boosts in resources. hospital admissions.
16 THE SPECIALIST | JULY 2018 WWW.ASMS.NZ | THE SPECIALIST 17
WAGE AND SALARY SHARE OF GROSS DOMESTIC REAL COMPENSATION OF EMPLOYEES PER HOUR
INCOME COMPARED TO OECD MEDIAN COMPARED TO SHARING THE LABOUR PRODUCTIVITY
SOURCES: AMECO DATABASE, AUTHOR’S CALCULATIONS, SNZ GAINS 1989-2016
MARCH 2017 DOLLARS, MEASURED SECTOR
65 $41.00
63 $39.00
60 $37.00
58 $35.00
55 $33.00
WAGE-LED 53 $31.00
GROWTH:
50 $29.00
48 $27.00
HOW LOW 45 $25.00
1960
1963
1966
1969
1972
1975
1978
1981
1984
1987
1990
1993
1996
1999
2002
2005
2008
2011
2014
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
WAGES Denmark OECD Median New Zealand If wages had followed productivity gains Wage adjusted by living costs (CPI)
HOLD BACK
Wage adjusted by employers’ revenue (the GDP deflator)
PROGRESS inequality would have a powerful impact on
overall inequality. There is ample evidence
mathematical achievement and literacy,
worse infant mortality, more homicides,
But wages have not kept up with
productivity – see the graph above1. That
DR BILL ROSENBERG | COUNCIL OF TRADE UNIONS ECONOMIST AND POLICY DIRECTOR that deunionisation has been a significant high imprisonment rates, more births to is the case in the US and other parts of
cause of rising income inequality (eg, D. E. teenage mothers, lowered trust, more the world.
Card, Lemieux, & Riddell, 2003; D. Card, obesity, poorer mental health, drug and
Lemieux, & Riddell, 2004; DiNardo, Fortin, Productivity does need to rise for
alcohol addiction, and decreased
W e are frequently told “You can’t raise wages before you raise productivity”. But productivity is barely rising: employers are & Lemieux, 1995; Jaumotte & Buitron, 2015; sustainable increases in wages in the long
social mobility.
not investing to raise it. Why not? Perhaps they don’t feel the need to because wages are kept low. Perhaps raising wages Koske, Fournier, & Wanner, 2012; Western run – but there is nothing automatic about
would encourage productivity to rise, funding new wage rises and creating a virtuous spiral of rising wages and productivity. As I & Rosenfeld, 2011). With low wages, the tax • It can increase financial instability and (real) wages following productivity. Since
show below, there is good logic and evidence that that could be true. and benefit systems have much more work crises. For example, IMF researchers the collective wage setting system was
to do to redistribute income. Michael Kumhof and Romain Rancière largely destroyed outside the state sector
WAGES ARE IMPORTANT SOCIALLY otherwise high income countries. New Families, accommodation supplements (2010a, 2010b, 2011) find evidence in the 1991 Employment Contracts Act, that
AND ECONOMICALLY… Zealand’s low share of income going to and so on. …WHICH HAS BAD SOCIAL AND of increasing financial instability as has not been the case. So to say wages
wages is one indicator, as the figure on ECONOMIC EFFECTS inequality grows due to low and middle must follow productivity is simplistic.
Wages (including salaries) are important the right shows. Another is the dominance LOW WAGES CONTRIBUTE TO HIGH income earners becoming increasingly
socially as well as economically. They INCOME INEQUALITY… It’s worth remembering some of the reasons indebted in order to make ends meet. …AND PRODUCTIVITY GROWTH IS
of low wage industries in our economy, high levels of inequality are bad.
are easily the most important way that particularly in the export sector – One of Kumhof and Rancière’s solutions CHRONICALLY WEAK
employees get a share of the income their The wage problem is also about how
agriculture and tourism. Qualifications, • It can lead to social breakdown. There’s is restoring workers earnings through
income is distributed: income inequality But New Zealand has another problem:
work creates so they and their families particularly vocational ones, are poorly evidence from both common experience strengthening collective bargaining.
remains high in New Zealand (see Perry chronically weak productivity growth.
can live decent lives. On average, 60% of rewarded in higher wages (eg, Crichton, and carefully designed experiments that
again). In the CTU’s August Bulletin (http:// • It can worsen economic growth. As There is no single simple answer as to why,
the incomes of New Zealand households 2009; Crichton & Dixon, 2011; Zuccollo, people dislike unfair shares. With high
www.union.org.nz/economicbulletin192/), inequality rises, there is evidence for but perhaps an important reason is low
comes from wages (and even more in Maani, Kaye-Blake, & Zeng, 2013). We inequality, people feel they are being
I summarised recent research showing both more intermittent growth (eg, A. G. wages itself.
prime working age households). have too many working poor (four out of treated unfairly, social tensions rise,
growing wage inequality (Rosenberg, Berg & Ostry, 2011, 2011; A. Berg, Ostry,
ten children living in poverty come from 2017). Gender pay inequality plays an cohesion as a society breaks down. ARE LOW WAGES THE CAUSE OF LOW
…BUT LOW & Zettelmeyer, 2008) and for slower
working families, according to Perry (2017, important part too. Because wages • Inequality is highly correlated with, and growth (eg, Cingano, 2014; Wade, 2013). PRODUCTIVITY AS WELL AS THE
It is widely accepted that New Zealand’s p. 144)), and we would have many more are such an important part of people’s likely contributes to many other social, RESULT?
wages are low compared with other if not for income support: Working for incomes, raising wages and reducing wage There are therefore strong economic and
mental and physical ills. As Wilkinson
social reasons for improving wages in order Raising real wages can raise productivity at
and Pickett (2010) demonstrated
to reduce inequality. three levels.
in their book The Spirit Level: Why
More Equal Societies Almost Always WAGES AND PRODUCTIVITY – REALLY? MOTIVATING WORKERS
Do Better, “almost all problems which
are more common at the bottom of The standard answer from employers and First, it works at the level of individual
Inequality is highly correlated with, and likely contributes to many other social, mental and the social ladder are more common in economists when people complain about workers. Higher wages and fair treatment
physical ills. more unequal societies”. They included our low wages is: “You can’t raise wages lead to better motivated workers who put
lowered life expectancy, poorer before you raise productivity.” more effort and thought into their work,
18 THE SPECIALIST | JULY 2018 WWW.ASMS.NZ | THE SPECIALIST 19You can also read
