Rosters at heart of hospital argument

The union says the DHBs' proposals would drive more doctors away, but the DHBs say they would improve training. Photo / Sarah Ivey

It's an old-style industrial war with the odour of an earlier era - but modernised with electronic tactics such as TV ads and a Facebook page for people to have their say on the internet.

The dispute between the Resident Doctors' Association and district health boards over big changes the DHBs are seeking has made hospital managers edgy about the prospect of widespread strikes and their effects on patients.

The powerful association, representing 2800 of the country's 3100 house officers and registrars employed by DHBs, is feathering the trigger of industrial action but - doubtless wary of the public reaction to hugely disruptive strikes - is making a bid for public sympathy.

The dispute falls amid a campaign of industrial action by radiographers and laboratory workers linked to the doctors by their use of the same industrial advocacy firm, Contract Negotiation Services, run by Deborah Powell.

The health boards regularly highlight this link when speaking against the three unions' militancy and in support of other health unions, including the Nurses Organisation, which have negotiated a 2 per cent pay rise from next January.

The resident doctors' dispute is a re-run of arguments on hours of work, who decides how many doctors must be on duty and, although the union denies this, how much they are paid.

The multi-employer collective agreement between the union and the 20 DHBs expired in December. It was born of strikes in 2008 and 2006.

Nine months of talks, including mediation, have brought the parties to the brink of another strike. But before deciding whether to issue 14 days' notice of industrial action, granted in a ballot of members, the union executive has launched a publicity blitz: a website where people are invited to support a petition to the Government, television advertising, and handing out leaflets near hospitals.

The theme is: "Treating the doctors well means they in turn will be able to treat their patients well."

HOURS OF WORK

The collective agreement gives residents strong protections on rostering, ordinary hours of work and the maximum hours they can work. The DHBs cannot change rosters once they are set and must post them 28 days in advance.

"Run descriptions", which state the approximate hours of work in a particular department (general medicine, for example), "shall not be changed without the agreement of two-thirds of the resident medical officers concerned", the agreement states.

The ordinary hours of work are 40 a week, eight a day, Monday to Friday, between 7.30am and 5.30pm, or more - generally attracting more pay - if the run description says so.

Residents work at nights and weekends too and do round-the-clock shifts in the likes of emergency departments and intensive care units.

But Dr Powell, the association's secretary, says it is vital to retain weekday, daytime work as the predominant pattern. This is when senior doctors mainly work, so this is when residents learn from them.

The DHBs want to end what they say is the "broad right of veto" over the organisation of hospital departments given to the union by the agreement. Spokeswoman Karen Roach says this veto comes through the run descriptions.

The financially constrained DHBs say this system allows residents to be paid for more hours than they work. Most residents are paid for runs listed as 55 to 60 hours a week, yet the Medical Council's 2008 workforce survey shows residents typically work 53.

The health boards want to put residents on eight-hour shifts, like nurses, and have offered only to "consult" on changes to rosters after they have been posted.

Dr Powell says that as well as ruining training, this will increase the number of times a patient's care has to be "handed over" from one doctor to the next, increasing error risks.

Ms Roach says clinical hand-over isn't working well now. The set-roster approach will improve continuity of patient care because "the workforce will be spread more evenly over those shifts".

She says a great deal of clinical work already occurs in the evenings, such as acute gall bladder surgery and heart procedures. Because hospitals want senior doctors to work a wider range of hours than now, the training of residents won't be compromised.

"We want to protect their hours of work, pay them fairly and recognise the unsociable and often long hours they work."

MEDICAL EDUCATION

Ms Roach says the DHBs want to reinvigorate the apprenticeship training model, to strengthen relationships between residents and senior doctors, in line with government objectives. But this necessitates giving senior doctors more authority and flexibility to manage the functioning of their teams.

Some processes for registrar training are not working and the DHBs want to rectify this, she says.

But Dr Powell says the proposed changes to medical education leave are a mess.

For instance, only five days has been offered for applying to enter a training programme, yet house officers who want to become eye surgeons need several weeks to study for and sit the college entry exam.

Ms Roach says there is no intention to force residents to take annual leave or unpaid leave for medical education.

But Dr Powell says this is exactly what will happen. "These provisions will drive residents out of the country."

* * *

FROM THE UNION

Eighty per cent of unionised resident doctors voted in favour of allowing their union executive to call industrial action, says general secretary Deborah Powell.

She won't answer all questions on the numbers, so it's hard to judge whether she means 80 per cent of members, or of those who voted. Regardless, it looks as though the union's leaders hold a strong mandate to act.

This is the flip side of the district health boards' bid to take back the power they believe is theirs in the running of hospitals.

Especially when you consider that on Dr Powell's numbers, the union represents around 90 per cent of resident doctors - the kind of coverage that unionists in the non-government sector can these days only reminisce about.

What appetite do Dr Powell's members have for industrial action? "They are prepared for it," she says. "This [industrial negotiation] is really important to them. It's about how they do their jobs, how they live their lives and how they treat their patients. But it's not about the money; it's about how they work.

"This is about residents being able to do the best for their patients. If you treat the doctors well, they will be able to treat their patients well.

"The DHBs aren't listening to us. We've spent nine months explaining why [their proposals] are anathema to us. They have made very few changes."

However, Dr Powell says, the union has tried to avoid a repeat of the "industrial mayhem" of previous negotiations with the DHBs.

It has asked for a roll-over of the expired agreement and a 1 per cent pay rise (the employers dispute these assertions), to allow a "breathing space ... more time to talk".

But the DHBs' approach appears to be one of take it or leave it, Dr Powell says, and this was reinforced by their agreement to a variation of the senior doctors' collective to allow more talks.

"We took from that that they are going to blast ahead come hell or high water, otherwise why wouldn't they have given us breathing space?"

Dr Powell dismisses the suggestion, based on the union's last strike in 2008, that a significant number of resident doctors may disregard strike notices.

* * *

FROM THE DISTRICT HEALTH BOARDS

The district health boards' bid to rewrite their collective employment agreement with resident doctors is about sidelining a major medical union from the running of hospitals.

There is no ambiguity about this power struggle.

When asked if the current national collective agreement gives the Resident Doctors' Association too much power, the DHBs' spokeswoman, Karen Roach, says without hesitation: "Yes."

"In what other industry do the unions determine how work by this particular workforce, or any workforce, is delivered? The even crazier thing about that from our perspective," says the former Australian health manager who now runs the Northland DHB, "is that this is supposed to be a profession.

"Why has the pendulum swung that far that we have got this absolutely militant approach to what should be seen as a highly professional and, in the later stage of their professional lives, autonomous workers?"

The same focus on power, and who has it, emerges from Ms Roach's answers on why the DHBs want the right to change rosters after they are set, with an obligation only to "consult" the affected staff.

"We would argue, as the employer, that the responsibility for patient care is our responsibility, not the union's, and that we ought to have that flexibility.

"And if we are going to re-establish that relationship, that ability for senior doctors to be able to manage their clinical teams, something's got to change. Over the previous rounds of the MECA [multi-employer collective agreement] we've taken the position of allowing the union to determine how care will be delivered in hospitals.

"That just seems like an anathema to me, when you've got highly qualified, very experienced senior clinicians who feel like they are trying to provide care across their teams with their hands tied behind their backs.

Ms Roach is worried by the ease with which the union talks of strikes. "The intention to take strike action was almost a fait accompli for most people."

And she says DHBs - and resident doctors - are unhappy about all the "uncertainly and bad feeling".

But the DHBs say various reports for the Government on resident doctors conclude that "the status quo is not an option", and Ms Roach says the employers are "very determined" to win back the power they believe is rightfully theirs.

ON THE WEB

treatingdoctorswell.co.nz dhbnz.org.nz

THE ROW

*20 district health boards versus the Resident Doctors' Association and its 2800 members.

*The DHBs' offer radically alters the national collective agreement. They say it would improve training but retain limits on hours of work. Pay rises of 2 to 4 per cent.

*The union says the DHB proposals would weaken training and drive more doctors away. Sought 1 per cent pay rise and renewal of existing agreement.

*Current base salaries range: $52,843 for new graduates working 40-45 hours a week in metropolitan hospital, to $172,243 for senior trainee specialists in their 10th year, working more than 65 hours a week in a provincial hospital.