From the members and Board of General Practitioners Aotearoa
To the Honourable Dr Shane Reti,
First and foremost, many congratulations on being elected Minister of Health. We are hopeful having a current colleague as Minister will result in an excellent working relationship with you, and an informed understanding of the issues.
As a newly formed representative organisation and voice for GPs in Aotearoa we wish to brief you on the most important issues facing GPs and General Practice and call on you to consider these with urgency.
We are keen to meet you as soon as possible and start a constructive working relationship to address the issues we raise below.
1 – General practice is in crisis
Call it for what it is. Ten years ago, 40% of New Zealand’s doctors were GPs, now only 25%1. This decline is set to continue.
The GP workforce is shrinking because of the systematic fragmentation over the last 20 years of how general practice services are delivered.
At the same time, GPs treat patients with increasingly complex health issues and acute illnesses, while dealing with increased compliance requirements, more paperwork, more demands from rejected and devolved work from the public secondary sector, and a huge reduction in income for GPs who own their own practices.
The secondary care multi-employer collective agreement seems very attractive in comparison.
2 – GP shortage is dire. We call upon you to urgently address the shortage of GPs and GP trainees in general practice by improving remuneration, training and funding for primary care
To provide the most basic general practice care to the population of New Zealand, we currently estimate a shortage of at least 1000 GPs based on RNZCGP data1. This workforce is facing a tsunami of retirement. Some of that retirement is planned, and some early retirement of burned-out doctors.
If current net immigration numbers continue at 100,000 per year, we’ll also need an additional 120 GPs per year just to service that population.
This will cost the whole New Zealand health system dearly, and it will cost society. In countries like New Zealand, general practice looks after 90% of medical conditions2. The UK Royal College of GPs put it bluntly:
“If general practice collapses, the rest of the NHS will follow not far behind it.”
We would face a similar scenario here.
3 – The budget-savvy case for funding primary care
General practice care is far more cost-effective than hospital care, yet it is the most neglected. Funding primary healthcare is an easy financial win with fast returns for the Government.
The critical shortage of GPs means people have to wait longer for care. New patients in some parts of the country simply can’t register with a GP because their books are full.
This in turn overburdens the secondary sector as more people turn up to hospitals, and the whole system is at risk of collapse. The General Practice Leaders’ Forum calculated that a 6% drop in GP consultations will result in a doubling of emergency department (ED) presentations3.
The UK Royal College of Emergency medicine reports4 that even a small decrease in people being able to access GP consultations has the potential to put great pressure on hospital urgent and emergency care.
When people with minor issues go to ED because their GP is booked up, it means people have to wait for hours at ED where staffing and funding are already under pressure.
Recent health and budget policies have been hospital-centric. This is a false economy. There is an abundance of published evidence demonstrating that the return on investment in primary care is ten times the return on investment in secondary care5,6,7.
In Australia, data from 2019 and 20208 shows the astounding cost difference between someone who takes their illness or injury to ED rather than their GP. Even when the person was not admitted to hospital, the average cost to the government for someone visiting ED was $595.17. Meanwhile, it cost the government only $76.95 to support a patient to spend 20 to 40 minutes with their GP.
By working and knowing their local communities General Practice is best positioned to address health inequities and the specific needs of their community.
4 – Huge investment in General Practice is needed to address the long term underfunding of the pillar of primary healthcare
Now. Lots. For the benefit of the government Budget and New Zealand as a whole.
5 – The current funding model is a failure and we call on you to work with us to develop a more sustainable and effective funding model for general practice
GPs have become so underfunded, under-resourced, under-valued, and over-worked, the crisis it has reached is no longer sustainable.
The figures in the 2022 Sapere report9 show that full-time GPs who own their practices are spending at least 40 hours a week facing patients, much of which is either un-paid or underpaid. They then spend at least a further 10-20 hours a week working un-paid admin.
The Sapere report advised equity with public secondary specialists, who have 30% of their 40 hours a week quarantined for non-patient-facing work. Hospital doctors also get holiday pay, sick leave, KiwiSaver, CME leave and funding – none of which is available to a small GP practice owner or GP contractor.
We propose urgent changes to how GPs are paid. We strongly contend this Government cannot afford not to do so.
6 – We support reinstatement of smokefree legislation
The reversal of the smokefree legislation is not supported by evidence.
We have proposed better ways to improve the Budget within the health system, that don’t have a body count.
7 – We support re-drafting vicarious liability legislation
This legislation may work for a large emergency department, but the fear of vexatious lawsuits is yet another factor forcing the egress of existing GPs and deterring potential GPs who may be forced to endure the time and financial cost of defending themselves.
8 – Rural general practice is under threat
The rural GP network is at best fragile, held together with locums and telehealth. In places the rural primary care workforce is under-trained, and the emergency PRIME service is pitifully funded.
More than 30% of New Zealanders have a rural address, but all the conversation around health budget is focused on urban centres and hospitals, which is particularly disheartening for the struggling rural health sector.
Summary
General practice as we know it is about to cross a tipping point.
To avoid an inevitable collapse of our public health system once this point is crossed, General Practitioners Aotearoa wants to urgently meet with Government and work together to help provide a solution to restore a viable general practice sector that attracts our brightest and best to meet the health needs of New Zealand.
Kind regards,
Dr Buzz Burrell, Dr Jocelyn Wood, Dr Api Talemaitoga, Dr Marcia Walker, Dr Ari Pfeiffenberger.
The Board of General Practitioners Aotearoa
References
1 – ‘GP Future Workforce Requirements Report’. The Royal New Zealand College of General Practitioners 2022. https://www.rnzcgp.org.nz/news/college/gp-future-workforce-requirements-report-highlights/
2 – ‘The future of general practice’. House of Commons Health and Social Care Committee 2022. https://committees.parliament.uk/publications/30383/documents/176291/default/
3 – ‘Re: Draft Prescription for Capitation Payment Rates for Enrolled Persons Receiving Certain Services from PHOs from 1 July 2023’. General Practice Leaders’ Forum 2023. https://gpnz.org.nz/wp-content/uploads/GPLF-joint-response-to-draft-Prescription-Notice-7-June-2023-FINAL_WEB.pdf
4 – ‘What’s behind the increase in demand in Emergency Departments?’. Royal College of Emergency Medicine 2021. http://president.rcem.ac.uk/index.php/2021/08/06/whats-behind-the-increase-in-demand-in-emergency-departments/#_ftn6
5 – Veline L’Esperance, Matt Sutton, Peter Schofield, Thomas Round, Umer Malik, Patrick White, Mark Ashworth. ‘Impact of primary care funding on secondary care utilisation and patient outcomes: a retrospective cross-sectional study of English general practice’. British Journal of General Practice 2017; 67 (664): e792-e799.
6 – Starfield B, Shi L, Macinko J. ‘Contribution of primary care to health systems and health’. The Milbank Quarterly 2005;83(3):457-502.
7 – Gravelle H, Morris S, Sutton M. ‘Are family physicians good for you? Endogenous doctor supply and individual health’. Health Services Research 2008 Aug; 43(4):1128-44
8 – ‘Report on Government Services 2022, Section 12 Public Hospitals’. Australian Government Productivity Commission 2022. https://www.pc.gov.au/ongoing/report-on-government-services/2022/health/public-hospitals
9 – ‘A Future Capitation Funding Approach. Addressing health need and sustainability in general practice funding’. Sapere, 5 July 2022. https://srgexpert.com/wp-content/uploads/2023/07/A-Future-Capitation-Funding-Approach-July-2022.pdf