The issue getting a GP appointment is mounting with one in 16 Kiwis not even enrolled in a practice. RACHEL THOMAS, NIKKI MACDONALD and SOPHIE HARRIS have a look at the state of primary care as a part of Life Support, a week-long Stuff investigation into Recent Zealand’s health system because it grapples with unprecedented patient demand and the biggest structural upheaval in a long time.
Wendy might need two months to live, two years, or possibly the tumour in her stomach just isn’t killing her in any respect.
The Kāpiti Coast woman, in her early 70s, and her husband, Doug, don’t know because Wendy hasn’t been given an oncology appointment yet. The couple’s names have been modified as a consequence of the sensitive nature of their story.
They don’t have an appointment with an oncologist because she wasn’t referred for further tests till May this 12 months, despite complaining to her GP about stomach pain for greater than two years, Doug explains.
Until then, her pain and discomfort was put right down to irritable bowel syndrome (IBS). It wasn’t until a second GP assessed Wendy’s severe back and stomach pain, difficulty respiration and feeling full after a couple of mouthfuls, that she was sent for blood tests for potential kidney stones.
There have been no kidney stones, but a CT scan showed a suspicious tumour within the stomach.
The Kāpiti coast couple were told in May that Wendy (not her real name) has a suspicious stomach tumour. They are saying she was complaining of stomach pain to her GP for 2 years, but imagine their doctor was so rushed they couldn’t thoroughly check her symptoms.
The couple hold no animosity towards their GP, saying they understand the pressure on the system and the constraints of 15-minute appointments.
“They don’t appear to have the time to spend with you. I’m pretty convinced doctors are reasonably caring and need to do their best, but they’re under a lot pressure that you just’re on a conveyor belt,” Doug says.
Seven of the eight GP clinics of their area have closed books. Doug says it’s normal for them to face waits of at the very least six weeks to see their doctor, so that they book appointments three months prematurely to remain on top of prescriptions.
Wendy is certainly one of the 4.8 million Recent Zealanders – or 94% – who’re enrolled with a GP. Some 6% of Kiwis, including 17% of all Māori, usually are not enrolled in any respect. In some parts of Recent Zealand, overwhelmed GPs have closed their books to latest patients, meaning newcomers to the community are unable to enrol anywhere.
There are too few GPs coming in to exchange those leaving, explains Dr Bryan Betty, medical director of the College of GPs. This forces practices to shut their books to latest patients. “So when that happens, patients cannot get access … to basic medical care [and] they have an inclination to find yourself in ED.
“It is basically, really problematic once we see that beginning to occur … it is occurring throughout Recent Zealand now.”
Dr Bryan Betty, medical director of the Royal Recent Zealand College of GPs, says more GPs are urgently needed on the bottom to bulk up the workforce.
How did we get here?
While the dual outbreaks of Covid and flu have pushed some GPs to breaking point, pressure on family doctors has been ratcheting up for years.
In August 2020, almost a 3rd (31%) of GPs rated their burnout level as “high” in a workforce survey. This was up from 22% in 2016. Essentially the most common drivers were increased patient needs and complexity, funding issues and admin.
In the identical 12 months, 31% of GPs planned to retire inside five years, and almost half (49%) planned to retire inside 10 years. At that rate, by 2031, Recent Zealand can be in need of 300 GPs.
The flexibility of patients to urgently see a GP has also been getting consistently worse.
In 2011/12, 15.5% of Kiwis told the NZ Health Survey that that they had been unable to get an appointment inside 24 hours at their usual medical centre. By 2019/20, that had jumped to 22%.
Today, a whole lot of GP clinics in Recent Zealand have their books closed, though the situation varies widely between regions.
When there are too few GPs and practices close their books, patients who can’t access a GP are inclined to find yourself in ED, Bryan Betty says.
Within the Wellington region, 44% of clinics represented by Tū Ora Compass Health – the region’s essential primary health care organisation – usually are not taking latest patients.
In Palmerston North, 87% of Think Hauora’s clinics usually are not taking latest patients, while in Auckland 22% of ProCare’s general practices are closed.
Some parts of the country are facing one GP to 3000 patients, says Betty.
“We all know we want more trained GPs, we want more trained nurses who’re trained in allied health. If we do not do that, this problem we’re seeing this winter goes to be repetitive and keep going”
By the numbers
The basis of the issue goes back a long time.
In 1980, almost 4 out of 10 (about 38%) Kiwi doctors were generalists – family doctors who could do a little bit of all the pieces. But over time, doctors became more specialised, concentrating on narrow fields of experience. Although general practice is a specialist branch of drugs, with its own college and fellows, it often comes with lower status, and lower pay.
By 2021, only one in 4 (25%) doctors registered in Recent Zealand were GPs.
While general practice is a specialist branch of drugs, it often comes with lower status, and lower pay.
The feminisation of the workforce also has an impact.
In line with the aptly-named “Medical Manpower” report, women made up just 12.6% of all GPs in 1980. Today they represent greater than half (about 58%).
While having more female family doctors brings many advantages, women usually tend to work part-time (though that gap is narrowing).
So if trainee numbers are fixed, an increasing proportion of ladies can lead to fewer available patient hours. 2020 was the primary 12 months that the variety of GPs working part-time outnumbered full-timers.
The Royal Recent Zealand College of GPs says annual trainee numbers need to extend from about 200 to 300 to curb workforce shortages.
The variety of GPs per 100,000 people sat at 74 in 2021. It’s projected to fall to 70 by 2031.
The College of GPs has about 5600 members, but that features rural hospital doctors, registrars, non-practising members and part-timers.
The College argues annual trainee numbers need to extend from about 200 to 300.
The doctor getting medical insurance
Dr Dermot Coffey, GP, says he’s taking out private medical insurance for the primary time in Recent Zealand.
One GP says the situation is so bad that for the primary time, his family is taking out medical insurance in Recent Zealand.
“’I’ve been in Recent Zealand 20 years,” Dr Dermot Coffey says. “I’ve never once over that 20 years felt the necessity to get private medical insurance. We’re getting it now.
“That is thru absolutely no fault of individuals working in the general public system currently, but I just wouldn’t have faith that the urgency of the care that is required is there.”
Coffey, who works in a university clinic in Christchurch, trained and commenced his profession as a physician in Ireland – where access to care can depend upon whether you’ll be able to afford to pay for it.
Artur Widak/NurPhoto/Getty Images
There may be a “brutal” divide between private and public health care in Ireland, says an expat GP now working in Christchurch.
He fears if things keep going the best way they’re in Recent Zealand, our system could begin to mirror that of Ireland, where “there’s a brutal division between private and non-private care”.
“There are chronic access problems to publicly-funded care, and also you get this hugely inequitable division between what care people get.
“It’s all the time the people who find themselves unlucky, who’re already marginalised and have already got disadvantages, that suffer essentially the most. And bringing that model to Recent Zealand – and it’s going that way – in a rustic where the inequities are divided upon ethnic lines, could be an enormous worry.”
He has massive concerns for the wellbeing of fellow GPs.
Coffey himself says he takes antidepressants every day and it’s not unusual amongst his peers. His children can study whatever they like, so long as it’s not medicine, he says.
“It’s just not lifestyle.”
Doctors are constrained by 15-minute appointment times – a model which is under review.
The doctor will see you (for quarter-hour)
Fifteen-minute GP appointments have been the norm for 30 years.
In brief, general practices get a certain chunk of public money for one and all enrolled – that is generally known as capitation funding and dictates the length of appointments.
But, GPs argue, the needs of Recent Zealanders and general practices have shifted dramatically; people don’t go to the doctor with one easy problem now.
As Dr Samantha Murton of the College of GPs writes: quarter-hour isn’t enough time to fastidiously hearken to a mentally distressed teenager and their parents unwind their concerns after which put together a sturdy, supported treatment plan that’s effective and can make a difference.
Royal Recent Zealand College of GPs president Samantha Murton says the 15-minute appointment model simply doesn’t provide enough time for GPs to do their job.
Fifteen minutes isn’t enough for a whānau to fulfill with their GP when a baby is due his immunisations, and the nurse has realised their mother is struggling and desires care too, Murton says.
And as Wendy and Doug have found, it’s not enough time to detect a stomach tumour.
Health Minister Andrew Little accepts the present funding model is not any longer fit for purpose and fails to support those most in need, particularly Māori, Pasifka and other people in high deprivation areas.
A review of this funding model is under way, with NZ Doctor magazine reporting the draft is predicted to be finalised by the tip of August.
Minister of Health Andrew Little accepts the 15-minute funding model is not any longer fit for purpose. He’s seen talking to Stuff health reporter Rachel Thomas. Draft results of a review of the model are expected to be finalised in a month’s time.
Wendy’s case has been classed as semi-urgent. “The hospital has advised they aimed to see her inside six weeks but as a consequence of pressure on the system it may be several weeks beyond that,” Doug says.
Cancer is in Wendy’s family and her grandmother had stomach cancer.
“It’s all the time behind your mind. It’s all the time there. It’s all the time a worry,” Doug says. He’s doing the talking for Wendy as she is audibly breathless.
“The essential fear is that we’ll get the scope done and the results of that just isn’t good. It may be too late to have successful treatment.”
Within the meantime, the couple are getting their affairs so as.