New Zealanders' first point of contact for healthcare - their general practice - is increasingly harder to reach, to the detriment of the overall health system.
Author
Jackie Cumming
Professor of Health Policy and Management, Te Herenga Waka — Victoria University of Wellington
Our new research found 80% of general practices in Aotearoa New Zealand stopped enrolling new patients (known as closing the books) at some point between 2019 and 2022. While the pandemic has exacerbated the issue, it is not the only cause.
The key reasons for not enrolling new patients included workforce shortages, high workloads and staff burnout, funding issues, concerns about quality of care and insufficient physical space.
This can lead to no access, or delayed access, to primary care, worsening health conditions, undiagnosed or untreated diseases, and less or no access to preventive care for many.
In the short term, the government needs to consider increasing investment in primary care and the training of doctors and nurses. But in the longer term, New Zealand needs to consider if the current model of care works, or if there are alternative models that would better suit the healthcare needs of New Zealanders.
An entry point to the healthcare system
There are approximately a thousand general practices in Aotearoa New Zealand. While they are private businesses, they are largely funded by the government.
Being enrolled with a general practice means reduced consultation fees, the centralisation and management of patient data and higher levels of preventive care. Enrolled patients also then have a team who can take responsibility for prescriptions, referrals to specialised care and subsequent followups.
If someone can't enrol in a specific practice, many of these elements of primary care become a lot harder to access.
We interviewed 17 people (including general practitioners (GPs), practice managers, academic researchers, a nurse practitioner and a national general practice leader) and undertook a survey, to which 227 people responded (including practice managers, GPs, practice owners and administrative staff). The responses revealed six key reasons why practices closed their books.
1. Workforce shortages
A shortage of GPs was cited as one of the key reasons for closing the books. As one survey respondent explained:
Recruitment and staff retention, especially GPs and nurses, has been the key issue. Almost no job applicants, and those few that do, have multiple offers to pick between because there are so many vacancies around.
There is a growing number of GPs who are reaching retirement age. And, while 50% of New Zealand's GPs have been trained overseas, COVID restrictions made it more difficult to recruit from other countries.
There is also a significant pay gap between primary doctors and nurses and those in secondary and tertiary care (hospital staff and specialists). As a consequence, fewer medical students are choosing primary care compared with other fields.
2. Under-funding of general practices
There is also insufficient funding for general practices. They are partially funded through a formula based on the number of people enrolled and their needs. But many in primary care feel the model doesn't adequately account for the complexity of conditions many patients have.
As one interviewee told us:
Funding per patient does not reflect the workload that is required. It is problematic especially for high-needs patients.
3. High workloads and staff burnout
Underfunding and staff shortages have caused a higher workload among existing staff, resulting in staff burnout in general practice.
As one survey respondent wrote:
General practices are asked to take on more and more work, including work that was previously performed in hospitals. The paperwork has also increased. So, there is more work but a seriously declining number of healthcare workers (most particularly GPs) to carry out this work.
4. The impact of COVID-19
The pandemic had both direct and indirect impacts on healthcare. The workload of general practices increased with the rising number of sick patients. Along with an increase in patient demand there were added precautions needed to treat COVID-19 patients.
The pandemic also resulted in staff shortages due to staff or family sickness. The border closure enforced during the pandemic worsened New Zealand's existing workforce shortages due to a high reliance on overseas-trained medical professionals.
5. Quality of care concerns
Work shortages and increasing demands meant many of the research participants were concerned about the quality of care they were delivering to their patients. Practices closed their books to ensure they were able to still deliver care to clients - even if this didn't make the best business sense.
From a business point of view, there is a disincentive to close your book. But at some point, patient care has [to] take priority over financial benefit.
6. A lack of space
The final reason given for the rise in closed books was a lack of space in the current practices.
Our research participants noted there may not be a sufficient number of rooms for examination and treatment. In some practices, patient waiting areas were also limited. In some cases, staff were working in shifts to occupy the working spaces available to them.
The road to better primary care
When it came to improving primary care, 95% of our survey respondents said there needed to be better funding, 91% called for support for pay equity between general practice nursing and hospital nursing staff, and 89% called for pay equity for GPs. Some 77% called for an increase in medical students and 85% called for increasing the recruitment of overseas doctors.
As well as an increase in funding, policymakers should be asking if there are other models that could help meet New Zealand's needs. For example, could nurse practitioners work with community organisations to enrol patients so there is, at least, somewhere for them to go?
With ongoing issues around access and affordability, it is time to consider what are the necessary improvements in general practice care in Aotearoa New Zealand.
This research was completed with Nisa Mohan, Maite Irurzun-Lopez, Megan Pledger, Mona Jeffreys, all from Te Hikuwai Rangahau Hauora - Health Services Research Centre at Te Herenga Waka - Victoria University of Wellington.
Jackie Cumming receives funding from the Health Research Council of New Zealand and the Marsden Fund. This research was funded by a Lottery Health Research Funding Grant. She also undertakes research on behalf of a range of Health New Zealand/Te Whatu Ora and Pacific Perspectives. She is affiliated with the Kāpiti Health Advisory Group.
