As ageing or stressed general practitioners depart medicine in record numbers, we are not replacing them fast enough to keep up with patient demand. So what happens now? By Donna Chisholm.
Triaging used to be a term we associated with hospitals. On television, it's the stuff of high drama – think the flatlining "code red" patient surrounded by desperate scrubs-clad doctors and nurses sprinting alongside as the gurney thumps through the swing doors of the emergency department past a waiting room of the walking wounded and worried well.
Now, as New Zealand faces an escalating shortage of doctors in primary care, it's a term with which general practitioners are increasingly familiar as they struggle to cope with the demand for their care. It's turning the traditional GP booking model – first in, first served – on its head, as overworked doctors try to ensure those who need them most are seen first, while others are forced to either wait longer for appointments or consult another health worker such as a nurse.
For GPs, 2020 was not only the year of Covid, but also the year of burnout. When the Royal New Zealand College of General Practitioners (RNZCGP) put its thermometer under the tongue of more than 3000 GPs last August and September in its biennial workforce survey, it discovered a widespread fever.
The alarming symptoms of the malaise included these statistics:
• Nearly a third of GPs (31 per cent) rated themselves as "high" on the burnout scale – up from 26 per cent in 2018.
• Those reporting high burnout were more likely to be aged between 40 and 64, a practice owner or partner and working full-time.
• 2020 was the first time the number of part-time GPs exceeded full-timers.
• Almost a third of those questioned intend to retire within five years; almost half intend to do so within 10.
The sickness is compounded by a generational change, which 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. Women, who make up an increasing percentage of the workforce (now more than 58 per cent), are also working shorter hours than their older male colleagues.
The report recommended urgent action to address what it called an impending crisis in the GP workforce. It suggested pro-active recruitment and incentives for medical graduates to enter GP training, better childcare support and flexible working hours for GPs with young families, and more resources to recognise burnout and minimise workplace stress.
Since 2001, the average GP has given up one working day a week. In the same period, New Zealand has had a 70 per cent 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. This country has about 5500 GPs, but 900 GP jobs are currently being advertised. In 2001, we had 85 FTE GPs per 100,000 people. We now have a national average of 73, compared with Australia's 110. In the same period, on-call and after-hours work has dropped from an average 10 hours a week to four. Says one workforce expert: "We now have a whole generation choosing general practice on the basis that a full-time week is three and a half days."
Happy or not?
In the waiting room of Health Te Aroha, just off the rural town's main drag at the base of its famous mountain, a push-button feedback machine is a metaphor for the changing power base in primary care. Where once patients might have suffered silently through lengthy waits alongside the children's toy box and water cooler before a rushed 15-minute appointment, now they can tell their doctors, anonymously, what they really think by pushing the sad- or smiley-face button on the "Happy or Not" machine on their way out.
The instant feedback is one of the ways this general practice and others are moving to meet patient needs. Te Aroha was one of the first general practices to adopt a new model of patient care, Health Care Home, designed to make better use of GP time, giving patients alternatives to face-to-face consultations yet better access to their doctors and health records, and ensuring 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 by a nurse. This triaging is being credited for doctors now being able to reschedule 20-30 per cent of same-day bookings.
Before this, says practice partner Dr Hayley Scott, GPs were routinely seeing patients who didn't need to be seen the same day, but were taking up the time that could have been given to much sicker people.
Te Aroha also had big problems attracting GPs, the local doctors were "120 per cent 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.
She says the system "put us in an amazing position" when Covid struck last year. "Pretty much overnight, the Government said, 'You're going to virtual consults.' That, for us, was easy, because we were all used to talking to patients on the phone and using the internet. Some practices were like, 'Oh my God, this is so different for us, how are we going to manage?' It made life so much easier to already be in that space."
For patients such as Eileen Joyce, 71, 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 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 being 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."
Apart from fundamental changes to the way general practices are run, and an increase 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 health-improvement practitioners (HIPs). "Just seeing a GP is so yesterday," says former Pinnacle Midlands Health Network chief executive John Macaskill-Smith, who introduced the American-pioneered Health Care Home (HCH) model in 2011. It has since been adopted not only in Te Aroha but in another 195 practices covering more than 1.2 million patients nationwide.
The model has been introduced by the Pinnacle network of more than 85 general practices covering about 115,000 patients in Gisborne, Taranaki, Rotorua, Taupō-Tūrangi, Thames-Coromandel and Waikato.
A 2017 evaluation by professional services company EY credited the new model with a 14 per cent decrease in hospital emergency visits (down 24 per cent for Māori and 32 per cent for over-65s), fewer referrals to specialist care and 20 per cent fewer preventable hospital admissions.
Current Pinnacle Midlands Health Network chief executive Helen Parker is frustrated that some district health boards (DHBs), through which primary-care funds are channelled, can't see the sort of benefits the EY report highlights and believes DHBs generally don't understand primary care. Parker says the planners commissioning health services tend not to come from a primary- and community-care background. It has helped make DHB support for and buy-in to the HCH model patchy.
She says Covid has accelerated the move towards triaging and the HCH model, but emphasises it hasn't come at the cost of one-on-one care. "Some patients are opting for online care, but not as many as would be expected." She says every patient who needs to be seen the same day is being seen.
However, there has been a "tangible shift in workload" from hospitals to GPs, she says. "More and more GPs across the country report they're being asked by hospital medical teams to follow up results or order scans. The threshold for getting to see a specialist is higher, so GPs are having to manage more in the community." About 30 per cent of the Midlands practices have a vacancy for a GP and she says burnout levels are high, with Covid fatigue a contributor. "A lot of it is additional demand without any additional workforce."
A national issue
In Counties Manukau, the country's biggest primary-health organisation, ProCare, has 771 GPs covering nearly 800,000 patients in 169 practices using the HCH model. Clinical director Dr Allan Moffitt says patients have readily adapted to the changes.
Phone triaging has allowed about 20 per cent of patients to be seen not by a GP but "more appropriately" by a nurse, taking pressure off accident and medical clinics and hospital emergency departments.
But, he says, the GP shortage is "starting to bite" – one sign being the number of practices forced to close their books to new patients. He says 10 per cent of ProCare's practices closed their books in June, although they reopen as staffing allows. ProCare currently has vacancies for about 45 GPs and 30 nurses.
"This is a national issue. There are some towns where people just can't register with local practices. It's really problematic. In Auckland, they have to turn up and wait at accident and medical clinics, but in other places, people have to go out of town to somewhere else."
Moffitt says the incidence of burnout since the workforce survey has worsened and is a huge concern. "Practitioners are at the end of their tether. And we're also seeing it with patients. People were really quite forgiving around Covid, but they're over it now; they're like, 'No, I don't want to answer these triage questions, I just want to see my GP.' People's tempers are fraying somewhat and we are seeing behaviour that reflects that on occasion."
But he says, since Covid, patients are also tending to stay away from GP practices when they can. "They like virtual healthcare, but that means they don't get stuff done, such as blood-pressure checks or face-to-face examinations when those can be important. We're seeing a reduction in some of the cardiovascular-risk screening and people being offered smoking cessation advice and we've seen quite a dramatic drop in immunisation in children. That seems to be a nationwide phenomenon."
He believes the drop in immunisations for children might be a spin-off from people having concerns about Covid vaccines and the misinformation that has accompanied them. "It's rubbing on to vaccinations in general, even though they've been around for decades and are entirely safe."
Fit for purpose
In a 2018 discussion paper, representative body General Practice New Zealand (GPNZ) concluded increasing use of nurses and other health professionals, including mental-health workers and pharmacists, 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 chair Jeff Lowe, a Wellington GP. "We are trying to describe a workforce that will be fit for purpose for the challenges ahead."
He says Covid showed that when the reason for change is compelling enough, family doctors can innovate and adapt quickly. "Covid made us move to virtual consultations by phone and video over the course of one weekend. It gave us a glimpse of the future and should become the new normal."
He says the traditional model in which patients call up to book consultations is unsustainable and causing burnout. "There's a finite number of 15-minute appointments. We need to make sure we use them for people who really need them."
Patients are demanding access to their information online and often choosing a practice based on that, Lowe says. His practice, which has more than 15,000 patients, gets more than 105,000 hits a year – up 30,000 on pre-Covid levels – through its portal. In the year to July, doctors sent more than 24,000 emails to patients and received a similar number.
Lowe says Sir David Haslam, former chair of the UK's National Institute for Health and Care Excellence, estimated that 75% of patients seen in general practice didn't need to be seen face to face at all. "What we need to know at the beginning of the day is which 75 per cent," says Lowe.
Understaffed and under-resourced primary care causes not only substandard care for patients but wider financial problems, says RNZCGP president Samantha Murton, a Wellington GP. "As soon as primary care is overburdened, the hospital system has to pick up acute care. That's costly, with patients having investigations they don't need."
GP shortages mean some patients have to wait weeks for an appointment, seeing someone unfamiliar with their history, disrupting continuity of care.
This year, 214 doctors enrolled in the GP training programme, but about 300 are needed.
A bums-on-seats approach, allowing any registered doctor to set up in practice as a GP without specialist training, wouldn't solve the workforce 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 hang out your shingle, you may not be expert in 10 of the 20 disciplines we deal with every day. People who are untrained don't manage their uncertainty particularly well and referrals to hospitals increase."
Plans to ramp up trainee numbers, with a particular emphasis on rural practice, were set back in 2018 when the Government abandoned plans for a third medical school. Former Prime Minister Bill English had announced in 2017 that the school would be established by 2020 to address the country's GP shortage.
University of Waikato professor of population health Ross Lawrenson, a former Wairoa GP, told the Listener that his university, which was earmarked to host the new medical school, hasn't given up on the idea. "The New Zealand population is increasing and ageing, meaning that there is an increasing demand for doctors." Numbers have increased by 400 a year for the past six years, but that isn't keeping pace with demand.
"We only graduate 530 doctors each year and we lose 100 of these overseas. Given that 400 to 500 doctors a year retire, we are not keeping up with demand and we are still relying on importing a significant proportion of our medical workforce for the foreseeable future."
With fewer than 2 per cent of medical students wanting to live and work in small towns, and more than half of GP trainees based in Auckland, something needs to change, he says. But rural practices are often staffed by short-term locums who can't supervise trainees. About 40% of doctors on the GP training scheme are international graduates who are more likely to practise in smaller urban, rural and less-affluent areas where there could be a cultural disconnect between the doctors and the communities they serve, says Lawrenson.
Trust makes it easier
More than half of the country's rural doctors are international graduates. "We are doing a lot of work with Māori communities who say they want a doctor who understands their culture."
Māori GP Martin Mikaere, who works in Thames with rural iwi-based provider Te Korowai Hauora o Hauraki, agrees. Mikaere, a GP for five years, spent six years in emergency nursing in the United States before training as a doctor. He says the Hauraki clinics (in Thames, Te Aroha, Paeroa, Whitianga and Coromandel) have a constant rollover of locums in the rural areas, which can make it hard for patients to achieve continuity. Hiring outside the country has its challenges in trying to teach locums about working with Māori whānau and ensuring there are no barriers to healthcare. "If you can't develop a good rapport with the person sitting in front of you, you're likely to get 30-40 per cent less information, which leads to worse outcomes for our people."
Mikaere runs two-hour walk-in clinics in the mornings and afternoons during which patients are seen first by a nurse, then, if necessary, by him. "They're my people and I can relate to them," says Mikaere, who is from Coromandel and intends to stay in the region. "Trust makes it easier for me to do the job."
He describes general practice as the poor cousin of hospital medicine "who everyone looks down on and abuses a little bit. What they don't understand is general practice isn't filled with snotty noses and mundane things. On any day, I'll see patients with shortness of breath from heart attacks, asthma or pneumonia. Every week, we make one or two cancer diagnoses and have to work out how to convey this to the whānau. We deal with severe mental health and both young and old people. We are the speciality that goes from birth to the end of life."
Although general practice remains a popular option for medical students, interest levels are still not high enough, says Professor Phillippa Poole, head of the School of Medicine at the University of Auckland.
At graduation, about 20 per cent are keen to become family doctors and she says students keen on other specialities often change their minds. By their third postgraduate year, the proportion interested in general practice is more than 30 per cent, as young doctors are attracted by more predictable work patterns and the nature and location of the work.
Graduates now have an option to do three months of community practice in their first or second postgraduate year and this may be helping, she says. There is also increasing interest in rural work. She wants everyone involved in the development of the medical workforce to help safeguard the future of general practice. "Everyone needs to be interested in the pipeline to general practice, because it's healthcare for the whole of New Zealand. Everyone has to paddle their waka in that direction."
The Royal New Zealand College of General Practitioners reveals that 31 per cent of GPs intend to retire in the next five years. Joanne Black's doctor is one of them.
A couple of weeks ago, I got some bad news from my GP of 25 years, Dr Tony Crutchley. Thankfully, it wasn't test results, although it hit me hard just the same. He told me that he will retire in October.
For me, having a GP, lawyer, dentist and hairdresser that I like and trust is a sign that I am established somewhere. When we lived in the United States for three years, I never had a regular GP although, with my expensive health insurance, I could probably have had my own endocrinologist, gastroenterologist and cardiothoracic surgeon had I wanted them. Instead, other than a couple of visits to the local drop-in medical centre – the first after I did some gardening and discovered that poison ivy is not, after all, just a cartoon character – I saved up my problems until I made visits home and could see Tony.
My US medical insurance was wasted on me, but having once accidentally driven round a corner on the wrong side of the road, I retained it while we were there, just in case.
Tony was recommended to me when I moved to Wellington from Sydney in 1996 with a 10-month-old son and a husband who turned out to be a sprinter rather than a stayer. This husband announced two years later, on our daughter's first birthday, that he was in love, but not with me. I recall telling Tony in passing that this had happened, and he was genuinely surprised. Perhaps more than me, in fact.
Soon after my marriage ended, my father was diagnosed with cancer so advanced it was already terminal. For those final months, he and my mother sometimes came to stay with me and the kids in central Wellington. I asked Tony if he would take on my father as an inevitably short-term patient and, most importantly, prescribe Dad's morphine until he moved to Mary Potter Hospice. "I would be honoured to do that for him," he replied.
Tony cared for my children through their mishaps and illnesses and was soon looking after my new husband and a brand-new baby girl. I took her to see him soon after she was born, having had a difficult delivery that required barbecue tongs and a super-strength vacuum cleaner to extract her. I was worried about her crossed toes. "Never mind her toes," Tony exclaimed. "Look at her head! It is very compressed! He sent me off to get her skull x-rayed. It wasn't fractured, thank goodness, but with Tony as your GP, everything got checked.
My son, Seb, had an awful mountain bike accident, aged 11, which I wrote about here in the Listener. He was flown from Masterton Hospital to Wellington Hospital and was in a coma for a while. I stepped outside his room into the corridor one day and, leaning my face against the wall, looked up to see Tony coming down the corridor. As well as giving me good advice, and as much comfort as he could, he handed me a few sleeping tablets.
"You will need sleep to get through this," he said. "These are the lowest dose available and light enough that you'll wake up if the hospital rings you at night." As it turned out, I did get rung at night, but by my husband who had taken on the night-shift duty. "I have someone to talk to you," he said, and my son came on the line. "Hello, Mum," he said. Best. Words. Ever.
But it was in looking after my mother, Jocelyn, that Tony displayed his most diligent care and infinite patience. Mum did not go gentle into that good night. She lived with us for about a dozen years in a cottage in our back yard and, gradually, Graves' eye disease and depression took the joy from her. She had a few regular sayings for whoever was the first to visit her after work or school. "I'd get you to call me an ambulance but I wouldn't make it to the hospital," she'd say. Or, "I didn't know it was possible to feel this bad and still be alive." She had an adverse reaction to almost every tablet, apart from Panadol and Werther's Originals. The short-term remedies for her malaise, aside from the 800 audiobooks that my husband selected and downloaded for her over the years – "no one dying of cancer, no cruelty to animals, no war stories from the Eastern Front", she stipulated – were talking about the old days, drinking trim lattes from the Wholly Bagels cafe near our house, and visits from Tony. One was on Christmas Eve and he stayed for two hours. He talked to her, listened and suggested different drugs that he knew from experience she would cut into quarters, or take once every two days, preferring her own dosages. After he left, Mum told us he'd given her some bad news. "He says my heart is strong and I'll live for a few more years yet."
The downside of Tony's attentive care was that he was a shocking timekeeper. I know of some patients who left his practice because of it and I suspect that at times it was hard for the other doctors and staff. But as his patient, you knew that he ran late because he took the time to do more than you'd come for – ask after the family, throw a few probing questions or, if he didn't see you often, take the opportunity to do another screening test ("While you're here, we may as well …"). Part of this was a genuine interest in people and part was a doctor's sixth sense for what might be going on. He gave so much to his patients, I sometimes wondered what was left for his family. The Royal New Zealand College of General Practitioners' study says that burnout levels among GPs were at 31 per cent last year, up from 22 per cent in 2016. The median age of a GP is 52. They are retiring or quitting more quickly than they can be replaced.
While I was visiting Auckland for work recently, by chance two of my colleagues mentioned that their children had been sick the previous weekend. One had been unable to find a doctor to see his three-month-old son, but a doctor in the family had stepped in. Another colleague, unable to find a doctor to see his daughter, aged three, had given up after seeing the four-hour wait at a hospital emergency clinic. He tried the online site tend.co.nz and in short order had a consultation with a nurse, then a doctor, then a prescription sent through to a pharmacy. I guess that's the way the world is moving, and it probably solves many equity and access issues.
Still, the steady care of a GP with a vocational calling, who knows generations of your family and who has genuinely seen both the cradle and the grave, feels to me irreplaceable. I'm sorry to be losing it and sorry that others may never experience it. I also know that I am fortunate to have had it at all.