GP – Heart of the community campaign
July 12, 2017
To raise awareness of these issues and garner support for existing and future GPs, the Royal New Zealand College of General Practitioners has unveiled a new campaign: GP Heart of the community. Please take the time to find out more about this campaign and we hope you will give it your backing.
The campaign aims to attract extra government funding to train new GPs and make GP visits more affordable to those most in need. It will help increase understanding of the pressures felt by GPs, provide assistance to those who need it and help patients get the most out of their GP visits. At the campaign launch event, attended by Minister of Health Dr Jonathan Coleman and health sector representatives, Dr Malloy (Chair of the College) said 44% of GPs are ready to retire in the next 10 years, and we need more GPs overall. This comes at a time when our hospitals are running at capacity and need as much care as possible to be managed in the community by general practitioners.
No, before you ask, this is not a campaign for better pay. The aim is to make primary healthcare affordable to all and to ensure the sustainability of general practice in the future. We are trying to draw to attention the potential calamity that is about to befall primary care in NZ.
Shortage of General Practitioners
Already, in many parts of the country it is impossible to register with a GP because of full practice lists and an inability to recruit the new doctors required. In many areas, there is a wait of up to a couple of weeks to see the GP of your choice. Many of our colleagues locally, especially those who are single handed or work in very small practices, cannot recruit new doctors, cannot sell their practices and cannot employ locums to cover their practice for annual leave or sick leave, and have to shut down when they are not working. Clearly there are insufficient GP trainees coming through and the career pathway is not attractive enough to young doctors who have massive student debts or who do not want to drown in paper work. Most of our doctors find that they have 2 hours of paper work for every half day of consulting. That includes processing all results, reading all specialist letters, answering queries, generating repeat prescriptions, writing reports and chasing up patients who are due immunisations, mammograms, smears, or other tests. Younger doctors find the administrative side of general practice completely overwhelming and many older doctors burn out.
It is evident that we need more general practitioners, and given the training time for a GP is close to a decade we are really on the back foot.
Funding Issues – impact of free under 13s and VCLA funding
GPs have major concerns about how general practice is funded and many believe the system is so badly flawed it cannot be fixed and a new solution needs to be found.
The current funding arrangements are highly complex. Like Medplus, most practices rely on a co-payment fee from patients for each visit and get some 'capitation' funding for the patients enrolled with them. This capitation funding provides enough to pay for 4 visits per year for the under 6 year olds, 2 visits a year for the 6-13 year olds, very little for adults of working age and a small amount for the elderly. This is why the price of a consult is age dependent. There is no funding increase for patients with a community service card or who are on low incomes. Rural areas get higher funding per patient than urban areas. Unfortunately the amount of capitation funding given does not vary to reward practices who operate in evenings or weekends, are well equipped, provide additional services, employ high quality nurses and administrative staff or operate out of high quality facilities.
Practices are not allowed to charge a fee for under 13 year olds, whether they attend once or a hundred times. So, if all the under 6 year olds come 4 times or less a year and the 6-13 year olds come 2 or less times per year the practices' costs will be covered for those age groups. However, the utilisation rates for youngsters varies enormously meaning some practices operate at a loss. The aim of making healthcare free to this vulnerable group of society was laudable, and we all hoped it would make a difference to the many children growing up in poverty in New Zealand. Interestingly it is practices like ours, on the affluent North Shore, that have ended up having higher utilisation rates, and colleagues from poorer areas report less of an impact. Is this the worried well? Perhaps. However, we strongly believe that parents need to be encouraged to seek help if they are worried about their childrens' health and never discouraged. The adverse consequence of this is that many of our enrolled children come way too frequently for their funding, meaning the practice ends up subsidising their healthcare costs at the expense of other age groups.
Another perverse funding issue regarding children is that of 'claw back fees'. The practice a child is enrolled with has to pay a 'claw back' fee of $25 each time the child is seen at another practice or accident and emergency centre. So, if your child is sick whilst you are away on holiday and you see a local GP, or if you decide to go to Shorecare in the middle of the night we end up being sent a bill even though you may not have had to pay anything.
If capitation is accepted by a practice the co-payment fees can only go up by a certain percentage each year, this year the rise is capped at 1.32% overall. So, practice owners who invest heavily in staff, training, equipment and facilities cannot put their fees up to re coup their outgoings without going through serious red tape.
Whilst most practices are funded on the system detailed above there are a few practices that have a completely different funding – the VCLA model. This is Very Low-Cost Access funding, and it applies if the population supplied by a practice has 50% or greater "high needs" which means that 50% of the patients are Maori, Pacific or those that meet the NZ deprivation index of quintile 5. For these VCLA practices the funding is higher and so the fee charged to adults is capped at $18, a fraction of the true cost of an appointment. The injustice of this system is that a poor person living in an area like Hauraki does not get the benefit whilst poor people living in poor areas do. Conversely, rich people living in poor areas benefit from highly subsidised general practice visits and only have to pay $18. Most of us would agree that if there has to be differential levels of funding, the increased funding should follow those most in need of subsidised health care. Another perverse effect of VCLA funding is that neighbouring practices find their patients make an exodus to the cheaper VCLA practice nearby.
It is impossible to be competitive on price when there is an uneven playing field.
The following links offer more information on this difficult issue;