‘We’d see more people dying in ambulances’: Doctors fear GP system is on brink of collapse

Thursday, 7 March 2024

Nearly half of the country’s GPs reported high levels of burnout in their most recent workforce survey, which the college warns is an increasing concern and a key contributor to the GP crisis.

General practice is an integral part of our health system. But some of those working in it say it’s a system on the brink of collapse; with GPs burning out, closing their books, and critical workforce pressures. Hannah Martin reports in this three-part series.

Dr Mamaeroa David’s father saw a doctor on a Tuesday and died of a heart attack two days later.

With this always forefront of her mind, she says rushing patients through 15-minute slots, as if on “a conveyor belt”, is not the sort of general practitioner she ever wants to be.

But it’s a situation GPs report struggling with, due to workforce shortages and a funding model many say is “not-fit-for-purpose”.

Doctors and professional bodies were proposing urgent changes to the way GPs are funded and paid, saying the prospect of a future without general practice is not one New Zealand can afford.

General practices operate as private businesses and are funded in a number of ways, including the capitation model – where the Government subsidises the fee for enrolled patients, based on age and gender.

It’s not full funding, as practices also receive revenue from patient fees and other sources, the Ministry of Health said.

Doctors say a career in primary care is one of the most rewarding career choices available, and we must grow and develop the workforce. In the meantime, many are having to work for free to complete crucial patient follow-up.

GPs have become “so underfunded, under-resourced, under-valued, and overworked, the crisis it has reached is no longer sustainable”, General Practice Aotearoa advised in a briefing to the incoming minister in late January.

The briefing said 2022 data found full-time GPs who own their practices were spending at least 40 hours a week facing patients - much of which was either unpaid or underpaid - and a further 10-20 hours on unpaid admin.

The Royal New Zealand College of GPs this week published results of a time-in-motion survey, recording work performed over two weeks.

It found 56% of their time was spent doing consultations, with the rest largely admin - including non-contact clinical time, training and education, clinical governance, practice improvement and running the practice.

Fourteen per cent reported working all 14 days during the study.

The funding model was based on patient-facing time, Tauranga-based GP Dr Luke Bradford said.

Dr Mamaeroa David, a GP based in west Auckland, has over time reduced her clinic hours to a “safer” level, so she is more able to give her patients the care, time, and aroha they need.

This meant “people end up doing a lot for free”, Bradford ‒ college medical director ‒ said.

The impact of burnout on the GP workforce was discussed in part one of this series, here.

Last year, David’s (Te Whakatōhea, Ngai Tūhoe, Ngāti Porou and Niuean) weekends were spent processing an “enormously overwhelming” amount of paperwork, forcing her to decrease her clinic time to a “safer” 2.5 days.

The fear being, if you fall behind, “you don’t know what little bomb is hiding in those results” ‒ like a new cancer.

Decreasing clinic time wasn’t easy, but she could feel herself growing tired being in “constant survival mode”.

Now, she felt more able to be more present and pay attention.

Dr Bryan Betty, then-medical director of the College of GPs, warns problems will repeat themselves every winter if workforce shortages are not fixed. (Video first published July 2022. Betty is now the chair of General Practice NZ.)

“I need to know I’m doing my best for everyone who shows up. If they’ve been waiting two weeks, you need to make that two weeks’ wait worth it.”

Anecdotally, some GPs were not taking a wage to pay staff, while others were unlikely to pass a solvency test.

The reason the system hasn’t fallen apart yet was goodwill and loyalty to patients, Dr Buzz Burrell said.

Fundamentally, GPs “give a shit”, so were willing to continue going the “unpaid extra mile” for patients, colleagues and communities.

“But you can only take advantage of that for so long.”

When GPs’ books are closed and appointments full, people overload stretched EDs as a ‘backup’ for primary care.

“What’s almost guaranteed to happen, [is that] early cancers will become late cancers. We will see an increased incidence of heart attacks, strokes, poorly controlled respiratory conditions, diabetes.

“It might take five, 10, 15 years for the data to emerge, but it’s inevitable. That’s what really, really saddens me,” Burrell said.

A point of contention was general practice care was reportedly “far more cost-effective” than hospital care, but “the most neglected”, doctors say.

Dr Buzz Burrell says GPs fundamentally ‘give a shit’ about their patients, colleagues, and communities, but worries general practice as we know it could cease to exist in the future unless things change. (File photo)

Ninety per cent of medical problems were dealt with in general practice, yet GPs feel “almost irrelevant” because they’re not the hospital, Wellsford-based GP Dr Tim Malloy said.

Though, if general practice were to fail, “the whole system would fail”.

“The consequence of that is people will die,” Malloy said.

Burrell described the issue as such: “General practice is not sexy… and therefore politically is really unexciting”.

The General Practice Leaders’ Forum calculated that if there was a 6% drop in GP consultations and all these people went to ED, that would mean a doubling of ED presentations.

If this were to happen, we’d see more people dying in ambulances in front of hospitals, unable to get in, Burrell said.

GPs say huge investment in general practice is needed to address long-term ‘underfunding’.

“We’re so close to that.”

Issues around funding were not new.

In 2022, the Sapere report found a 9% funding increase was required just for practices to break even on average – a figure higher in communities with the highest needs.

It stated funding for general practice was “problematic” for a number of reasons: the core issue being that “funding does not align with patient need”, and “systematically underfunds” services for Māori.

Last June, general practice organisations rejected a proposed 5% funding increase, saying at least 14% was needed to keep services going.

“Many wonder how they’ll keep their doors open unless we get this much-needed investment,” they said.

GPs love their work, college president and Wellington GP, Dr Samantha Murton said, “and punch above our weight, [on] what we deliver”.

But, if anyone else did a job “where their funding was eroded completely, constantly bagged for not doing a good enough job, totally responsible for any poor outcomes that happen, [and] told they have to work half of that job for free – no-one would carry on doing it”.

So, why do they?

“It’s incredibly rewarding, incredibly stimulating and very purposeful. You make an absolute difference to people’s lives, it’s an amazing job.”

But something had to change, she said.

Health Minister Dr Shane Reti said he’d been on-the-record that the overall funding model for general practice wasn’t fit-for-purpose.

Any changes to funding would be guided by the Sapere report’s principles, he said.

“Now it’s for us all to think about how we can make further progress towards implementation.”

A Ministry of Health spokesperson said primary and community healthcare services were a core part of the health system, and play a “vital role in keeping people well and reducing demand pressures elsewhere”.

The ministry acknowledged “concerns” with the capitation funding model, and wider system settings for primary care.

It was working with Reti on his priorities for primary and community healthcare.

“Once these priorities are established, we will communicate these with the primary and community health sector.”

The final part of this series will be published on Friday.