Trade union/government partnership for transformation:

1. Trade union/government partnership for transformation: The case of Chris Hani Baragwanath Hospital

2. Contents • The budget • Staff shortage • Management weakness • Discipline • Training & advancement • Trade union initiative for change • Surgical Department pilot project • Strategic planning • Issues

3. 1. The budget:the apartheid legacy • CHB has 2.5 X more beds than Joburg Gen • CHB has 14% more budget • CHB personnel expend per bed is 34% • Personnel expend per patient/day is 70% • Total expenditure per bed is 58%

4. 2. Staff shortage • 32% shortage of staff (total) • 36% shortage of nursing staff • 73% shortage of pharmacists • 45% shortage of allied health • 46% shortage of managers/ administrators • 30% shortage of support staff

5. Workload • “We sometimes only do the most critical patients. Sometimes we just ‘top and tail’ patients instead of giving them a full wash.” - CPN in-charge • “I have to rush time - I must stop washing and serve tea. If there are no ward attendants I must make tea myself. There’s no point in washing the patient and giving medications, but failing to feed him. Again, how can you leave a sick person in a wet bed and go for lunch?” – NA • “The most important change with democracy is the shortage in staffing levels.”

6. Workload • “We have to ignore the rules we were taught in our training. We were taught that you cannot wash the patient alone, but must always be two. According to the rules, there should be two nurses to turn a patient. At present we wash alone, we turn alone, we make beds alone, irrespective of how obese or how ill the patients are.” – NA • “Unbearable” stress: resignations, absenteeism, late-coming, anger, aggression, irritability

7. 3. Under-management at CHB • Managerial capacity • absolute shortage of executive & senior managers • lack of management development • Lack of management systems • financial, HR, patient care benchmarks • Personnel management instead of HR management

8. Inefficient silo management structure Nursing Support Doctors Surgical Ward

9. Management cont... • Centralised control by DoH • Chronic disempowerment of management and staff • Management culture • management of Personnel, Administration & Rules rather than Strategy, Operations & People • “management by memo”

10. Experience of managerial vacuum • ‘When we meet with management we complain about the shortage of staff, the linen, cleaners - they tell us to try your best! It’s a joke! They come with no solutions. Who do we cry to?” - CPN • ‘’We are sick, stressed. We are doormats for everybody. We are running this hospital for the hospital’s management.” - CPN In-charge • “No-one takes responsibility.” - CPN • “There is a disease in management of not acting.” - PN

11. 4. Discipline • A minority of all categories are lazy, absent without cause, avoid work, do their own business, drink at work, carry guns • All staff complain that supervisors do not implement disciplinary procedures • Inconsistent discipline: “Uyaziwa.” • Role of unions

12. Discipline cont… • 1992 strike • challenge to apartheid discipline • violence, intimidation, dismissals • conflict between workers (nurses & general assistants, strikers & strikebreakers) • breakdown of discipline • legacy of distrust, conflict, guns • failure to establish new legitimate disciplinary regime

13. Discipline cont… “There are no disciplinary measures from top to bottom. If a nurse steals the clothes of a patient there will be no disciplinary action, they will give a lecture on how to conduct ourselves. But the culprit is known.” - NA “Are we not supposed to be disciplined? Where is this discipline? A known habitual loafer is never disciplined.” - NA

14. Discipline cont… “Management knows the rotten potatoes, and leaves them alone.” – PN “The union is defending those who are wrong. There should be clear rules. What is the point of having rotten members? We are the real union members.” - NEHAWU members

15. 5. Training & advancement • Some categories feel their skills & experience are not recognised (NAs, WAs) • Most categories feel they have no access to further training (WAs, NAs, WCs, CPNs) • Most categories feel there are no prospects for advancement (as above) • No HR capacity for skills development, training

16. 6. Trade union initiatives for change • NEHAWU asks NALEDI to investigate and develop proposals for transformation into a ‘People’s Hospital’ (2000) • All unions & management & hospital board & Gauteng DoH co-operate (2002) • Identify pilot project in Surgical Department (2003) • Union role crucial in driving the process

17. 7. Surgical pilot project • New way of managing & working • Integrated management structure • Appoint Ward managers • Appoint HR officer • Integrated work organisation and team working • Participatory management • Training and development • Appropriate staff levels • Constraints…

18. 8. Strategic planning • Formal political endorsement as ‘partnership project’ (2004) • MEC mandates management to develop a strategic plan for CHB (2004) • Indicates budget will be revisited • Workshops with all occupational categories • 3-day strategic planning workshop with all stakeholders • New sense of potential for change

19. Strategic planning cont… • Strategic plan: • Management autonomy to run the institution within agreed budget & targets • Develop zero-based activity-based budget, capacity & systems by next budget year • Develop and implement new organisational design based on distinct business units • Develop HR strategy, capacity and systems • Will require provincial agreement, expanded budget & investment in capacity

20. 9. Issues • Pilot for Government/management/union partnership for transformation • Excessive centralisation constrains institution-level innovation • Managerial control by DoH • Bargaining sector agreements • Quality of working life and quality of service delivery are connected

21. Issues • Budget issues: • “progressive reallocation to primary care” • destruction of institutional capacity • Apartheid legacy • Necessity for investment – future savings • Management capacity

22. Issues cont… • The skills shortage suggests rethink of work organisation • Increased numbers & skills at the bottom • Deploy scarce hi-level nursing skills appropriately • Change the cost structure of employment • Learnerships for WAs, NAs

23. 11. Issues: labour • Problem: union approach to discipline

24. Forward to Transformation of the public service!