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Rural Primary Health
A GP voice from South Taranaki
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I believe current government and District Health Board (DHB) policies are not addressing the rural health workforce problem in a way that will help. When it comes to promotion, support and enhancement of rural and semi-rural primary health, GPs in small towns are not just ignored, they are discriminated against. Annette Kingís Health Workforce Advisory Committee (HWAC) is not representative of nor seems particularly informed about the physicians who provide the backbone of rural primary health care (GPs) nor has it bothered to report on the high quality published literature on the subject, assuming it knows of its existence.
In the Rural Expert Advisory Group 2002 report "Implementing the Primary Health Care Strategy in Rural New Zealand" to the ministry [http://www.moh.govt.nz/moh.nsf/wpg_Index/Publications-Index], the stated "ultimate goal" is to achieve "accessible and appropriate primary health care services for people living in rural New Zealand." This goal will be achieved through attention to the three aims:
Until recently South Taranaki averaged 2,000 patients/GP (about 15 FTE/30,000 people), and most practices coped, often by seeing people less often. With the departure of 1Ĺ GPs (Dr Perkins & Taylor) on 30th June, Hawera practices will be stretched, which flows on to unmet health needs or greater use of Emergency Department and secondary services.
 Rural Retention Funding:
This is a joke. Firstly we have to meet strict criteria on what a "Rural GP" is. The Rural Ranking Score is more relevant to the South Island. However, places like Stratford and Inglewood qualify, despite being if anything over-doctored and much closer to Base Hospital, as do Eltham & Manaia (15 minutes out of town), while Hawera, sitting in the middle of one of the most under-doctored areas in the country doesnít. This is largely because the efforts by many people (including GPs) to develop better emergency services (ED and ambulance), makes it appear that Hawera is better catered for. The DHB has interpreted this Rural Ranking Score very strictly, despite instructions from government to be flexible. Midwives in Hawera are classed as Rural, but not GPs (as the only remaining GP doing Obstetrics, my obstetric work is rural but my general work isn't!).
On-call and locum funding has been trickled to a few rural practices, some havenít seen any. Again, through our own efforts we have a joint arrangement with the Emergency Department where GPs provide back-up when they are busy and they cover GP after-hours when they are not busy. This arrangement covers 8 South Taranaki GPs, so I have a one week in 8 roster. Without this arrangement even more GPs would leave.
The worst parts of the funding are the bureaucracy associated with it and the linking of payments to PHO membership, so that patients of any GP who doesn't join a PHO are left out (see ).
We are still unable to get locums that often, I just get other practices to cover or donít take holidays. Smaller places like Okato have to close with no cover!
 Increasing medical student numbers:
This sounds like a good idea if we want to pay for some of the best trained doctors in the world to service USA, Canada, Australia, Britain and affluent areas of NZ cities. The problem is not so much that we are not training enough doctors, we are not attracting them to the rural sector nor retaining current rural GPs. Annette King did understand that accepting more medical students from rural areas increases the possibility that they will be interested in working in the rural sector. However she doesnít seem to understand that by making life more difficult for rural GPs, recruitment and retention problems get worse (see , ).
I was born and bred in Auckland but when I did the Family Medicine Training Program, we had to work in a country practice for three months (I did Warkworth) and a city practice for three months (I did Mangere Health Centre). A large clinic in South Auckland is not a nice place to work, particularly after experiencing a medium sized rural town, the real community one experiences in such a place and the access to outdoor activities. It wasnít hard to look at moving to the rural town of Hawera in South Taranaki when I saw an ad from a local GP in the New Zealand Medical Journal.
Most, if not all student and registrar training has been aimed at the specialties, so we should ask how much rural and generalist experience are students and registrars now getting? Politicians provide much of the funding; they should be expecting positive answers to this question. Even the Internal Medicine Society of Australia and New Zealand (IMSANZ) recognises we will need fewer highly specialised physicians and more generalist physicians [Graham, N & Larkins R "General Medicine in Australia and New Zealand: The Way Foreward" Health Policy Unit of the Royal Australasian College of Physicians http://www.racp.edu.au/hpu/workforce/gm.htm or ftp://www.medeserv.com.au/racp/genmed.pdf ].
There is a move in Canada and Australia to train more doctors and physicians in "rural medicine". Ontario has established a new medical school -its first in 30 years- with a curriculum focussing on rural practice [David Spurgeon "New medical school to focus on rural practice" BMJ 2001;322:1270 (26 May)]. In 2001 the Australian Federal Health minister announced nine new clinical schools and two new University Departments of Rural Health, with a AU$117.6 million package to ensure at least 25% of all medical students receive a minimum of 50% of their clinical training in rural and remote areas. ["OZ Rural Training CANBERRA" Society of Rural Physicians of Canada FEB 6, 2001 http://www.srpc.ca/issue303.html].
A very full review and policy recommendation on rural and remote practice issues was unanimously approved at the 2000 Annual Meeting of the Canadian Medical Association (CMA). There are 28 recommendations on training, compensation and work/lifestyle support, many relevant to New Zealand rural primary care. The full document is easily accessed in the Canadian Medical Journal and on-line: [CMA Policy "Rural and Remote Practice Issues" CMAJ 2000 (17 Oct); 163 (8): 1047-1050 http://www.cma.ca/staticContent/HTML/N0/l2/where_we_stand/2000/09-20b.pdf]
New Zealand doesnít have to re-invent the wheel, just look at what Canada and Australia are doing.
 Informing New Zealand graduates of NZ opportunities:
 Informing New Zealand graduates of NZ opportunities:
In order to attract NZ graduates, they need to know what is available. The Hawera Hospital Steering Committee wanted to attract New Zealand graduates by trying to write directly to doctors currently working as senior House Officers or Medical Registrars. We thought it is probable that some donít know what they want to do yet (ie how do you decide if you want to specialise if you donít know what choices there are?). We found it impossible to learn who they were or obtain a mailing list!
Likewise, local GPs wishing to attract associates are forced to look overseas as they are denied direct access to Family Medicine registrars. City DHBs will not provide that information, as they want their registrars to stay with them. The NZ Resident Doctors Association wonít help either, as they have told me that rural General Practice or rural Hospitalist (Medical Officer) careers are "dead-end"!
Funding for training programs should include the requirement that a secretary of each training program circulates information about New Zealand career opportunities to all trainees (ie confidentiality is maintained, but prospective employees and GP associates have a contact point).
 PHO model imposition:
Well meaning efforts are doomed to failure when based on political ideology (left or right) while ignoring what studies tell us or failing to listen to rural and semi-rural GPs. This is clearly contrary to stated government policy on public consultation.
Introducing a pepper-pot system of some low cost access practices in South Taranaki (or South Auckland) creates huge stresses for all GP practices. It is a stressful working environment which makes retention difficult in rural General Practice [see my review of the subject of rural GP & physician recruitment and retention on-line at http://home.bitworks.co.nz/blayney/tdhb2.html#3].
Those practices that either donít qualify (as most wonít) or elect not to enter the PHO model, face unfair competition and loss of their lower income patients. This will force them to either reduce their marginal profitability further (see ), or only cater to those with insurance or high income. Their low income patients are either forced to move to a PHO practice with 6-9 minute consultation times or through loyalty or an understanding that high quality primary care is worth paying for, stay with their non-PHO GP and have less money for other things in life. The PHO model creates such a "two tier" system in primary health as it doesnít target the needy by targeting individual practices (which only tells us it is about control not equity).
Those practices that do become part of PHOs face yet another layer of bureaucracy, greater demands for information and less control of their practice methods. Increased funding is expected to go towards reducing fees and co-payments are discouraged or capped. This forces GPs to work long hours or markedly reduce consultation times in order to generate enough practice income to avoid a drop in personal income.
Both scenarios increase stress, which studies reveal is the major reason GPs leave rural practice, or even General Practice. Neither system improves working conditions for rural GPs.
 Income and other remuneration:
While some GPs can generate a lot of income, most want to provide a good service and have to limit the number of patients they can see in a day, so incomes under $70,000 are common. PHOs remove some of the independence and control of practice conditions that partly compensate for a lower income, so by adding to the stress of rural practice they may well drive GPs away from General practice to work in a DHB job for twice the income or overseas where a GP can easily earn three times the amount.
Instead of accepting more managers and restrictions, I would be much better off away from General Practice working in a hospital or a salaried clinic where I could double my income and have lots of holidays. In the "New Zealand Doctor" of 9 April 2003, the Association of Salaried Medical Specialists states that a Vocationally Registered (which I am) but Salaried GP working for a DHB would earn $120,000-$125,000 pa for a 40 hour week, with on-call paid as overtime above this, a minimum of 5 weeks annual leave (I manage about 10 days, which is very tough on my family life), paid sick leave, two weeks CME and dollar-for-dollar Superannuation subsidy.
Most GPs would give up their independence if they were salaried but only a few clinics offer salaries, and GPs have little say in their governance, so they are not very attractive after tasting the relative freedom of private practice.
 Independent Nurse Practitioners:
Despite claims that these nurses would work in teams with GPs, we all know the Independent Midwife story with all the "easy" work taken and the more complex given to specialists. GPs have been forced out and I am the only GPO left in South Taranaki (and I only continue for the sake of innocent women and children who would otherwise be an hour away from obstetric help, certainly not for the money which is only 4.6% of my income). The HWAC has ignored the fact that women now have less choice and face more risks with no financial saving to the country as a result of midwife independence (as GPs expected when we learnt who would be the deputy-chair of the committee and that midwives outnumbered the one GP). We already see a huge fragmentation in care from school clinics where nurses are "de-facto" prescribing oral contraception and the GP only gets to see the girl when things go wrong and they often object to paying for our input.
It is only by seeing the "easy" cases that GPs can keep a lid on fees (swings and roundabouts philosophy) and maintain some degree of overview, providing preventative care and ensuring the overall health management of a patient is appropriate, efficient and safe.
The more we see super-clinics, diabetic and asthma educators, alternative therapists etc all having an input in management, the less efficient and more difficult patient management becomes. It is the GP who can most appropriately determine if and when someone is ready for a physiotherapist, a dietitian, a specialist review etc, yet many of these services are being supplied (and publicly funded) at the request of any number of practitioners (or the patient themselves) at the wrong time or inappropriately. I know that sounds like "patch protection", but it is true. Remove the gatekeeper and limited resources get wasted.
Overseas studies support the use of Nurse Practitioners (working in association with a GP), not Independent Nurse Practitioners. If we start having Independent Nurse Practitioners seeing GP patients, they will face higher fees when they do want a GP, or they will find the GPs have left to go where they are needed and so place a greater strain on secondary and specialist services. On the other hand, my Practice Nurse provides invaluable support within the practice and in co-operation with the GP, but now receives a much smaller subsidy and expects much higher wages. The government clearly doesnít support Practice Nurses under GP control/supervision.
Prescribing is a complex process and limited knowledge of pathology, pharmacology and Evidence Based Medicine is a recipe for big mistakes. Just look at the evidence on "simple" antibiotic access there is a direct relationship between access and resistance rates (Very high resistance rates start to occur where there is no restriction as in Thailand and New Zealandís disaster with OTC Bactroban). I must refuse requests for antibiotic use for leg ulcers by nurses at least twice a week (strong evidence that without cellulitis all they do is create resistant strains of bacteria).
If the government really wants to support and encourage high quality rural health care, I believe it is going about it the wrong way. More medical students will not provide a short-term answer and is unlikely to be a long-term answer unless conditions for current rural and semi-rural GPs improves to the point where rural General Practice becomes attractive. The schemes that have been proposed are likely to fail because they are divisive, restrictive and piecemeal, whether one is talking about PHOs or Independent Nurse Practitioners. Systems that have been useful, such as the Practice Nurse subsidy have been eroded.
Restrictive definitions of what is rural and who qualifies for the rural subsidy are counter-productive if it excludes GPs in rural towns as is the case for Hawera. It is in rural towns that rural General Practice can not just survive, but flourish and interact with community hospitals and small emergency departments, making after-hours cover viable. Schooling, social facilities and professional support (CME, peer review, back-up etc) in rural towns will help attract and retain doctors. The rural town GPs usually supply medical care for their surrounding rural communities and can back up the few remaining isolated rural GPs, particularly with after-hours and emergency cover (co-ordinated with ambulance and emergency Department services). However this is neither recognised nor supported by health authorities yet the loss of GPs in rural towns would be disastrous for rural communities.
Dr Keith T Blayney
Hawera 12th April 2003
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