The town where the doctor is always in

Saturday, 31 August 2024

When Girish G decided to quit the rat race, he plumped for Te Kūiti. In every conceivable sense, that was a long way from Singapore. To be fair, he didn’t research the move particularly thoroughly, and may not have known he was about to become one of those scarcest of things - a young rural doctor.

But he knew he wanted open spaces, and Te Kūiti fitted the bill. The deal was clinched when he heard about the friendly staff and the opportunity to work both in general practice and the neighbouring hospital.

G walked away from the 60-hour - sometimes 80-hour - weeks of a hospital doctor in Singapore and two years ago found something altogether more fulfilling.

He is surrounded by the open spaces he craved, and it’s a short walk up the hill to work from his flat.

And the 33-year-old is just what the doctor ordered.

The New Zealand GP shortfall is estimated at 485. Young doctors are in particularly short supply as an older cohort reaches retirement age, and rural areas are finding the going especially tough. Some are operating with locums, and plenty have closed their books to new patients.

Perhaps not surprisingly, a study last year found mortality rates were higher in rural areas than major urban areas across all groups aged under 60. It revealed a particular disparity for younger people and for “amenable” health problems - those that can be improved by access to care.

Amid a welter of dire headlines, no one’s thinking there’s an easy fix, given the decades of underfunding to get to this point.

There’s no sense of crisis, though, at Te Kūiti Medical Centre where the first thing a visitor notices is its relaxed atmosphere. The second is its idiosyncratic waiting room, in which all the chairs face directly away from reception.

As odd as that initially seems, it gives patients a soothing aquarium in a back corner to focus on while they wait to be called. And once in their GP’s room, they have something just as distinctive - an expansive view through the window, with picturesque farmland rising in the background. On Monday this week, that rural setting finds concrete expression in a mud-spattered ute in the car park outside the centre. Word has it that the occasional person turns up on horseback, but not today.

This health centre above the town is a curious mixture of past and future, personified by presiding spirit Keith Buswell, G’s supervisor for his first year in New Zealand and a founding partner of Te Kūiti Medical Centre.

Back in 1993, the DHB couldn’t get junior doctors to work in the hospital on the hill, and struck a deal with the town’s GPs. It converted a geriatric unit into a medical centre and the GPs that moved in provided the doctor services at the hospital.

They still do today, in an innovative model that may help point the way to the future as New Zealand grapples with delivery of primary healthcare.

Buswell’s room is last on the right for those ushered from the waiting room, and the view from his window includes a nearby helicopter pad - there is a chopper evacuation typically every couple of weeks.

That speaks to the dual role of these doctors. The centre has 10 GPs - six full-time equivalents - serving 9000 enrolled patients while also staffing the hospital’s 12-bed ward and ED. The current model is for junior doctors to work in the hospital permanently, under the oversight of a senior.

Benneydale man Graeme Simpson is among those enrolled with the centre. The former bushman, one of the few out and about on Te Kūiti’s main street on Monday morning, is happy with the service, which he might tap into two or three times a year.

What about the long wait times that have been the subject of so many stories?

“I haven't had that trouble, it's like the next day,” he says.

Mum of two preschoolers Kiana Ormsby is similarly positive. She’s from Ōtorohanga but goes to the Te Kūiti clinic after she had difficulties getting some services during Covid in her hometown.

She decided to switch permanently. She uses it “pretty often” during winter, what with flus and colds. “I like it up there.”

Simpson reckons the hospital side of it’s good too. “You get better service here than Hamilton.” He laughs. “Hamilton's shocking. I know people who’d gone up there 10 o'clock in the morning for an appointment and they're still there 10 o’clock at night.”

Buswell’s connection with Te Kūiti started in 1986 when he arrived with his wife, also a GP, and they bought a sole practice. The couple brought up their family here, and have enjoyed the outdoor lifestyle. His wife is on the verge of retirement and you might think Buswell would be as well, given he’s 67. But he’s expecting to keep going for a few more years. Partly that’s because he enjoys it. Partly it’s because they have young doctors coming through who need support from seniors. For various reasons, some of the partners are finishing up or taking a break, which puts pressure on the practice over the next 12 months or so. The good aspect of that is they have been able - against trend - to recruit younger doctors. Buswell thinks that’s helped by providing an enjoyable working environment, and by the variety that comes from working across general practice and rural hospital medicine.

“I see that as the future of rural medicine, is for people to have that training in that broader field, which includes rural hospital medicine. Because it gives people confidence and skills in dealing with the emergencies that you get in rural care.”

It’s not to everyone’s taste, he says, and some have left because they don’t like the broader scope.

But Girish G is a big fan. He is doing his rural hospital medicine training, which will take him to Thames next year and then elsewhere for a couple more years before a likely return to Te Kūiti. He loves the connection with patients that is so at odds with the big hospital experience.

“We get to walk through what happens in patients' lives. We get to collaborate with the specialists in terms of the treatment plans, and we are part and parcel of how things go.”

He may have turned his back on the gruelling urban hospital hours, but he’s working hard in his new role and doesn’t begrudge it. He’s learning more and forming connections.

“The fact that people want to come to see me, and they're willing to bring their children, to bring their parents and their family to see me - I think that's deeply rewarding,” he says.

“I'm feeling connected with the people around rather than, say, in a big city where I don't even know who I'm talking to or who I'm dealing with.”

Buswell says a strength of the model is GPs can look after their patients while they're in the hospital. “That's real continuity of care, and it breaks down to a degree that primary-secondary care interface.”

If someone arrives who’s not managing at home it’s easy to nip them into the hospital, without endless phone calls and battling overworked registrars.

The Te Kūiti hospital deals with the likes of older people with heart failure and respiratory problems, or people with bad skin infections, Buswell says. “Generally things that are managed medically as opposed to surgically.”

It is also involved in discharge planning for the likes of older people who need services organised for them to return home.

Could this integrated model be a way forward?

Buswell says the DHB as it was then would have loved to have seen the same thing in Tokoroa and Taumarunui, but it takes a lot of buy-in from the different parties. “Circumstances meant that it happened here but it hasn't happened in other places.”

As a longstanding GP, Buswell has seen changes in healthcare. One of the biggest, particularly in the last five to 10 years, has been the increasing use of highly skilled nurses and others in a team approach.

Appointment times have also changed with increasing complexity of patients’ problems.

Buswell used to see five or six patients an hour and now he might see three or four.

As people age, they need more medical treatments, and the ability to treat them has become more sophisticated. And GPs are left with the job of doing that as cases that used to be seen in stretched hospital outpatient clinics are put back on primary care.

That's not to say it's the wrong place for them, but Buswell thinks the resources for primary care haven’t kept pace. He gives the example of people with slightly more complicated diabetes who would once have been managed in a hospital diabetic clinic, but are now managed in general practice, with only the most extreme cases going to hospital clinics.

Amid the diabetes epidemic, doctors can do more than they used to. There are more drugs and more people are on insulin. “But that takes a lot more input from your primary care provider to do it.”

That said, tele-medicine is making a difference. “It reduces the need to come out for less serious problems. That's the biggest thing and especially with the hospital - I mean someone has to be available, but with tele-medicine we're getting less of the less-serious things to deal with.”

Next year, Te Kūiti will be among the first four sites to take a cohort of Auckland University students in a rural immersion scheme aimed at getting more students embedded in rural communities. Three fifth-year medical students will train with them for the full year.

“The idea is they live here, they become hopefully involved in community activities and get more connected with the community,” Buswell says. “And also get that continuity when you're working in one place with one population of people over a longer period of time.

“Maybe one of them might marry somebody that lives around here.” He laughs. “Because that's the best way to get people trapped, of course.”

Joking aside, the immersion scheme is an example of what the proposed Waikato med school is likely to do should it win Government funding, and Buswell is a supporter.

“I think that the two older medical schools, and obviously I'm a graduate of one of them, haven't really risen to the challenge of preparing students to want to be working in rural areas and being rural doctors, and I think to a degree that the College of General Practitioners haven't done that either.”

Those organisations don’t necessarily understand all that is required of a rural GP.

“When you're a rural GP, it goes without saying that you’re going to need to do after-hours call. And in the city, that's no longer really required. It's all being done by clinics and emergency medicine clinics and things like that, but in rural areas that doesn't exist.”

He sees newly training GPs who are not used to doing calls. “It's not really part of their mind set of what being a GP is about and, quite frankly, they're frightened by it because of what you might meet.”

Registered nurse Christine Purdie similarly says you never know what is going to come through the door. The previous day they had an emergency delivery. And there are those who turn up on horseback. “We've had that on occasion.”

As if to reinforce the point, this week the ED has a further emergency delivery two days after the first one.

Purdie is one who married into the district, and stayed. The former Aucklander lives on a farm a 15-minute drive (“with no traffic lights”) from the health centre where she has been working for the past 15 years.

Unusually among the nurses, she works part time at the hospital and part time at the medical centre.

As for the variety, you can be coordinating, dealing with admissions, reordering medications, restocking, covering ED.

“The workload can change very quickly.”

There is no agency pool, and another dimension is added after hours when there is no doctor on site.

For Purdie, it’s all good.

“I love it. I love living rurally. and I like the diversity of the role here.”

They’re a tight unit, being rural. “People care about where they work and I think we're all very accountable because of it.”

Girish G, as new as he is to the town, is definitely one who cares. As he sees it, the connections with individuals that you build up in rural areas make a difference to their health outcomes. He often hears of patients who feel they have been taken better care of in Te Kūiti than in a bigger centre.

“I've got lots of respect for Keith Buswell and all the senior doctors around who have actually established this and built it up to where it is today,” he says.

“My motive is, wow, these people have created such a system, the least I can do is try and maintain it.”