Covid made “virtual” doctor appointments a necessity during the pandemic but now, telehealth is being hailed as a gamechanger for Māori healthcare and a crucial safety net for critically understaffed general practices.
In January 2023, Healthline, the 0800 number providing 24/7 health advice, launched a new offering for its users. At the push of a button, callers could choose to be put through to a Māori nurse or paramedic. Not only did they have access to a clinician of their own ethnicity, but the wait time was shorter, too. The Māori pathway is also offered through the stop-smoking Quitline.
A small and subtle step, perhaps, but for a healthcare system that has overseen historically poorer access and outcomes for Māori patients, it is a sign of a vital change in attitude.
When Covid forced the first nationwide lockdowns in March 2020, Whakarongorau Aotearoa/New Zealand Telehealth Services, which runs Healthline and other 0800 health services, had to rapidly crank up staff numbers from 450 to about 3500, before falling to 525 by late last year. It was launched in 2015 to combine and deliver telehealth services with the aim of saving the government $100 million over a 10-year contract. It has already achieved that target.
Healthline calls are free for patients, but the service costs about $24m annually – a significant chunk of Whakarongorau’s total budget of $70m.
But today, virtual care is increasingly regarded as much more than a port in the pandemic storm as New Zealand faces a critical GP shortage, particularly in rural areas. Dr Samantha Murton, president and chair of the Royal New Zealand College of General Practitioners, says the country needs another 1000 GPs – about 1000 practices are currently advertising for a doctor.
New Zealand has only about 74 doctors per 100,000 people; other comparable countries such as Australia and Canada have more than 100, she says. “If we got it up to 80 it’d be great but we’re not even close to that. In some regions it’s terrible – about 56.”
For Whakarongorau chief executive Glynis Sandland (Ngāpuhi, Ngāti Hine) and chief clinical officer Dr Ruth Large, an emergency physician, telehealth isn’t the ambulance at the bottom of the cliff but the trampoline “bouncing” patients to where they need to go.
“A safety net is quite static, you just fall into it,” says Large. “But with a trampoline it’s almost like a catch and release – you can fall and then bounce to the continuity of care you need.”
In effect, they say, the service is a “virtual emergency department” that is helping reduce pressure on hospital EDs and community accident and emergency clinics.
“We have people who have been registered for a callback online, and they’ve gone to an emergency department and we have been able to sort their problem out for them while they’re waiting in the ED,” says Large. “People are learning to cover their bases while they wait.”
More than 60% of general practices are now signed up with Whakarongorau to provide after-hours phone care for patients who cannot be seen in person. In the year to June, the service answered more than 112,000 calls from practice patients – up by about 10,000 on the year before. In the past year, that has been extended to offering virtual consultations during office hours.
“The sheer volume of work that GPs are getting through now does mean they need to guard their in-person time a little more, or prioritise it,” says Large. “If you’re a doctor short or someone is sick, the nurse can book them into a phone or video doctor.
“We do hear about general practice not coping. We are not a general practice but where we can make a difference is in supporting practices to offload some of their acute volume so they can concentrate on that continuity-of-care space.”
Gamechangers
She and Sandland are hailing telehealth’s potential for Māori patients because it’s removing historical barriers to care – lack of transport (in urban and rural areas), lack of money (the cost of GP consultations is prohibitive for many) and lack of time (the inability to leave work or childcare duties to visit a doctor).
“A lot of it comes down to just feeling heard,” says Sandland. Indeed, the motto painted on the reception desk at Whakarongorau’s central Auckland headquarters says as much: “A brave voice deserves a sympathetic ear.”
Although telehealth consultations overall have declined since the Covid peaks of 2020-2022 (Healthline answered 477,000 calls from 367,000 people in 2021/22 and 432,800 from 322,000 people in 2022/23), the numbers choosing a Māori clinician are increasing – up from 230 in February 2023 to nearly 450 in November.
Since March, Healthline has allowed callers to upload videos to show to the clinicians, and Māori are embracing that offering, too. Nearly a quarter of video uploads are by Māori, who make up 20% of Healthline users, whereas the 60% of Healthline callers who are Pākehā are responsible for just half the videos uploaded.
Triage nurse “Helen” (Ngāti Whātua o Kaipara), who asked that her name be withheld, has answered Healthline calls for two years. One of three Māori nurses or paramedics available from 8am-8pm, she says the role involves treating the whole whānau rather than a nuclear family unit – and hearing about some of the discrimination they’ve experienced in the system.
“I get frustrated after some of the calls. What hurts me the most is the way some of our people are being spoken to by health professionals. Just really dismissive and derogatory. It’s mostly based in racism.”
Some patients also felt their GPs were judging them on their lifestyle. They would go to the doctor for a blood pressure check or for advice on a sore leg and the conversation would immediately turn to their weight and diet.
Helen says she does address those issues, but in a different way. When discussing exercise, for example, “I’ll say, ‘What do you like to do? Do you like swimming in the ocean?’”
Another woman phoned to say her doctor wanted to prescribe the blood thinner warfarin but told her too much vitamin K – found in green leafy vegetables such as pūhā – could make the treatment less effective and she should limit her intake to just a tablespoon a day.
“She loved her pork and pūhā boil-up, so that wasn’t going to happen. I said to her, ‘You’re going to be on warfarin for the rest of your life. We need the medication to work for you, not you to work for the medication. We don’t need you to change your diet, we need to alter the levels of medication to meet your diet.’”
The GP’s advice meant the patient was either going to be non-compliant with the regime “or risk bleeding to death because she’s on 3mg of warfarin and eats a whole pot of pūhā”, says Helen.
Cost is a key barrier to care. “A lot of people call the 0800 number to be transferred to their GP because they don’t have credit to call the practice.”
Other issues were the typical time limit of 15 minutes on consultations when there were sometimes multiple problems to talk about.
The video upload service has been a boon for the clinicians, she says, enabling them to see a patient’s breathing and colour, as well as examining sore throats, rashes and wounds. Without it, she says, “you are basically nursing with your eyes closed”.
She says telehealth is frequently an advocacy service for patients who have tried but failed to navigate “the system”. With the patient’s consent, she often contacts GPs herself to discuss an individual patient’s needs.
Closed books
Patients who call Healthline have often been unable to enrol with a GP because practice books are closed. “I’ve been with Whakarongorau for two years and in the whole of that time there have been no services available for new patients in Taranaki, for example,” says Helen.
An unexpected bonus of working on the Māori pathway line has been the ability to use te reo during consultations. “I’m not fluent but I can understand more than I can speak. I’m picking up a lot because there are a lot of fluent te reo speakers in our country, which is beautiful because there never used to be.”
Whakarongorau has discussed offering traditional rongoā medicine, including herbal remedies, through the Māori pathway but that’s unlikely to happen because of a shortage of available qualified practitioners and the fact that much of it, such as massage, is “hands on”.
The vast majority of Healthline calls are handled by the triaging nurses and paramedics, but about 2% of calls through the Māori pathway and 0.5% of the others are referred to the clinical response team of 20-30 doctors who provide direct care to callers and also support paramedics in ambulances and GP clinics with peer-to-peer advice.
The greater number on the Māori pathway needing a doctor’s intervention suggests patients’ problems are more advanced or serious by the time the first call is made.
Although all of the doctors in the clinical response team are New Zealand-registered and some are working in practices locally, some prefer the flexibility of working from home, while others are travelling or working overseas.
Murton says telehealth is an extremely valuable service in a GP-starved health system but it does have fishhooks. The most important is that there’s no way of knowing if patients take the advice they’re given, for example, if they’re told to see a doctor in person for the condition they’ve described.
“What’s good about it is that it’s easily accessible. The problem is they don’t know the patient. They’re using a formula, an algorithm, and they don’t have the opportunity to examine somebody. And even when they make a recommendation, that may not be what happens.”
Murton says because of the caution of the algorithms used, patients may be getting services they don’t need.
Continuity of care is vital. “Going to a doctor who knows you is important and saves money. If these services are being used all the time by people as an alternative, that’s not actually safe.”
Missed diagnoses are uncommon, but critical, she says. A University of Oxford study published in the BMJ Quality & Safety journal last year, which analysed remote consultations in Britain’s National Health Service between 2020 and 2023, concluded that they risked harming patients and that “deaths and serious harms” had occurred because of wrong or missed diagnoses and delayed referrals. It said some deaths had occurred after distracted GP receptionists had failed to call patients back.
It recommended that doctors should not use phone consultations for elderly and deaf people as well as “technophobes”. Errors made over the phone included an underestimation of the severity of a range of conditions, including sepsis, cancer, congenital heart disease and diabetic complications.
Equity focus
Large says the results were not a surprise to her, given that they came when the United Kingdom was being “hammered” by Covid. She did not believe New Zealand risked the same scenarios because of “a difference in the environment, the way we experience telehealth and the way we screen”.
Large says she has presented at conferences overseas on New Zealand’s telehealth services and many people had commented on the efforts being put into equity here, including that ethnicity was being taken into account.
“You’d be amazed how many people are not even counting what ethnicity patients are. Colleagues in the United States say they put all these services in but they immediately introduce inequity because they are being delivered into a white, middle class-type market and are potentially growing that market.”
She says artificial intelligence is a potential tool of the future to make consultations safer and predicts it will be in use within five years. There are currently training modules in which clinicians could practise consultations with a “conversation generator”.
“AI is very hot at the moment and there are ways we are looking at the potential to use it but we wouldn’t want to be putting it in a national system [yet] because of so many unknowns, like where the data is going to be stored.”