Restoring flow to the Aotearoa New Zealand vascular workforce pipeline requires tangible strategic interventions

The delivery of quality vascular services in Aotearoa New Zealand (AoNZ) is threatened by recurrent, acute exacerbations of surgeon workforce shortages. As the second smallest surgical subspecialty, only 27 of the 241 surgeon members of the Australia and New Zealand Society of Vascular Surgery practice in AoNZ.1, 2 For AoNZ, this equates to a ratio of 0.53 vascular surgeons per 100 000 people, which is well below the 2011 Australasian College of Surgeons (RACS) Workforce Strategy minimum safety recommendation of 0.76 per 100 000.3 To cover this shortfall, twelve new and fully qualified vascular surgeons would be needed immediately. Over the past decade, less than 10% of vascular surgical education and training (SET) trainees have been selected from AoNZ.4 Furthermore, 44% of the surgeons who are vascular RACS fellows are above the age of 60, suggesting that further staffing shortages can be expected within 5 years.5 This lean workforce is challenged to meet the needs of the growing burden of vascular disease from an ageing population, the increasing prevalence of obesity, diabetes, and renal failure, while providing increasing intraoperative vascular assistance to other surgical specialties.6, 7 While a small speciality, vascular surgeons also provide important and fundamental services to support other specialities in providing their bread and butter care and assist in managing their day to day patient workflow, for example, in dialysis care, oncological support and access for spinal and cardiology procedures.8 An insufficiently staffed or overburdened vascular workforce can prove detrimental to a tertiary institution's ability to provide modern safe surgical care.7, 9 Incongruence between a small, unreplenished vascular workforce and the growing demand for services is also being seen in the USA and UK.10-12 Together, we believe that an urgent 'call to action' is needed to ensure the sustainability of the vascular surgical profession in AoNZ. While it is clear there is no silver bullet solution to systemic workforce shortfall in a small subspecialty, corrective efforts need to be multifaceted, with tangible solutions targeting the workforce training, employment culture and the wider health system structures that influence the attraction, recruitment and retention of vascular surgeons.13 Workforce policies often seek to address staffing shortages by training more doctors. Increasing the number of AoNZ trainees accepted into SET training is an important part of the strategy towards boosting the workforce but is a simplistic approach when implemented in isolation. Future career prospects and employment conditions play a substantial role in how attractive a surgical specialty is to junior doctors. Currently, doctors in vascular surgery work the second highest number of hours (61 h per week) of all medical specialties,14 and are at particularly high risk of stress and burnout.15, 16 In a recent unpublished survey of 49 house officers and final year medical students in AoNZ by the first author, interns reported that poor work-life balance, high-pressure work and inadequate stress-to-compensation ratio deter them from choosing vascular surgery as a career. Recognizing the importance of mentorship and building on positive exposure to vascular surgery throughout medical school can increase contact with the speciality and foster interest for early career doctors.17 Acceptance into the five-year bi-national Vascular SET programme depends heavily on academic attainment in the structured curriculum vitae, positive referee reports and interview performance. Increasing the number of successful candidates into SET training from AoNZ requires focused early support to ensure AoNZ applicants are competitive candidates for limited training positions. Within AoNZ, early efforts have been made to establish a junior vascular collaborative group, intended to build inclusive community, promote mentorship for cross-discipline early professionals and draw attention to local opportunities for AoNZ applicants. At a structural training level, the equity and sustainability of training policies needs to consider the broader nuances of the AoNZ vascular workforce needs, including the need for the vascular surgical workforce to have representation from Māori and Pacifica communities. Ring-fenced training positions, and racial equity pathways, without a commitment from training programs to provide to mentorship and cultural safety, can perpetuate a lack of belonging and inclusion, unintentionally exacerbating discrimination and bias.18 Systemic change that promotes diversity, equity and inclusion is needed across all levels of training, health service delivery and policy, aligning health workforce training strategies with the needs of local communities. Workforce sustainability relies on retention of trained vascular surgeons (both from AoNZ, Australia or as Specialist International Medical Graduates). A major report on health professional mobility in Europe identified three key factors that influence whether staff stay or go: employment quality, work quality and organizational quality.19 Compared to their equivalent in Australia, on average, the salary of AoNZ specialists is 40% less, and the top step on the Te Whatu Ora specialist base salary scale is slightly below the lowest base salary step for a newly qualified Australian specialist.20 This is in part due to the structure of healthcare reimbursement in Australia, where private insurance can generally cover both emergent and elective surgery pathways and the private sector is the primary provider of surgical services,21 whereas in AoNZ, acute surgical care is predominantly public. While renumeration is important, workforce retention is also influenced by opportunities for flexible working arrangements, career progression, social benefits (retirement policies and pensions), and conditions that enable reasonable work-life balance. Chronic high stress, large administrative workloads, dissatisfaction with organizational management or the feeling of being around inappropriate or unsafe work has a negative effect on retention and clinician wellbeing.19 Advocacy by clinicians and policy-makers at the health policy and government levels are imperative to address these factors. With rising demand for acute and elective services, increasing complexity of care, and a small workforce with little growth, vascular services in AoNZ are heading towards a crisis point. Urgent action is required to muster and maintain an adequately sized workforce, by attracting, recruiting and retaining vascular professionals, to avoid significant disruption across a number of health domains. Dr. Sarah J. Aitken is an Editorial Board member of the ANZ Journal of Surgery and a co-author of this article. To minimize bias, they were excluded from all editorial decision-making related to the acceptance of this article for publication. Open access publishing facilitated by The University of Auckland, as part of the Wiley - The University of Auckland agreement via the Council of Australian University Librarians. Anantha Narayanan: Conceptualization; data curation; formal analysis; funding acquisition; investigation; methodology; project administration; resources; software; supervision; validation; visualization; writing – original draft; writing – review and editing. Korana Musicki: Conceptualization; data curation; formal analysis; investigation; methodology; supervision; validation; writing – review and editing. Sarah J. Aitken: Conceptualization; investigation; methodology; supervision; writing – review and editing. Lupe Taumoepeau: Conceptualization; investigation; methodology; supervision; writing – review and editing. Manar Khashram: Conceptualization; data curation; formal analysis; funding acquisition; investigation; methodology; project administration; resources; software; supervision; validation; visualization; writing – original draft; writing – review and editing.