Why are we waiting? Inside the GP crisis

Sunday, 10 September 2023

From taking loans to pay staff, to locking down clinics to prevent patient abuse, family doctors are stretched and stressed. Nikki Macdonald measures the pulse (and waiting times) of the country’s GPs, and asks how we got here.

Neil Hopkins should be relaxing in retirement.

Instead, the Northland GP of 24 years is still working, trying to keep the lights on at his desperately short-staffed medical practice.

“I’m sticking around because, if I didn’t, the service would be even in a worse predicament…In the short-term, we’ve just got to knuckle down and do what needs to be done, for the sake of the patients.”

In four years, Dargaville Medical Centre has gone from 12 full-time-equivalent doctors to about four. Some left, some retired. But their 12,000 patients still get sick, so each doctor’s patient load has tripled.

Given one doctor to 1000 patients was manageable, one doctor to 3000 patients is clearly not.

Not prone to hyperbole, Hopkins says: “It’s very stretched”. On a good week, the wait for a non-urgent appointment is 4-5 weeks. When one or two doctors are away, that balloons to eight weeks.

Like 98 out of New Zealand’s 193 rural practices, they’re searching for replacement docs. But there are precious few available. Hopkins is pleased if he can find cover for more than a month.

The clinic is trying everything to reduce the number of patients needing to see a GP. They’ve contracted out-of-area doctors to run a phone triage service; they’ve employed nurse prescribers, specialist cardiovascular and diabetes nurses and North American-trained physician assistants, who are similar to paramedics.

That’s all fantastic, Hopkins says. But still the doctors are working 11-hour days just to keep up. Something has to give. And that something is the 8am to 8pm urgent care service the practice provides for West Kaipara.

“With so few of us, the demands of doing that ongoing, and doing the same on Saturdays and Sundays, is beyond what we’re able to continue doing,” Hopkins says.

So they’re negotiating with Te Whatu Ora about cutting back.

“How we cope with the absolute shortage of GPs, we don’t have too many good solutions,” Hopkins says.

And that’s the nationwide problem, in a nutshell. The “perfect storm” of older and sicker patients, an ageing and dwindling workforce and a funding model GPs say is fundamentally broken, means patients are not only facing longer waiting times. They may lose access altogether.

What our survey found

DOCTOR’S NOTE: “The current government has made general practice unsustainable and unsafe. We are hanging on by the skin of our teeth. Underfunded, unable to recruit or retain staff…increasing demand…We are buckling under the workload and burning out.” – Lower North Island GP practice.

To gauge GP waiting times, the Sunday Star-Times surveyed more than 800 medical practices nationwide.

The 171 responses told of angry patients and dispirited doctors. More than one third reported waits of longer than a week for non-urgent appointments, with patients at 14 practices (8%) waiting 2-3 weeks and 12 clinics (7%) reporting waits exceeding three weeks.

Half the practices rated their workload as “high”, and another 35% rated it as “extreme”.

Nationwide, almost half of all GP practices – 477 out of 1089 – are not enroling new patients, according to Healthpoint data.

“Most sustained pressure in 40yrs as GP = I plan to leave soon,” one GP responded.

With several practices “on the brink”, more would close without an urgent funding increase, another wrote:

“One colleague has had to take out a loan to pay staff. Fix GP and you fix wait times in ED…what part of HEALTH CRISIS do they not understand? Yours sincerely a nearly 60-year-old GP,” another wrote.

How long is too long to wait?

DOCTOR’S NOTE: “All staff bear the brunt of the frustration (and often anger and abuse) from patients when we cannot see them in a timeframe they would prefer.” – Upper North Island clinic.

After 30 years of open doors, Samantha Murton just locked down her central Wellington clinic, so patients have to be buzzed in.

They’d already put up a sign, following verbal abuse. “We value and appreciate our receptionists. We expect you to as well,” it read.

About a month ago, an upset patient smashed up screens and the reception. That’s the toll of practices under pressure – stressed patients; stressed staff.

A straw poll of Wellington parents found most could get same-day or next-day GP appointments for sick kids. Some practices had prioritisation systems. But there were also concerning stories. One mum reported a 7-week wait to see a doctor for a chest infection and a 5-week wait for her 4-year-old, who failed a hearing check.

A Christchurch woman resorted to removing a problematic under-skin contraceptive implant herself, after being told it would take six weeks to get an appointment.

Murton, who is president of the Royal NZ College of GPs, says a week or two’s wait might be fine for a routine medication review, but waiting with symptoms encourages self-diagnosis, which is never good.

And while most GPs hold urgent same-day slots, with a prioritisation system, that depends on recognising what symptoms make a case more urgent.

“A week can be a long time in someone’s healthcare…I love my job – you save people’s lives every day. But the level of distress in the community has completely transformed.”

And some patients simply give up. The 2021/22 New Zealand Health Survey found 11.5% of people had a medical problem in the previous 12 months, but did not visit a GP because the wait was too long. That ballooned to almost one in five (19.2%) for Māori women.

So why are we waiting? It’s complex, Murton says. But it starts with an ageing, sicker population. More older people with more health problems; more mental health issues; and more people being denied specialist care. All of which take time.

Sicker patients: I was barely keeping people alive

DOCTOR’S NOTE: “We have not enough staff, and because hospitals decline all the referrals, we have lots of patients we can’t help. We spend all day apologising for the hopeless health system.” – Canterbury GP practice.

Corinne Glenn is a changed woman. New Zealand’s health system broke her, but Australia’s is putting the pieces back together again.

“It's incomparable. I would never go back,” Glenn says from Melbourne. “I am so much more relaxed. I’m contemplating hobbies. I’m laughing more. I pretty much didn’t laugh.”

Glenn came to New Zealand from Australia in 2011, and worked as a GP from 2014, in Wellington’s Hutt Valley. When she arrived, the health system worked pretty well.

But over time, waits for hospital care blew out. And then referrals were simply declined. That’s family doctors’ hidden burden – the patients not deemed sick enough to make hospital waiting lists, who are shunted back to GPs, who don’t have the tools to manage them, Glenn says.

“It felt like I was going to work, and I was barely keeping people alive. It was just constantly plugging holes, and new ones emerging.”

Even making a diagnosis could be challenging, with tight restrictions on funded pelvic ultrasounds, and their $260-$280 cost out of reach for many patients.

“To see suffering, and know that – in a developed country – we should have been able to meet the needs of these people, and we weren’t.

“That’s kind of a moral wounding, and that’s hard to manage.”

Responsible for 1600 patients, Glenn would go home, eat dinner, then do paperwork. Sunday afternoon was also paperwork time. It was all work, and no life. So in December, she left the job – and New Zealand.

“I was broken…I didn’t have time or energy to have social interaction. I dreamt about work. My sleep was poor. That was just all I did.”

In Melbourne, she still works hard. But because Australia’s funding system doesn’t assign 24/7 responsibility for a patient to their GP, she doesn’t do buckets of unpaid paperwork. If she has no available appointments, her patient can visit another clinic. And diagnostic imaging is cheaper and more accessible.

“If you love your job, and you do it well, and you care about doing it well, but you’re working in a system where everything is trying to prevent you doing it well, it takes a toll.”

A long-heralded shortage

DOCTOR’S NOTE: “We are exhausted and discouraged. We feel abandoned…The latest pay increase for the DHB nurses has put us in the impossible position of having to increase our nurses’ wages while making a financial loss.” – Waikato clinic.

No-one should be surprised by the shortage of GPs. Hopkins remembers years of concerned chatter at GP conferences, where hair colour was more salt than pepper, about who would replace those nearing retirement.

A 2020 Workforce survey found 31% of GPs planned to retire within five years, and almost half within 10 years. That would leave the country short 300 GPs by 2031.

That's compounded by the fact fewer medical graduates now choose general medicine. In 2021, just 25% of doctors registered in New Zealand were GPs, compared with 38% in 1980. GPs are often seen as the poor cousin, with lower status, and lower wages.

As Murton points out, family doctors earn about $100,000 less than hospital specialists – and they’re striking for better pay.

Te Whatu Ora is increasing GP training places from 200 to 300 a year by 2026, and cutting the pay gap between hospital and GP trainees. But Murton says they need 317 more GPs a year, just to tread water.

The Rural Health Network, which manages rural GP locums, says 98 out of New Zealand’s 193 rural practices have one or more long-term vacancies.

“It’s terrible,” says network chairperson and Whangamatā GP Fiona Bolden. Unable to recruit staff, clinics close their books, and waiting times grow. And almost daily she gets emails trying to lure her to Australia, for double pay.

“It’s a perfect storm, really. You’ve got the leftover effects from Covid, from when all international recruitment stopped…You’ve got international pressure on doctors…And they haven’t been training enough people here for years.”

But it’s not just about GPs. Murton, Bolden and several survey respondents all say it’s a struggle to attract – and keep – vital nursing staff, who can earn more in the hospital sector.

Te Whatu Ora gave primary care an extra $31 million a year to narrow the pay gap for practice nurses. But GPs say they've already fallen behind again.

Murton says “nursing services in primary care are desperate”. It's satisfying but busy and challenging work. So why stick around if you can earn $20,000-$30,000 more in a hospital job?

A flawed funding system

DOCTOR’S NOTE: “We are financially under pressure, so we need to keep enroling to keep our business solvent…This is the worst year we have ever had within the primary care sector! We are very close to closing.” – Northland GP practice.

Family doctors in New Zealand get public funding through a system called capitation. That means they’re funded per enrolled patient, rather than per visit. That’s topped up by the per-visit fee paid by the patient.

The great thing about that system is that one clinic has responsibility for the patient, which means more consistent care. But its strength is also its weakness.

If a GP sees a note in a patient’s electronic record, of a hospital-ordered test that hasn’t been followed up, they feel a moral duty to do something about it. But that shouldn’t be their problem, and they’re not paid for it.

As Murton puts it, “I can't be responsible for everyone’s activities in health, for my one patient”.

GPs also say the capitation funding system hasn’t kept up with changing health needs.

A recent survey by GP practice owner association GenPro found 35% of GP clinics made a loss in the last quarter, and 88% feared for their future financial viability.

A 2022 review of capitation found it underfunded services for Māori and underestimated the time needed for high-needs patients. GP practices ran at an average (and unsustainable) annual loss of $29 per person, the report found.

“Funding does not align with patient need…This is a serious deficiency in a core part of New Zealand’s health system.”

It recommended that patients instead be funded by age, sex, ethnicity, deprivation and level of health problems.

What’s the treatment?

Somewhere between Thames and Paeroa, Virginie Jouan is seeing patients – in Palmerston North.

The GP works for Health Hub Project, which is among several practices nationwide trying to do things differently.

Jouan does mostly virtual consultations, then every three months she does clinical work on-site at Palmerston North.

Like Hopkins’ diverse team, the system aims to ensure only patients who really need to see a GP see a GP. Nurses triage patients, and can contact doctors on-site or by phone. Problems that don't need a doctor immediately are treated by a nurse practitioner, a nurse prescriber, or a nurse guided by a doctor.

Instead of seeing 26 rest home patients in a day, Jouan can see 20 in a morning, because a nurse sees them first and reports back.

There’s also a clinical pharmacist to help with medication management, a clinical psychologist for mental health problems and a physiotherapist to assess injuries for ACC.

It’s still a two-month wait for very non-urgent appointments, such as reviews of chronic conditions. But appointments are available on the day.

There are still frustrations – more patients are being declined specialist care and investigations such as ultrasounds are scarcer than in Jouan’s native France. But she’s still “very satisfied” with the job.

“We still have time to see properly the ones who need to be seen by a doctor. We are just changing the way patients need to think about their health.”

Hopkins also thinks the future of primary care will look different, necessitating a model with less emphasis on GPs.

Te Whatu Ora primary health care system improvement group manager, Adeline Cumings​, acknowledges the critical importance of primary care, and that the sector faces workforce shortages and burnout.

She notes that general practice got an estimated $73.8m funding boost from July 1, but agrees that the historical funding model needs revising. That work is under way.

Increased capitation funding is already in place for Māori and Pacific-owned general practices, and those whose enrolled patients are at least 50% Māori or Pacific.

A $61m Comprehensive Care Teams initiative is also designed to help Māori, Pacific and rural populations fund broader health teams, Cumings says.

But Murton warns any solution must make being a GP – and primary care nurse – an attractive and valued career.

“It’s not just about us. It’s about cost-effective and good service for the community. If we continue to erode, it will cost the country more and more, and it will cost patients’ lives.”