Darrin Hawkes

Having attended the Patient Voice Aotearoa roadshow meeting in Whakatāne, I was pleased to see attention being given to the very real pressures facing our health system.  There were some deeply concerning experiences described at the meeting. Dr Malcolm Mulholland spoke about serious shortcomings experienced by patients and families around New Zealand, while local attendees raised genuine concerns about access to GPs, pressure on Whakatāne Hospital's emergency department, diagnostic services and mental health care.  Those stories deserve to be heard.

However, there was another substantial and, in my view, extremely important contribution to the meeting that was completely absent from the Beacon's account.  Dr Byrdie Johnston, a practising GP with around 20 years' experience who now operates her own practice, spoke at length about what is happening on the other side of the consulting-room door.  Her contribution was particularly valuable because it moved the discussion beyond examples of where healthcare has failed and towards another important question: why is the system struggling, and what might actually make it work better?

One of the more interesting points Dr Johnston raised concerned the number of GPs.   She discussed the quantity of GP numbers indicating that in the 1970s, New Zealand had approximately 1,500 GPs serving 2.8 million people, or roughly one GP per 1800 people.  Today there are around 3600 serving 5.2 million, approximately one per 1400. On those figures alone, the number of GPs relative to population has actually improved.  So why does seeing a GP seem to be getting harder?

The answer is more complicated than simply counting doctors.  There are fewer full-time GPs, while the work confronting modern general practice has become considerably more complex. GPs are increasingly managing patients with multiple chronic conditions, numerous medications, mental health needs, preventative care requirements and ongoing treatment following hospital care.  In effect, the job itself has changed.

Dr Johnston described today's GP as increasingly a "community physician", managing post-hospital care, medication changes and patients' health over long periods rather than simply treating an isolated illness.  That helps explain something that GP numbers alone cannot.

Dr Johnston also challenged what might be called the "15-minute myth".  Modern primary care medicine increasingly expects complicated health problems to be dealt with inside a consultation model built around short appointments.  Quality care within 15 minutes can be extremely difficult when one patient may have a relatively simple problem while the next presents with complex chronic disease, multiple medications or a serious mental-health issue.

Dr Johnston described previously seeing as many as 23 patients a day and commonly running an hour behind. In her own practice she now sees around 16 patients a day, allowing more time per patient.  This provides useful context when we hear that people are waiting weeks to see a GP.   The obvious response might be: why don't doctors simply see more patients?  But faster throughput is not necessarily better healthcare. If a shorter consultation means less opportunity to understand a patient's history, medications, recent hospital treatment or wider health concerns, we risk treating the immediate complaint while overlooking something more important.  The challenge isn't simply getting more patients through the door. It is having enough clinical capacity to provide good care once they are there.   I was left considering this is the role of “Primary Healthcare” and would practically contribute to improving New Zealand health statistics and reducing the demand upon hospitals.

That distinction is also important when considering proposals to make GP visits free.  At first glance, removing the cost of seeing a doctor seems an obvious way of improving access. But Dr Johnston raised an important qualification: if making consultations free increases demand without increasing the number of clinicians or appointments available, the result can be even greater pressure on an already constrained service.  Cost and access are not necessarily the same problem.

Removing a patient's financial barrier may help that individual afford an appointment, but it doesn't create another GP, Nurse Practitioner or hour in the working day. If substantially more people seek appointments from essentially the same clinical workforce, waiting times can potentially become longer.  That doesn't mean cost barriers should be ignored. It means funding policy needs to address both affordability and capacity.  Otherwise, we risk making healthcare cheaper to request without making it any easier to actually receive.

There is also a significant part of a clinician's workload that happens when the patient is not sitting in front of them.  Information arriving in a general-practice inbox, including test results and specialist correspondence, is checked by a GP or nurse, appropriately actioned and then filed. Only after that process may the information become available through a patient portal, at the discretion of the filing clinician.  There is a very good reason for that.  Automatic release of every result before clinical review could mean someone encounters serious medical information, such as a cancer diagnosis, through an electronic portal before the appropriate clinician has had an opportunity to communicate that result and explain what happens next.  That inbox work is largely invisible to patients, but it is part of modern healthcare.  It reinforces the broader point: GP workload can no longer be measured simply by counting the number of 15-minute appointments completed each day.

A significant part of the solution discussed at the meeting was making better use of the wider healthcare workforce.  Nurse practitioners work at an advanced level of clinical practice. They can independently diagnose conditions, order investigations and prescribe most medications, with a scope of practice comparable to that of a GP.  That's an important point because there can be a public perception that seeing a nurse practitioner instead of a GP somehow means receiving a lesser form of healthcare.  That isn't how Dr Johnston described the nurse practitioners working alongside her. They are capable of working autonomously. At the same time, medicine has become sufficiently complicated that GPs and nurse practitioners benefit from working in a collegial environment where clinicians can seek advice from one another when required.  Collaboration shouldn't be mistaken for lack of capability.

Dr Johnston also discussed the role pharmacists can play in reducing pressure on general practice. Pharmacists and other health professionals can appropriately take on some healthcare work, freeing doctors to concentrate on patients who most need their skills.  But there is another side to that solution.  A seemingly routine GP consultation can provide an opportunity to pick up other health issues, understand medication changes, monitor an ongoing condition or simply build the longitudinal knowledge of a patient that comes from continuity of care.  Dr Johnston distinguished between acute, one-off conditions that may appropriately be managed elsewhere and ongoing conditions where fragmented care becomes more concerning.

The objective, therefore, shouldn't simply be to move as many consultations as possible away from doctors.  It should be to use GPs, nurse practitioners, nurses, pharmacists and other health professionals intelligently, while preserving the communication and continuity that allow clinicians to see the whole patient rather than a sequence of unrelated medical problems.

This brings me back to the purpose of the roadshow. We need to discuss solutions as well as failures.  Dr Mulholland and Patient Voice Aotearoa are right to highlight cases where New Zealanders have not received the standard of healthcare they reasonably expected. Some of the experiences described at the Whakatāne meeting were deeply concerning and should not be minimised.  But if the purpose of travelling the country is genuinely to "take the pulse" of healthcare in our communities, then surely, we also need to understand what is happening inside the system and listen to the people trying to deliver that care.  Dr Johnston's contribution perspective did not contradict the experiences of patients struggling to access healthcare.  In many respects, it helped explain them, and it raises a question worth asking:  Are we primarily collecting examples of where New Zealand's health system has failed, or are we also trying to understand why those failures occur and what practical changes might prevent them?

There is value in listening to people whom the system has let down.  There is greater value in listening to them alongside the doctors, Nurse practitioners, nurses, pharmacists and other health professionals working within that same system.

The Whakatāne meeting contained both sides of that conversation, unfortunately, Beacon readers only got to hear one of them last Friday.  If we genuinely want better healthcare in Whakatāne and the Eastern Bay, we need to hear both.  Dr Johnston brought an informed frontline perspective to that conversation.