When Local GPs are a Closed Book
Does the health system know (or care) when people can’t sign up at their local Medical Centre?
by Gordon Campbell
Earlier this year I happened to overhear an elderly woman talking to the receptionist at Newtown Medical Centre in Wellington. Since the woman had just moved to Newtown, she said she’d now like to sign up, and switch her care to a local doctor. Sorry, the receptionist said, we’re full up – so much so that the Centre hadn’t been operating a waiting list for the past eight months. The receptionist offered a helpline number instead. “Oh well,” the elderly woman said philosophically, “ so long as I’m still healthy enough to get on the bus over to Khandallah, I suppose I can keep on seeing the doctor I had over there.”
The incident was troubling. Surely, someone so frail should be being cared for locally. The known health benefits of continuity of care – as this woman gets older – mean that when her health deteriorates, she should be already settled in at Newtown, and not still trying to bus across town to Khandallah in winter for primary care. She is not alone in this respect. Newtown has a low income, ethnically diverse and transient population with a relatively high number of migrants and students. If they didn’t have ready access to GP care, where were they going – to the local hospital’s accident and emergency department, given that the nearby after hours clinic would almost certainly be too costly to afford?
The known reality is that if people are denied ready and regular access to primary care, they will be forced into deferring treatment until their condition worsens, and then forced by an emergency to take themselves or their family members to clinics they can’t afford. The Newtown situation comes on top of substantial funding cuts by Capital Coast and Health DHB to the low income Newtown Union Health Service, a decision that has already resulted in the sacking of the team that provided obstetric care to (a) the suburb’s substantial refugee population, and (b) to those local residents coping with special needs arising from poverty and addiction.
At a wider level, New Zealand’s health strategy is supposed to be based on primary (ie GP-based) care, and on its integration with other health services – although for obvious reasons, the primary care system seems driven as much by the profit margins of the providers, as by patient need. For demographic reasons, the GP workload is set to increase. Our population is ageing and the early detection (and treatment) of chronic conditions at GP level is becoming the chosen path for a health system that is chronically short of funds. So much so that the early stages of cancer treatment appear likely to be devolved to GPs, and paid for by their patients. In its early stages at least, cancer is going to become more and more of a user pays disease.( See “General Practices To Take On Cancer Care” NZ Doctor magazine, 29 August 2012.)
At the same time, core government policies are based on the assumption that access to primary health care is readily available to all. Come next July for instance, the next stage of the government’s welfare reforms will – at least nominally – require beneficiaries to ensure their children undergo a series of quarterly childhood health checks with doctors, thereby putting additional strain onto GP workloads, and onto the existing primary care system as a whole. So far, this issue has been debated largely in terms of affordability to patients – but what about the barrier of GP availability?
The Newtown incident made me curious about just how widespread the problem of GP availability and closed waiting lists at medical practices may be. Initial research indicated that in some parts of the country, the problem has existed for some time. Take the case of Feilding in the Manawatu, in 2008-2009:
General practitioners are in short supply everywhere, but in Feilding it’s particularly bad. All the town’s practices have closed their books to new patients, and people waiting to enrol are being sent to doctors in Palmerston North. Across the MidCentral Health district there are more than 300 people looking for a GP. Of those, 155 have been referred to practices and are waiting to hear whether they can enrol. More than 30 of the remaining 146 live in the Manawatu district, with 17 joining the waiting list in the last month.
[Manawatu Primary Health Organisation manager] Nicky Hart said some wait-listed people were enrolled with a GP but wanted to change, and there was little capacity to offer what she believed was an important choice. The 0800 central waiting list service has handled 641 requests to find a GP since it was set up last June. While about two-thirds of those people had been put in contact with practices, few from Feilding had been placed in town. Most had to travel to Palmerston North. Casual appointments were sometimes available in Feilding, but patients who weren’t enrolled there had to pay more for their visits.
In 2010, the waiting list problems in the Foxton /Levin region of Horowhenua were off the graph:
The number of people in Horowhenua wanting to register with a doctor has stretched to nearly 2000 people and continues to grow. One Horowhenua practice reported turning away an estimated 20 patients a day and Foxton Medical Centre said they had people ringing weekly and sometimes daily to register with them, including people from Levin. A total of 1769 residents had been turned away from local practices in Horowhenua, which includes Te Horo and north to Foxton and Shannon. The figure contrasts starkly with neighbouring Kapiti, which has 218 residents waiting to register with a GP.
Earlier this year, Marlborough was experiencing its own GP shortage problems.
New GPs arriving in Marlborough are unlikely to ease patient waiting lists, but…..Marlborough PHO is hoping to eliminate the region’s GP shortage within four months.
Before Christmas, the Kimi Hauora Wairau (Marlborough) PHO placed a notice on its website warning people moving to Marlborough that practices were full. The notice said patients may need to retain contact with their current doctor for three to six months.
As one would hope, the bureaucrats running the health system have been aware of these shortfalls. In its 24 September 2008 issue, NZ Doctor had reported on the GP shortage (in a story headlined “Closed Books Have Patients Waiting”) and cited the Health Ministry’s response in these terms :
The Ministry of Health says it is now requesting regular updates from DHBs regarding the number of GPs who have closed their books. NZ Doctor understands close attention is being paid to the Capital & Coast, Hutt Valley, Whanganui, MidCentral and Southland DHB areas, and Ashburton and Timaru…
If such “regular updates” ever did occur, they no longer happen. When I contacted the Health Ministry earlier this year for information on the national picture of GP availability and the current location of closed book “ hot spots” I was told that such information did not exist, and that if I wanted to find out, I would have to contact the DHBs myself. Or the PHOs within them. Or the actual GP practices within each PHO. To repeat : the availability of affordable primary healthcare is supposed to be the foundation stone of our entire health strategy. Yet astonishingly, no one appears to be maintaining an up-to-date picture of just how available such care is, in reality, in various parts of the country.
This article is an attempt at collecting pieces of that picture. With hindsight, I can now see there were more useful (and more revealing) ways of asking for the relevant data. My initial goal however had been to establish whether the higher administrative level of the system – ie. DHBs – were aware of the extent of closed books/waiting lists at GP level. Clearly, many do not have a clue , and such knowledge – if it exists at all – is held at PHO level, at best. Therefore, the more relevant question would have been to ask flatly what percentage of GP practices within their DHB boundaries have closed their lists, and are not taking on new patients. That would have taken an eternity to compile and – judging by the situation below at say, Waikato DHB – at considerable personal cost for the analysis to be done. Perhaps local journalists can press each DHB and PHO more closely, and fill in some of the blanks here.
Before getting into the DHB data, a few relevant points. In its Briefing to the incoming Minister after the last election, the Health Ministry (p.6) claimed that there is no real problem with GP availability:
We have a responsive system where people are enrolled to receive subsidised general practice services. New Zealanders report high levels of access to primary care on the same or next day as their need arises
In fact, those “ reports of high levels of access to primary care “ are attitudinal responses to the 2010 Commonwealth Fund international survey. They’re what a sample of respondents believe about the system based on their experience of it – not on any actual survey of GPs, or of medical affordability for low income groups or the extent and location of GP waiting lists. Even though shortly afterwards in the same briefing papers, the Ministry added :
However, analysis of the regularity of primary care contact shows that people with high health needs make less use of primary care than the general population. There are many reasons for low levels of access, including: availability (my emphasis) transport, cost, poor health literacy and responsiveness.
Clearly, a tally of the averaged-out experience, attitudes and beliefs about the health system – which is what the Commonwealth Fund international survey really is – will obscure a myriad of regional differences and pockets of need. Moreover, if you follow the Toplines link available here even the Commonwealth Fund survey data contains some disturbing attitudinal responses. (On Q905 for instance, only 37% of New Zealanders felt our health system works pretty well and needs only minor changes, while 51% felt it needed fundamental changes, and a further 11% felt it needed to be totally rebuilt.)
Does New Zealand have enough doctors…and are they located in the right places? Numbers, locality, workload and income are all important factors that culminate in the crunch issues of availability, waiting lists and affordability. Like many other OECD countries, New Zealand has seen an increase in the raw numbers of GPs, with just over 3% annual increases recorded since 2009. Yet as health economist Bronwyn Howell has argued (NZ Doctor. 1 Jun 2011) last year’s OECD comparisons were not rosy :
New Zealand sits at the low end of the OECD in practising physicians per capita (2.46 per 100,000, behind the UK (2.61) Australia(2.97) and Austria (4.6 – the highest) but on a par with the US (2.43)….Furthermore, the number of medical graduates is low at 7.2 pr 100,000, down from a high of 9.2 in 1981…[and] a far cry from Australia (11.1) and OECD leader Austria (21.6), but still ahead of the US…
Moreover, it is not as if we go to the doctor – or can afford to go to the doctor – whenever the need or desire arises. As Howell points out, our average number of doctor consultations per capita per annum sits at the low end of the OECD figures, behind Australia, Canada and the UK, although once again, slightly ahead of the US.
Little wonder then, that we have unequal access around New Zealand country to the inadequate number of GPs available. (In an aside on the current resale value of patient lists and medical practices (NZ Doctor, 1 August 2012) the Medical Assurance Society claimed that the average GP has a whopping 1,640 strong patient list, many of whom of course, may not be actively coming through the door regularly for treatment.
Given the apparent absence of monitoring of GP practices and the lack of centrally held data within the Ministry, Werewolf wrote to every DHB in the country for basic information on the situation within their boundaries. Each DHB was asked exactly the same questions about the ratio of GP membership within local PHOs, the extent of practices having closed books and waiting lists, and the measured extent of “patient churn” in their region – as patients joined, left, or transferred between practices and PHOs.
As will be obvious from the variable quality of the results recorded below, this is very much a work in progress. To enable colleagues in the mainstream media to pursue this issue within their region if they so choose, I have included the contact email for the communication officer at each DHB – which may be a useful reference tool, given that some DHBs do not have up to date or accurate contact information (or in some cases any media contacts listed at all) on their websites. At the other end of this laundry list of DHB responses of highly variable worth and detail provided, there is a concluding segment.
1. Bay of Plenty DHB
Contact person : Diana Marriott
Diana.Marriott@bopdhb.govt.nz
Three PHOs operate within the BOPDHB border. Western Bay PHO, Eastern Bay Primary Health Alliance and Nga Mataapuna Oranga PHO. In addition, two PHOs outside the BOPDHB border have General Practices within the BOPDHB border [and] these are Rotorua PHO and Midland Regional Health Network. 98% of General Practices in the BOPDHB region are signed to a PHO.
(a) How many, if any, general practices are currently not taking on new patients? (‘New’ meaning those not previously enrolled with that PHO, and who may, for instance, have moved to the area, or who may be actively seeking to change their GP.)
There are six General Practices currently not taking on new patients.
(b)How many if any, of the PHOs in this DHB region currently operate a waiting list for new patients wishing to access a doctor at their PHO ?
The General Practices will see non-enrolled patients at the “casual” rate and who are then put onto a waiting list.
(c) What percentage of patients ceased to be patients of their PHO during the last recorded year of its activity? i.e. This information will give some idea of patient ‘ churn’ within the boundaries of the DHB.
This information is not readily available to DHBs. The information will need to be sourced from the PHOs.
2. West Coast DHB
Contact person : Bryan Jamieson bryan.jamieson@westcoastdhb.health.nz
There is only one PHO operating within the borders of this District Health Board, and 100% of GPs within this DHB region have signed to a PHO.
(a) How many, if any, of these PHOs (containing GP practices) are currently not taking on new patients ? None.
(c) How many if any, of these PHOs currently operate a waiting list for new patients wishing to access a doctor at their PHO ? None.
(d) What percentage of patients ceased to be patients of their PHO during the last recorded year of its activity? (i.e. I am requesting this information in order to gain some idea of patient ‘ churn’. If there are any other readily available indices of churn in the PHOs within the boundaries of your DHB, I would be grateful. Answer : Approximately 15%.
3. Southern DHB
Contact person : Melissa Garry
Melissa.Garry@southerndhb.govt.nz
One PHO operates within the borders of the District Health Board, and 100% of GPs in the Southern DHB region have signed to a PHO.
(a) Some practices are not enrolling patients, e.g. approximately two thirds of Invercargill City general practices (17) are not enrolling patients.
(b) Southern DHB is unaware of any practices operating a waiting list for new patients.
(c) The Southern DHB does not collect data on the percentage of patients ceasing to be patients of their PHO during the last recorded year. However, enrolled patient numbers have increased steadily over the past 12 months.
4. South Canterbury DHB
Contact person : Fiona Pimm FPimm@scdhb.health.nz
“South Canterbury DHB does not have any PHOs in our district.” The DHB provides the services that would otherwise have been provided by a PHO from the Primary & Community Services (PCS) division of the DHB.
100% of the GPs in the district are under the umbrella of the SCDHB PCS, via a service agreement with South Link Health Incorporated.
(a) The extent of closed books and waiting lists ? We have three practices (out of 28) taking new enrolments on a regular basis. However, most other practices will enrol new patients if they are known to other patients eg family members of existing patients; or if they are requested directly by the waiting list manager. Priority is given to pregnant women, children, elderly and then all others.
Timeframes vary from one month to the next but generally speaking patients don’t have to wait more than two months to enrol. Also, if they need medical care while on the waiting list they can be seen by the duty doctor on the day. However, having said all that if patients want a particular doctor then they may have to wait a lot longer.
While practice books are relatively full we do have some practices enrolling new patients. South Link Health Incorporated operate a waiting list for patients wishing to enrol with a practice. This is generally for people wanting to change GPs rather than people new to the district but can vary from one month to the next.
(b) And the rate of patient churn ? Churn is difficult to identify. Here in South Canterbury we are experiencing overall growth from one quarter to the next but we cannot identify how many people left the district and how many people are new to the district – only the net effect.
5. Nelson-Marlborough DHB
Contact person : Rosemary Barnes
Rosemary.Barnes@nmdhb.govt.nz
The Nelson Marlborough District Health Board has two PHO’s in its district. One operating in Nelson and Tasman and the other in Marlborough. All General Practices within the district have agreements with the PHO’s.
(a) The extent of closed books and waiting lists ? Patients enrol with their general practice and PHO. The number of practices not taking enrolments varies over time and can change month to month. Currently, approximately 44 % of the practices in Marlborough are accepting new enrolments; and approximately 80% of practices in Nelson and Tasman are either enrolling patients or taking limited enrolments…..Neither of the PHO’s have a waiting list. [ N.B. Waiting lists will be operated by GP practices, and many (most?) PHOs do not routinely monitor this situation.]
(b) And the rate of patient churn? With the PHO‘s and practices confined to specific geographic areas the PHO “churn” is generally related to migration.
6. Canterbury DHB
Contact person : Karalyn Vandeursen Karalyn.Vandeursen@cdhb.health.nz
(a) Three PHOs operate within the borders of this District Health Board, and 100% percentage of the GPs in this DHB region have signed to a PHO.
(b) How many, if any, of these PHOs are currently not taking on new patients ? (‘New’ being those not previously enrolled with that PHO, and who may, for instance, have moved to the area, or who may be actively seeking to change their GP.)
All PHOs are enrolling patients. Not all [GP] practices are enrolling patients however and when this is so, the PHO makes all attempts to find an accessible practice for the patients…In response to your enquiry we surveyed our largest 20 practices again last week, across Christchurch and the Selwyn District, and all but one of these are currently accepting new enrolments. The one exception is a Very Low Cost Access practice which is funded to charge adult patients no more than $17 for a consult..The ‘non-enrolment/no waiting list’ situation is not a major issue in Canterbury region.
(d) What percentage of patients ceased to be patients of their PHO during the last recorded year of its activity? (i.e. I am requesting this information in order to gain some idea of patient ‘ churn’)
Following the earthquakes, many patients moved around in Canterbury and a few left the region. Between April 11 and January 12, one PHO had virtually no change, another lost 1.9% of its roll and the third PHO gained 2.1%. All up, the enrolled population of Canterbury decreased by 9257 patients (1.88%) between April 2011 and January 2012. In January 2012 the total enrolled population was 484,355, and by April 2012 this has increased to 484,690.
7. Waikato DHB
Contact person Mary Anne Gill
MaryAnne.Gill@waikatodhb.health.nz
Three PHOs operate within this District Health Board and 100% of GP
practices in the Waikato are aligned with a PHO.
(a) From time to time individual practices may not take on
new patients. We have not however ever had any PHO unable to take on new patients across the entire PHO. Practice level information on this issue is not routinely reported to the DHB, and would best be sourced from the PHOs.
(b) Waiting lists.
From time to time individual practices may operate waiting lists…..Practice information on this issue is not routinely reported to the DHB and would best be sourced from the PHOs.
© The extent of patient churn
This is not an analysis that is routinely undertaken by the DHB. We estimate that it would take between 6 and 18 hours to undertake the analysis, depending on the method used and how many issues arose during the analysis. Under the Official Information Act 1982, Waikato DHB may impose charges for the time taken and the resources used in dealing with a request. This time would be chargeable to the requestor. The Waikato DHB’s charges are $38.00 per half hour (or part of a half hour) including GST, for all actual time spent after the first 4 hours (first 4 hours are free of charge). Based on the estimate above, the likely charges would be between $152.00 – $1064.00 depending on the length of time it takes to collate this information and any other special/relevant factors. hotocopying charges will also be payable for paper/materials. The costs for this are 20 cents per A4 page after the first 20 pages which are free of charge.
[Waikato is a not uncommon example of where the DHB seems to have little idea of GP availability, data on which is held ( if at all) at PHO level.]
8 & 9. Waitemata and Auckland DHBs
Contact person : Paul Patton (WDHB)
Paul.Patton@waitematadhb.govt.nz
Waitemata has two PHOs, Auckland has four PHOs (one of which operates within Waitemata DHB, for a total of five. All GPs receiving primary care funding are signed up to a PHO. The exceptions are those GPs who only provide certain services under contract to a rest home for example, and there is a different arrangement in place for the GP provider on Great Barrier Island (Auckland DHB).
(a) Closed Books
(i) Auckland PHO has four practices with closed books. Alliance Health Plus – has no practices with closed books that it is aware of
Waitemata PHO has two practices with closed books, although one of which is taking on those with existing family at the practice, and the other has practices close by which have open books.
We do not have the figures for the other two [biggest] PHOs ( ProCare and National Hauora Coalition.) We are however aware through our locality work in West Auckland of eight ProCare practices with closed books.
(b) Waiting Lists. Do any PHOs currently operate waiting lists for new patients ?
Generally, patients want to become enrolled with a particular practice, not the PHO, so no PHOs maintain waiting lists. As a number of [GP] practices are located close to each other, an alternative practice can normally be found.
(c) Churn rate of patients. The churn figures for patients, the DHBs advised, are more likely to reflect the change of affiliation of GP practices with particular PHOs, than to indicate patient mobility as such. Some sense of the short term churn can be gleaned from these figures supplied in response to my request :
Auckland PHO had 54,890 patients at the end of June 2012, being an increase of 591 after inflows of 8,946, and outflows of 8,335 in the previous three months.
Procare Networks PHO had 867,930 patients as at the end of June 2012, being an increase of 6,817 after inflows of 98,526 and outflows of 91,709 in the previous three months.
Alliance Health Plus Trust PHO had 71,842 patients as at the end of June 2012, being a decrease of 414, after inflows of 12,690 and outflows of 13,104 in the previous three months
National Hauora Coalition PHO had 263,903 patients at the end of June 2012, being an increase of 2,348 after inflows of 38,181, and outflows of 35,833 in the previous three months
Waitemata PHO had 186,484 patients at the end of June 2012, a decrease of 5,032 after inflows of 20,574 and outflows of 25,606 in the previous three months.
10. Wairarapa DHB
Contact person : Tracy O’Neale
Tracy.Oneale@wairarapa.dhb.org.nz
Wairarapa PHO has one PHO operating within the District Health Board, 100% of General Practitioners operating in this District have signed to Wairarapa Community PHO.
(a) Closed books /waiting lists ?
The PHO is open for enrolment of new patients, however enrolment processes are managed at a practice level and individual practices or practitioners may periodically close for new enrolments. These practices may operate waiting lists at the practice, or actively encourage patients to enrol in another practice within the PHO.
(b) Patient churn ?
Providing the number of percentage of patients ceased to be enrolled requires detailed analysis of the register summary. We can report the overall register of patients enrolled in the PHO in the past calendar year increased by 581.
11. Taranaki DHB
Contact person : Jenny McLennan
Jenny.McLennan@tdhb.org.nz
All GPs in Taranaki have signed to a PHO with one exception.
Closed books / waiting lists ? No advice that PHOs are not taking new patients [and] No waiting lists that we are aware of.
Taranaki DHB had no information on the extent of patient churn
12. Tairawhiti DHB
Contact person : Kathy McVey
Kathy.McVey@tdh.org.nz
All GPs in the Tairawhiti DHB region have signed to a PHO.
Closed books/waiting lists ? 4 out of 5 practices have temporarily ‘closed their books’ to new patients, however one of these still accepts new residents to the district, but not those wishing to move practice.
Extent of patient churn? We’re unable to answer this one…sorry, however MOST movement is actually between [GP] practices, not PHOs.
13. MidCentral DHB
Contact person : Joe Howells
Joe.Howells@compasshealth.org.nz
(Central PHO is the only PHO serving the MidCentral DHB region and all GPs in the area have signed up with it, amounting to over 100 GPs in 40 GP practices
(a) Closed books/waiting lists ? Mid Central “answered” this question indirectly by saying it runs an enrollment scheme :
Central PHO runs an enrolment scheme that matches up people who wish to become enrolled with a practice in the locality taking enrolments through a 0800 number. The only people on a waiting list in MidCentral are those waiting to find another GP to enrol with – i.e. transfer to another GP – or who are “waiting” to enrol with a particular practice. We work hard to ensure that all people have at least one practice that they can become enrolled with – beyond that it is up to individuals to choose
(b) Patient churn ? Practice enrolled populations tend to be quite stable in MidCentral region – the only reasons people have disenrolment are because of death, moving away from the region, or transferring to a Practice which belongs to another PHO (which can happen at our boundaries e.g. people living between Waikanae and Otaki may chose to go south (Compass Primary HealthCare Network PHO) or north to Otaki or Levin which is part of central PHO) – in the past two years our enrolment has grown overall by about 1,700 people in the past two years, mainly due to a drive to achieve full enrolment in the Horowhenua..
14. Lakes District DHB
Contact person Sue Wilkie
Sue.Wilkie@lakesdhb.govt.nz
All GPs in the Lakes District DHB are aligned to a PHO.
(a) Closed GP books / Extent of Waiting Lists ?
We are not aware of any GPs who have closed books in the Lakes DHB area.
Patient churn within the region ? ? You will need to approach the PHOs directly as our portfolio manager for this area does not have this level of detail.
15.Hutt Valley DHB
Contact person Jill Stringer
Jill.Stringer@huttvalleydhb.org.nz
Only one PHO (Te Awakairangi Health)operates within Hutt Valley DHB, and 100% of the GPs in the DHB region are signed to it.
(a) Closed books/waiting lists ?
Please go to this link on our website, which is updated fortnightly.
(http://www.huttvalleydhb.org.nz/content/3971f5b6-00e4-4e35-81d9-1acac7ead0de.html)
At time of writing in early October, this showed that only ten out of the 28 medical centres listed were taking on new patients.
http://www.huttvalleydhb.org.nz/content/82c5da41-8f5c-4496-b944-3b90f2f22ac1.html
Information on waiting lists and the extent of patient churn were not available.
16. Capital & Coast DHB
Contact person : Izzi Brown
Izzi.Brown@ccdhb.org.nz
Capital & Coast DHB has four PHOs in its region, one of which is a cross boundary PHO with Hutt Valley DHB. There are 338 GPs operating in this DHB district, including locums. There may be a very small number ( e.g those working as a GO with a specialised interest in sports medecine) not signed to a PHO.
(a) Extent of closed books/waiting lists ?
Cosine Primary Health Care practices and Ora Toa PHO are taking on new patients. Well Health Trust’s four member practices have open books and are taking on new patients. …Individual Compass Primary Health Care practices may have open or closed books at any given time.
Ora Toa PHO does not have a waiting list for new patients moving to the area but does have for patients wanting to change PHOs within the area.
Extent of patient churn ? There were 281,106 patients enrolled in the DHB area in July 2011, and 24,469 (8.7%) were not enrolled with their previous PHO on the same register on July 2012. [However] 2026 patients were still enrolled but with a different Capital & Coast PHO…
17. Whanganui DHB
Contact person : Sue Campion
Sue.Campion@wdhb.org.nz
The Whanganui DHB immediately directed the queries to the PHO, the Whanganui Regional Primary Health Organisation, which did not reply to my written queries.
18. Hawkes Bay DHB
Contact person : Anna Kirk
Anna.Kirk@hawkesbaydhb.govt.nz
There is one PHO in the Hawke’s Bay DHB region – this is a merger of three PHOs into the one last year. (Hawke’s Bay PHO, Wairoa PHO and Totara Health) “ There are a number of GPs in Hawke’s Bay taking on new patients.” The ratio of closed books and the extent of waiting lists was unspecified.
However, as Hawkes Bay DHB chief executive Dr Kevin Snee advised :
Hawke’s Bay DHB wants to have a better gauge on what is happening in general practice and is going through a process of appointing eight of its senior managers to also act as relationship managers with general practice These eight managers will be responsible for building and developing relationships with individual general practice.
19. Northland DHB
Contact person : Liz Inch
Liz.Inch@northlanddhb.org.nz
Like Whanganui, Northland DHB immediately re-directed the queries to the two PHOs in its region, Te Tai Tokerau and Manaia, and noted that GPs manage their own patient registers. Written inquiries to Te Tai Tokerau and Manaia PHOs brought no response from Te Tai Tokerau, but Manaia PHO spokesperson Lisa Wickham replied :
Manaia PHO have 22 member practices – of these, 4 currently are not taking enrolments. The remainder are taking enrolments however some only take enrolments if the patient lives in their area or to replace departing patients.
And as for churn rates of patients? Manaia PHO advised : I am afraid I do not have patient churn rates on hand, and would have to do undertake some analysis to get these. I wonder if this may be something that sector services at Ministry of Health could assist with?
20.Counties-Manakau DHB
Four PHOs operate in the Counties-Manukau District Health Board area. Namely, East Health Trust, Alliance Health Plus, National Hauora Coalition and Procare Networks Limited. As elsewhere, all general practitioners providing primary health care services funding through a PHO agreement are members of a PHO.
(a) Closed books/waiting lists ?
All PHOs have advised that all practices are currently accepting enrolments of new patients….There are no waiting lists – as no practices have closed registers.
(b) Extent of patient churn ?
. Note, this is the percentage of change in register numbers [between]June 2011 and June 2012 Changes in total register numbers may be due to the movement in practices from one PHO to another, as well as the movement of patients between practices.
Procare Networks Limited + 1.6%
National Maori PHO Coalition Incorporated + 6.7%
East Health Trust + 3.4%
Alliance Health Plus Trust ‐3.9%
Conclusion : Clearly after 20 OIA’s and numerous follow ups, there is still not anything like a clear national picture of GP availability. However, Hutt Valley, Invercargill, South Canterbury and Nelson -Marlborough – to name a few – appear to have significant problems.
Yet even this highly incomplete picture usefully demonstrates (a) that many (most?) DHBs have no idea about the state of GP availability in the GP practices within their regions, and (b) even at PHO level, the state of knowledge is patchy. Only at the Medical Centres themselves, and among the anxious patients trying to access them, is the scarcity of GPs in some parts of New Zealand being played out. Given that primary care is supposed to be the foundation stone of our health system…that situation seems astonishing. Or at least, as astonishing now as it was when it first became apparent to me that GP availability could be a problem, via that incident several months ago in the Newtown Medical Centre.
ENDS
Tags: cancer treatment, DHB amalgamations, DHBs, doctor waiting lists, GP availability, GP numbers, GP training, health statistics, healthcare afforability, PHOs, primary health care, regional GP shortages
Its how the DHB’s do things, they pass the buck and pretend the provision of specialist health care is someone else’s ( a PHO’s/gp’s) obligation.
What about asking questions to the
Chair of the PHO Performance Programme Governance Group
Helen Mason via the PHO Performance Programme Manager
Serena.Curtis@dhbsharedservices.health.nz
The Wellingtonian published an article “Health cuts bite” it was about the CCDHB’s recent $5.6 million dollar funding cuts. Hard hit was Newtown Union Health Services and a debate summary between Dr Gray and the CCDHB was published. In this you could see how the CCDHB did not care that the NUHS was providing the need of highly specialist care, specialist care that is the CCDHB’s obligation to fund.
*The NUHS is not to be confused with the Newtown medical centre.
I would also like to make it clear that there was no confusion – actual or implied – in my article between the Newtown Medical Centre and the Newtown Union Health Service. The ability of people in the same catchment area to access quality healthcare is an issue however – although in these two instances, the reasons differ.
Sorry Gordon, I only mentioned it incase I caused confusion by my mentioning of another Newtown primary care practice in my comment.
It’s worse in Tairawhiti than they admit. A situation ongoing for at least a few years is not “temporary”. Once enrolled with a centre where we had no designated GP, we could not get in to other centres to get a dedicated GP (my daughter has a chronic health condition, we need continuity of care),although they would accept new patients from out of Gisborne. A new mega centre run on a business model has just opened, easing the situation.
GP workforce is a huge potential problem. The average GP is well into his or her 50s now. Many are at retirement age. Many are concerned with how on earth they will exit GP in the next few years, as there is no new workforce of GPs wanting to take on their patients. There is a crisis in Horowhenua, I recently worked there. Levin is hugely underdoctored with hundreds of people being unable to enrol with a GP. What is worse is the high turnover of locums needed at high cost to keep rural practices limping along. There is no light at the end of the tunnel for aging practitioners or rural practices. The West Coast is vastly underdoctored and precarious. Many of our rural practices are sole practices, and Medical assurance wont lend money to buy a sole rural practice anymore.
There certainly is a crisis. GP training is not well funded, doctors take a big loss in income and conditions to train as GPs. They often have young families and mortgages at the time to consider GP training, and just cannot afford the financial losses to become a GP in an increasingly depressed workforce. This year HW Aotearoa are trumpeting the ‘increased funding’ for GP trainees, which is a net loss in conditions or money for any doctor working as a hospital registrat in 2012. I know doctors who will continue working as GPs untrained, because they cannot afford the loss in income to become a GP trainee.
The workforce of 50 somethings are under increasing pressure of devolution of services from secondary to primary care. MOH have all sorts of great ideas for things that GPs can take over from them, minor surgery, colonscopies, cancer treatment. They also want medical students at all stages trained mroe in prmary care AND all the advanced trainees is hospital specialities are to be required to train in primary care. How does a diminishing workforce manage all of this with no increase in funding, or space and facilities? Doctors who want to retired are selling their practices to foreign companies like Peak Primary
- so NZ health $ creating a profit for offshore agents. South health and Southern Cross also getting on the the act of buying up practices. But who will work them?
There is a huge crisis in Primary Care in NZ, and its going to get worse very soon.
“At a wider level, New Zealand’s health strategy is supposed to be based on primary (ie GP-based) care, and on its integration with other health services – although for obvious reasons, the primary care system seems driven as much by the profit margins of the providers, as by patient need.” – what obvious reasons are those, for the ignorant of us?
In the Napier/Hastings Area as everywhere, there are GPs and gps. Some GPs are very good and thorough, others verge on incompetent.
Getting onto the books of a GP with a good reputation is difficult. Most have closed their books and have a waiting list. There is always room on the books of the gps who are no good, have a bad reputation or are just plain obnoxious to their patients (sorry, I mean ‘clients’).
The good news is that we are getting some newer GPs from overseas who are smart, young and treat their patients well. The downside is that some of the Gps imported from overseas are the opposite but have not yet got a reputation locally to prevent patients from going on their books.
The lesson is to ask around and be prepared to do your homework before you move house. Be prepared to change doctors if you have problems. Once you have found a good GP, *only see that GP*. Don’t give into the pressure put on patients (I mean ‘clients’) at medical centres to see ‘any old doctor’. That causes loss of continuity of care. Locums *do not read the files of those they are seeing* and spend most of the consult taking history and ordering tests that have already been done. These visits are often wastes of time and money for all concerned.
Of course you could go to a Gp outside of the PHO, but it’s $60 a time to see them whereas the PHO fee for 15 minutes is $28.
Other weaknesses in the HBDHB system: the slow processing of test results with increasing delays in result delivery and increasing difficulty (almost an antagonism) in communications between pharmacies and Medical Centres (they still use fax machines rather than email!). The nationwide (and decades long) problem of prescription collections being tied to one pharmacy continues as a connected medical/pharmaceutical database remains in the ‘too hard’ basket.
Who owns the PHO’s.
The whole medical system in crisis has just developed with a stronger and more intensive focus on money. Meanwhile in the dark DHB bat caves corrupt usage of public funds increased with no accountability thrives.
The DHB’s( in my opinion and through first hand experience) have cultivated an extremely inhuman way for the clinicians to view some of their patients. In reality we have no medico legal system in place ( the HDC does not function and frequently supports the violation of patients rights with their “toilet paper” responses and expensive lieawyer ) .
Working with the greedsters, many providers have lost sight of even the basic responsibility to provide appropriate medical services for patients, others cannot get funding for patients care or medical needs and do not rock the DHB gravy boat.
I am not saying ALL GP’s obey the DHB&PHO profit mantra, but when the corruption and greed is stacked so high to the top it takes a courageous GP (and a real doctor) to move against profit mongers .As more and more doctors get f’d in the A maybe more will see how wrong things are and want a real change.
People often wonder how the doctors in Germany could have done such terrible undoctorly things, well we can see they felt pressure to do wrong and did it . The pressure today is not fear for ones life, but a hypnotized state of apathy towards patients and fear of the HDC/govt scape goating them if they speak out.
At the same time the hopes of NZ youth to gain independence are crushed on a reduced wage which is even under min wage, the GP’s get a salary increase to secure their unquestioning loyalty to the profit mongers.
Medical work force issues have been a political football AND a sweep them under the carpet problem for at least 25 years. I first came to New Zealand as a GP 27 years ago. There was no true work-force planning then, and there isn’t now. (Contrast that with the UK where GP manpower control was extensive) I made enquiries at the time, not one organisation seemed able to respond to my queries with any sensible answer. Of course, the neoliberal and market driven reforms of this country straddle this time, I was told that the market, under the reforms of the 1990′s National Government would deal with this!!! The blame for the continuing problem lies pretty well right though the health system, including GPs themselves. NZ has depended for so many years on importing GPs, mainly from the UK, but also South Africa and now from many other parts of the world. Immigrant GPs often come here ill prepared for the semi-chaotic health organisation of this country. UK immigrants in particular will find, as I have, that they end up getting paid much less than in the UK, perhaps working a little less hard, true, and ending up retiring with little or no pension. I calculate my move to NZ has cost me at least $500,000 in reduced income and perhaps $500,000 in index linked pension entitlements. NZ trained graduates have much better understanding of this, they either leave the country, or enter a central city/suburban practice, where conditions are reasonable, cover is available and financial rewards are highest. GPs in country towns, however, earn much less, work much longer hours and are much more stressed. It’s no wonder NZ has difficulty filling GP positions, and the next ten years are going to prove really troublesome, as the average age of GPs throughout the country is approaching 50. But NZ GP’s must share the blame as they have proved to be very intransigent in agreeing to any sort of controls on practice here. The UK solved this intransigence by making sure that GPs remuneration was adequate recompense for the loss of independence.
But the problems of the GP workforce is reflected in many other aspects of life here, the fact, for instance, that politicians can’t even agree a strategy for pensions is plain crazy. I’ve been a baby-boomer all my life, politicians their advisors have had at least 50 years to make sure that my generation will not be a problem for society, but apparently, for politicians, even 50 years is not long enough notice to come up with a cross-party, generally agreed policy.
Primary health care in NZ is a mess, that it works at all is a tribute to the hard work and dedication of the professionals who work in the health system. . Midwifery services hived off in a very political take over, thanks to Helen Clark, the Community Card System, expensive to run and of limited if any benefit, the ACC adding it’s spoon to stir the mixture, political short-termism and dogma – for instance the National Party ruinous reforms of the 1990′s, a far too high fee structure for GPs which is a real impediment for the poorer population to get help, fees in primary health, but not for secondary, which creates problems for ED departments around the country, fragmentation of many bodies, Maori, charitable, trusts, DHB, the beginnings of corporate ownership etc. etc.
I don’t know the answer, though. There certainly won’t be any simple one. Some suggestions to get on with
PHOs and DHBs need to be rationalised.
Salaried GPs, with paid holiday leave, paid locums, paid study time, government owned premises and the promise of an adequate pension would attract a lot of younger GPs who will see some security in such arrangements.
Move fee-earning GPs to a full capitation system, with locums/holidays/pension entitlements,
Scrap the Community Card System
All GP consultations to be at minimal (token cost) and free in certain areas.
Much greater use of nurse practitioners.
Re-integration of maternity care throughout the country.
All this to be paid for by an increase of general tax revenue, I would favour an increase in income tax, a wealth tax, inheritance tax and a two-tier GST system, eg essential goods and services say 12.5% and luxury items (cars, watches, jewellery, travel, entertainment) a 25% GST), others can argue about the details. I look at it this way, an inefficient, fee for service, uncoordinated service, is costing this country hugely, nobody wants to pay tax, I know, but in fact, the country as a whole would likely gain financially and our health, particularly of the lower deciles, would massively improve. .
Maybe greed could be the problem.
What a shame, there is this forum for GP’s and doctors to talk about the problems in the health system and yet there is not the input needed.
Only one doctor says all the healthcare agencies/bodies such as ACC, DHB,NHB and multiple “trusts” eat up the healthcare dollar (and so NZ Gp’s get less money than the UK).
Surely more than one doctor in NZ wants to see the problems of the corruption with money sucking out of the of healthcare.
Is it OK to not have the autonomy.
Is the changed role of a doctor accepted.
I am sad to see you all happy/compliant with the health system.
Only I must want see that to solve the problems a start would be to eliminate ACC, DHB’s, PHO’s , HDC ,the bogus trusts, excess bueaurosplats, the feed australia program and the NHB.
I have no sympathy for doctors salaries, when doctors cared more about their patients they would treat their ailments for what that person could pay.
…happy with the stated role of a doctor as “custodian for the health dollars” ?
You know damn well that is not true, its to ask a dr to denying medical treatment/care to his/her patient so as to provide more for the ongoing top level corp parasites in the health system.
At some point either fully accept a complete role change start by looking at the books OR remember who you are and start to resist the destructive unhealthy trends.
You know that with parasites in the body unless they are removed the body remains ill, this is just that, a case of big hook worms in the health system.
…happy with the stated role of a doctor as “custodian for the health dollars” ?
You know damn well that is not true, its a way to ask a dr to deny medical treatment/care to his/her patient so as to provide more for the ongoing top level corp parasites in the health system.
At some point either fully accept a complete role change start by looking at the books OR remember who you are and start to resist the destructive unhealthy trends.
You know that with parasites in the body unless they are removed the body remains ill, this is just that, a case of big hook worms in the health system.
Thanks Gordon for asking these questions, and revealing that even with multiple layers of health bureaucracy (Ministry, DHB, PHO etc), the system is unable to collect (let alone make public) basic statistics about the health of the health system. However, as I’m sure you’re aware, this article barely scratches the surface of the health care problems in this country.
Those who do manage to get a consultation with a GP seldom get assessed as a whole person, seeking professional advice on how to increase their health. Instead they are treated as a faulty biochemical machine, and their symptoms either masked with pharmaceuticals (eg steroid cream to suppress eczema) or dealt with by swapping out parts (surgery).
When was the last time a GP asked any piercing questions about your diet? Your housing situation? Your your state of mind? Your home/ work life balance? Your connectedness to extended family and neighbourhood? Your exercise habits? Potential environmental influences on your health? Yet there is peer-reviewed medical research that shows all these can be causative or aggravating factors in illnesses that are routinely written off as a simple body failure, and treated with drugs or surgery.
Perhaps the catastrophic lack of primary care you describe could be addressed by allowing people subsidized primary care visits to the healing practitioner of their choice, whether that be an allopathic (drugs and surgery) doctor, naturopath, chiropracter, herbalist, acupuncturist etc? Obviously to be eligible for subsidies the practitioner would need to hold a recognised qualification in their field, including the same studies in things like anatomy and physiology that allopathic doctors learn in basic medical training, and ideally significantly better studies in nutrition and environmental medicine than allopathic doctors currently receive.
The health system currently is like a car we bought that we have to push everywhere.
But we (both patients and doctors) are told to keep pushing it around increasing its bulk. its an institution we created with the idea of making health care accessible and more affordable for all, yet as time past it become destructive and it fails us on every count.
We have a doctor shortage yet the institution hires them and funds them to solely work on changing their reported numbers and statistics, hiding their failures repeatedly.
I can’t even read the health ministers press releases anymore, they are so disgusting and untruthful.
I don’t know what changing the delivery of medical care to pharmacists care will do, but for those using one of the 200 drs that should’ve been struck off I can’t imagine it will be any more tramatic/fatal?
Do note that it is only woman who have been told to get pharmacy medical treatment of their bladder health problems and not men. I guess men’s bladder health is more important to the govt, they can get medical care but woman shouldn’t.
So the new pharmacy GP health system came about a little history….
There was significant disengagement between clinicians and dhbmanagers.
So in 2009 the National Government commissioned “In Good Hands” from a Task Force Group on Clinical Leadership.
After spending money on their task force the government sought to develop a new partnership with the health professions.
Recommendation did not involve trying to engage the managers who were found to be unresponsive and rude in many cases.
One may only guess at how well the patients are doing with the new financial incentives for the clinicians to act like dhb managers/mercenaries.
Its mind boggling stupidity, behavioural problems were found in the managers and the ministry solution was that the drs should behave like the managers -bling.
So now everyone is out for money, and no ones focus is on the patients needs.