Rural GPs under the pump

Saturday, 24 August 2024

Kāwhia GP John Burton makes a decent pitch for the rich and varied life of a rural doctor.

He describes being on weekend call, assisted by his most recent medical student, a fifth year.

It was an eventful time.

They visited a patient who had to be shocked three times after a cardiac arrest. They also had to set up an infusion for another patient in his end stages. The patient died, and they later attended his tangi.

The following weekend, they saw someone with an anaphylactic reaction who needed four injections before they responded.

You don’t get all that in a hospital.

“He was blown away by the experience he got here,” Burton says. “He loved it.”

But medical students are turning away from rural practice in their droves, drawn instead to hospital work in the main centres.

And after decades of underfunding, the regions are bearing the brunt of a dire shortage of GPs. That is driving the proposed establishment of a Waikato med school, which is back in favour under a new Government.

College of GPs medical director Luke Bradford says rural general practice is struggling with recruitment and retention.

Ruapehu Health Centre in Raetihi is without a GP and is offering virtual consults, while Waihi’s last permanent GP finished up three weeks ago. Bradford, who is a Tauranga GP, has also heard of two eastern Bay of Plenty clinics without doctors.

Practices can’t be run for a sustained period without a GP or nurse practitioner because they are needed to meet contractual obligations, he says.

“So it tends to be a crisis situation.”

He says they are also seeing more practices unable to find replacement staff and not enrolling new patients. That means there are places, especially in rural areas, where patients can't find a GP.

Primary health care provider Pinnacle, which has more than 80 practices in its network across central North Island regions, says 25 of its practices - almost a third of the total - have closed their books to new patients.

Even in practices taking on new patients, people are often waiting longer for appointments.

Whangamatā GP Fiona Bolden says at her centre patients wait up to two or three weeks for an appointment with their own GP, although urgent cases can be seen on the same day. Bradford says he has people waiting weeks for an appointment with him. “You do feel like you’re letting people down.”

Online consultations are not the magic bullet, he says.

“It's been extolled as the solution to rural [shortages] - ‘we'll just put telehealth in’ - but if you're not being examined, you're not getting your screening done properly, you haven't got the ability to go and form that relationship, we know you actually get worse outcomes.”

We can’t say we weren’t warned. Burton recalls a Pinnacle workforce assessment 20 years ago that pointed to a cohort which would be retiring around now, with a gap behind them, and the point being made that something needed to be done to replace them.

“The problem was it needed something politically done and politicians aren't interested in something in 20 years’ time,” he says. “So nothing happened.”

Instead, New Zealand spends just 6% of its healthcare budget on primary care, compared to the OECD average of 14%, according to Pinnacle.

And as doctor numbers decline, the complexity of cases with an ageing population is increasing, putting yet more pressure on GPs.

New research shows, for every day seeing patients, GPs are doing up to half a day’s unpaid paperwork, says Whangamatā’s Bolden, who is chair of Hauora Taiwhenua Rural Health Network.

She paints a grim picture of a profession under pressure.

“What we're seeing is the massive under-resourcing of general practice overall, but hugely so in the rural health area, for decades,” Bolden says.

She says the so-called capitation (per patient) funding formula for primary care is outdated and doesn’t account for the complexity of cases.

“We've hit the concrete now full on, and you're starting to see rural services fall over, and you're starting to see withdrawal of people doing out of hours cover.

“Doctors do not do that lightly. They have a huge commitment to their rural communities and want to provide the best service and make sure people are safe.”

Whangamatā Medical Centre, with five doctors, offers a 24/7 primary emergency medical response, but Bolden says it is “hugely underfunded”.

Although rural GPs need a broader skill set than their urban counterparts, funding support is lacking, she says. GPs have to pay for their own training in the likes of use of point-of-care ultrasound, including loss of income while they are away from work.

An education fund to help boost the rural skill set would be “only fair”, given it is for the benefit of the community and also helps reduce secondary care referrals, she says.

“It's something that's done in other countries. Australia has got a very good mechanism around that. So the more this isn't done, the more the younger docs just think, ‘Well, why would we stay in New Zealand?’”

When it comes to bringing on the future workforce, rural training is important, Bolden says.

“We know that people who are trained rurally are five to six times more likely to end up working rurally, and also people from a rural origin are much more likely to end up in rural.

“The system that we've had, just training people in urban centres, hasn't done well for producing rural practitioners, or even GPs, actually.”

The proposed Waikato med school has a focus on primary care, including GPs, and is set to pump out 120 graduates annually, should it get Government support, with Cabinet due to consider the business case by the end of September.

Rural and regional practices stand to benefit from its likely focus outside the main centres.

One potential advantage is its graduate level entry, taking on students who already have a bachelor’s degree and cutting the medical training to four years, from six.

Burton says that could help Māori students, at a time when Māori are underrepresented in the profession.

He recalls a Māori health worker in Kāwhia who could see the potential for her son when the idea was first mooted eight years ago.

He had gone to university and done well, but would never have considered medicine.

“He hadn't had the opportunities at school to do fantastically well compared to Auckland Grammar, or whatever,” Burton says.

“He was now showing that he was able to study and get good marks at university and then he could have got in as a graduate entry.”

Iwi could look at how to support their promising students into a graduate entry medical school, Burton says.

If Waikato gets the go-ahead, he would like to see integration between the three med schools.

Bolden talks of a distributed rural hub model, with those involved in medical practice and education working together. She describes them as centres of excellence where students can be based across provincial New Zealand.

“If there was some government support for that, that could get up and going fairly quickly.”

Bolden also wants to see coordination of student placements, including nursing, so smaller practices are not overwhelmed by influxes.

“We just really, really need to massively change the health workforce right now, which is why we can't just do one thing. We have to do a whole heap of different things.”

Faced with all the challenges, Burton’s enthusiasm for the rural doctor’s life is refreshing.

At 65, he is far from ready to hang up his stethoscope.

“At the moment I still feel like I've got something to contribute and am enjoying doing so, and I'm loving the teaching.”

Back to that rural sales pitch.

“You have to learn to do stuff yourself rather than rely on there being lots of specialists around that you pass stuff onto,” he says. “Plus you get the ongoing care of the patient and you see them at different stages of their treatment.”

Students who spend a year in a rural community get a varied experience. “You’re getting a bit of general medicine, you're getting a bit of exposure to what happens on the surgical ward, you're getting a bit of psychiatry coming in, you're getting to just appreciate all the different needs that the family have, you're seeing a whole much bigger perspective.”

Contrast that with the usual experience of a student spending almost all their training time in an urban hospital and then also spending their house surgeon years in an urban hospital. Burton is critical of Waikato Hospital, which he says has been poor at letting its house surgeons go out into general practice.

“Good primary health care gets patients before the problems get too bad often, and because of that saves a lot of suffering and a lot of money.”

Given his love of the job, his response perhaps isn’t surprising when he’s asked about financial incentives as a way of attracting graduates into rural medicine.

“I guess the biggest attraction for rural New Zealand should be that working in rural New Zealand is a great place to work,” he says.

The similarly enthusiastic Bradford is keen the good side is spelled out.

“It is something that's really important we get out there, that it is hard work and it's not sufficiently funded but it can be incredibly rewarding.”

GPs are a key part of their community.

“People do genuinely seem to love the actual work and their patients, it's just there's too much work and not enough support.”

He describes himself as an eternal optimist but sees colleagues losing hope and looking over the ditch to Australia or looking towards retirement.

“My belief is we have got some incredible clinicians in this country and we can do a lot of good, we just need to be backed to do it.”