Nurses walking on a minefield

In the final of our series on struggling hospitals MATHEW DEARNALEY looks at another front in the battleground of Auckland health - nurses' pay talks.

Wayne Brown, the "tough love" chairman charged with sorting out the Auckland District Health Board, is fast getting used to public controversy as he opens a debate on how to contain the board's soaring financial blowout.

Looming fast is another combat zone. Auckland nurses and doctors - claiming to be short-staffed and overworked - have already started stoking public fears that patient care will suffer if Mr Brown's cost-cutters take too big a knife to his board's $72 million deficit.

But their attention will soon turn closer to home as they take their pay claims into the public arena.

This week, nursing union organisers left the three Auckland health boards - Auckland, Waitemata and Counties-Manukau - in no doubt that settling a regional pay claim is not going to be easy.

Talks are set down for March 4 and March 11, and patience is running out.

Some 5500 nurses from the three boards are seeking double-digit pay rises, their expectations stoked by increases of 20 to 25 per cent granted last month to striking Auckland radiation therapists.

The Auckland District Health Board alone pays $106 million a year to nurses, out of a national public sector salary bill of about $1 billion.

A 10 per cent pay rise, which unionists will not confirm while negotiations continue, would add about $15 million to the region's nursing salary bill.

A 10 per cent rise given to Canterbury nurses, even though their employer, Canterbury Health, faced a $20 million deficit, has also raised hopes.

Although the Nurses Organisation has been negotiating for four months for an Auckland multi-employer agreement, northern union manager James Ritchie hopes enough goodwill exists to meet members' pay expectations without a strike.

His optimism is not matched by Auckland District Health's managers, who have warned directors of a "real risk of industrial action" given the board's financial constraints.

The warning came after a two-day strike by 3500 Canterbury health workers in December, when 80 seriously ill patients and expectant mothers were taken outside the region for treatment.

Auckland nurses are wary of making strike threats.

Senior Auckland Hospital nurse Vickie Willis believes union membership is important but hopes she is not forced to abandon her cancer patients.

"To have to decide to go on strike would pose a real dilemma for every single nurse - if it came to going on strike I personally would have to think extremely hard," she says.

"But nurses have been the doormat of the health system for so many years and it really is sometimes the only way to get people to listen to you."

Ms Willis, who has worked for 11 years on Auckland Hospital's haematology ward, looked after two evacuated Canterbury patients.

"I know the Canterbury nurses got extremely bad publicity, but they [the patients] supported the nurses 100 per cent."

Ms Willis earns an above-scale basic salary of about $45,000 in recognition of her professional development achievements and boosts her income with considerable overtime.

It irks her that computer graduates can earn much more in their first year out of training, "and they are not responsible for people's lives".

Mr Ritchie says new technologies and concepts of total patient care should have long ago dispelled the image of nurses as doctors' handmaidens.

But it was not so many years ago, he says, that a manager resisting a pay rise claim told him nurses needed money only to supplement family income to buy items such as fridges and washing machines.

The pay round is just one of the potential minefields facing Auckland nurses.

The Auckland board is also working on a plan that will see many clinical/manager jobs eliminated.

Chief executive Graeme Edmond is consulting staff representatives on cost-cutting options. He has pledged to do his utmost to avoid losing vital clinical expertise.

But on the wards, harried health workers fear the proposed removal of unit managers - each responsible for several departments at a time - will put increasing management loads on charge nurses.

Mr Brown, whose board is the region's largest employer, with 7500 staff, says there is no problem with clinical standards in Auckland. "Only money's the problem."

And he is under orders from the Government that his board live within its budget.

He does not want to cut nurses' jobs. In fact, that option does not exist. Auckland faces chronic nurse shortages and the hours worked by junior doctors are above contractual limits.

The Auckland board is 207 nurses short of its desired fulltime workforce and the two other boards also face problems.

Nurses cite heavy workloads, health and safety woes, inadequate post-graduate training support and what they see as a general management failure to accord them professional respect. A worldwide shortage has seen large numbers of our nurses lured overseas by higher salaries, while the work piles up for those left behind.

The Auckland staffing deficit is not as desperate as it was last August, when 310 vacancies forced a three-week stop to elective surgery at the Starship.

Auckland district nursing director Mia Carroll says the board has held induction courses for 124 overseas nurses for whom English is a second language.

It has also run a refresher course for 26 former nurses who had been out of the workforce for some years and hired 140 people - "a whole bunch of really stunning nurses".

The turnover remains high. Among first-year nurses it is 11 per cent, rising to 36 per cent for second-year nurses and tapering off only slightly to about 30 per cent in the third and fourth years.

The Nurses Organisation is annoyed that the board charges overseas nurses $500 and locals $300 to take its courses.

"There's a shortage, for goodness sake," says Mr Ritchie.

Meanwhile, doctors' pay agreements will come up for renegotiation throughout the country this winter.

Many junior staff mired in student debt continue to flee to higher-paying jobs overseas.

Dr Deborah Powell, secretary of the Resident Doctors Association, says her union, which represents house surgeons and registrars before they graduate as medical specialists, has repeatedly threatened the Auckland board with legal action for breaching limits on working hours to 16 a day or 72 a week.

The latest threat was at Auckland Hospital's neurosurgery department, where she says the union met managers last week after registrars - who perform most routine operations - complained of having to work for 56 hours at a stretch at weekends.

Legal limits are now being observed, she says, but only under a temporary arrangement which cannot last.

"If I were going in for surgery, I would demand on the consent form to know how long the person about to operate on me had been awake," says Dr Powell.

She alleges similar breaches in other services - orthopaedics, general and paediatric surgery and the ear, nose and throat department.

Auckland's junior doctors earn flat rates with no overtime loadings, starting at just $20.44 an hour, but they are entitled to penalty payments of $135 for each contractual breach.

Dr Powell says Auckland hospital managers jump only when threatened, and forked out penalty payments of about $2 million last financial year. They should have called in locums, even if they cost more, she says.

Winter is usually a crucial time for retaining doctors, with many from overseas returning home, but Dr Powell says Auckland District Health was left with an alarming 27 vacancies in December after recruiting the latest batch of graduates.

"They should start the year fully staffed - this is incredibly concerning."

Auckland District Health's new chief operating officer, Marek Stepniak, says every large organisation employing legions of people is bound to have isolated problems but its shortage of junior doctors has since been reduced to manageable levels.

He says that in the longer term, the whole country faces a major challenge to its ability to retain junior doctors in the face of a global shortage and a projected demand for tens, if not hundreds, of thousands more in the United States within 10 years.

Northern Clinical Training Committee chairman Pat Alley, a North Shore Hospital surgeon, warns that Auckland will face a growing exodus if it continues to overwork junior doctors who are already deep in student debt to the point that they cannot make the most of their training.

"People want value for money - if there are breaches of the contract and people are being made to work over and above 16 hours, which occurs on a frequent basis, they will vote with their feet and not work at Auckland."

The Government's Clinical Training Agency has warned that a national shortage of 245 to 300 specialists "represents a crisis for New Zealand".

Staffing shortages are not confined to nurses and doctors.

Dr Powell is cautiously optimistic that the pay rises radiation therapists won after a series of strikes and work bans will stop them going overseas.

But she fears a shortage of public hospital laboratory staff, who will also soon lodge pay claims.

The Government is leaving this year's round to the Auckland health executives to resolve but keeping a nervous eye on the situation.

The problems are so endemic, however, it has set up a national planning team to address long-term issues.

nzherald.co.nz/hospitals