In my early years working for the Association of Salaried Medical Specialists I received wise advice from a very experienced (now retired) Hutt Valley paediatrician Dr Archie Kerr.
He opined that he would much rather be an underpaid paediatrician than an overpaid secretary. This succinct pearl of wisdom has remained prominent in my consciousness ever since.
What Dr Kerr was saying was that by having less secretarial staff than required to ensure an efficient and effective paediatric service, he was having to spend too much of his time filling the secretarial vacuum. Consequently he was left struggling to have sufficient time to spent diagnosing and treating children.
When thinking about those working in our district health board (DHB) public hospitals most people think of doctors and nurses. Some might also think of the many lower profile and less numerous allied health professionals such as physiotherapists, occupational therapists, scientists, laboratory technicians and psychologists. They might also think of (although not sighted) senior managers.
But few will know of and therefore appreciate those involved in non-clinical work. They work in both DHB or hospital-wide roles and within clinical departments and services. However, they are often not seen by patients.
Non-clinical workers include those working in IT, clerical and administration, ward clerking, transporting patients in vehicles or around the hospital (orderlies), patient coding, procurement, payroll, finance, cleaning, catering and the boilers (boilermakers proved to be indispensable to keeping Christchurch Hospital going immediately after the massive 2011 earthquake).
Being generally unsighted by patients and their families, their contribution is often not appreciated. But it is greatly appreciated by the health professionals who depend on them.
This is because public hospitals are highly integrated and complex organisations employing a huge variety of occupations. Occupational interdependency is a defining feature of our hospitals. The clinical are dependent on the non-clinical.
From devaluing to demonisation
Unfortunately the relative invisibility of this non-clinical workforce lends itself to being devalued (less so by the health professionals and clinical service managers who depend on them). Unfortunately, owing to political opportunism, they are also vulnerable to demonisation.
When he was National’s health spokesperson (2005-08) one of his campaigning slogans was ‘from back office to frontline’. His elaboration that too much was spent on management and much of this funding should be transferred to the frontline. Ryall disingenuously branded non-clinical staff as management.
After becoming health minister in late 2008 Ryall introduced an arbitrary cap on the employment of the so-called ‘back office’ that lasted for a little longer than his six years in the portfolio.
It introduced an unnecessary and inflexible constraint on DHBs by ignoring the considerable variety of essential functions performed by non-clinical staff and how integral they were to the work of those working at the clinical frontline.
As well as disrupting the functioning of the clinical frontline, Ryall’s cap devalued the important roles of these non-clinical workers for several years. In fact, it was worse than this. I recall a current DHB chief executive describing it as demonising and bullying a valued workforce.
Sadly, even after the cap was subsequently discontinued this demonisation and bullying led to the devaluing of non-clinical employees becoming an ongoing legacy for both this workforce and the health system.
What about now
While the cap on non-clinical staff is now long gone, problems still remain due to the continued underfunding of DHBs by successive governments. This was highlighted by the Otago Daily Times in an 8 February article on the need for more administrative support for clinical staff in Dunedin Hospital’s emergency department:
This call follows recent close scrutiny of the quality of patient care in the hospital with the release of two Health & Disability Commissioner reports into separate 2019 patient deaths. Both recommended that prosecution over against Southern DHB these deaths be considered. Among the quality of care concerns raised was clinical auditing.
The emergency department’s clinical director Dr Richard Stephenson has advised that while only 30% of people who arrived at ED were admitted into the hospital (the rest were able to be discharged), they tended to be older and have more complex health needs. Consequently it took time to record those details; more time than they are currently resourced for.
Dr Stephenson identified the need for more administrative support for health professionals working on quality improvement including clinical auditing. He also identified improving patient flow for patients requiring transfer from ED into a hospital ward as an important activity for which more administrative support would help.
Value (and loss) of transparency
This is experience is not confined to Dunedin Hospital’s emergency department. Several other clinical services in Dunedin Hospital and the other Southern DHB hospitals face shortages of non-clinical staff.
Further, this is not just a Southern DHB experience. Similar experiences can be found in many clinical services in all the other 19 DHBs in the country which are also riddled with shortages.
What is different about this experience is that the clinical director raised the concerns at Southern DHB’s hospital advisory committee which was open to the public and attended by a diligent ODT journalist.
This is the type of transparency that will be lost when our public health system becomes much more centrally bureaucratised through the abolition of DHBs and their replacement with a new national bureaucratic structure, Health New Zealand, in July.
Transparency is a prerequisite for accountability. It is difficult not to believe that this loss of transparency is an intended rather than unintended consequence of government decison-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, labour market, and political commentator living in the small river estuary community of Otaihanga (the place by the tide). First published at Otaihanga Second Opinion