Recruitment and retention of specialists

• Abstract
• Purpose of health policy or idea
• Characteristics of this policy
• Political and economic background
• Purpose and process analysis
• Expected outcome
• References

Abstract

A Commission has made recommendations for improving the recruitment and retention of medical and dental specialists employed in public hospitals. Recommendations include: strengthen clinical leadership and improve clinical-management partnerships, regularly adjust medial school student intakes, link workforce planning more systematically to regional and national service planning processes, support immigrant doctors seeking vocational registration, and improve the work environment.

Purpose of health policy or idea

The Commission on Competitive and Sustainable Terms and Conditions of Employment for Senior Medical and Dental Officers Employed by the District Health Boards was established in October 2008 to recommend a national recuitment and retention strategy for specialist doctors and dentists. The Commission reported in June 2009. It found that a major factor inhibiting recruitment and retention is the fact that specialists working in the public sector feel undervalued both within their organisations and within the wider health sector. Specialists also reported dissatisfaction with aspects of their work environment. While pay rates were clearly a factor here (especially when compared with reimbursement rates in Australia), concerns about space, equipment and facilities to provide quality care appeared to be of greater importance.

The Commission made recommendations covering the following broad areas:

• More effective clinical leadership and stronger clinician-management partnerships;
• A clear process for regional and national service planning to enable aligned planning of the numbers and mix of the specialist workforce;
• Regular review of medical student intakes;
• Coordination of intiatives for medical training;
• Systematic collection and analysis of information on issues affecting the specialist workforce;
• District Health Boards and the Association of Salaried Medical Specialists (which negotiates employment contracts on behalf of specialists) develop a bargaining model that is supported by accurate information and that is led by senior representatives with delegated authority to reach agreement;
• Implementation of a programme for the development of specialist leadership;
• Improved support for immigrant medical graduates seeking vocational registration;
• Co-ordination of recruitment functions across District Health Boards;
• Improvements in the space and facilities in which specialists work.

Main points

Main objectives

To improve the recruitment and retention of specialists

Groups affected

Specialist doctors and dentists, District Health Boards, Ministry of Health

Degree of Innovation	traditional		innovative
Degree of Controversy	consensual		highly controversial
Structural or Systemic Impact	marginal		fundamental
Public Visibility	very low		very high
Transferability	strongly system-dependent		system-neutral

Political and economic background

During the 1990s, New Zealand took a very hands-off approach to the medical workforce in line with the more-market approach that prevailed in the overall management of the health system. However, in 1999 an incoming center-left coalition government rejected the market approach to both the workforce and to the health sector more generally. In 2000, it restructured the health system emphasising collaboration rather than competition, and established a Health Workforce Advisory Committee. This led to a more planned approach to workforce development.

The Commission's report discussed here, entitled "Senior Doctors in New Zealand: Securing the Future", is one of five reports recently released by the Ministry of Health into different aspects of the health professional workforce. Other work streams have covered medical education and training, issues facing the resident doctor workforce, a review of how the health professional workforce is planned and funded, and the strategic oversight of nursing education.

In early 2009, a newly-elected center-right coalition government announced two policies that are relevant for the retention and recruitment of specialists. First, the number of government-funded medical student places is to be increased by 50% over the next five years. While this has been welcomed by the medical community, the training period time lag means that any effects will not be translated into an increased supply of specialists until about 2025. Second, the government aims to empower clinicians by re-engaging clinical leaders in service management and planning and in strategic decision-mkaing (Ministerial Taskforce on Clinical Leadership, 2009). The hope is that such re-engagement will make specialists feel more valued and so improve retention rates in the public sector.

Purpose and process analysis

Current Process Stages

	Idea	Pilot	Policy Paper	Legislation	Implementation	Evaluation	Change
Implemented in this survey?

Origins of health policy idea

The total numbers of specialist doctors and dentists employed in public hospitals in New Zealand has increased by 46 percent over the last 10 years. However, the recruitment and retention of these specialists has become a growing problem such that overall vacancy rates now stand at around 10%. A major response to date has been the employment of international medical graduates who now comprise 40% of the specialist workforce (and up to 80% in some rural hospitals). However,  the demand for specialists is increasing worldwide and New Zealand is relatively disadvantaged in the international market for senior doctors and dentists. The country is geographically distant from potential sources of doctors, remuneration rates are lower than some countries, and the small size and distribution of the population means that hospitals are often smaller than other countries and hence may offer fewer opportunities for professional and technological developments. 

These problems have been played out in the context of industrial negotiations around the terms and conditions of employment of specialists, such that negotiations have sometimes been prolonged. Therefore, in October 2008, the Director General of Health established this Commission to recommend to the Minister of Health a recruitment and retention strategy that will provide a sustainable pathway for the employment for specialists doctors and dentists working in the public health system. The Commission reported its finding to the Minister in June 2009.    

Initiators of idea/main actors

• Government

• Providers

Approach of idea

The approach of the idea is described as:
renewed: Few of the recommendations made in this report are entiely new. However, implementation of the recommendations may require new approaches including new collaborations between some key stakeholders.

Stakeholder positions

The need to develop strategies for improving recruitment and retention of the specialist workforce is widely accepted throughout the health sector.

Two organisations representing doctors in New Zealand (the Association of Salaried Medical Specialists and the New Zealand Medical Assocaition) both welcomed the formal confirmation that the Commission's report gives to the vulnerability of the specialist workforce and to the existence of a 35% gap in pay rates between New Zealand and Australia. They also strongly support the need for specialists to have a greater role in management decisions and to be more engaged in strategic decision-making. However the Association of Salaried Medical Specialists is critical of the Commission's focus on fiscal sustainability and its view that New Zealand must rely on factors other than pay rates to recruit specialists. In accepting that New Zealand cannot afford pay rates that are internationally competitive, the Association considers that the Commission has failed in its task of recommending a strategy that "will provide a sustainable pathway to competitive terms and conditions of employment" for specialists.

Actors and positions

Government
Ministry of Health	very supportive		strongly opposed
Providers
District Health Boards	very supportive		strongly opposed
Specialists	very supportive		strongly opposed
Medical Associations	very supportive		strongly opposed

Actors and influence

Government
Ministry of Health	very strong		none
Providers
District Health Boards	very strong		none
Specialists	very strong		none
Medical Associations	very strong		none

Positions and Influences at a glance

Adoption and implementation

The Ministry of Health has accepted and begun implementing all 13 of the Commission's recommendations. The recommendations are broad ranging. While some of the recommended strategies can be implemented fairly readily, others may only be effective after many years with the success of implementation depending in part on cooperation between many different stakeholders in both the health and education sectors.

Expected outcome

All of the recommendations made by the Commission are fairly uncontroversial. However, their success in improving recruitment and retention of specialists depends  to a large extent upon the effectiveness of some rather soft incentives. For example, will engaging specialists more in management decisions make them feel more valued? And if it does, will this improve their levels of job satisfaction sufficiently to offset any continued dissatisfaction with pay and conditions of employment? The Commission did not make any recommendations about how pay rates in New Zealand could be made more competitive with Australia and other countries. In the absence of strategies for addressing this gap, problems in recruiting and retaining specialists are likely to persist.

Impact of this policy

Quality of Health Care Services	marginal		fundamental
Level of Equity	system less equitable		system more equitable
Cost Efficiency	very low		very high

If successful, the changes recommended by this Commission could have a very important effect on the specialist workforce in terms of improving its stability and possibly also improving the quality of health services. However, it is our view that, in the absence of more fundamental changes to the pay and conditions of specialists, these recommendations alone may have only a marginal impact on the retention and recuitment of specialists.

References

Sources of Information

• Ministry of Health. SMO (Senior Medical and Dental Officers) Commission. www.moh.govt.nz/smo
• Commission on Competitive and Sustainable Terms and Conditions of Employment for Senior Medical and Dental Officers Employed by District Health Boards. Senior Doctors in New Zealand: Securing the Future. Wellington: Ministry of Health. 2009. www.moh.govt.nz/moh.nsf/pagesmh/9231/$File/smo-report-jul09.pdf
• Ministerial Task Group on Clinical Leadership. In Good Hands.2009. www.beehive.govt.nz/sites/all/files/In%20Good%20Hands%20Report.pdf        

Author/s and/or contributors to this survey

Toni Ashton, CHSRP

Suggested citation for this online article

Ashton, Toni. "Recruitment and retention of specialists". Health Policy Monitor, October 2009. Available at http://www.hpm.org/survey/nz/a14/3