Walking wounded: Inside the NSW doctors’ strike

When the New South Wales government’s Ministry of Health ordered letters be sent to every working doctor in the state threatening them with potential professional standards investigations if they went on strike, it was enough to push the anaesthetics department at one hospital over the line.

Previously undecided, they were ready to walk out for better pay and conditions.

“There is no ‘right’ to take industrial action when orders against industrial action have been issued. Taking strike action is a breach of the IRC’s [NSW Industrial Relations Commission’s] Order,” reads one version of the template letter sent via local health districts and hospitals.

“NSW Health Agencies have obligations under the Health Practitioner Regulation National Law. Depending on the impact of the conduct of the medical officers during the industrial action, NSW Health may make notifications to the Australian Health Practitioner Regulation Agency [AHPRA]and/or to the Health Care Complaints Commission.

“Employees are encouraged to seek independent legal advice about the potential risks of unauthorised strike action.”

The Australian Salaried Medical Officers’ Federation (ASMOF) of NSW – better known as the doctors’ union – was “astounded” by the threat, according to its junior vice-president.

“The AHPRA and the medical board hear serious complaints about misconduct, people who are performing while they are impaired at work or deviating from acceptable professional standards,” says Dr Tom Morrison, a neurosurgery registrar at St Vincent’s Hospital in Sydney. “They’re not ways of dealing with an industrial dispute and the members were outraged.

“What I can tell you is that after that letter was sent out, the entirety of the anaesthetic department at my hospital said, ‘Well, this is the decision point for us to go in.’  ”

By the time the strikes began on Tuesday, the union had registered more than 5000 doctors – junior and senior colleagues alike, for the first time in the state’s history – who intended to join the action. It was an unprecedented number and members broke the union’s Zoom subscription after the strike decision was announced.

In their view, it was a collective response to years of dangerous conditions, overwork exacerbated by the pandemic and a steadily growing wage gap, owing to a Coalition government decision to cap public sector wages at 2.5 per cent annual growth.

They have encountered a wall of resistance from the NSW Labor government.

“It has been especially disappointing to see the Ministry of Health and the minister [Ryan Park] try and pretend that this is a strike by rich doctors, when junior doctors in NSW are the lowest paid in the country and have the worst conditions,” one medical registrar tells The Saturday Paper.

“Interns are paid $38.33 an hour, last behind Tasmania. Queensland manages $45 an hour and is actively recruiting to fill gaps in its system. And there are parts of NSW that are some of the most expensive places to live in the country and we have fewer workplace protections, which means fewer protections for patient safety.

“Is it any wonder junior doctors are looking around and asking themselves why would we stay?”

Queensland, for instance, has fatigue pay for doctors who are called back to work after less than a 10-hour break between shifts. During this time they must be paid double their usual rate – a financial incentive for hospitals to avoid relying on tired doctors to fill rostering gaps.

NSW policy forbids rostering a doctor without a 10-hour minimum break, but they can be called back in to work with no financial penalties to the hospital. The policy recommends managers “avoid” overtime allocation following long afternoon or night shifts.

“The neurosurgical doctors at my hospital work very unsafe hours,” one doctor in training tells The Saturday Paper.

“It is common for them to work all day, 6.30am to 6pm, operating. They will then often be on call overnight until the next morning. They are on call for my hospital, but also the whole of northern Sydney, Central Coast and for spinal surgery for most of the north of NSW. One time we calculated the number of phone calls they had received, and it averaged out as one call every seven minutes over a 24-hour period.

“Imagine trying to get some sleep with that. Unfortunately, they will have to also come in to then operate overnight. Just last week one of the neurosurgical doctors was operating all day and she was called in to operate on a spinal trauma emergency, which went from 11pm to 4am. She had to then come back at 6.30 to start her next day. She has no minimum break between shifts guaranteed and she has no cover for her operating list if she doesn’t show the next day.”

This doctor frequently makes those calls to neurosurgical colleagues on overnight shifts and recounts an especially disturbing moment after seeking specialist advice. “They called back five minutes after hanging up to clarify if we had spoken at all,” this doctor says.

“They were unsure whether the conversation we had was real or a dream and were therefore worried about what they may have said, so wanted to make sure the advice was correct.”

The Covid-19 pandemic exacerbated structural problems in health systems across the country and medical staff have left because of burnout. Some could have been retained with better conditions, but those conditions never came.

One doctor who worked in intensive care during the early stages of the pandemic subsequently transferred to the emergency department at Liverpool Hospital in Sydney’s west, where he was shocked into leaving.

“That completely broke me. I had to quit,” he says. “I worked at ICU during Covid. I saw how quickly we could mobilise resources, how quickly we could get high numbers of staff. And then I moved straight away after that to Liverpool emergency department, which was severely under-resourced, understaffed and experienced some pretty horrific, horrific things.

“I basically saw a patient on crystal methamphetamine decapitate himself with trauma scissors – so, like, blunt scissors – and it’s in front of me.

“After that, I was essentially told that that’s tough, mate, but we need you to keep going back to work. I was devastated, hearing that from my colleagues who just needed another body on the floor to keep seeing patients. I felt like I was just a number on a spreadsheet.”

NSW Health Minister Ryan Park has repeatedly said it would cost the state $11 billion to meet the demands of the doctors’ union. The demands include a 30 per cent catch-up pay rise and measures to install safer working conditions.

Doctors have struggled to work out how that figure came about.

The entirety of the staff expenses bill for Health in the state this financial year is budgeted at $19.5 billion and doctors make up just 10 per cent of that workforce. When questioned, Park’s office conceded that figure is conceived over four years and is broken down further: $1.8 billion for pay increases, $4.7 billion for changes in conditions and $1.3 billion for “staff uplifts”.

It did not say where the remaining $3.2 billion was allocated.

In other words, most of the $11 billion figure would go towards making hospitals better staffed and safer for patients. But that is not how it has been sold.

On Wednesday, Park attempted to offer a more conciliatory tone when he took to Instagram to speak directly to doctors.

“I want to be very clear: I understand, as your health minister, and someone who’s been around health for some time now, that doctors’ wages are problematic, I understand that for all healthcare workers,” he said.

“I also understand, particularly for our junior medical officers, that’s a real challenge because they’re on the lowest of those medical wages.

“That’s come about because of around 12 years of wage suppression in NSW brought about by the former government’s wages cap. That’s a challenge and that is why there’s differences in wages in NSW compared to other states and jurisdictions who didn’t have a wages cap in place. And after 12 years, that gap is substantial.”

What he can’t do, he said, is make up for that lost time in a single year.

For that Park has some sympathy, even among the striking doctors. But as one points out, a crisis is a crisis. “When I have a patient come to me I don’t get to blame all of the people that treated them first or the circumstances that led them here – my job is to get in and stop the bleeding,” he says. “That is not happening.”

Minister Park’s department has offered the ASMOF NSW a 10.5 per cent pay rise over three years but nothing on the substantive matter of conditions.

“This is not a union without options,” he said in a statement on Monday.

“It is inexplicable ASMOF would actively choose to jeopardise patient safety over resolving its claim in the IRC.”

The union has repeatedly said, however, that its strike is being coordinated with the Ministry of Health so that hospitals were still running during the week as if they were staffed to the standard of a weekend or public holiday.

“Is the minister now trying to tell us that every weekend across this state that patients are unsafe? Because if that is the case then he should do something about it,” one doctor says.

“During the strike the most urgent patients will still get seen, emergency departments are still operating, chemotherapy is still being delivered. But some patients who are in a hospital and stable will not be seen by a doctor every day – only every other day, for example. Elective surgeries were moved and postponed, and that is difficult for those people. The simple fact is we didn’t want to have to do any of this.”

Tom Morrison at St Vincent’s said he was a little concerned about what support they might receive from patients and the broader public but was overwhelmed by the response.

“Lots of patients have reached out saying they support us. Members are saying they’re getting lots of congratulations from patients in hospitals and encouraging us to stand up for safe care, because at the end of the day, that’s what this is about,” he says.

“If you can’t appropriately staff and have safe conditions, you can’t have safe care for patients.”

The most recent quarterly health data for NSW shows a grim state of affairs. Between October and December last year, the percentage of T2 Emergency patients (requiring treatment within 10 minutes) who “started treatment on time” was just 53.4 per cent, a fall of 2.2 percentage points from the same period the year before.

Urgent T3 cases (treated within 30 minutes) started treatment on time 60.5 per cent of the time, a 3.4 percentage point drop from the previous year.

On Tuesday, federal Health Minister Mark Butler was asked about the strike. “I’ve been very clear, we need to think very carefully about the impact on patients of this. We know that it’s likely that hundreds of elective surgeries will have to be cancelled or pushed back significantly,” he said.

“I’m very worried to watch for any impact on emergency departments or other unavoidable patient admissions that need to take place. I really encourage the government and the doctors’ union to get back to the table and to sort this out in the interests of patients.

“We’ve provided next year, a billion dollars in additional funding to the NSW government, we’ve provided similar amounts to other states as well, because we recognise there is significant wage pressure in the health system across the country.

“This is the biggest increase to hospital funding in many, many, many years, and I hope that it will better equip the NSW government and other state governments who are dealing with these wage pressures to come to an agreement.”

As The Saturday Paper has previously reported, however, that funding was provided only for a single year as an emergency rollover of the National Health Reform Agreement (NHRA) addendum. It followed a directive by Prime Minister Anthony Albanese to halt negotiations on deeper structural reform for six months, to force states and territories to also agree to share additional National Disability Insurance Scheme costs.

Instead, ahead of the election being called, no agreements on either policy subject were struck. Hospital funding limped along, as it has since the Coalition government wound back a provision in 2016-17 that would see Commonwealth contributions to state hospital funding rise to 50 per cent. Albanese’s government agreed to at least reach 45 per cent in practice by 2035, with a target of 42.5 per cent by the end of the decade. It rejected calls to go higher, and discussions stalled.

While Butler sold the one-year funding rollover as a fillip to state hospital budgets to help ease wages pressure, Minister Park told his state parliament’s budget estimates in February that the “money cannot and will not be used for that” when asked about negotiations with the Nurses and Midwives’ Association.

“We did not secure a five-year deal. We would have wanted a five-year National Health Reform Agreement, rather than a one-year one. But that decision wasn’t taken,” he said. “The next thing about that federal money is that the $407 million, which is roughly what it is, we haven’t seen it yet. It hasn’t hit our bank account, so we’re waiting for that. But that will primarily flow through to staff through hospital activity. As you know, that’s what it will largely result in.”

A review of the NHRA released by Minister Butler identified critical structural issues that need to be addressed in future health funding arrangements – notably that the current agreement prioritises activity funding that “tends to drive care toward inpatient settings”, without addressing where that demand comes from.

Such reform, if it happens, must now wait beyond the federal election. As it stands, hospital administrators focus on maximising “bed flow” and make hiring or staff changes based on how much activity funding those roles might attract because that is what those agreements emphasise.

In the meantime, the NSW Ministry of Health is demanding efficiency gains before it hands over any more money to doctors. It tried to tie award negotiation outcomes for staff psychiatrists in the NSW public system to increased productivity, despite the core issue that these roles were overworked and underpaid.

“None of this takes into account how well the patient is actually treated,” one medical registrar says.

“It takes into account how well I document – when I can be bothered to and when I have time to – the things for which the hospital can bill more money through the national weighted activity unit (NWAU).”

For striking doctors, the antagonism from their employer is misdirected.

“They’re attacking a symptom – you know, this ‘greedy doctors’ myth – but won’t even think about treating the underlying sickness,” a resident medical officer says.

It’s the government version of the timeworn doctor’s advice: take some paracetamol and get some rest.

“Except they can’t tell us to get some rest,” the doctor says.

“Because if we did, the system would fall apart.” 

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