GUEST BLOG: Ian Powell – David Farrar’s incomplete health workforce analysis

Rightwing publisher David Farrar has produced some interesting data on the number of resident medical officers (RMOs; otherwise known as junior doctors) leaving New Zealand. On 6 December he posted the following short piece in his Kiwiblog.

Resident medical officers are medical graduates (five year degree). In their first two years or more they are known as house officers while they work out what branch of medicine they want to specialise in.

Resident doctors from house officers to registrars before becoming specialists

Then, subject to acceptance in a recognised programme (first ‘basic’ and then ‘trainee’), they become registrars for around five years.

Assuming all goes well they can then become vocationally registered with the Medical Council (ie, specialist).

Eye-catching data

Under the eye-catching heading The surge in doctors leaving David Farrar reveals summary data on how many RMOs left Aotearoa New Zealand ever year from 2018-19 to 2022-23 which then led to his brief conclusion:

• 18/19: 55
• 19/20: 85
• 20/21: 76
• 21/22: 121
• 22/23: 266

This is part of the reason the health system is now under such strain – the huge exodus of doctors from 2021 to 2023. It may not be coincidence that this was the period of Labour’s mega-merger health reforms.

David Farrar: partly right but largely incomplete

Farrar has shown initiative by asking good questions of Health New Zealand (Te Whatu Ora) under the Official Information Act. His above-mentioned blog post is based on its response (9 February) to his questions.

It is surprising that it has taken around 10 months for him to publish his short summary in his own blog. Given the time lag it would have been possible for him to make a similar request for the 2023-24 year.

In fact, his data is restricted to the years of the Labour-led government; years before and after National-led governments are excluded. However, that is his call and I’ll leave it to others to speculate why.

Exploring the data further

David Farrar does not explore the reasonably detailed data provided by Health New Zealand. This is not a criticism because the detail did not lend itself to much further discussion.

Value of exploring data

Nevertheless, I found it interesting that over the total five year period covered, 17% left New Zealand after three years of obtaining their medical degree. This was the biggest group of departees. The third biggest was those departing four years after (12%).

This is significant because it is likely to comprise those who have completed their house officer training and are seeking to commence (or complete most of) their registrar training overseas.

Overwhelmingly this will mean migrating to Australia because, at least in respect of the various branches of hospital medicine, the training programmes are the same.

The second biggest group comprises those with 20 or more years after obtaining their medical degrees (14%).

This latter group will have overwhelmingly (if not completely) been overseas recruited medical graduates who required further registrar training.

This would have been because of important differences in medical training between New Zealand and wherever they obtained their medical degrees from. Presumably they would have been in their mid to late 40s or older.

Where health restructuring fits in

Farrar argues that the reason for this significant increase in ‘doctors in training’ departing for overseas, particularly since 2021 is as follows: “It may not be coincidence that this was the period of Labour’s mega-merger health reforms.”

There is validity in this observation. It is more than coincidence but nevertheless it is incomplete. Certainly Labour’s shockingly poorly thought out and implemented restructuring was destructive.

Heather Simpson’s review largely sidelined by Labour government

Particularly through the abolition of district health boards, it had little in common with the preceding Heather Simpson review of the health and disability system.

It overturned the principle of subsidiarity that had prevailed since 1938. This principle required that there should be a reasonable level of decision-making close to where most healthcare is provided, both in communities and hospitals.

DHB abolition came completely from left-field for the health system. There was no prior debate, consultation or forewarning.

Instead it was the result of elitist technocratic thinking; consequentially pre-determined and blinkered.

Jacinda Ardern and her ‘kitchen cabinet’ further destabilised a health system already in crisis

And further: what responsible government committed to the wellbeing of its people would disestablish the structures responsible for planning and providing healthcare in the midst of a pandemic?

However

However, there is always a ‘however’. In 2017 when Labour returned to government it inherited a health system that was already in crisis.

It was ravaged by widespread severe workforce shortages leading to fatigue and burnout. Increasing hospital overcrowding was one of the consequences.

Hospital overcrowding inherited and then made worse by Labour

This was due to a combination of nearly nine years of relative underfunding, workforce neglect, and rising acute demand for healthcare (rising at a greater rate than population growth); a guaranteed recipe for a health system crisis.

Instead of focussing on this addressing this crisis the contribution of Labour in government was to overturn the health system; to further destabilise what was already destabilised. This failure led to continuing neglect and consequential worsening of the crisis.

Why would RMOs leave New Zealand: push and pull

Worsening workforce fatigue part of push factor

For RMOs to leave New Zealand’s health system both push and pull factors are required. The push factor arose out of the failure of successive governments to address the crisis. This failure continues today.

Why would these RMOs want to stay when they see so many of those in the roles they would otherwise like to assume in due course fatigued or, even worse, burnt-out. This is not what they want to become.

Australia the pull factor

The pull is Australia, the overwhelmingly main port of call. It has the advantages of size that enable better working conditions. Its health system has not been destabilised anywhere to the same extent as here.

Training programmes are the same. Australia also has shortages but not on New Zealand’s scale. Relative proximity to home, family and friends is also important.

But trumping this all is pay. In 2019, when I was Executive Director, the Association of Salaried Medical Specialists commissioned economic consultancy BERL to undertake a comparative survey of 40-hour per week core salaries for salaried specialists.

Its conclusion was an over 60% pay gap in the wrong direction! Contrast this with the average pay gap with Australia of around 25-30%.

The value of data is usually not that it provides answers. Rather its value is in identifying questions that need answers. ‘What’ is a precursor to ‘how’ and, more importantly ‘why’.

Not going beyond ‘what’ leads to simplistic or incomplete conclusions such as what David Farrar has made.

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