Underfunding, staff shortages, burnout: Why many GPs are turning away new patients

Friday, 19 July 2024

Staff shortages are the number one reason GPs are unable to take on new patients, with an estimated 79% of general practices having closed enrolments at some point between January 2019 and August 2022.

A recent study published in the New Zealand Medical Journal (NZMJ) today cites a shortage of GPs or nurses as the reason most frequently cited by respondents for why practices are unable to take on new patients.

Other reasons for general practices closing their books included underfunding of general practices, high workloads and staff burnout, impacts of Covid-19, concerns about quality of care, and insufficient physical space.

The mixed-methods study was done by doctors Jacqueline Cumming, Nisa Mohan, Maite Irurzun-Lopez, Megan Pledger and Mona Jeffreys to ascertain both the reasons and the impacts of closed enrolments in general practices.

Cumming said the challenges identified in the study were things that had been spoken about for years, but “this was a systematic way of collecting good information about how widespread the problems are and where there were particular issues”.

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There are approximately 5600 GPs and about 1000 general practices in New Zealand. The study captured the views of 227 respondents, of whom 119 were practice managers, 85 were GPs, 52 were practice owners and 20 were other staff. (Some respondents fell into more than one category.)

A briefing to Health Minister Dr Shane Reti earlier this year showed New Zealand is 485 GPs short, with fears this number could double in the next 10 years.

Cumming said a growing proportion of GPs retiring, difficulty in recruiting overseas staff, and pay inequity between GPs and their hospital counterparts were all cited as reasons for the shortage.

This exacerbated high workloads and staff burnout in general practice where GPs were expected to increasingly do more work that would have previously been done in hospitals.

Because GPs receive capitation funding based on the number of enrolled patients - and there is no legal limit as to how many patients a general practice can accept - it makes sense from a business perspective to accept new patients.

However, many GPs closed their books due to concerns about the quality of care they will be able to provide if they have too many patients to look after.

Practices being unable to accept patients had a knock-on effect on the rest of the healthcare system as these patients are unable to access continuous care, and have to turn to after-hour clinics or hospital EDs when they become unwell.

“[We have] patients trying to enrol from outside our community because they have been unable to enrol in their home town - these are people who are one-and-a-half hours from our practice,” one of the respondents said.

“Funding per patient does not reflect the workload that is required. It is problematic especially for high-needs patients,” said another.

It was announced yesterday that the government’s capitation funding would increase 4% with GPs given the go-ahead to increase patient fees by 7.8%, to give an overall income boost to practices of about 5.9%.

General Practice New Zealand chairperson Dr Bryan Betty said this was “absolutely inadequate”.

General Practice Owners Association (GenPro) deputy chairperson Stephanie Taylor said the GP funding model was “simply not fit for purpose” with one in three GP practices losing money. The association calculated that 14% was needed to keep vulnerable practices financially sustainable

The NZMJ reported that across 22 OECD countries, an average of 14% of healthcare budgets was spent on primary care. In NZ, only about 6% goes to general practices.

Cumming said this calculation was based on 2016 data, the most recent available and in NZ only looked at money for primary health organisations. “There will be other funding going to primary and also to community care providers. But it does look like the proportion [of primary care funding] here is much lower than in other countries.”

Meanwhile, Bryan Betty, also a Porirua GP, said it was a fact that New Zealand underfunded primary care. “What is really interesting is when you look at the international research, for every dollar that is invested in primary care, you get a $13 return.

“There is a wealth of evidence [showing] if you have a robust working general practice primary care sector, you take pressure off hospitals, people stay well longer and you get a huge return on investment,” he said.

“About 96% of the population get their medical care in general practice in this country and, if we allow it to degrade, we'll have major problems in our health service going forward.”

Study respondents recommended relaxing immigration rules to recruit staff from overseas; establishing pay equity between primary and secondary staff; increasing medical school places; longer placements in general practice for medical students; and increasing remuneration in primary care.

“We hope this study helps recognise how important the issue actually is, by putting down on paper that these are the causes and implications of closed books in Aotearoa New Zealand,” said Cumming.

“What we would like to see is real action to [make the necessary improvements].”