Health Workforce in New Zealand
The Health Workforce Advisory Committee (HWAC) released a discussion paper titled "Fit for purpose and for practice: a review of the medical workforce in New Zealand Consultation document" produced by the "independent" Medical Reference Group (MRG) and published in May 2005 and still available to download at http://www.hwac.govt.nz/publications/fitforpurpose.htm.
The "independent" Medical Reference Group (MRG) is chaired by the HWAC and 4 of its 10 members come from the HWAC (one being a GP), the Minister of State Services seems to be ex-officio and we only have one non-HWAC GP.
After reading this discussion document, I believe that the MRG has produced a political document that has got it all wrong and if they have their way, we will see even fewer NZ trained GPs working in New Zealand, particularly in rural areas such as South Taranaki. As it is, I am the only New Zealand trained GP left practising full-time between Stratford and Wanganui.
My submission to the HWAC makes the following main points:
- MRG ignores the fact that the "next best thing" for Maori wishing to have "by Maori, for Maori" is to have New Zealand graduates with a reasonable grasp of Maori concepts, culture and some commonly used Maori terms, rather than trying to attract overseas trained doctors (OTDs) aka International Medical Graduates (IMGs), who currently make up 40% of the workforce.
- MRG initially recognises that vocationally trained and registered GPs are specialists and that that GPs are remunerated at a much lower level than other doctors. Subsequently there is a total failure to make the connection between this lack of specialist recognition, the associated abuse of GPs by health managers and some politicians for any attempts by GPs to obtain a fair remuneration and the difficulty in retaining GPs, particularly in semi-rural areas. No one complains about dentists, hairdressers, vets, accountants and lawyers charging many times the fees that much more highly qualified GPs ask.
- MRG notes a "conscious move away from one size fits all approaches" in health, but then uses the PHO concept to exclusion, ignoring the 248 non-PHO General Practices (23%) and the populations they serve.
- MRG notes the campaign by the UK National Health Service, as well as Australia, Canada and the United States to attract our graduates, but their only answer is to say "The efficiency and effectiveness of the whole health workforce must improve." So HWAC dosen't want to look at why GPs are leaving and why our graduates don't want to go into General Practice in New Zealand, it just wants to reorganise those left in order to control them and force them to be more productive! MRG ignores the evidence that controlling GPs increases their frustration and stress and that capitation makes them less efficient.
- The MRG has failed to grasp the very simple and basic concept that retention of those we train must be paramount and this does NOT mean telling GPs what to do and for miserly compensation.
- The MRG is critical of competition in health with no evidence to support such a political view. They ignore the fact that competition keeps private doctors efficient, honest and motivated to provide high quality care, while removing competition has been a disaster for providing "timely, effective and efficient patient care". Removal of GP as the "gatekeeper" produces loss of continuity of care and often inappropriate use of specialists.
- The statement "We assume that: a significant private health sector will continue" is one of the few times the most efficient, productive and attractive sector for graduates is mentioned.
- The statement "In 2003, there were 477 rural GPs" is misleading, as only about 300 rural GPs are recognised as rural and get any assistance, the rest are consistently ignored. GPs in rural towns up and down the country are not supported, even though many have practices of around 2,000 patients per GP and face many of the problems more rural GPs face. HWAC should use a term like "rural and semi-rural" or this significant and critically unsupported section of the medical workforce will continue to be excluded from retention programs to its further detriment.
- The claim that since 2000, the medical practitioner to population ratio had been maintained only with the assistance of temporary OTD registrants (90% where a "suitably qualified New Zealand resident doctor could not be found to fill the position") is a major inditement into the lack of planning and importance health planners have placed on medical manpower retention in New Zealand. Furthermore, the statement "New Zealand is the only one of the comparable countries to see a significant decline in its GP to population ratio in recent years" not only tells us that contrary to the first statement, we are not maintaining that ratio, but it also should make us wake up to the fact that we are out of step with other countries who value their medical graduates, and compensate them appropriately instead of collectivising them and trying to force them to accept lower fees.
- DHBs find it difficult to fill RMO positions, especially in rural and community hospitals, and rely on OTDs, but very little has been done to encourage New Zealand graduates to work in the rural setting. The simple answers involve funding rural hospitals more and allowing them to offer better pay and working conditions, including debt repayment options for longer service. Allied with this is the need to support vocational training for the "Hospitalist" or generalist Medical Officer.
- New Zealand citizens are less likely to leave NZ and so should be given priority entry to Medical Schools and loan forgiveness options could be applied to graduates who elect to work in smaller hospitals or General Practice outside cities. Of course not many will continue to stay unless something is done to improve conditions for doctors working outside cities.
- The claims that "Public confidence in the medical profession has been undermined in New Zealand and overseas by a perception that the profession has put its self-interest ahead of that of patients and the public" is another political comment not supported by the facts. The latest New Zealand "Most trusted profession" poll happens to place General Practitioners at the top and politicians at the bottom. The myth of the "greedy doctor" promoted by health bureaucrats is one of the major causes of the current shortage of GPs in New Zealand. If we were greedy, why would we stay in New Zealand and accept low incomes? Comparisons with other countries don't take into consideration the relative spending power of their monetary units.
- There is no consideration given to the significant number of GPs who do not wish to be in PHOs and are currently unhappy in one or have remained outside. There is a serious possibility that many of these GPs will leave, as happened in the UK when the National Health was introduced.
- If PHOs are so inherently popular, why has the government refused to reduce prescription fees for non-PHO patients or increase Practice Nurse, over 65 and 18-24 subsidies for non-PHO practices? Answer - because there would be a huge exodus of GPs from the scheme.
- Could the statement "The health sector is again looking to doctors for leadership as well as technical skills" see the replacement of a raft of non-medically trained managers with a practising Medical Superintendent??
- The most important factor determining the success or failure of changes in skill-mix and roles have been left out, namely: - that the GP remains the co-ordinator of care and that the "trained health professional" does not try to take over that role. Otherwise health costs rise and expensive specialists are used as GPs.
- Political support for health insurance (say in the form of tax deductions) could well reduce public health costs far more than was ever lost in tax collection. It would also encourage many doctors to remain in New Zealand and provide the sort of care they were happy with.
- Non-PHO practices would be able to offer the same or better opportunities for work if they had the same funding. Evidence to date shows lower morale and poorer quality in capitated systems.
- The MRG acknowledges that the planning and development of the medical workforce must include those who practise, partially or completely, outside the public health system, but refuses to do so! If health decisions are made with only the inefficient, money gobbling, over administrated public sector examined, it is not surprising that the MRG is proposing a "barefoot doctor" system in New Zealand.
A mix of public and private must end up being the fairest, most efficient and cheapest health system.
- If the public system concentrated on health promotion/protection on one hand and emergency medicine on the other with much of the "elective" work done with private input, either by contract, or by charging everyone a fee, in proportion to their income, then we would have a far more efficient health system.
- "The central role of doctors will continue to be the diagnosis of clinical problems and providing and co-ordinating patient-centred care" is critical to understand and accept if any system is to work. The MRG then tells us to concentrate on populations and to develop "new professional roles". Clearly there is confusion!
- A review of undergraduate medical education is sensible, provided it isn't a plan to reduce quality and shorten the course. Mature students, particularly post-grad students should only be accepted if their scientific qualifications are equal or higher than undergrad students. Early exposure to clinical experience is useful to give some perspective and motivation to otherwise purely theoretical concepts, but not in order to rush through a shorter medical course.
- Any review of hospital and primary health workforce must not be by a politically selected panel. We need a majority of appropriate practising doctors (eg GPs for primary care) instead of bureaucrats, academics, midwives and other "health care workers".
- Interprofessional learning and practice been slow to develop in New Zealand because of different roles, and different levels of understanding. The idea is generally daft and should be dropped.
- Making the rural/Community Hospital "MOSS" role more attractive and effective should be a major focus of this whole process as small hospitals throughout New Zealand depend on these "Hospitalists". The first step would be to stop using the silly term "MOSS", which refers to a salary scale, and not to their internationally understood role as a generalist Medical Officer. The second would be to establish a vocational pathway that is registerable and recognised as a specialty (the Hospitalist), the same as vocational registration in General Practice should.
- The whole approach by the MRG misses the vital concept clearly outlined by Martin London that Retention must occur before recruitment, as then most recruitment will be unnecessary, and we will have doctors New Zealand trained for New Zealand conditions.
- There needs to be both systems for debt forgiveness for New Zealand graduates moving out of cities and into semi-rural General Practice AND serious attempts to make General Practice in New Zealand a high earning option. I suggest semi-rural, not rural settings as new graduates should not be working in isolation and it is the semi-rural sector that is in most need of support.
- Improving the status and remuneration of General Practice should be one of the key messages of this review instead of further degrading it by seeking to control GPs and objecting to even modest fees in the name of access. There is more evidence to support retaining a significant GP fee than the current drive to lower it both in terms of access and for GP retention.
- Private local providers employing Medical Officers (such as in Emergency Departments) will improve retention and where necessary recruitment without difficulty by paying well above the standard MOSS salary rates. It is a supply and demand economic issue.
- The dire shortage of semi-rural GPs is not addressed, so I suggest the next logical step is to include semi-rural GPs in some targeted funding to improve their "workforce situation and working conditions".
- GP trainee remuneration should be upgraded to be as good or preferably better than in other training schemes and ALL GP trainees would have to spend at least three months working in a rural or semi-rural setting.
- The repeated belief that "Benefit to users, rather than benefit to providers, is the ultimate measure of improvement" is the reason we have a medical manpower shortage in the first place. This attitude not only produces poor health outcomes but drives our best graduates and many experienced GPs away to go somewhere they are appreciated. What the user really needs is a good service, not a cheap bad service. What New Zealand graduates want is to provide that service, and get a reasonable income and be able to have reasonable time off.
- Market forces were never allowed to be applied in New Zealand so they can not be dismissed.
- The answer to our workforce crisis is not another committee of bureaucrats with wooly thinking.
- Restoring the central role of the GP in co-ordinating care would "enable the various stakeholders to work together more productively".
- According to the MRG, GPs will not get much of a say in the workforce committee, we are only recognised through through the NZMA or the RNZCGP, whose roles have been denigrated and listed as "secondary players".
- This whole exercise seems to boil down to having the Health Department (under the direct influence of the Minister of Health) with a few academic socialists tell the Minister what she wants to hear in vague enough terms that will sound like something is being done when it isn't, and certainly nothing that actually improves conditions for those greedy GPs who want to earn more than hairdressers, and without any significant input from the lazy GPs who could earn a lot more if they would only see 50 patients a day, joined the PRIME scheme to be on call at nights and enrolled more Maori in their PHO practice. Those GPs who refuse to join PHOs are to be ignored totally, just like the GPs who still think they have any place in maternity services. By the way, the last GP to leave, please turn out the lights.
The bottom line: What the user really needs is a good service, not a cheap bad service and what New Zealand graduates want is to provide that service, while achieving a reasonably good income with reasonable time off.
Any recommendations aimed at retaining our highly trained graduates and vocationally trained GP specialists have to address these issues, not some political agenda.
Dr Keith Blayney MBChB DipObs FRNZCGP (GP, Hawera)
If you wish, you may read my full submission to HWAC as an MS Word document here:.