FAQs – Why I’m voting ‘No’ on the DHB offer to PSA Nurses

PSA members in Mental Health and Addiction Services – including these workers at Porirua Hospital – voted to reject a DHB offer and take nationwide industrial action in 2005.

After more than ten months of MECA bargaining, PSA nurses have finally received a formal offer from the DHBs. Below I share what sits behind my decision to vote “No”. If I was to offer my decision in a sentence, it would look a little like this:

“To me, the offer does not adequately advance either fair pay or safe staffing and as such I wish to stand alongside my colleagues in other heath unions and continue to fight for a sustainable health system with safe and valued staff.“

But summary sentence aside, I do invite you to read the longer more considered version because the stakes have never been higher than right now, with our health system in crisis and our workforce at breaking point.

Background

PSA members covered by the MECA for the three Auckland DHBs, or the separate MECA for the rest of New Zealand, can now log in (at this link) to access the proposed Terms of Settlement and an FAQ document from our bargaining team. Voting on whether to accept or reject the offer will run from September 9 to 16.  

The PSA bargaining team is recommending acceptance of the offer, but adds: “It is solely the responsibility of members to vote, and the outcome of that collective vote determines the decision, as per any democratic organisation”. 

I encourage each member to carefully consider the Terms of Settlement and FAQ document and arrive at their own decision on how to vote. Union decisions are strongest when they are made by all of us.

But decisions are also best when they are debated and discussed. This article may even be updated, in light of any new information or different perspectives shared at Zoom meetings being held this week for PSA members at my DHB. It is in this spirit of constructive discussion and debate that I offer my carefully considered decision and rationale.

Decision Basis

As I see it, PSA nurses and NZNO nurses share the same aspirations:

  • A pay increase which recognises our value and retains staff in the DHBs, and
  • Meaningful action to address the unsafe staffing levels now jeopardising the wellbeing of nurses and health consumers alike. 

I’ve tested the offer against our key aspirations and below is my personal take on how the offer meets these key claims. 

Shouldn’t we be standing together with NZNO Nurses and other health workers? 

Yes. This for me is the first obvious question, because when union members stand together in the DHBs – and across the wider public sector – everyone is better off. 

Nurses belonging to NZNO, midwives belonging to the MERAS union and senior doctors belonging to ASMS have all rejected their DHB pay offers. Nurses and midwives have taken nationwide industrial action, while the senior doctors held stopwork meetings across all DHBs for the first time since 2007 and are being surveyed on further actions they would support to get a fair settlement. 

The health system is teetering on the edge of a crisis. Our colleagues have realised that now is the time to step up. By voting “No” and joining with them, we can strengthen the efforts to fix things.

Is this pay offer similar to the offer which NZNO members rejected?

The PSA bargaining team says, “Yes, it is similar on the salary offer”. But let’s be honest. The offer (for a full-time employee, before tax) consists of: 

  • $1,800 increase on base rates from 1 September 2021, funded out of DHB operating budgets
  • $1,100 lump sum payment, in lieu of back pay 
  • $4,000 increase on base rates, as an interim pay equity payment 
  • $6,000 lump sum in advance of pay equity (PE), which will be deducted from your PE backpay; and 
  • A possible additional $1,000 lump-sum payment – if a PE settlement is not agreed by 30 November 2021. 

This is not just “similar” to the NZNO pay offer. It’s virtually identical. The only difference in the numbers is that NZNO members were offered an extra hundred dollars in their lump sum – $1,200 in lieu of back pay, rather than $1,100. 

30,000 of our NZNO colleagues and co-workers have decided that their offer wasn’t good enough. I’m with them. 

Should pay equity be part of our MECA bargaining? 

No. Pay equity should not be part of our MECA bargaining, for a number of reasons. Firstly, PE and MECA bargaining are separate process – and it’s not just me who says so. 

At a media conference on 17 August, Health Minister Andrew Little said, “It’s important to clarify there have been two separate processes under way to improve on nurses’ pay. The first is the pay equity process, which started in 2018.

“The second process for nurses’ pay is the conventional renewal of applicable collective agreements. These negotiations generally focus on a cost of living adjustment for pay rates, as well as addressing other conditions in the collective agreement.”

“Nurses, certainly since we committed in 2018,” he added, “have always been going to get a pay equity deal.” 

The increase in base rates and back pay for PSA members under the PE deal is not affected by this MECA bargaining, and shouldn’t be mixed up with it. MECA bargaining, in the words of the Health Minister, should “focus on a cost of living adjustment”. 

The Health Minister also said on 17 August that he had written to the unions, the DHBs and the Ministry of Health and invited them to commence negotiations on the pay equity claim – separate from the MECA negotiations – “as soon as possible”. “I would hope that by the end of the year, we should be at, or close to an agreement.”

Voting to accept the DHB offer would mean payment of the lump sum “as soon as practicable” after 1 October 2021. This probably only brings payment forward by a matter of weeks, at most. But at the same time, it would have serious negative consequences for a lot of other PSA members. 

If PSA nurses accept an offer with a $1,800 increase on base rates – which is below inflation for most – and which is padded out with pay equity money, then it will set a benchmark for other groups. Around 13,000 of our PSA colleagues in allied health are also in bargaining with the DHBs at the moment, and they’re not in line for an advance payment of pay equity money. A “Yes” vote by PSA nurses would increase pressure on them to settle for less than a cost of living adjustment – to say nothing of the negative impact on PSA members in the wider public sector. 

Are the DHBs at least funding a cost of living increase? 

No. Stripped of the pay equity money, which is coming to PSA members through the separate PE process very soon anyway, the increase in base pay rates in the DHB offer is just $1,800 (pro rata, before tax, over 27 months).

In percentage terms, that equates to annual pay increases ranging from 1.0 percent (for a Community Mental Health or Public Health Nurses on their top step) to 1.9 percent (for a Mental Health Assistant on Step 2, noting that it is proposed to delete Step 1of the salary scale). 

The cost of living, as measured by CPI, rose by 3.3 percent in the year to June and the NZIER “consensus forecast” says it will stay above 2.0 percent for the next year, too. In other words, the pay offer funded by the DHBs falls short of a cost of living adjustment, for all PSA members. 

Isn’t the PSA opposed to the Government’s pay freeze? 

In the lead-up to the Budget in May 2021, the Government announced two more years of “pay restrictions” for workers in the public sector. The announcement took the form of a Government Workforce Policy Statement and Public Service Pay Guidance from the Public Service Commission.

Both of these documents stressed that pay equity (for those public sector workers covered by a PE claim) is a separate matter. The expected pay restrictions applied only to base rates in collective agreements (such as our MECAs), or in individual employment agreements. 

Our union immediately voiced strong opposition and demanded that public sector employers must value our work: “The PSA is taking a stand against the unacceptable Government pay restrictions.”

A delegation of PSA leaders met with Government ministers and advocated for “cost of living increases for all union members covered by collective agreements.”

“Change happens when ordinary people are prepared to make it happen,” said National Secretary Kerry Davies.

The current DHB offer to PSA nurses is virtually identical to the offer made to NZNO nurses in July – and Health Minister Andrew Little clarified at the time that that offer was in line with the Government’s pay restrictions. The offer to PSA nurses by the DHBs through collective bargaining is also in line with the pay restrictions – and it doesn’t represent a cost of living increase, either. 

As PSA members, we need to be prepared to make change happen. Let’s keep taking a stand against the unacceptable Government pay restrictions, insist on at least a cost of living increase through our collective bargaining and reject this sub-par DHB offer. 

Is this best we can get? 

No, I personally don’t believe this is the best offer we can get – and it appears that our bargaining team aren’t convinced, either. The Terms of Settlement which our negotiators have signed mention that if there’s a “group covered by another health sector MECA bargaining, and that other group arrives at a subsequent settlement that is materially different to the settlement agreed with the PSA”, then we’ll meet and discuss a proposal to “vary” our MECA.

If we really think that the nurses, midwives and doctors who are now fighting hard might get a better deal, then as unionists we’re morally obliged to help in that fight. It would be wrong to sit on the sidelines, letting them do all the work, and then try to claim the benefits afterwards. Let’s join together now, and get the best for all. 

Will the commitments on safe staffing make a real difference? 

The FAQ from our negotiating team barely mentions safe staffing. But I know that for many PSA nurses like me, the daily experience of being dangerously understaffed and seeing colleagues leave for Australia or quit the profession altogether must be addressed through this MECA round.

The Terms of Settlement mentions three “nursing wide initiatives [which] will be initiated as part of this settlement.” But once again, let’s be honest. The Minister of Health has now stated that an independent evaluation of CCDM implementation and effectiveness is going to happen anyway. And the other two nursing wide initiatives (a Ministry of Health recruitment campaign and a $5 million CCDM Progression Fund) will also go ahead, regardless of what happens with our MECAs. 

In reality, there’s only one thing in the DHB offer to address our dire situation – another steering committee. It will meet face to face, according to its proposed terms of reference, at least three times a year, with some virtual meetings in between. At least three people from the union, and three from the DHBs, will be present. 

Does this really sound like a realistic response to the crisis? 

If you believe the DHB offer will make a real difference, then you’ve got more faith in steering committees than I do. I’m voting “No”, because the scale of the crisis demands a solution far better than this.

Should this DHB offer have been recommended?

Yes it probably should have been – under the circumstances. This answer might surprise. But our bargaining team have given a clear explanation of why they’re recommending an offer for PSA members which is – at the very least – “similar” to the offer put to NZNO members in July, with no recommendation on its acceptance.

“PSA has a policy that our bargaining teams always make a recommendation, to either accept or reject an employer’s offer coming out of bargaining”, they said in their FAQ.

This was also the policy in NZNO, up until 2018. In fact, making a recommendation was a requirement for all NZNO bargaining teams, under the NZNO Constitution.

But after the NZNO MECA negotiating team made three recommendations for members to accept DHB offers, and after these offers were all rejected, NZNO members decided that the policy needed to change. At the union’s AGM in 2018, NZNO delegates voted to update the Constitution so that bargaining teams could no longer recommend employer offers.

If PSA nurses reject this MECA offer, perhaps it will be time to look at PSA policy, as well. 

NZNO Board Election – Why I’m backing Anne and Nano

Voting got under on 4 August in the NZNO Board Election. There are six candidates, standing for the two positions of NZNO President and Vice-President. What should guide our vote? I think there are seven key considerations. You can click on each one below, to find out more:

For most NZNO members, a 150-word candidate profile statement is all they have to go on. I have the benefit of some additional information, having known the majority of the candidates for many years and worked alongside several on the NZNO Board before. 

I’ve thought long and hard about how to present this information. Ordinarily, I would shy away from sharing my knowledge about how other candidates measure up against key considerations like these. But the stakes today are too high. NZNO is on a knife-edge, balanced between two different pathways. Right now, powered by a phenomenal DHB MECA campaign, NZNO has the possibility of becoming the union its members want and need it to be. Alternatively, there’s a very real chance that the wrong leaders could cement NZNO’s past failures. 

‘Our union needs to change’

The opening words in Anne Daniels’ profile statement get straight to the heart of the matter: “Our union needs to change.” 

The change we need is already under way. The 2021 DHB MECA campaign is demonstrating what a great union NZNO can be. The campaign is engaging, united, member driven, transparent and strong – light years ahead of where we were in 2018. 

Powered by a phenomenal DHB MECA campaign, NZNO has the possibility of becoming the union its members want and need it to be.

But this must not be a one-off, and it mustn’t be limited to DHB members only. 

To complete the transformation and extend its benefits to everyone, we need an NZNO Board that mirrors our union at its best. The first step along this pathway is to elect a new NZNO President and Vice-President. The next step will come in 2022, when seven other Board members will also be up for election. 

The fundamental choice now is between fresh leadership for NZNO, or a continuation of the secrecy, personal agendas and disregard of the membership which have derailed the Board, weakened the union and cost us all dearly. 

Back ourselves to make the change 

Anne Daniels for NZNO President and Nano Tunnicliff for Vice-President

If we want a union that fights for us, it needs to be led by people like us. Anne Daniels and Nano Tunnicliff are nurses who work on the floor, in busy hospitals. They aren’t based in an office, working nine to five. They understand the pressures we feel about understaffing and poor pay because they experience it personally, too. 

The same cannot be said about any of the other candidates. 

We need people who are proud to be union 

When I was elected to the NZNO Board in 2015, I was shocked to discover that the other Board members didn’t believe NZNO should be focused on the pay and conditions of its fee-paying members. They were even uncomfortable with the idea that we’re a union.

“NZNO is, to me, firstly a professional organisation”, wrote one. “If union passion could be harnessed for professionalism, imagine how much more visible nurses could be!”. Excluding myself, that was the general consensus. None of them had ever taken industrial action with their fellow members to improve pay and conditions for all. Most had never been on a union protest. Several were business owners themselves. One was married to an MP in the governing National Party, which was busy passing anti-union laws, and another didn’t believe that unions should exist.

When it came time at a Board meeting in early 2019 to start developing a new Strategic Plan to guide NZNO into the future,

“The chief executive drew the Board’s attention to the previous strategic plan process where the description of NZNO was changed in 2015 from a “union and professional association” to a “professional association and union”, reflecting a stronger emphasis on promoting the profession.  The chief executive acknowledged that NZNO needs to do more to profile the nursing profession and advised that the media have been able to cherry-pick information about NZNO activities making a stronger reference to being a ‘union’ than a ‘nursing professional association’.

I was the only Board member at that meeting who objected to this pathway, which would have taken us even further away from a union focus on the pay and working conditions of my fellow members. I was very disappointed when the others (including current Vice-Presidential contender Cheryl Hammond) went along with it. 

But that future direction for NZNO changed when Anne Daniels and others were elected to the Board in late 2019. For 30 years, Anne had proudly led a multitude union actions and campaigns to protect NZNO members. Under her influence, the Board’s development of the Strategic Plan 2021-25 took a very different path – focused on making NZNO a membership-led union. She also established a Board MECA committee to make sure that NZNO learnt the many lessons of the troubled 2018 DHB MECA campaign, as contained in the independent reviewer’s report by former CTU president Ross Wilson. 

‘Always standing strong for nurses’ – Anne Daniels (Pictured, Right) leads NZNO members on strike at Thames Hospital, March 1999.

Nano Tunnicliff’s union credentials are just as impressive. I first got to know Nano in 2008, when we were both on what was then the top elected union body in NZNO – the DHB National Delegates Committee.

Union leadership – President Nano Tunnicliff (Right) heading the NZNO delegation to the 2009 CTU Conference, with Grant Brookes (Left).

But Nano had been a successful union leader for years by that time – including as a negotiator for the historic first DHB MECA in 2004, and before that as a union organiser in the Australian Nursing Federation (which partly explains her strong support for nurse-patient ratios). 

None of the other candidates come close, in their commitment to union members, leadership experience and union pride. 

Nurses are ethical – our leaders should be too 

Anne Daniels has proven that she’s that special kind of leader who puts ethical values ahead of her own personal advancement. Along with fellow Board members Katrina Hopkinson and Sela Ikavuka, she took a principled stand in April 2020 when she courageously resigned from the NZNO Board. “Our personal and professional values were constantly compromised”, the trio wrote. “To remain would be condoning behaviour we know does not meet the members standards.”

Long-running concerns about unethical behaviour on the NZNO Board, which Anne Daniels and I experienced personally, were finally validated by an independent NZNO Governance Review in late 2020 which inquired into the Board’s activities over the previous 24 months. 

The review was conducted bi-culturally, by commercial corporate lawyer with the Tuia Group, Guy Royal (Ngāti Raukawa, Parehauraki, Ngāti Hine, Ngāpuhi), and leadership development manager at Canterbury-based company Brannigans Human Capital, Chris Bailey. Both of the reviewers and their terms of reference were approved by Te Poari as well as the Board. 

Despite a statement that the review would “highlight what can be improved upon and this can be conveyed to members”, the final report has been suppressed. Only its 33 concluding recommendations have been released to the NZNO membership, so we do not know the full extent of the ethical issue it uncovered. But the recommendations clearly reveal its existence, stating that the Board should review its Code of Conduct, “including clarifying the consequences of breaching the code”. They also called for the Board to “improve the capability of the Chair with respect to Board ethics”. 

Incumbent Board members now standing for election as President and Vice-President, as well as those who were on the Board during the 24 months from 2018 to 2020, have questions to answer about ethical governance. Does Cheryl Hammond, for instance, believe it was ethical for the Board to spend three times as much members’ money on its own legal wrangles in 2018-19 as the entire amount budgeted ($80,770) for the 2018 DHB MECA campaign

The questions are even more pertinent for the candidate standing for both positions, Tracey Morgan, whose ongoing praise of Co-Chair Kerri Nuku shows no acknowledgement of the review findings. 

Morgan’s statement of skills and experience declares an extensive list of past governance roles, including a stint assisting Nuku as NZNO’s Tumu Whakarae. Yet it also contains omissions. Why for instance is there no mention of her past role as director in a company which was 100 percent owned, according to Companies Office records, by Nuku’s husband (although oddly, Nuku has also claimed to be the owner herself). What should voters make of this failure to declare a web of past business dealings with another member of the NZNO Board – one whose own capability with respect to Board ethics should be “improved”? What else has been omitted from the information presented by this candidate? Is there any truth to the serious and detailed allegations made about her by a former NZNO Board member in public Facebook posts?

End the secrecy – give us Board transparency

Many people were shocked to learn, when three Board members resigned last year, that elected NZNO Board Members are obliged to sign a non-disclosure disclosure agreement which prevents them from sharing information with other NZNO members. “Right from the start, we were required to sign a confidentiality agreement before our first meeting”, they said

Ex-directors reluctant to break confidentiality, Kai Tiaki Nursing New Zealand, July 2020

The Board of any organisation shapes the culture of that organisation. The NZNO Board’s appalling misuse of standard governance confidentiality obligations has created a culture of secrecy which has infected the union as a whole. In many areas of NZNO, members and staff have been silenced and are now too afraid to speak up. It appears that the independent NZNO Governance Review conducted in late 2020 identified this problem, as it recommended that, “The Board establishes a Board-level protected disclosures (whistleblower) policy.” But there is no sign of progress on this recommendation. On the contrary, the current Board’s lack of transparency is getting worse.

Knowledge is power. By keeping the membership in the dark, the Board actively disempowers us. But the reverse is also true. The unprecedented openness and transparency seen in the magnificent DHB MECA campaign this year is a source of our new-found strength. It is part of the reason why we can now stand up for fair pay and safe staffing. In this election, we must vote for a President and Vice-President who will carry this change forward, not roll it back. 

Only two candidates speak about the issue of Board transparency and member empowerment in their candidate profile statements – Anne Daniels and Nano Tunnicliff. 

After being elected to the Board in 2019, Anne Daniels put up the strongest opposition to the gagging order preventing Board members from sharing information with the membership. She was the very last Board member to sign it. I wish to apologise publicly for being the one who persuaded her to do this. I hope that by speaking out now, I can go some way towards making amends. 

When Anne Daniels says, in her candidate profile, that she stands for “a union that empowers members to take the lead”, you can believe her. Her track record speaks for itself. So does Nano Tunnicliff’s. When she says in her profile statement, “I want to see improved transparency”, she means it. 

Fulfil the promise to be ‘membership-driven’ 

Members and staff alike are sick and tired of NZNO being driven by personal agendas at the top, not the needs of the membership as a whole. That was the clear message which came through the strategic planning consultation in December 2019. As the reviewer said, “Demonstrating that NZNO is a membership-driven organisation – this was by far the strongest message to come through from almost everyone”. 

In early 2020, under the influence of Anne Daniels, the Board was pushed to sign off a draft Strategic Plan which reflected this feedback. As a fellow Board member at the time, I can personally vouch for the truth of her statement: “I helped write the current strategic plan, advocating for a member led union.”

But in June 2020, just weeks after our resignations from the Board, the back-peddling had begun. Kaiwhakahaere Kerri Nuku pulled support for the membership-driven Strategic Plan 2021-25, complaining that (amongst other things) it was too “DHB-centric”.

Thankfully, with the 2020 AGM and the deadline for finalising the plan fast approaching, it was too late for it to be rewritten. The Strategic Plan 2021-25 went through, as originally drafted, to become the guiding light for today’s member-driven DHB MECA campaign and also for Nano Tunnicliff’s Vice-Presidential pledge: “I will work towards the goal of the strategic plan to ensure that NZNO is a membership driven organisation.” 

And yet, outside of these campaigns, it’s almost like the document does not exist. No other candidate in the election is talking about NZNO as a “member-led” or “membership driven” organisation. Their profile statements don’t even refer to our union’s overall guiding strategy. It’s as if the prediction I made before the 2020 NZNO AGM is already coming to pass: 

“There are unlikely to be major changes to the draft NZNO Strategic Plan 2021-25 at this late stage, given that it’s been approved by the Board, sent for final consultation to all member groups and is due to be formally adopted at the AGM next month. What’s more likely to happen is that it will be adopted without the blessing of the kaiwhakahaere, then sit in a drawer for the next five years gathering dust while her agenda sets the direction.”

There is another pathway we can take. Powered by the phenomenal 2021 DHB MECA campaign, we can elect new leaders who will make NZNO the membership-led union we all want it to be. 

Pick the champions of safe staffing 

‘Today I took to the streets to strike with my fellow health care colleagues’, wrote ED nurse Devon Kilkelly on 9 June – https://tinyurl.com/SafeStaffingSDHB

Isn’t it incredible that today, in the midst of a nursing crisis which is shaking the entire health system, four of the six candidates standing for NZNO President and Vice-President make no mention at all of safe staffing in their election statements? 

NZNO has been treading the same path in pursuit of safe staffing for almost two decades. We are no closer to that goal. We need leaders with a new plan that can work. Anne Daniels has such a plan. 

In 2020, she and I co-wrote a policy remit for a “Review of NZNO strategies for safe staffing”. When it was put to NZNO members in a referendum last August, they voted:

“That NZNO shall, during the 2021/22 year:

  1. Conduct an independent evaluation of its current Safe Staffing strategies, including CCDM, and publish any results showing significant outcomes for nursing workloads and patient safety at a national level; and
  2. Present options to campaign for additional Safe Staffing mechanisms, including legislated minimum nurse/ patient ratios, for consideration and endorsement by NZNO members.”

Sadly, after Anne Daniels, Katrina Hopkinson, Sela Ikavuka and I resigned from the Board in April 2020, the impetus for this member-driven change was suppressed. The remaining Board members have tied up the review of safe staffing strategies in bureaucratic red tape. The proposed start date for the review came and went months ago, without even a murmur. In reality, unless there is fresh leadership on the Board, the review that NZNO members voted for and desperately need is unlikely to lead anywhere. 

Anne Daniels now says, “I co-wrote a successful remit to start the work towards safe staffing legislation. This must happen.” Nano Tunnicliff agrees, saying: “I will advocate for nurse patient ratios.” 

The choice in this election is clear. Pick the champions of safe staffing. 

‘Electing a Board to achieve NZNO’s potential’ – Letter to Kai Tiaki

The 2021 DHB MECA campaign is demonstrating what a great union NZNO can be. The campaign is engaging, united, member driven, transparent and strong. 

Now we need an NZNO Board that mirrors the union at its best. It isn’t what we have at the moment, and this means members are missing out. 

In 2016, delegates at the NZNO AGM voted, “that the NZNO Board meetings agendas and minutes be made available to the membership and staff.” 

In moving that motion, the Nurse Managers Section said, “Board members are elected to ensure resources are used to carry out the mission of the NZNO. Board meeting minutes should be made available in the interests of transparency and engagement.”

Under NZNO’s member driven Constitution, AGM votes are binding on the NZNO Board. Yet the Board is not making its agendas or minutes available on the NZNO website. None have been posted since the departure of the previous Chief Executive in February. 

It is concerning that the Board now appears to believe it can flout the Constitution, disregard the will of the membership and operate in secrecy. 

More concerning still is their failure to release NZNO’s 2020/21 audited financial statements and Annual Report. 

The Acting Chief Executive is constitutionally required to make these available to all member groups at least two months before the NZNO AGM, to give members time to scrutinise the documents and hold the Board to account. That deadline came – and went – on 16 July. 

Members seeking transparency are now being told that the auditors have not yet presented their audit opinion. 

I personally oversaw four annual audits of NZNO’s finances, so I know what they normally involve. Did the Board simply fail to commission the audit on time, or have the auditors perhaps uncovered financial irregularities requiring a longer investigation? 

The lack of transparency from a Board disengaged from its membership seems to be a continuation of the disturbing failures uncovered in last year’s NZNO Governance Review – in areas such as Board ethics and capability – although we can’t know for certain as they have refused calls to release this report, too. 

Thankfully, members will soon have a say about their Board. An election for two leading Board members – the NZNO President and Vice-President – runs from 4 August until 10 September. Seven more Board members are up for election next year.

With great people standing in this election, members can have hope that we will soon have a Board willing and able to achieve NZNO’s full potential. 

Grant Brookes, RN

This article was updated on 19 August 2021, to reflect the letter as published in the August issue of Kai Tiaki Nursing New Zealand.

Our future health system – My feedback to the PSA on the Health & Disability Reform

When the Government announced its response to the Health and Disability System Review in April 2021, the PSA invited members to provide feedback to a Working Group made up of delegates from the DHB and Community Public Services sectors. An email address has been set up exclusively to gather these member responses.

To further guide feedback, a health reform presentation [PSA, 2021] was produced in June containing three specific consultation questions for discussion. Below is a response to these questions.

1. Suppose you could develop a charter for the NZ health workforce, what values should be included to create what type of culture for workers?

A charter for the New Zealand health workforce has been proposed by Health Minister Andrew Little. In his announcement of the Government’s response to the Health and Disability System Review, he said: “A key element in creating a new culture will be a new New Zealand Health Charter, designed with health and care workers, to set down the values and principles of the national system” [Minister of Health, 2021]

Development of this charter, however, does not occur in a vacuum. Health and care workers may make our own culture, but we do not make it under self-selected circumstances; rather under circumstances existing already, given and transmitted from the past. It is worthwhile to briefly and critically review the historical context. 

A clear signal about salient circumstances transmitted from the past has been given in the Minister’s choice of language. Both the title and the description of this proposed document clearly reference the previous New Zealand Health Charter [Department of Health, 1989]. This earlier, short-lived charter contained five principles to guide the development and operation of the New Zealand health service. 

  • Respect for individual dignity
  • Equity of access 
  • Community involvement 
  • Disease prevention and health promotion
  • Effective resource use 

Viewed critically, it possible to discern how prevailing historical ideologies of the time may have shaped the selection of these values and principles and to what extent they might not be fit for purpose today. The description of “Effective resource use”, for example, as “extracting more health for more New Zealanders from every dollar of health expenditure” is a clear statement of neoliberal values (or in the more descriptive Australian terminology of the time, “economic rationalism”). 

Equally, “Respect for individual dignity” elevates Margaret Thatcher’s mythical “sovereign individual”. Even “Equity” is described as “a dimension of individual dignity”. In addition, it is framed as equal “access” (or opportunity), rather than equal health outcomes, reflecting the shift from post-War social democracy towards a Blairite social liberalism which was starting to take place in Aotearoa at the time. 

Viewed from the vantage point of 2021, it also striking that the principles in the 1989 New Zealand Health Charter make no reference to Māori values or Te Tiriti o Waitangi. Indeed, the word “Māori” never even appears. And yet this charter, launched by Health Minister Helen Clark, does contain some useful starting points. 

Having considered the purpose and background, here are five possible values and culture statements which could be included in a charter for the NZ health workforce (note that proposed translations have not been subject to consultation with mandated Tangata Whenua representatives, either within or or outside of the PSA, and represent my thoughts as Tangata Tiriti only):

  • People-centred/He Tangata, He Tangata, He Tangata: A shift from designing health systems around diseases and institutions towards health services designed around, and for people means that service users and communities should become active partners in improving health service delivery. 
  • Egalitarian/Mana Taurite: When the contribution of each person in the health workforce is valued without regard to social stratification, it fosters a health and disability system response attuned to each person’s health need. 
  • Democratic/Manapori: “Work culture is positive, trusting and effective through strong industrial democracy mechanisms that give workers strong collective voice through their union” [PSA, In publication].
  • Equitable/Taurite Ora: “In Aotearoa New Zealand, people have differences in health that are not only avoidable but unfair and unjust. Equity recognises different people with different levels of advantage require different approaches and resources to get equitable health outcomes” [Ministry of Health, 2019].
  • Respectful/Mana Tangata: A just culture allows people to report and learn from mistakes. Shifting from a culture of blame to a mana-enhancing culture of respect and trust has the potential to deliver significant benefits for the health system in terms of saved lives, harm prevented and resources freed up for the delivery of more and better care. [Ministry of Health, 2001a; E Tū, 2017]
  • Bicultural/Tikanga Rua: Colonisation, failure to honour te Tiriti o Waitangi and institutional racism have established and maintained relative disadvantage for Māori within the wider determinants of health, and within the health system. Overcoming monocultural perspectives is necessary to end victim-blaming and deficit thinking about Māori and other groups under-served by the system, improve system performance and support Equity [Health Quality & Safety Commission, 2019].

2. How can we make sure that community health services are better valued, understood and integrated into the health system?

“Community health services” (also known as “Tier 1” services) span a myriad of different structures and functions, from Primary Health Care to Disability Support, Aged Residential Care to Community Pharmacies, Dentists, Māori and Pacific providers and Laboratories. The task of better valuing, understanding and integrating them is extremely complex and involves daunting challenges, for which there are no easy answers.

The case for valuing, understanding and integrating them has been clear since at least as far back as the 1989 New Zealand Health Charter, which highlighted the need for “Community involvement” in order to direct greater attention to “Disease prevention and health promotion”. It is also very clear in the final report of the Health and Disability System Review [2020]

The recommendations in that final report for driving integration all have merit. It speaks, for example, of creating more interoperability of digital systems across hospitals and community health services. It recommends planning on a locality basis, from a population health perspective, and so on. 

A New Zealand Health Charter as suggested above, which values People-centredness/He Tangata, He Tangata, He Tangata, could also make a difference. But there are barriers to system integration, like the circumstances shaping workplace culture, which are given and transmitted from the past. And these are significant. 

The Health and Disability System Review [2020] recommends the creation of a NZ Health Plan which looks ahead 20 years, as a mechanism for valuing, understanding and integrating community health services. This too is a worthy goal.

But similar long-term strategies for Tier 1 have been created before. The Primary Health Care Strategy [Ministry of Health, 2001b], which established Primary Health Organisations two decades ago, was also intended to drive integration and planning on a locality basis, from a population health perspective. This was followed by “alliancing”, with the same goal. And yet it remains the case, as the Health and Disability System Review [2020] reported, that “the system is characterised by limited national planning, so that decisions which could be made once for the whole population are repeated multiple times.” Why has so little progress been made? 

The fundamental problem, which dates back to the creation of the modern public health system by First Labour Government in 1938, is clearly articulated in the case of Primary Health Care by Crampton [2005], Matheson [2017] and Gauld et al. [2019]. “The elephants in the room”, they write, are that “GPs, after all, are largely private business people” and “Ownership confers governance responsibility (ultimate control) for an organisation, and accountability for its actions.” The Ministry of Health, as system steward, can plan for integration of community health services and universal coverage. But ultimately, it is up to private businesses to decide how, when and where Primary Health Care is delivered, and at at what cost to patients. 

Gauld’s conclusion is applicable not only for Primary Health Care, but for many other community health services: “Further research is needed into the business ownership model, including whether this is fit for purpose for the future in meeting the increasingly complex health needs of diverse communities.” This issue has not been addressed at all by the current Labour Government. 

Neither has the contracting model, based on the “funder-provider split”. This was introduced to the health system in the 1990s, as part of radical neoliberal reforms aimed at creating a competitive health care market and fully commercialised health and hospital services, as precursor to privatisation of the public health system. A sustained wave of popular protest and low-level industrial action by unionised health workers managed to overturn some of the most unpopular reforms, such charging patients in public hospitals, but the funder-provider split remained intact [Hamed, 2013].

Under this neoliberal model, accountability for service delivery was to be delivered to departmental CEOs through contractual obligations (rather than, say, through tiers of democratically elected, Bicultural/Tikanga Rua governance, from the health service provider on upwards). These contracts, which now rule the provision of community health services, typically run for periods of one to three years and are regularly put up for tender.

The model is institutionally racist and inimical to Equitable/Taurite Ora values, producing shorter contracts and a heavier compliance burden for Māori health providers [Came et al., 2018]. The fixed term contracts drive short term thinking, prevent strategic system planning and integration and undermine the “predictability of funding” for Tier 1 which was called for in the Health and Disability System Review [2020]. Retaining this neoliberal model will almost inevitably defeat the proposed 20-year NZ Health Plan, as well.

For all the talk, in Health and Disability System Review [2020] and Department of Prime Minister and Cabinet [2021], about the need for need new structures “which ensure government is both closer to communities, and more nationally connected”, the fundamental structures of “embedded neoliberalism” in the health system [Kelsey, 2015; Bertram, 2020] have not been touched. 

Given that the Labour Government appears to have no appetite for dismantling neoliberalism, options for civil society actors such as unions, community groups and health service providers are limited. Nonetheless, they do exist.

One such option for the PSA to make sure that community health services are better valued, understood and integrated into the health system is to pursue bold industrial strategies. MECA coverage across both directly-employed Health NZ staff and those in the Community Public Services Sector, for instance, would reduce the incentives for outsourcing (disaggregation), foster a culture of “one team” and drive integration. Fair Pay Agreements setting common pay and conditions across the myriad of community health service providers would greatly reduce the incentive for competitive tendering for contracts, which tends to undermine integration. 

Ultimately, however, ensuring that community health services are fully valued, understood and integrated into the health system will require the political will to grasp the nettle of private ownership and control, under a very different social and economic system. 

3. How do we make sure that workers’ voice will guide the future health system?

The health system should be guided by the voice of all workers, in a way which recognises their different contributions. Broadly speaking, the types of worker voice can be categorised as clinical and non-clinical. The differences in contributions between these two groups are related to differences in training, along with professional obligations and legal requirements.

The benefits of clinician guidance in a health system are well established. In the New Zealand context, they have been confirmed by the Ministerial Task Group on Clinical Leadership [2009]. The New Zealand Nurses Organisation Tōpūtanga Tapuhi Kaitiaki o Aotearoa [2019] comments that, “Nurses can add real value to strategic decision-making in health care governance through their in-depth knowledge and experience of the human aspects and logistics of service delivery”. The Association of Salaried Medical Specialists Toi Mata Hauora [2015] concludes: “A health system led by clinicians is better for patient care and safety, and makes better use of available resources.” 

Two components of this clinical worker voice have been defined. Both are necessary for the future health system: “Clinical governance refers to the system where clinical goals are set and reported on. Clinical leadership is the operational system that allows health workers to do what is needed based on these goals” [ASMS, 2015].

Despite the widely recognised benefits of clinician leadership and the promotion of the idea by Health Ministers for the last 20 years, little progress has been made [ASMS, 2019]. Over this time however the barriers to progress have been clearly identified and well documented. If we are to ensure that the clinical workers’ voice guides the future health system, then these barriers must be overcome:

  • Lack of time, coupled with chronic workforce shortages. It’s very difficult to make room in the diary for clinical leadership activities when there aren’t enough clinicians for the clinical work required.
  • Professional capture. Clinical governance and leadership must be genuinely interprofessional and multidisciplinary, rather than a synonym for “doctors making the decisions”. 
  • Insufficient opportunities for training and mentoring. Leadership and governance by clinicians requires investment and a willingness to delegate and collaborate. 
  • Outdated management attitudes, shared by incumbent leaders of health systems who have risen within the hierarchy based on command and control methods. 

Management attitudes reflecting hierarchical, as opposed to Egalitarian/Mana Taurite values suppress worker voice among clinicians and non-clinicians alike. These attitudes are sustained, in turn, by other factors. Attention is turning increasingly towards one in particular. 

Since the start of 2020, organisations in the UK with more than 250 employees have been legally required to disclose the “pay ratio” between the salary of their CEO and their lowest paid employee. One of the reasons for this new requirement is that, “High CEO-employee pay ratios… send a message to company employees that a main purpose of the company is to serve individual self-interest. As social science studies reveal, this focus on self-interest gives rise to unethical cultures within companies” [Dallas, 2017]

There is a negative correlation between worker voice and CEO pay: “CEO pay is clearly lower in countries with greater worker voice in corporate decision-making” [Baker et al., 2019]. Capping CEO pay ratios in the health system therefore will have a material effect on strengthening worker voice. 

One further mechanism for ensuring worker voice in health system guidance is co-determination – the practice where workers employed by an organisation have the right to vote for representatives on its governance board. 

New Zealand lags behind in this practice. Board-level employee representation in the public or private sector is already required by law or custom in a majority of OECD countries, and in 19 out of 28 EU member states [Williamson, 2016]. Concerns which have been raised by unions and employers as to how worker representation at board level could work in the UK – for example, over co-option, confidentiality or skill deficits – have been addressed by the Trades Union Congress [Williamson, 2013].

Other parts of the wider New Zealand Public Service already have staff representatives on their governance boards. Under Section 171B of the Education Act 1989, for instance, every tertiary education institution must have at least one elected member of the teaching and/or general staff on their Council. Section 119 of the Education and Training Act 2020 requires that the Board of a State school must include a staff representative. 

The Government has shown its willingness to make bold changes to the health system – in particular in its decision to create a Māori Health Authority, with full commissioning powers. To make sure that workers’ voice guides the future health system in a way which reflects Democratic/Manapori values, they should require elected clinical and non-clinical staff representatives on the boards of publicly funded health providers. Given that almost 80 percent of the healthcare and social assistance workforce is female [Stats NZ, 2018], elected worker representation will also tend to create co-benefits for gender equity, alongside what must be respect for Bicultural/Tikanga Rua values and te tino rangatiratanga of Māori health workers. 

Finally, existing legal protections for health worker voice must be respected and extended. These include the obligation in Section 6(1) of the Public Health and Disability Act 2000 for DHBs (and by extension, Health NZ and other parts of the future health system) to “be a good employer”. And it definitely includes the right for health workers to comment publicly and engage in public debate on matters within their expertise and experience (enshrined in Schedule 1B of the Employment Relations Act 2000 and elaborated in collective agreements for many occupational groups). 

References

ASMS. [2015]. Making distributive clinical leadership work. https://www.asms.org.nz/wp-content/uploads/2015/07/ASMS-Advice-Making-Distributive-Clinical-LeadershipWork_163930.pdf 

ASMS. [2019]. ASMS Research Brief – Collective leadership: harnessing the knowledge and skills of clinicians to transform health care. https://www.asms.org.nz/wp-content/uploads/2019/08/Research-Brief-Distributed-clinical-leadership_172592.2.pdf

Baker, D. Bivens, J. & Schieder, J. [2019]. Reining in CEO compensation and curbing the rise of inequality. https://www.epi.org/publication/reining-in-ceo-compensation-and-curbing-the-rise-of-inequality/

Bertram, G. [2020]. The Future of New Zealand’s State Sector. https://www.newsroom.co.nz/ideasroom/the-future-of-the-new-zealand-state-sector

Came, H., Doole, C., McKenna, B. & McCreanor, T. [2018]. ‘Institutional racism in public health contracting: Findings of a nationwide survey from New Zealand’. Social Science & Medicine, 199, 132-139 https://doi.org/10.1016/j.socscimed.2017.06.002

Crampton, P. [2005]. ‘The ownership elephant: ownership and community – governance in primary care’. NZ Medical Journal, 118(1122), 68-78 https://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.501.7241&rep=rep1&type=pdf

Dallas, L. [2017]. Behavioral Implications of the CEO-Employee Pay Ratio. https://corpgov.law.harvard.edu/2017/04/19/behavioral-implications-of-the-ceo-employee-pay-ratio/

Department of Health. [1989]. The New Zealand Health Charter. https://www.moh.govt.nz/notebook/nbbooks.nsf/0/1DF75C37B5FDC9AB4C2565D700186C3F/$file/Health%20Charter.pdf

Department of Prime Minister and Cabinet. [2021]. Our health and disability system – Building a stronger health and disability system that delivers for all New Zealanders. https://dpmc.govt.nz/sites/default/files/2021-04/heallth-reform-white-paper-summary-apr21.pdf

E Tū. [2017]. Building a Just Culture in the Workplace. https://etu.nz/wp-content/uploads/2017/07/Building-a-just-culture.pdf

Gauld, R., Atmore, C., Baxter, J., Crapmton, P & Stokes, T. [2019]. ‘The ‘elephants in the room’ for New Zealand’s health system in its 80th anniversary year: general practice charges and ownership models’. NZ Medical Journal, 132(1489), 8-14. https://assets-global.website-files.com/5e332a62c703f653182faf47/5e332a62c703f676dd2fc63f_Gauld%20FINAL.pdf

Hamed, O. [2013]. A social movement history of public opposition to New Zealand‟s health reforms, 1988-1999. https://www.scribd.com/document/131575075/Health-and-Hospitals-PHD-Thesis-Draft

Health and Disability System Review. [2020]. Health and Disability System Review – Final Report – Pūrongo Whakamutunga. https://systemreview.health.govt.nz/assets/Uploads/hdsr/health-disability-system-review-final-report.pdf

HQSC. [2019]. He Matapihi Ki Te Kounga O Ngā Manaakitanga Ā-Hauora O Aotearoa 2019 – A Window On The Quality Of Aotearoa New Zealand’s Health Care 2019. https://www.hqsc.govt.nz/assets/Health-Quality-Evaluation/PR/Window_2019_web_final.pdf

Kelsey, J. [2015]. The FIRE Economy – New Zealand’s Reckoning. Wellington: Bridget Williams Books

Matheson, D. [2017]. The Kurow Cure – Worth Another Crack. https://ucannz.wordpress.com/tag/the-kurow-cure/

Minister of Health. [2021]. Building a New Zealand Health Service that works for all New Zealandershttps://www.beehive.govt.nz/speech/building-new-zealand-health-service-works-all-new-zealanders

Ministerial Task Group on Clinical Governance. [2009]. In Good Hands – Transforming Clinical Governance in New Zealand. https://www.aemh.org/images/AEMH_documents/2018/15_In-Good-Hands-Report.pdf

Ministry of Health. [2001a]. Reportable Events Guidelines. https://www.health.govt.nz/system/files/documents/publications/reportableevents.pdf

Ministry of Health. [2001b]. The Primary Health Care Strategy. https://www.health.govt.nz/publication/primary-health-care-strategy

Ministry of Health. [2019]. Achieving Equity. https://www.health.govt.nz/about-ministry/what-we-do/work-programme-2019-20/achieving-equity

NZNO. [2019]. Growing Nurses Into Governance – A Governance Toolkit. https://www.nzno.org.nz/LinkClick.aspx?fileticket=BMuMA18DWM8%3D

PSA. [2021]. The Health and Disability Reform. https://drive.google.com/file/d/13snmexSVgR21xFXsmZQoriiHmbaxzbj4/view?fbclid=IwAR1TXgmbyJJ35EfBhXh5HJkZgQcoZ-YRIvJeCe8_uY51Ox5cz9kXSliF9wU

PSA. [In publication]. Our strategic goals – the outcomes we want to achieve 2021 – 2027.

Stats NZ. [2018]. Employment highest ever for women. https://www.stats.govt.nz/news/employment-highest-ever-for-women

Williamson, J. [2013] Workers on Board: The case for workers’ voice in corporate governance. London: Trades Union Congress. https://www.tuc.org.uk/sites/default/files/Workers_on_board.pdf

Williamson, J. [2016]. All Aboard – Making Worker Representation on Company Boards a Reality. https://www.tuc.org.uk/sites/default/files/All_Aboard_2016_0.pdf

Reflections on the LHP Symposium: ‘From Kinleith to the dole queue: workers’ struggles of the 1980s’

Reflections on the 2021 Labour History Project Symposium by Paul Maunder and Grant Brookes.

Paul Maunder, LHP Bulletin Editor, reflects

The seminar left me with the feeling of having experienced a contradiction at a deep level, but one which is not easy to articulate.

Having started off on a high (the victory at Kinleith), the union movement, as a social and political institution, obviously diminished in power and influence during the 1980s. From the Federation of Labour having a high media profile and with ready access to government, the body became something of a marginal player. And this diminishing has never been reversed.

Of course this is explicable. During the decade the manufacturing sector virtually disappeared, and this sector had provided the labour intense work sites that were often the base of militant unionism. But as well, white collar jobs were re-organised with short term contracts and an approaching digitalising of work. Meanwhile the service sector grew, characterised by low wages and precarious conditions. There was probably only hard-fought-for continuity in health and education, both sectors proving resistant to neoliberalism.

This was the negative story of the day.

The positive story was the diversification of the union movement during this same period, opening itself to women, other gender, Maori and Pasifika voices, leading to campaigns for equal pay, against sexual harassment and racial discrimination and beginning to bring tiriti relations into the movement.

The contradiction is that the garden in which this flowering took place diminished in size, even though the impulse was shared with more human rights focused campaigns. And there have been some notable blooms: the important care workers campaign and of course the more recent living wage campaign.

Yet, at the end of the day, at the negotiating table, a worker is a worker and a manager a manager, no matter what gender, race or sexuality either might be. The culture of the organisation getting the case together and the negotiating process should be inclusive, but that is not ultimately the matter up for negotiation, nor can failure be excused by good intentions.

Put it this way: If the negotiating team is ethnically, gender and sexually diverse, yet doesn’t achieve a good result, there is a cultural achievement yet ultimately a union failure. Scale this up to workers not getting their share of the cake and growing inequity, the end of union monopoly and the reduction of collective bargaining, poor health and safety, the housing crisis, an inadequate benefit system… The latter can be downplayed and the former celebrated – and there is cause for celebration − but also a failure if it becomes the goal of the union movement, that is, if the culture of the union movement becomes the central focus of the movement, as a way to sidestep the dominant crisis.

And was it in the eighties that this possible confusion of intent, imposed by crisis, became present?

In writing this I become aware of being on dangerous ground, but perhaps I am old enough and irrelevant enough as a Marxist to test the thinning ice of post modernism.


Grant Brookes, PSA Eco Network National Co-Convenor and nurse, reflects

History, as they say, is written by the victors. And in Aotearoa in the 1980s, there is no doubt who the victors were. 

So complete was their control of the narrative that up until February’s Symposium even my own memory, as a young adult during that decade, contained recollections of dole queues but none of the strike at Kinleith. 

As a consequence of this, the newly restored ‘Kinleith ’80’ film, shown at the start of the day, was an eye-opener. For me it was riveting to see the power of working people when we organise and the way that industrial struggle can transform every area of our lives, from our gendered relationships to cultural attitudes. The people in the film looked and sounded like my uncles and aunts. It brought the history to life. 

From that high point, as a number of speakers observed soberly, the trajectory for our class was downhill. 

But not everything was lost. As I entered the workforce myself in the following decade, the gains from Fighting sexual harassment in the 1980s had been sustained – at least in my unionised, public sector workplaces. Those oral histories from the Clerical Workers Union in the early eighties were eye-opening, in a different way. They were shocking. 

A highlight of the day for me was the presentation on Workers’ resistance to destructuring in the 1980s. This challenged the prevailing state-centred account of the rise of neoliberalism, which sees it as a response to the failure of Keynesian policy prescriptions and an organised takeover by ideologues in Treasury and in the Fourth Labour Government. 

The alternative explanation offered, in terms of a class assault to address a crisis of capitalist profitability, seems to me to allow an answer to the question posed in the final Panel on Intergenerational conversations: “Does history provide the answers for how to address our current crises?”

That answer is – yes it does, when theorised correctly. Many of the systemic drivers are the same today. Viewed through the right lens, history provides us with track markers and signposts the pitfalls. Although they do not know it, multitudes of working people in this country owe a debt of gratitude to LHP for keeping the flame of scholarship alight and organising symposiums such as this, where answers might be found for us all. •

First published in LHP Bulletin, 81, 52-3. Re-posted with permission. For a one year individual membership of the Labour History Project and subscription to the Bulletin, deposit $30 to the LHP Kiwibank account, 38 9012 0672630 00, and email malatestacampbell@gmail.com with notification of deposit.