The Association of Salaried Medical Specialists (ASMS) is the union representing salaried senior doctors and dentists. Overwhelmingly, our members are employed by district health boards (DHBs). Since our formation in 1989, we do the usual things associated with unions. We negotiate and enforce collective agreements, and represent members over various employment-related matters. However, our approach to unionism is broad. Since the imposition of the controversial business market-led government policy towards the public health service in the 1990s, ASMS has been actively involved in health system issues. This has extended to participating in debates over clinical leadership, and more recently, the impact of international trade agreements on health. In addition to our industrial team, ASMS’s national office staff now includes a policy and research team.
The vulnerability of the medical (and dental) workforce in DHBs has also been central to ASMS’s work, ongoing research and publications in our role as ‘knowledge brokers’.1,2 Since the outflow of specialists to Australia, which peaked around 2006–09, we have maintained a careful watch on the resultant entrenched shortages, increased reliance on international medical graduates and an increasingly stressed and strained workforce.3 The paper on presenteeism in this edition of the New Zealand Medical Journal is an important contribution to our understanding of the health of New Zealand’s senior medical workforce, and paints a worrying picture.
The research suggests that 88% of respondents routinely work through illness, with three-quarters suggesting that they have turned up to work with an infectious illness. This is in the context of a workforce who have a negotiated entitlement in their collective agreement for largely open-ended sick leave. The average number of sick days reported by the survey respondents was less than three days per year.
This research also looked at why senior doctors and dentists felt pressured to work when they were sick. The comments left by the respondents provided several insightful observations, some of which are dramatic and distressing. These qualitative indicators suggest that presenteeism is affected by workplace structural factors such as availability of cover, idealised and gendered norms about being part of the medical profession and diverging views on what constitutes an acceptable threshold for taking sick leave.
We know that presenteeism is both a symptom and a consequence of an overworked and overstretched workforce. Contributing factors include the aging New Zealand populace (including increased frailty), growing unmet need as well as persistent government underfunding and increasing government demands on what health care should be provided. Additionally, however, the size of the senior medical workforce must be considered. While there are over 4,000 permanently employed senior doctor and dentists in New Zealand’s DHBs, they are unevenly dispersed among employing authorities. Even in large DHBs, many work alongside a relatively small number of medical or dental colleagues. Given the difficulty of obtaining locums at short notice for unplanned sick leave, it is understandable that many doctors and dentists will choose to work through illness rather than further burden their colleagues. DHBs need to recognise the impact of unplanned sick leave and account for this when estimating senior doctor workforce numbers for each of their services.
Other research by the ASMS suggests that official DHB data on specialist vacancies is misleading and significantly understates the size of the problem. Official vacancies are only those positions DHBs elect to advertise. We know that the advertised roles are far fewer than that what is needed to sustain safe accessible services delivered through patient centred care, and the high rates of presenteeism further illuminate the pressures that the senior medical workforce is under to maintain service provision.
The ASMS has participated in many discussions over the subject of presenteeism in the past year with DHB senior management. This has included whether the culture of medicine or workplace pressures are contributing factors to presenteeism behaviour. One can never deny the importance of culture in respect of presenteeism, but it can become a pretext for DHBs avoiding their responsibilities for addressing workplace pressures.
International research has clearly shown that presenteeism is a known correlate of burnout; additional research by the ASMS recently published in the BMJ Open suggests that a worryingly high proportion of the New Zealand senior medical workforce are suffering from high levels of burnout.4 Other research has also found 24% of respondents to another ASMS survey are either likely or extremely likely to leave the DHB workforce over the next five years.5 The most commonly cited reason was age (60%), with the second most common being exhaustion, burnout and pressures of work (17%). Combined, the high rates of presenteeism and burnout, as well as the high level of intentions to leave DHB based employment, suggest a workforce under stress where senior doctors and dentists are torn between a high level of commitment to their patients, to their colleagues and to sustaining the New Zealand public health system.
In his formal address to the ASMS Annual Conference in November 2016, ASMS National President Dr Hein Stander asked conference delegates whether a ‘Mid-Staffordshire’ might happen here in New Zealand.6 He suggested that on the basis of the presenteeism, burnout and workforce intentions data, New Zealand is already experiencing our own ‘Mid-Staffordshire’; it’s just happening in slow motion. He used the analogy that New Zealand’s senior medical workforce is a frog and we are slowly warming up the frog in the water. If we don’t act soon, the frog will be boiled before anybody realises it.
Our senior medical workforce is clearly vulnerable and clearly at risk. The article from Chambers, Frampton and Barclay in this issue identifies an important element of this vulnerability. Combined, these findings act as a clear call to the Government, health policy makers and DHB chief executives to urgently address the vulnerability of the senior medical workforce, and remove the heat from under the frog before it’s too late.