The Failure of Primary Care

In an ageing and growing population, the failure of primary health care in New Zealand is a dire problem. Many general practices are shadows of their former selves. There are too few doctors and too many patients. Many people can't even get enrolled. Those who are enrolled report wait times to see a GP of up to a month. The hours that GPs work have reduced and virtual appointments now seem to be their preference.

A high profile case occurred in Lower Hutt where the High Street Health Hub - now managed by Green Cross - has closed its doors to in-person appointments. They have 9,000 patients on their books. Sick people are going to either the After Hours clinic which is open from 5.00pm to 10pm, or to the Emergency Department at the Hutt Hospital. Queues at the After Hours reportedly stretch down the road prior to opening time. "It's a circus" was a firsthand report I heard from a patient waiting in the Hutt Hospital Emergency Department.

I didn't expect to find myself alongside her. 'People shouldn't be turning up at ED unnecessarily' was my former take on the situation.

But I had developed a blistering rash around my left eye. Three days in (Wednesday) I tried for a doctor's appointment via the phone but was told a GP was only available on Tuesday or Thursday in the morning and I would have to ring back the next day. Next port of call was the pharmacist, who refused to sell me any cream or ointment as she suspected I may have shingles. She advised I get medical help. This time I walked into the GP surgery and asked if I could book an appointment for the following morning. No. I could try my luck tomorrow morning but no appointment could be booked in advance. But she could see my eye was a problem as I relayed the pharmacist's advice. She consulted with the nurse who had  said over the counter, "We are only operating a triage system. You will have to go to After Hours or ED. Because it is near your eye you shouldn't leave it." This made no sense to me. I was being told medical attention was urgent but that it would not be provided there, my local surgery of 30 years. You can only stand your ground so long.

I duly drove myself to ED and arrived at 2pm. The place was packed. I was picking up snippets of conversation to the effect that wait times to see a GP were a month or more. That the After Hours was even worse than ED. That course of action had already been tried and abandoned.

Age-wise there was a cross section of people waiting for help: a fair number of distressed parents and babies, and a fair fewer older people in wheel chairs. But everyone was exceedingly patient and well-behaved.

The reception staff were efficient and warm. Two or three times they asked that anyone who wasn't a patient stood or waited outside due to seating shortages. Nobody grumbled. Patients were checked for BP, temperature and pulse rate not long after arrival but warned that the wait times were around 6 to 8 hours. As shifts changed, announcements were updated. Everyone was kept in the picture. After 8 hours a nurse sorted through the files of those who had been there throughout (a number had given up and left) and vital signs were re-checked. I was also offered sandwiches and pain relief.

About midnight a medical staff member came out and said they were at capacity and thanked everyone for their patience and courtesy to staff. PA announcements were also made staff-to-staff that intensive care could not accept any further admissions. There were also incoming trauma cases for resuscitation.

For a few hours it seemed nobody was processed though obviously unseen ambulances would also be ferrying people in. Surrounded by people whose need was greater than mine I accepted my wait would be longer. People were generally in reasonably good spirits and looking out for each other. As I drifted in and out of sleep, I Iistened to a mother telling her adult sick daughter about what is was like was she was "growing up." "You could ring for a doctor's appointment and get one on the same day - or next day at worst. And you were even offered a range of times!" The trip down memory lane probably wasn't making her daughter feel any better.

But that is the primary health system which most of us were familiar with. It has disappeared. At least it has where I live.

At 3.30am my name was called. The doctor was profusely apologetic about the wait. I was just happy to be seen. The suspected shingles had not progressed to the actual eye and a script for anti-viral medication was written. I was advised to return if the rash or my vision worsened (my heart sinking at the thought of another 13 hour wait).

My own GP could have done the same in ten minutes. That would have saved all of the additional attention and resources required at the hospital.

Workforce shortages appear to be part of the problem, though Green Cross seems to have its own share of management issues. Unfortunately the company also now runs my local healthcare centre which has significantly reduced in doctor numbers and hours of care provided.

It seems the doctors we train no longer want to be GPs. They want to work in hospitals. Or overseas where student loans can be repaid more rapidly.

If the demands on primary healthcare were reducing, the problem might be less serious. But our increasingly top-heavy population will only increase demand.

According to Royal NZ College of General Practitioners in a 2023 briefing to incoming Health Minister Shane Reti:

"We estimate if all the GPs who are at, or over, retirement age all stopped practicing tomorrow, there would be an additional 725,000 New Zealanders without a GP.
When waiting times are at an all-time high and practices are closing their books to new patients, having this many people searching for a new GP is unacceptable and goes against everything that our workforce stands for as we strive to provide complex, comprehensive, timely and equitable care for our communities."

So the Hutt experience isn't unique. In fact it would appear representative.

Depressingly, it is hard to envisage what would dig us out of this hole.  Primary care looks like a row of dominoes. But there is no point or justification in getting angry with those who remain as GPs under the stress and strain. Their staff are understandably trying to gate keep them from more.

But standing at the gate the message received is, "If you get sick - you're on your own."