Insight: NZ's GP Service in a 'Critical Condition'

Already more than half a million New Zealanders can't afford to see their GP, and family doctors fear the situation could get even worse. They are angry about what they believe is a lack of government action over the way GP visits are funded, despite recommendations for sweeping changes.

In Whangarei, GP Andrew Miller is incensed many of his patients can't afford to see their family doctor.

At the same time, those going to other practices might be paying rock-bottom fees, even if they have a million-dollar yacht moored in the marina.

Dr Miller, who works at the Bush Road Medical Centre, believes it's a bad situation for patients who often end up getting more unwell than they need to. They end up at the hospital emergency department and, health-wise, their outcomes are considerably worse.

"New Zealand has got the worst access to equitable primary care in the world, second only to America, which I think most people would be surprised to hear."

At his practice, adults pay $38 per consultation. He estimates a third of his enrolled patients have high needs and can't afford it.  

"At the coalface every day I am talking to people with real-life problems related to high rents, unable to meet the cost of living. I don't see any 'rockstar economy' in Whangarei," he says.

The issue is that, elsewhere in town, GP practices with Very Low Cost Access (VLCA) subsidies charge all adult patients just $18.

Dr Miller describes the situation as "completely illogical" and he thinks patients are mystified as well.

While the system continues, his practice is losing patients.

He chairs the Manaia Primary Health Organisation representing practices in the Kaipara area, and explains that all newcomers enroll with a GP at a practice with VLCA subsidies - not one like his.

"It's a sensible decision. If you can fill your car up for $1 in one service station and it costs you $2 in another service station, it's generally a reasonably sensible decision to drive into the $1 service station to get your car filled."

A government-appointed working group recommended major changes to the VLCA scheme, to ensure better targeting of funds, but it is still awaiting a response.

In the meantime, Dr Miller and others feel ignored.

GPs argue what is needed is a review of the entire funding system, including the rates they are paid, which are based on the number of patients on their books. According to GP organisations the value of government support has eroded, increasing pressure on GPs to raise the fees they charge patients to keep up a healthy cash flow.

Medical Association General Practice Council chair Kate Baddock says that is essential if GPs' practices are to stay open. Otherwise more of them will go out of business, she says.

"We will have fewer GPs in New Zealand than we need and we will not have doctors going into general practice as an option. That's the future."

But many family doctors find this an alarming thought when the goal of the health system is to deliver more care, closer to people's homes, under the government's 'Better, Sooner, More Convenient' policy.

Takapuna GP Heidi MacRae set up her practice on that basis. But she has faced a multitude of costs for things like quality accreditation, free access for under-13s and developing online patient portals so patients can manage some aspects of their health records and appointments.

"The whole system relies on GPs' goodwill, and I think that GPs tend to have a huge social conscience. They tend to do the morally right thing for their patients, which puts them at a disadvantage in the business world where we have to see appropriate funding."

Patient portals are one of the latest must-haves for GPs, but they have to fund it.

"I've been trying to promote that service to other GPs in the area, and really cost is a huge barrier to most of them. They don't want to have to pay. The Ministry of Health is demanding that general practices start to implement portals but there's no funding to follow through with it."

GPS are doing a lot more in the community that used to be done in hospitals, such as minor surgery, but Dr MacRae believes even more could be done.

"One area that is screaming for additional funding for general practice is mental health. We have a service that's completely overwhelmed at the hospital. They can only deal with the most severe cases and yet there's no funding for general practice to support those patients with more minor degrees of depression and anxiety who could be very well helped in general practice."

The general feeling among GPs appears to be that district health boards are not releasing enough money to enable more health services to be provided locally.

DHBs agree but argue it is due to the growing pressures they're also under, according to their spokesperson - and Northland DHB CEO - Nick Chamberlain.

The challenge is that hospital service costs and the demand for acute treatment are both growing at a very rapid rate and so some DHBs find that they don't have enough money to do everything they need to do, he says.

Minister of Health Jonathan Coleman, however, is promising to take a tough line with district health boards - and require them to spend more of their money in primary healthcare.

But the uncertainty is damaging, in the opinion of Christchurch-based professor of primary care Les Toop.

"If you're having to create more wards and extra people are being hospitalised who could be looked after in the community, it's bad for morale. It's bad for patient care, bad all round really. That's what happens if you neglect one part of the workforce."

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