GUEST BLOG: Ian Powell – An undervalued and demonized healthcare workforce

During my early years working for the Association of Salaried Specialist Physicians, I received expert advice from a very experienced (now retired) Hutt Valley pediatrician, Dr. Archie Kerr.

He felt that he would much rather be an underpaid pediatrician than an overpaid secretary. This succinct pearl of wisdom has remained prominent in my awareness ever since.

What Dr. Kerr was saying was that by having fewer secretarial staff than needed to provide an effective and efficient pediatric service, he was spending too much time filling the secretarial vacuum. Consequently, he had to struggle to have enough time to devote to diagnosing and treating the children.

Dr. Archie Kerr: I’d rather be an underpaid pediatrician than an overpaid secretary

Professional independence

When thinking of those who work in public hospitals in our District Health Board (DHB), most people think of doctors and nurses. Some might also think of the many smaller and fewer allied health professionals, such as physiotherapists, occupational therapists, scientists, lab technicians and psychologists. They might also think of senior executives (although not sighted).

But few will therefore know and appreciate those who are involved in non-clinical work. They work both in the DHB or hospital-wide and in clinical departments and services. However, they are often not seen by patients.

Non-clinical workers include those working in IT, clerical and administrative staff, service personnel, transporting patients in vehicles or around the hospital (nurses), coding patients, l supply, payroll, finance, cleaning, catering and boilers (Boilermakers proved essential to sustaining Christchurch Hospital immediately after the massive earthquake of 2011).

Generally ignored by patients and their families, their contribution is often not appreciated. But it is highly appreciated by health professionals who depend on it.

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Indeed, public hospitals are highly integrated and complex organizations that employ a wide variety of professions. Professional interdependence is a defining characteristic of our hospitals. The clinical depends on the non-clinical.

From devaluation to demonization

Unfortunately, the relative invisibility of this non-clinical workforce lends itself to being devalued (less so by the healthcare professionals and clinical service managers who depend on it). Unfortunately, due to political expediency, they are also vulnerable to demonization.

Former Health Minister Tony Ryall devalued and demonized non-clinical staff

When he was national spokesperson for health (2005-08), one of his campaign slogans was “from the back office to the front”. His elaboration that too much has been spent on management and that much of that funding should be shifted to the front. Ryall dishonestly referred to non-clinical staff as executives.

After becoming health minister at the end of 2008, Ryall introduced an arbitrary cap on so-called ‘back office’ employment that lasted slightly longer than his six years in the portfolio.

It introduced an unnecessary and inflexible constraint on DHBs by ignoring the wide variety of essential functions performed by non-clinical staff and how integral they were to the work of those working on the clinical frontline.

In addition to disrupting the functioning of the clinical front line, Ryall’s cap has devalued the important roles of these non-clinical workers for several years. In fact, it was worse than that. I remember a current DHB Managing Director describing it as demonizing and intimidating a valued workforce.

Unfortunately, even after the cap was lifted, this demonization and intimidation led to the devaluation of non-clinical employees, becoming a permanent legacy for both that workforce and the healthcare system.

And now

While the cap on non-clinical staff is now over, problems remain due to the continued underfunding of DHBs by successive governments. This was highlighted by the Otago Daily Times in a February 8 article on the need for increased administrative support for clinical staff in the emergency department at Dunedin Hospital:

A clinical chief asks for more administrative staff in the emergency department

The appeal follows recent scrutiny of the quality of patient care at the hospital with the release of two reports from the Health and Disability Commissioner into separate patient deaths in 2019. Both recommended d consider legal action against Southern DHB for these deaths. Among the quality of care issues raised was clinical audit.

The clinical director of the emergency department, Dr Richard Stephenson, indicated that while only 30% of people who arrived at the emergency department were admitted to hospital (the others were able to be discharged), they tended to be older and to have more complex health needs. Therefore, it took time to record these details; more time than they currently have resources.

Dr. Richard Stephenson advocates for increased administrative support to improve quality of patient care

Dr. Stephenson identified the need for increased administrative support for healthcare professionals working on quality improvement, including clinical audit. He also identified improving patient flow for patients requiring transfer from the ER to a ward as an important activity where additional administrative support would be helpful.

Value (and loss) of transparency

This experience is not limited to the emergency department of Dunedin Hospital. Several other clinical departments at Dunedin Hospital and other DHB Southern hospitals are facing non-clinical staff shortages.

Plus, it’s not just a Southern DHB experience. Similar experiences can be found in many clinical wards in the other 19 DHBs across the country which are also plagued by shortages.

What is different about this experience is that the clinical director brought his concerns to the Southern DHB Hospital Advisory Board, which was open to the public and involved a ODT journalist.

This is the kind of transparency that will be lost when our public health system becomes much more centralised, bureaucratized by the abolition of DHBs and their replacement by a new national bureaucratic structure, Health New Zealand, in July.

Transparency is a prerequisite for accountability. It’s hard not to believe that this loss of transparency is an intended rather than unintended consequence of government decision-making.

Ian Powell was executive director of the Association of Salaried Medical Specialists, the professional union representing senior doctors and dentists in New Zealand, for over 30 years until December 2019. He is now a health systems commentator , labor market and political living in the small river estuary community of Otaihanga (the place by the tide). First published at Second opinion of Otaihanga

Michael A. Bynum