It looked like a wart, so Corie Haddock, who didn’t have a GP, decided on DIY healthcare using something from the pharmacy. The “wart” on his right palm (nickname Warren) continued to grow. Haddock took himself to his general practice, Moa Medical, in Inglewood, which has no GP. The nurse could see him, took one look and said she couldn’t help. She then took snaps of Warren and sent them off to HQ in Waikato.
A month later he had a remote consultation with a Hamilton-based doctor who gave him four and a half minutes and referred him to New Plymouth Hospital. By this time Warren was oozing a malodorous discharge and needed to be dressed three or four times a day. It was more than a little inconvenient for Haddock (not to mention worrying), whose job for a government agency required meeting and greeting people – and shaking their hands.
Another month passed, and by this time Warren was the size of a 50-cent piece. But finally, in early December, the growth, officially a benign pyogenic granuloma, was cut out.
Haddock lives in Eltham in south Taranaki, one of the worst-affected areas for GP shortages. He moved there two years ago but has stayed with his practice in Inglewood, 32km away, because all other practices he’s called are full and not taking any new patients, and he’s not going to pay “stupid money” to go to urgent care. He’s been at Moa Medical since 2016 and says it often has periods of many months where there’s no GP on the premises.
Moa Medical’s owner, Primary Health Care Ltd, says it is not uncommon for a nurse assessment to be followed by a remote consultation, depending on the clinical condition. “This is a practical approach given the current nationwide GP shortage which has been widely reported on, and it ensures that patients are seen as quickly as possible rather than waiting for a face-to-face appointment.”
South Taranaki has been feeling the pinch for years, but the GP shortage is now creeping into main centres and it can take days, if not weeks, to get an appointment. In fact, skipping a doctor visit because the wait time is too long has skyrocketed in just a year, according to the latest annual health survey.
The Ministry of Health survey shows “Unmet need for GP due to wait time” has nearly doubled, from 11.6% last year to 21.2% in the 2022/23 survey. On top of that, fees at many general practices are on a steep incline.
What’s going on? The term “perfect storm” is a tired old phrase, but it aptly describes the big squeeze that besets GPs and that squeeze has been slamming patients, particularly in rural areas, for years. It’s now stretching into urban areas.
Workforce shortages
First there is the “silver tsunami”: Long predicted, like global warming, it’s here already and about to get a lot worse. A survey last year said 44% of registered GPs plan to retire in five years, and that rises to 64% in 10 years. This bubble of older GPs has a limited pool of young ones to replace them. The survey, commissioned by the Royal New Zealand College of General Practitioners, says 300 doctors need to be trained as GPs every year to fill the gap but it’s averaging 200 or so at present.
With immigration proving no quick-fix solution post-pandemic, everyone, including the Health Minister Shane Reti (also a GP) is getting twitchy about that one.
There are 5700 GPs and rural hospital doctors in NZ and the survey says, if all 425 GPs aged 65 and over chose to retire immediately, there would be 725,000 patients left without a doctor.
High fees
Fees are undoubtedly on a steep curve – $80-$90 and above is not unheard of for the standard 15-minute appointment. Covid added huge pressure to all parts of the health system, but general practice has its own special set of problems that have been on the critical list since before the pandemic. This includes the funding system described as “broken”. In Aotearoa, GP visits are subsidised by the government, but much has changed since this funding formula came in 20 years ago.
Many general practices are starting to struggle financially and having cashflow issues. Some are on Inland Revenue payment plans or have taken on overdrafts. Anecdotally, there’s even talk of some GPs forgoing their own salaries for a few months so staff get paid.
New Plymouth practice manager and chair of the practice managers association (PMAANZ) Mary Morrissey says, “You can’t say ‘woe is me’ - everyone is in the same boat.”
The main form of state funding (known as capitation) is calculated on a per-patient basis and varies widely according to age and gender. For example, for women aged 45 to 64 it’s $173 a year and for men the same age it’s $129 a year. But for the over-65s it’s about $300 a year for women, and $258 for men. And that must also go towards the running of the clinic, reception staff, premises and related business costs.
The issue is, says RNZCGP president Dr Sam Murton, for a growing number of patients, 15 minutes is not nearly enough. Patients are older and sicker than they were 20 years ago, there’s a greater layer of complexity now and the funding rates have not kept up with the cost of delivering healthcare.
Christchurch GP Angus Chambers, who chairs the General Practice Owners Association, has concerns that the funding formula significantly underestimates cost increases and is based on old data that fails to consider things like services being devolved from hospitals to general practice.
A 2022 report on capitation by Sapere said practices need increases of at least 10%, even up to 231% for some, and put the level of loss at around $136 million.
So while the subsidy rates stagnate, practices’ only option is to load the costs onto patients in higher copayments.
Murton puts it like this: “If you are seeing a person every 15 minutes you get the capitation fee and the over-the-counter fee, if you are seeing them for half an hour you have to charge them double for over-the-counter fee (which you may not) and you do not get a double capitation fee.”
Yet the pool of patients who can be tapped for fee increases has also shrunk. The former Labour government’s 2018 initiative removing cost as an obstacle to care means Community Service Card holders – well over $700,000 New Zealanders – pay a fixed rate of no more than $19.50. As all children under-14 get free care now, the “squeezed middle” in this case is everyone else to whom clinics must pass on the cost overflows.
Pay and stress
GPs often feel like hospital doctors’ poor cousins, and that’s reflected in the pay. It takes 10 years to become a GP which is standard for any medical specialist. But GPs who are not practice owners earn $100,000 less than their counterparts with 15 years’ experience in the public hospital system, Murton says. And the gap further widens when you count specialists in private practice.
For full-time GPs, the median income for men is $212,500 yet just $162,500 for women - a massive $50,000 pay gap. Why the discrepancy? Murton says it’s because women GPs tend to take on patients who take up more time (such as patients with mental health issues) and this is reflected in their pay. But senior doctors union (ASMS) executive director Sarah Dalton calls it a straightforward case of sexism at work: “Come on, let’s not pretend! This is how the patriarchy works.”
She says for senior doctors in hospitals – where rates are far more prescribed – the gender pay gap is 9-11%.
Dalton also rejects suggestions that GPs are worse off than doctors in public hospitals, where staff shortages also bite. “It’s swings and roundabouts,” she says. “A range of factors make people’s day-to-day jobs better or worse.
“I have real sympathy for GPs but if we want to be a country that’s genuinely serious about health care, we need to stop and think about how we invest in it,” she says. She’d like to see free GP visits for all.
A large number of GPs are stressed and tired. Last year’s survey showed self-disclosed burnout rates had shot up to just under 50%. In 2016 those reporting high-level burnout was just 22%.
And it’s not just the doctors: Practice nurses are tired, burnt out and leaving. And given there’s a global shortage of nurses, clinic owners also face losing their nurses to hospitals where there’s better pay.
Solutions
Everyone has a fix for this particular problem: $500 million should do it, says Murton. Just under $30 billion is spent on health annually and of that, $1.36b goes towards subsidising GP visits. An extra $500m “would be close to what we need”, says Murton, arguing more money spent on dealing with patients’ problems in GP clinics means far less money spent on hospitals further down the track when patients have become much sicker and need much more expensive hospital-level care.
Chambers believes capitation should rise by 25%: “That would get us back to baseline [when capitation was first introduced in 2003].”
But he’s encouraged by new Minister of Health’s comments on solving funding problems.
Reti told the Listener he acknowledges there are significant issues in general practice and primary care and it’s important these issues are dealt with urgently.
“With widespread support for the Sapere Review within the sector, I will be asking officials to do some exploratory work on developing an implementation plan. This will depend on a range of matters, particularly how quickly systems could accommodate a staged approach to implementation of its recommendations.”
He says practices with patients with the highest needs should be the priority.
Meanwhile, Corie Haddock is just relieved to see the back of Warren - and hopes he won’t have any serious ailments before Moa Medical gets a new GP.