Predicted critical shortages of family doctors are forcing big changes in primary healthcare. Is general practice terminally ill or can it be saved? Donna Chisholm reports.
Four hundred patients a week are having their say, and as one of the practice’s four GPs, Dr Hayley Scott, examines the previous fortnight’s results on a midwinter day when the Listener visits, she’s troubled. The satisfaction ratings have fallen from their usual 97% to about 77%, with one unprecedented dip to 64%. Within a day or two, Scott has called a meeting in the town’s theatre for early August, between the doctors, their patient-focus group and locals, 5400 of whom rely on the practice for their primary healthcare, to find the cause of their discontent and how to address it.
Te Aroha was one of the first general practices in the country to adopt a new model of patient care designed to make better use of GP time, give patients alternatives to face-to-face consultations yet better access to their doctors and health records, and to ensure the sickest patients are seen first. It’s turning the traditional patient interaction with general practice – phone up in the morning to make an appointment, see the doctor the same day – into something its supporters say will future-proof access to primary care in the face of looming doctor shortages, particularly in poorer and rural areas.
Now, patients who ask for a same-day visit will get a call back from their doctor to talk about why they need the appointment, whether they can get advice by phone, be seen less urgently or seen by a nurse. It’s called triaging – the sort of thing that happens in hospital emergency departments – and it’s being credited for doctors rescheduling 20-30% of same-day bookings.
Before triaging, Scott says, she was routinely seeing patients who didn’t need to be seen in person, but were taking up the time that could have been given to much sicker people. Te Aroha had big problems attracting GPs. The local doctors were “120% booked” and seeing about 28 patients a day each. Now, they’re down to about 20 a day, appointments tend to be longer if required, they have better work-life balance and their income hasn’t dramatically fallen.
The recent blip in patient dissatisfaction may be the result of doctor sickness causing longer waits. In the past, though, not only would the practice have been oblivious to the complaint, but also it wouldn’t have been able to do a lot about it. “Now, we say it’s not about the doctor. If the patient is having this problem, we need to fix it. We can reschedule people who aren’t urgent and deal with it in a different way.”
For patients such as Eileen Joyce, 69, the changes have been transformative. “It used to be quite regimented, very formal. You’d make an appointment to see the doctor and that was it. Coming in to see them was the only way you could have contact with them.”
Now, through an online portal for patients, Joyce can read her notes, check her blood-test results, email her doctor for advice or book appointments. “It’s been amazing. I like to know what’s going on and now I’m so much more aware. It’s no longer a case of the doctor is the boss and they tell you what to do. You can read the notes and say, ‘I don’t understand this, tell me more.’ Before, they talked, you listened and you did what you were told. I didn’t worry about that at the time because I didn’t know any different.”
Wave of retirements
The crisis in New Zealand’s GP numbers is being driven by a wave of retirements of older doctors, with 47% of the 5000-strong workforce indicating they’ll retire within the next decade, a generational change that has seen younger GPs working fewer hours as they balance work and parenting duties, a population that’s getting older and sicker, and a specialist training scheme that hasn’t recruited or trained enough family doctors.
But Des Gorman, until December the executive chairman of Health Workforce NZ, says the two biggest problems are reduced productivity among GPs – he says since 2001, the average GP has given up one working day a week – and the capitation system by which general practice is Government bulk-funded, according to the number of patients on practices’ books. “It means the incentive for GPs is to enrol as many people as possible who’ll never come and see them, then close their books. If I get $500 a year in bulk funding, I’m winning if I see you only once, but I’m winning even more if I don’t see you at all. I get money if I don’t have to do anything. The best thing you can say about capitation is that it hasn’t protected productivity in general practice. The worst you can say is that it has aided and abetted a dramatic fall-off in GP availability.”
It’s a system that has a racist effect, he says. Although higher funding is available through the Very Low Cost Access Scheme to practices with 50% or more patients with high needs, other doctors are cherry-picking enrolments, he says. “If you come along to enrol and say you’ve got diabetes, asthma and chronic obstructive pulmonary disease, I say, ‘My book’s full, I’m very sorry.’ And you don’t enrol people who are old and sick. Why on earth would I enrol you if you’re a frequent flyer?”
He says capitation was meant to be associated with published quality measures for practices that would drive choice, but those hadn’t happened. “The general practice community wouldn’t have a bar of it,” says Gorman.
Since 2001, when the payment system was introduced, New Zealand has had a 70% increase in specialists per head of population and a relative drop in full-time-equivalent (FTE) general practitioners, partly because of the reduction in hours worked. In 2001, the country had 85 FTE GPs per 100,000 people. It now has a national average of 73 and Australia has 110. In the same period, on-call and after-hours work has dropped from an average 10 hours a week to four. “We now have a whole generation choosing general practice on the basis that a full-time week is three and a half days.”
In 2015, a Medical Council survey estimated that areas with the fewest doctors per capita (Counties Manukau, Taranaki, MidCentral, Waitematā and Hutt) had only two-thirds of the GP coverage per 100,000 population compared with those with the most (Southern, Auckland, Capital & Coast and Nelson-Marlborough). Auckland has not only the most doctors (82 per 100,000 people) but also 29 of the country’s 36 after-hours clinics.
Apart from fundamental changes to the way general practices are run, and a rise in the number of salaried as opposed to business-owning GPs, we can expect increasing diversification of the primary-care workforce. More work will go to nurses, nurse prescribers, clinical pharmacists, health coaches and “HIPs” – health improvement practitioners. “Just seeing a GP is so yesterday,” says former Pinnacle Midlands Health Network chief executive John Macaskill-Smith, who introduced the US-pioneered Health Care Home (HCH) model in 2011 that has since been adopted not only in Te Aroha, but also in another 160 practices covering 1.2 million patients nationwide. “People have been trying to pour more money into the old model and put sticking plasters over it and say, ‘Let’s train more doctors’, but it’s not the right answer,” says Macaskill-Smith, who now heads Midlands’ innovation arm, Ventures.
He says general practices have until now been run on a first-in, first-served basis. In Midlands, where 114,000 patients are enrolled in HCH practices, a 2017 evaluation by Ernst & Young credited the new model with a 14% decrease in hospital emergency visits (down 24% for Māori and 32% for over-65s), fewer referrals to specialist care and 20% fewer preventable hospital admissions.
When assessing how many patients full-time GPs should have on their books, a figure of 1:1500 is often suggested as an appropriate norm. It’s a crude figure, depending on the demographics of a practice and the ability for GPs to call in or rely on related support services. In Taranaki, where that figure has blown out to 1:2500-3000 – one of the worst in the country – it’s very difficult to get a same-day appointment.
Some GPs are worried that phone triaging and the patient portal are potentially risky options for patients who may not be able to adequately communicate their problems. What if serious ailments are missed? Macaskill-Smith and former Ventures general manager Helen Parker, recently appointed Midlands’ chief executive, have heard all the what-ifs, to the point of despair. “Helen and I spend our lives with the owners of practices. I used to be skinny and have lots of hair,” says Macaskill-Smith. “We spend many, many evenings having philosophical discussions with them and say, ‘What does the future look like? It’s not sustainable. How are you going to attract the next generation – who are you going to sell to? What’s going to make this work?’”
They’re also frustrated that some district health boards, through which primary-care funds are channelled, can’t see the sort of benefits the Ernst & Young report highlights. “DHBs generally don’t understand primary care and I don’t think they feel as if they have a responsibility around primary care. There is often a sense that GPs go home at five and don’t work weekends, so by default everything ends up at the ED [emergency department]. They are quite focused on hospitals, and primary care is this private enterprise that happens outside. Some of them have a belief that GPs just take the money and buy a new BMW.”
Parker says the planners commissioning health services tend not to come from a primary- and community-care background. It’s helped to make DHB support for, and buy-in to, the HCH model patchy.
In Counties Manukau, where the biggest primary health organisation, ProCare, has 12 practices and 107,000 patients converting to the HCH model, the organisation’s chairman, Ōtara GP Harley Aish, says patients readily adapted to the changes. “When there is a lot going on, Māori and Pacific patients and their whānau use the portal to the maximum. They are messaging us, checking their notes, ordering repeat prescriptions and making appointments. I didn’t expect Māori women in their fifties to be the power users, but when they have chronic conditions, they know how to use it.”
Phone triaging has also allowed about 20% of patients booking at his practice, the Ōtara Family and Christian Health Centre, to be seen not by a GP, but, “more appropriately”, a nurse. “If they’d rung up and been told all the GPs are booked, they might have gone to the ED. Instead of thinking about the GP and saving time, you think about the patient experience and they just think it’s fantastic.” The practice sees many patients with infections, and a nurse can manage that by providing standing-order antibiotic prescriptions already signed by the GP.
Fit for purpose
In a discussion paper released in April, General Practice New Zealand (GPNZ) concluded increasing use of nurses was one of the key solutions to the GP workforce crisis, although GP-nurse ratios would change in favour of doctors in high-need patient populations.
“We are not seeing the death of general practice, but an evolution,” says GPNZ chairman Jeff Lowe, a Wellington GP. “We are trying to describe a workforce that will be fit for purpose for the challenges ahead.” In his practice, nurses now do iron transfusions and intravenous (antibiotic) treatment for cellulitis – procedures previously done by GPs.
He says the traditional model in which patients call up to book consultations is unsustainable. “It’s causing burnout, because there’s a finite number of 15-minute appointments. We need to make sure we are using those for people who really need to be seen face-to-face. Let’s say you have someone time-poor in Wellington who has a simple urinary tract infection such as cystitis. They’ve had it before, they know exactly the symptoms and they’re not unwell, but they need a prescription for an antibiotic or it’ll get worse and may develop into a kidney infection. With a few simple questions, we can safely deal with them over the phone and say, ‘Okay, you can have a prescription, but if you get worse, we want to see you.’ We can save that person a couple of hours driving from town, sitting in our waiting room next to someone who might have the flu, and then save another appointment for someone who really needs to be seen that day.
“The biggest part of the workforce who need to lift their game are patients themselves – we need them to be self-managing far better. We can equip them with the knowledge, data and advice they need, but we do need patients to take ownership of their own health.”
His practice’s patient portal gets 75,000 hits a year. “Patients are demanding it, and they are starting to choose a practice based on whether they have a portal or not. People are voting with their feet, saying it’s something they want and value.”
Lowe says when Sir David Haslam, then chair of the UK’s National Institute for Health and Care Excellence, visited New Zealand in 2017, he estimated that 75% of patients seen in general practice didn’t need to be seen face-to-face. “What we need to know at the beginning of the day is which 75%,” says Lowe.
Practices aren’t coping
The April discussion paper, written with input from health economist Tom Love of the Sapere Research Group, proposed increasing the ratio of nurses to doctors in general practice to 2:1, and suggested the primary-care team should include a counsellor, social worker, healthcare assistant, clinical pharmacist and physiotherapist, with the distribution of those roles depending on the community it serves. The estimated cost of its two models – for high-need and general populations – was about $2.2 billion, $500 million more than the current system. GPNZ plans to talk to the Treasury and the Ministry of Health to discuss its model further.
Tom Love says some practices are trying to cull their enrolments because they can’t cope with the numbers as patient needs become more complex. A decade or so ago, those practices were working sustainably, he says. A survey by the Royal New Zealand College of General Practitioners (RNZCGP) in 2017 found nearly 40% of practices in Tairāwhiti, on the East Coast, aren’t taking enrolments, followed by 32% in South Canterbury, 31% in Hawke’s Bay and Taranaki and 24% in Whanganui.
Whanganui, however, is something of a success story when it comes to attracting new doctors, thanks to an initiative launched in the early 2000s that allows GPs to work for salaries rather than having to commit to buying their own practice.
“We’d lost about a third of the GPs we needed, through retirement and people moving away and being unable to replace them, says John McMenamin, a GP who’s practised in the area for nearly 40 years. It had left Whanganui with only 22 of the 33 GPs it needed. McMenamin, who supervises GPs in training, says the inability to retain them led to a group of independent GPs establishing a day-service at an after-hours clinic in Whanganui, staffed by two of the registrars trained the year before and supported by locums. It allowed the doctors to stay on in a supported environment without investing financially in a future there.
The clinic was so successful it spun off other services, including an accident and medical clinic in the grounds of Whanganui Hospital where patients with minor injuries or low-level medical problems are triaged and sent to the hospital only if they need more intensive care. McMenamin says the DHB is committed to equitable health services, and an iwi-led practice, Te Oranganui, in the central city and Waverley, is also helping to meet Māori health needs.
Understaffed and under-resourced primary care not only causes substandard care for patients, but also has a wider financial effect, says RNZCGP president Samantha Murton, a Wellington GP. “As soon as primary care is overburdened, the hospital system has to pick up acute care, and that’s costly, with patients having investigations they don’t need.” GP shortages mean some patients have to wait weeks for an appointment, or they may end up seeing someone who’s not familiar with their history, which disrupts continuity of care.
Bums-on-seats won't work
This year, 193 doctors began the general practice training programme and 197 have been accepted for 2020, but about 250-300 a year are needed. Because most of the coming retirees are older male doctors who’ve been working full-time and many new GPs work only part-time, more than one doctor is needed to replace each one. Health Minister David Clark told the Listener that funding isn’t limiting trainee numbers. Murton says Clark told college representatives last month that more trainees would be funded if they qualified for the training.
A bums-on-seats approach, allowing any registered doctor to set up in practice as a GP without specialist training, wouldn’t solve the shortage, she says. “GPs are skilled in dealing with multiple, complex conditions at one time. That is what you are trained to do. In a hospital, you do a variety of different things and if you suddenly put up your shingle, you may not be expert in 10 of the 20 disciplines we deal with each day. I’m dealing with paediatrics, geriatrics, endocrinology … our training ensures everyone is as skilled as they can be in each of those disciplines. People who are untrained don’t manage their uncertainty particularly well and referrals to hospitals increase.”
It’s important for patients to keep using their GP, despite the shortages. “As soon as one of my patients turns up at an after-hours service, I get money clawed back [from the capitation payment] to pay for them going somewhere else, because the money is tied to the patient, not to the practice. It doesn’t feel fair – it drives us all mad.”
By the time medical students graduate, general practice is one of their top career options, with 25% keen to become family doctors, says Andy Wearn, an associate professor who heads the University of Auckland’s medical programme and is also a GP. Students have an option to do three months’ general practice in their first post-graduate year, and this year, a compulsory three-month community attachment was added in the second post-graduate year.
But students who are keen on general practice when they graduate often change their minds after their first- and second-year hospital runs as house officers, says Phillippa Poole, a professor and head of the University of Auckland’s School of Medicine. It happened to her. She was interested in primary care before being shoulder-tapped as a house surgeon and introduced to specialist physician training. “Someone said, ‘Come and try it’, and I liked the work, the people, the patients and the challenge. So you need to reach down from senior staff to be role models [in general practice].
“We can do all we can at medical school to educate and orientate towards general practice, but then, at the end, they’ve got to apply for a job at a district health board as a house officer doing medicine and surgery in a hospital. You get into the four walls of the hospital and it’s hard to imagine getting out.”
She says although each group involved in workforce training has its own areas of interest, they have to work together. “Everyone needs to be interested in general practice, because it’s healthcare for the whole of New Zealand. Everyone has to paddle their waka in the right direction.”
General practice – by the numbers
- 43% of GPs are 55 or over and 47% intend to retire in the next 10 years.
- 55% are women, increasing to 65% among those 55-plus.
- Only 4% of GPs identify as Māori, increasing to 8.5% among those under 40. Pacific people make up only 2% of GPs. The percentage identifying as Asian is 18%.
- 39% of GPs were trained overseas, rising to 46% among rural doctors.
- 75% of GPs work in urban settings.
- GPs work 34.8 hours a week on average (men 38.9, women 31.6).
- 26% of GPs rated themselves high on the burnout scale, a figure that has steadily increased. Doctors reporting burnout were significantly more likely to be aged between 50 and 64.
- 31% of GPs reported their practice had a vacancy for at least one doctor, up from 26% the year before. In rural practices, 39% had a vacancy.
- 11% of GPs said their practice wasn’t accepting new enrolments.
- The average GP income was $156,000; the median was between $100,000 and $125,000.
Dr Lance O’Sullivan is pursuing a healthcare system that’s good to go.
O’Sullivan says it would break down the access barriers of cost and time and the clinics would be largely staffed not by GPs, but nurses and healthcare assistants providing “96% of the care” a GP offers.
Although some health experts have praised the plan, others have cautioned it will be financially and logistically challenging. O’Sullivan says he’s bought the first clinic, in Rotorua, which he hopes to open in September, followed by a second in Kaitaia in November.
This article was first published in the August 10, 2019 issue of the New Zealand Listener.