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Changes in a Stressed System


It has recently been reported by Dr Buzz Burrell, GP Lead representing General Practitioners Aotearoa, that “the concept of the family doctor is dead,” and while we wouldn’t disagree with him, the rebuild of the new look model for general practice is well underway in some practices.

 

Recruitment and interest in emerging General Practitioners to embark on a career model where they own and operate their own general practice models is certainly not popular. The desire for work/life balance and the emergence of a higher ratio of female doctors and less interest in the traditional business ownership model is driving change. Throw into the mix the recent study by the RNZCGP highlighting part-time GPs are working full-time hours due to the lack of recognition of the impact of non-patient facing administration work. This along with a high percentage of doctors entering retirement age across the Whanganui rohe has thrown a real clanger into a model of general practice that has served Whanganui city and our rural communities well over many years.

 

The Whanganui Regional Health Network (WRHN) has chosen to inherit general practices in Whanganui, Raetihi and Taihape as their owners have exited. This is a sound strategy to support the community, but no matter who owns the practices recruitment of a workforce is still an ongoing issue. This has meant that clinics have had to look at different operating models in order to continue to enable people to register and attend clinics.  

 

There has been a move away from seeing ‘your doctor’ to one where you can get to see ‘a doctor’ or a nurse, a nurse practitioner, a physiotherapist, a health coach, a pharmacist, a health improvement practitioner a kaiawhina, a kairongoa, a whānau ora navigator, or you can have a telehealth option. These are all of the different options we are starting to see in some of our clinics.  For those who are used to a traditional doctor option this can be quite confusing and may leave them feeling anxious, but this diversification is needed in these changing times where the GP population is aging and where there is a real gap in the recruitment of GPs in primary care.  The future of primary health care is starting to change, but with the intent of still supporting their patients in the community. 

 

The traditional doctor and nurse led (and owned) general practice in some of our communities, is probably now less than 50%. The shift we are seeing began during COVID-19 but has escalated at pace since then. Recruitment and retention of doctors to provincial and rural New Zealand is challenging and we are feeling the impact of that. The financial sustainability of general practice is being questioned strongly by GP owners and operators, so is not as attractive as a career option, and COVID-19 has had a worldwide impact on medical recruitment. Australia appears to offer better work conditions and city placements tend to be favoured by recruitment agencies. Provincial and rural New Zealand tend to attract special characters that enjoy the challenge of medicine and love our outdoor recreational pursuits and our rich cultural heritage.

 

The challenges remain access for patients and timeliness for appointments. If the system is clogged and access to general practice is poor then people will also have problems accessing hospital services, as this often needs a referral from general practice. 

 

For acute and urgent requests WRHN practice members work hard to offer an appointment on the same day or within 1-2 days. Many of the practices are moving to nurse led phone triage, which means a nurse may be your first port of call when you ring, to take your history and view your notes and possibly offer you options. These may include an appointment, repeat prescription, access to one of the clinical team, or if they consider you need services outside of the general practice team, then a referral to Whanganui Accident & Medical (WAM) or ED at the hospital.

 

Rochelle Palmer, Lead Nurse, Impilo Family Clinic states:

 

“We nurse triage and support the doctor in a treatment plan if able. We keep urgent appointments for on the day. We ensure that children are always seen on the day. Phone consults when and where convenient are offered.

 

Unfortunately, when life gets busy with patient care volume, then the back-office stuff doesn’t get completed in a timely way, such as recalls. If patients are aware they are due recalls for an immunisation, cervical screening, etc., then we suggest they should book in and not wait for us to call them.”

 

Jamie Procter, Service Manager, Te Waipuna Health states:

 

“We do daily nurse triaging and have daily acute/unwell appointments available.  We use our Manaaki Hauora and Community Nurse Teams as much as possible and carry an extensive list of Standing Orders to reduce wait times for a doctor.  But the reality is the entire primary care sector is under pressure and for those practices that don’t have adequate General Practitioner workforce they will be struggling.  We are using locums a lot more frequently because of the demand, yet this will add financial pressure in the long run.”

 

General practices indicated that the amount of work being offloaded from hospital services (due to their workforce pressures) is increasing. Dr Emma Davey, WRHN Clinical Director states:

 

It is intended the WRHN leaders will be discussing in detail with the clinical leaders at the hospital how we can work together to manage risk for general practice, but also reduce risk for patients that are caught up in a complex system that is not responding as well as it needs to, to meet patient need and demand.”

 

Karen Greer, Practice Manager, Bulls Medical Centre confers with a lot of the approaches already stated, but also outlines some additional services that offer rural people better access:

 

“Bulls Medical operates a respiratory clinic to better manage winter coughs and colds. Given the practice location on State Highway 1 and 3, the clinic offers an urgent walk-in service for accidents and emergencies. This extends to a Saturday morning clinic from 8am-11.45am at Bulls Medical and is available for everyone, including casuals who are not enrolled at the clinic.”

 

Rosalie Glynn, Practice Manager, Wicksteed Medical Centre described a workforce under pressure particularly over the winter months, with the team being short of two General Practitioners out of seven:

 

“To mitigate the impact on patients we have employed telehealth locum doctors (at considerable expense). We have ringfenced urgent appointments in clinic daily. The clinic team have done all they possibly can do to minimise presentations at WAM and ED, by managing their enrolled patients’ needs within the clinic.”

 

Wicksteed Medical Clinic has implemented a ‘Practice Plus Book on Behalf’. This is a virtual doctor service where the clinic books an appointment for the patient if they are unable to access an in-centre appointment. The clinic provides the patient with a voucher to subsidise the cost for the patients. This cost is met for the patient by the practice.

 

Other practices using this service are Gonville Health, Ruapehu Health and Taihape Health. This is an example of how technology and innovation has changed how patients access services in a timely way.

For people living rurally, telehealth and virtual medical services are also offered as an option for after-hours healthcare through Ka Ora, potentially preventing travel to an urgent care centre, ED or hospital and that for some could be an hour or so away from home.

 




Jude MacDonald, CE WRHN says we must not underestimate the environmental impact of winter:

 

“Winter peaks are ‘a thing’. They are the breeding ground for coughs, colds, flu, COVID and that makes existing conditions worse for some people. Conditions that can be prevented through vaccinations such as meningitis, flu, measles are all conditions that require health care intervention generally, so being committed to getting your whānau vaccinated when they are due or eligible is a self-management strategy that really helps primary care and the hospital manage at busy times; not to mention keep your whānau free from risk.” 

 

Whanganui Accident and Medical (WAM) clinic is an urgent and afterhours service that is seeing increased volumes of patients accessing primary health care. Over the twelve-month period from July 2023 to June 2024, 25,602 patients were seen at WAM. Almost half of the people seen were for ACC injury and accidents (12,189) and the remaining (13,403 presentations) were for medical presentations across the age bands. The breakdown in ages for volume presentations for 2023-2024 is as follows;

 

Age Band

ACC

Non-ACC

TOTAL

0-14 years

3075

4694

7769

15-39 years

4159

3796

7955

40-64 years

3132

2945

6077

65+ years

1823

1978

3801

TOTAL

12,189

13,413

25,602

 

Overall, 48% of people presenting at WAM over the past year were for accidents and injuries, the remaining 52% of people who presented were for medical related reasons. Adults under 39 years of age and children are the most frequent attenders at WAM for the 2023/24 year. What is interesting is that 54% of presentations in the 39 years and underage group relates to medical health issues (not an accident or injury). What the system needs to unpick is are people presenting at WAM in preference to their general practice because they do not have an appointment in a timeframe that meets their concerns, or is this age group demonstrating a preference to ‘walk in and be seen’ services any day of the week, as is provided at WAM. Currently, WAM is working on surveying whānau who present, to capture data on why they have chosen to go to WAM.  

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