GUEST BLOG: Ian Powell – General practice visits, emergency department presentations, and social determinants of health
Good data does not always provide answers. It is often the case that the value of good data is the identification of the right questions that require answers.
Invaluable data about the health and wellbeing of New Zealanders is provided by the Ministry of Health through its New Zealand Health Survey (NZHS).
The NZHS became a continuous survey in 2011 enabling the publication of annual updates on the health of New Zealanders.
It is an ongoing official government pulse-taking of health system access and a range of public health matters, such as rates of smoking, drinking and obesity.
The annual update for the year between July 2023 and July 2024 has recently been published: 2023-24 annual update of NZ Health survey.
General practice visits and emergency department presentations
One interesting revelation in this update is that over the past five years general practitioner visits declined while hospital emergency department visits increased.
General practice visits declining
The survey reveals 75.6% of adults visited a GP in the past 12 months compared with 78.1% five years ago (2018-19). For children the pattern is worse; falling from 72.8% to 66.6% over the same period of time.
On the other hand, the results are opposite for visits to hospital emergency departments over the same five year period.
Adult visits increased over the past five years from 15% in 2018-19 to 17.8% in 2023-24. For children the increase was from 15.1% to 21.3% respectively.
Contributing causal relationship
The relationship between decreasing general practice visits and increasing emergency departments is not linear or automatic. But neither is it coincidental or casual.
Instead it is causal; that is a relationship involving a connection between two variables where one variable influences or causes a change in the other variable.
In other words, increasing general practice accessibility contributes to reducing the demand for emergency department presentation. Conversely, reducing the accessibility of the former contributes to increasing the demand for the latter.
The operative word in the above paragraph is “contributes”. However, there is a greater causal relationship than that between general practice visits and emergency department presentations.
Social determinants of health: a greater causal relationship
There are two variables in this greater causal relationship. The first is the social (or commercial) determinants of health and the second is the health system (including but by no means confined to general practices and emergency departments).
Social determinants drive health system demand and costs
The first variable is external to the health system. These determinants include low incomes (the most important), poor housing, limited educational opportunities, social and community contexts, and healthcare access.
The increasing impact of these determinants on the health system are largely driven by increasing poverty (both extensively and intensively), the aging of the population, and population growth.
The effect of the increasing impact of social determinants of health is to increase both the demand for and cost of healthcare.
This is manifested most in the rise of acute patient demand which, for over a decade, has been increasing at a higher rate than population growth.
Social determinants of health have a direct and huge effect on our health system. But the health system can only have a limited mitigating effect on social determinants.
Instead government policies and legislation are required if New Zealand is going to assertively eradicate the impact of social determinants on the health system.
The New Zealand Health Survey provides a revealing insight into the connection between social determinants and health. From 2022-23 to 2024 the proportion of children going hungry increased from 21% to 27%.
This has an obvious impact on the health system; hunger contributes to illness as surely as day follows night. There is nothing the health system can do to mitigate this social determinant.
Health system mitigation of social determinants
However, there is still some capacity for the health system to mitigate social determinants. This begins by improving access to general practitioners in order that social determinant driven illnesses can be diagnosed and treated in a timely manner.
David Meates as chief executive led a district health board that had some success in social determinants mitigation
The forward-looking and innovative former Canterbury District Health Board’s focus on integrating community and hospital healthcare through clinically developed and led world-leading health pathways helped mitigate the impact of social determinants.
The success of these pathways was reflected in the above-mentioned impact of rising acute health and its origins in the social determinants. Canterbury led the way in bending the curve of this increasing demand.
What is also interesting is the impact on Māori life expectancy. The perception of Canterbury is that it has a small Māori population. In fact, it has the sixth largest Māori population of the former 20 district health boards.
Whereas for several years the life expectancy of Māori throughout New Zealand has been seven years less than for non-Māori, in Canterbury this inequitable difference has more than halved to three years.
This raises an intriguing question of the extent to which Canterbury DHB’s innovative approach to integrating healthcare across community and hospital has impacted on this remarkable outcome.
It is more a question of how much, rather than whether, it contributed to this outcome.
It’s obvious, stupid!
It is obvious that increasing general practice visits will contribute to reducing emergency department presentations.
Bill Clinton: from it’s the economy stupid (1992) to its obvious stupid (2024)
However, as important as this is, there is something even more critical; something that is obvious as obvious can be.
This is having a government committed to implementing legislation and policies focused on first reducing and then eradicating the social determinants of health.
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
Thanks for your description of the health challenges we face. I was fortunate enough to be born into a church that has a focus on the health message and while I abandoned it in my early adult life I have since come back to it and are increasingly aware of the importance of our choices. As you say government actions play a huge part in what ability to choose that people have and while my parents were able to start their married life with their own home (with a low debt to income ratio) as most couples then did and the ability to grow some of their food that is not the case today, people are constantly subject to advertising imploring them to buy food that is slowly poisoning them yet all governments support private profit over reducing social cost because it gets the votes and financial support for them.
The biggest deception regarding food is that most of the population believe that letting their taste buds and feelings determine their choices is essential as will be seen in the negative reaction whenever anyone suggests using tax or restrictions to change the choices that people make.
This government with it’s profit first approach is likely to increase the health inequality but most of our systems all promote a big picture view of the economy while ignoring the suffering of many so that the big end of town can feel good about itself. While our prophetic understanding tells us that hard times are coming we are constantly told that things will get better even though it is self evident that they never do.
They never do under National governments Bonnie however we always see some improvements under Labour led governments because they put the people first, not their donors like National.
Well said Ian and this govt obviously isnt
However, as important as this is, there is something even more critical; something that is obvious as obvious can be.
This is having a government committed to implementing legislation and policies focused on first reducing and then eradicating the social determinants of health.”
good luck with that
I don’t challenge you analysis but I wonder if the aggregated data on ED presentations would benefit from fine tuning. Region by region, for example. That must be available. Ethnicity also. It strikes me that around a third of NZ’s population lives in Auckland. It’s no secret that Auckland has become super-diverse in the past two or three decades, and from my own experience many recent migrants appear to favour the long waits at ED departments rather than GP visits. If this is still the case I’m sure there is an explanation. Cost most likely. Lack of knowledge of how the public health system is supposed to work. Take into consideration Hamilton and Wellington, both increasing diverse, and you’re probably looking at around 50% of the country’s population.
Then of course is the other side of the picture. It’s been reported in the media that wait times for GP visits are long in some regions, if you can actually get a practice to enrol you. Again, there may be some correlation with income but surely not being able to see a GP must have some impact on why many present at ED departments. A complex picture indeed.