Talk is cheap, actions speak: the story of Te Whatu Ora, Dr Seuss, and other fantasies of medical workforce planning

It is important for those of us who work within and use the New Zealand health system to believe in its integrity, where actions should match the words, or, as Dr Seuss puts it: “we say what we mean, and we mean what we say”. This may be what we all want, but in a chronically under-resourced health system, there have been repeated compromises, and actions have not always matched the words. One of the most important areas this has been in is the under-resourced medical staffing.

The recent report from Te Whatu Ora – Health New Zealand on workforce planning outlines the staff shortages and reflects the lived experience of those of us working in the health system. That is, we are short of staff. The report Health Workforce Plan 2023/24 (July 2023)¹ is most welcome, as it puts some real numbers around the size of the defect in the health workforce, and, without some sort of data, it is next to impossible to plan and manage a way through this issue. The report points out that today we are short of about 1,700 doctors. To give an idea of what this number means, it is more than the collective output over three years from both the medical schools in Aotearoa New Zealand. The report also outlines the magnitude to which this problem will balloon to by 2032.

View Tables 1-2.

The report not only describes the size of the problem, but also outlines a framework for a plan that may help manage the problem. With regards to the medical workforce, it acknowledges that it takes a long time to train a doctor, let alone a specialist, and that the medical workforce is very much a commodity (which is in short supply) on the international market. The suggested plan may be briefly summarised as: 1) recruit more overseas graduates (international medical graduate [IMGs]), 2) train more doctors ourselves, and 3) retain who we have. All three of these are difficult.

1) Recruit more overseas medical graduates

Last year there were 18,784 doctors registered to practice in New Zealand, an increase from 18,250 from the year before.² The New Zealand health system has always been dependent on overseas graduates, with 40% of practicing doctors in New Zealand being IMGs.² IMGs bring skill sets and differences in culture that add considerably to the New Zealand medical environment.

Last year, according to the Medical Council of New Zealand’s annual report, there were 583 new registrations from New Zealand trained doctors and 942 new registrations from IMGs.² While these numbers reflect a growing workforce, they also outline the significance of the gap, as most of these new doctors are merely replacing retiring doctors (despite 1,525 new registrations, the actual workforce only increased by 534). This is even more apparent when we look at new specialists: there were 748 new registrations; however, there was a net increase of only 40 after accounting for those who retired. The gap of 1,700 doctors is in addition to those needed to replace those who stop practicing.

We all have heard repeatedly that there is a worldwide shortage of doctors. Aotearoa New Zealand recruits largely from the UK and Ireland. At the end of last year, however, there were around 124,000 health care vacancies in England; of these, nearly 9,000 were doctors.³ The situation is thought to be getting worse in the UK due to Brexit, where it is estimated that greater than 4,000 European doctors are not going to the UK each year because of Brexit.³ It is against this background that we are looking at recruiting the extra 1,700 doctors we need today.

2) Train more doctors ourselves

The Te Whatu Ora – Health New Zealand workforce report suggests that we increase the number of doctors we train by 50 a year.¹ Clearly this will not help in the short term, or even by 2032, given the length of time it takes to train doctors (>12 years for specialists). However, in the longer term, this will help reduce slightly the dependency we have on overseas graduates.

A third medical school has been explored repeatedly over the last 20 years, with suggested plans put forward over this period by Christchurch, Wellington, and most recently, Waikato. All have had the same issue, which is that the hospitals associated with the proposed medical schools are already committed to medical students from one of the two existing medical schools. It will be interesting to see if the proposed third medical school (to be located in Hamilton) recently suggested by the National party actually gets past the business case test. Waikato and surrounding hospitals are already taking Auckland medical students, and their replacement with Waikato medical students is unlikely to increase the actual overall numbers of medical students in any significant way. It has the familiar ring of fantasy about it, along the lines of the number of new houses that were promised to be built by the present Labour government at the last election.

We may need to reconsider how we train doctors. In the north of Scotland where this was an issue, they now have medical schools that train doctors, mostly in general practice settings, with limited hospital rotations. An alternative, and possibly a more cost effective and faster way, may be to negotiate with some of the 21 Australian medical schools to take New Zealanders on some sort of bonded bursary system.

3) Retain who we have

The third arm of the plan is to retain doctors. The recent headlines in a Stuff article that “senior salaried doctors and dentists in New Zealand are set to shortly hold stop-work meetings to discuss potential strike action”⁴ suggests that the actions do not match the words when it comes to trying to retain the present staff.

The development of the “fly in and fly out” doctor moving from New Zealand to provide care in Australia is increasingly popular, allowing doctors to avoid working in difficult and under-resourced New Zealand hospitals with poor pay rates.

The issue of retaining doctors in not new. A report with the interesting title The Future of the Leaking Bucket: A commentary on the SMO Commission Report, Senior Doctors in New Zealand: Securing the Future⁵ from 2009 reported that there was a collective specialist pay gap of around 35% between New Zealand and Australia. Shortages in the district health board (DHB) specialist workforce have made the system “vulnerable,” and retention is deteriorating (the gap was estimated to be about 10% of senior medical officer [SMO] posts at that point unfilled).⁵ The last point it made is relevant still today, but perhaps for other reasons (post Covid stress), that there is serious disengagement of senior doctors and dentists from DHB management. The Commission attributes this disengagement to the “significant, detrimental influence” of managerialism that developed in the 1990s commercial business era.⁵

There has been much talk for many years about the importance of retaining the work force; in reality, little has been done about it. It will be interesting to see if Te Whatu Ora – Health New Zealand senior management are resourced and willing to walk the walk, not just talk the talk.