GUEST BLOG: Ian Powell – From thriving to surviving: ‘Poster Child’ general practice struggle symbolises primary care crisis

‘Poster child’ is not a commonly used term in health systems. Its origin is as a North American noun that for something or person that epitomises a specified quality or cause.

‘Poster boy’ is a kindred term referring to a male in particular. The only occasion I can recollect it being used (possibly by myself) was over an earlier iteration of the Health New Zealand (Te Whatu Ora) Commissioner Lester Levy.

This was around four decades ago when he was a prominent populariser of the then National government’s failed attempt to create an internal competitive business market to run Aotearoa New Zealand’ health system, public hospitals in particular.

Zooming into Waikanae Health

In contemporary times the Waikanae Health general practice has had the term ‘poster child’ applied to it because the strength of its processes and staffing. That is, until very recently.

NZ Doctor has an impressive record for drilling down to a workplace level in order to better understand the extent of the crisis in primary care.

Fiona Cassie drills down further in NZ Doctor

This is explored by NZ Doctor journalist Fiona Cassie continues this practice in a recent paywalled article (11 October): ‘Poster child’ practice workload ‘almost beyond tenable’.

Located 60 kilometres north of Wellington on the Kāpiti Coast, Waikanae is defined by Statistics New Zealand as a medium urban area covering 19.59km.

Its estimated population, as of June 2024, is 13,150, with a population density of 671.26 people per km.

Waikanae on the Kāpiti Coast 

Like all of the villages and towns on the Kāpiti Coast, Waikanae is a Māori name. Its English translation is “waters of the grey mullet” referring to fish in the Waikanae River..

Disclosure: My now deceased parents retired to Waikanae and were both patients at Waikanae Health. For over 10 years I have lived in Otaihanga on the south side of the Waikanae River.

From thriving to surviving

Cassie reports that three years ago, the practice had 12 full-time equivalent doctors and 11,000 patients.

Health Minister Shane Reti used Waikanae Health for major health announcement

In recognition of this long-established and respected practice, it was chosen for the Minister of Health Dr Shane Reti as the venue for the media launch in June of government funding for direct GP referrals to free radiology services. This was a good initiative.

By then, however, the practice had transitioned from “thriving to surviving”. Covid-19 had accelerated some planned GP retirements.

This forced it to ‘close its books’ to new patients and impose a “sinking lid” enrolment policy after it struggled to recruit and retain staff in the midst of a widespread general practice shortage.

By October the number of full-time equivalent GPs had fallen to 5.3 and the number of enrolled patients had fallen by over 200 to less than 9000 patients. With Waikanae a popular retirement area, a high proportion of these patients are elderly and frail.

Waikanae Health beach satellite now closed [Image: Waikanae Watch]

In April 2018 Waikanae Health opened a satellite clinic at Waikanae Beach to better serve the many high-needs residents who lived in the beach settlement.

However, last September the practice was forced to close it. This satellite was an important feature of the ‘poster child’ status.

Other service cuts include stopping sessions at four local rest homes, cutting back to just one evening clinic, outsourcing its after-hours care to telehealth and a Paraparaumu urgent-care centre, downsizing its daytime walk-in urgent-care clinic to a triaged afternoon clinic, and dropping most minor surgical procedures that used to be routine.

Staffing shortages and beyond untenable workloads

Due to staffing shortages senior GPs at the practice found themselves forced to increase their patient load thereby having to work up to 80-hour weeks. Their workloads had become “almost beyond untenable” and “unrelenting”.

Cassie reports a GP who had worked at the practice for 25 years as observing that “The question is, how long can we keep this up?” GP shortages, a “broken funding formula” and workloads had forced the practice to retrench.

I have discussed this “broken funding formula” in my Newsroom published opinion piece (1 November) on the implications for primary care over the formal complaint of GenPro, representing general practice owners, over a breach of fair trading’ to the Commerce Commission.

I argued that the complaint is a response to a severe power imbalance over funding that serves to undermine healthcare: Power imbalance in general practice funding.

According to the above-mentioned GP, the workload is “unrelenting” – the toughest in the 25 years he has been at the practice – and getting “almost beyond untenable”.

There may be a small light at the end of the tunnel with new overseas bringing the full-time medical equivalence up to 7.5, along with two nurse practitioners this month. But this still leaves 2,500 patients without a doctor.

As a temporary measure, in July, Waikanae Health sold a minority share to Latitude (the practice ownership arm of its Primary Health Organisation, Tū Ora Compass) until the practice can attract new in-house shareholders.

A health system needs a general practice like a child needs a village

What has brought this thriving ‘poster child’ practice to the brink has been severe funding constraints,  GP shortages and high workloads. This has led to some staff walking away “for their own health”.

Attracting new blood to a practice whose doctors are “burning out” is difficult. In the practice’s words, “It’s difficult to recruit. It’s difficult to retain. We bring in doctors from overseas and they just can’t cope with the service demand.”

The crisis the practice finds itself is a huge patient demand including many complexities, underfunded services due to a “broken funding formula” that doesn’t reflect inflation or its patient needs, and an “ageing and overworked GP workforce”.

Waikanae Health’s population has its own distinctive health needs as do the other practices on the Kāpiti Coast and, in fact, the rest of New Zealand.

However, the factors behind its crisis are common to all these other practices regardless of the differing distinctive health status natures.

There is a popular proverb that says “It takes a village to raise a child”. It means that an entire community of people must provide for and interact positively with children.

An adaptation to primary care in Aotearoa New Zealand might be “It takes a general practice to raise a health system”.

Waikanae Health’s ‘poster child’ dramatic migration from thriving to surviving highlights the wider risks for our health system when general practice is disenabled from doing this heavy lifting.

 

Ian Powell was Executive Director of the Association of Salaried Medical Specialists, the professional union representing senior doctors and dentists in New Zealand, for over 30 years, until December 2019. He is now a health systems, labour market, and political commentator living in the small river estuary community of Otaihanga (the place by the tide). First published at Otaihanga Second Opinion