Media release from Pinnacle General Practice Network

Staff shortages and the wrong type of working environment could severely hamper the delivery of primary healthcare within the next decade or two.

A survey conducted by the Pinnacle General Practice Network in the Central North Island shows that remedial action is needed to prevent a crisis developing.

These results came to light as part of annual collaborative research undertaken by the Pinnacle's Knowledge Management Team, which serves to compile and disseminate relevant information to the health sector. The survey focuses specifically on the Waikato, Lakes, Taranaki, Eastern Bay of Plenty and Gisborne regions. It is also unique in that it includes general practice nurses, not only doctors.

"We have a higher than average patient to doctor ratio and an unusually large proportion of our people live in small rural communities," says Pinnacle CEO John Macaskill-Smith. "Still, the newly released findings confirm many of the results of similar research done nationally."

Chair of Pinnacle, Dr Frank Cullen, says the primary health care sector relies on having high quality staff. "This is something the previous and current generation of New Zealanders have always had access to, with general practice and community based nursing services in both rural and urban settings.

"This report clearly highlights areas of fragility for health service provision. Failure to address these issues will have a major impact on health service access for individuals as well as major economic consequences for the entire health system in New Zealand."

The ratio of patients to doctors and general practice nurses will skyrocket as the Baby Boom generation ages and their medical needs increase, at the same time that many of the current service providers are expected to retire. There are proportionally fewer GPs in younger age groups to take over from their older peers.

A further complication is that in the research area only 12% of GPs under 45 years of age choose to own and operate their own practices, which is a major threat to the current business model.

As the Baby Boomer age-wave also occurs in most Western countries, New Zealand cannot expect to cover shortages with foreign professionals. In the past, local shortages have been addressed with overseas-trained staff. In parts of the region covered, New Zealand trained doctors are in the minority. According to Mr Macaskill-Smith, this source is becoming harder to tap, especially now that South African medical qualifications are no longer recognised in New Zealand. After the UK, South Africa has been the largest source of foreign doctors in the Pinnacle region.

"To make matters worse, local doctors may be lured overseas to alleviate the situation elsewhere. While nationally we are targeting resources to train additional health professionals, unless we start to create an attractive environment for them to practice in, we will effectively become a high-quality exporter of skilled personnel," warns Mr Macaskill-Smith.

Apart from issues arising from an ageing population, the continued provision of primary health service at current levels is likely to be affected by the growing number of female GPs, according to the study. Female GPs need to balance the demands of childbearing and family commitments with their career, which limits the number of hours they can devote to their profession. At present, the average female GP in the area canvassed works about 26 hours a week, compared to an average of 36 hours for males.

When it comes to practice nursing staff, the issues and outlook are generally the same as that for GPs. However, the gender imbalance is decidedly more serious. All but one of the practice nurses in the Pinnacle network are female. They have to cope with similar demands as female GPs.

Addressing the problems may require new ways of thinking, suggests the report. This includes the possibility of new types of medical professionals who are purposely trained to deliver the specific services most needed in a primary healthcare setting, potentially bridging the divide between practice nurses and GPs.

"Planning for the retention and recruitment of the primary healthcare workforce is more critical than ever," says Dr Frank Cullen. "This report is a key turning point, where planning can begin based on local facts, not just political possibilities."

A second report, to be released in the coming weeks, will look at population projections over time, specifically at high-need population groups.

Among the other findings of the survey are:

GENERAL PRACTITIONERS

Gender: Male GPs outnumber female GPs nationally. This gender imbalance is more marked in the Pinnacle network, with only 31% female vs 39% nationally.

Age: The average age for male GPs is higher than that for female GPs - 49 years compared to 45 years. Both nationally and in the Network, there are proportionately fewer male GPs under the age of 40 years and more over the age of 55 years compared to female GPs. Nationally as well as in the Network, proportionately very few GPs are in the younger age groups. The male Network GP workforce has a similar age distribution to that of the national male GP workforce. In both, two-thirds are over 45 years old.

Race: Maori and Pasifika GPs are significantly under-represented in the Network. This imbalance is particularly marked in the Network when compared to the enrolled population it serves. Maori and Pacific People are greatly under-represented in the GP workforce nationally compared to the NZ population as a whole.

Foreign vs NZ trained: Less than half of the Network GPs are New Zealand trained. Proportionately this is much lower than in New Zealand as a whole: 47% compared to 66%. The United Kingdom is the major source of non-New Zealand trained doctors in the Network, followed by South Africa. Overseas-trained GPs are more likely to be working in rural practices. Just under a quarter (24%) The next largest?received their first medical qualification in the UK/Ireland.  Another?group (14%) are African-trained, almost all of them in South Africa.  important source region is South Asia, with 8% trained in India/Pakistan/Sri Lanka.

Work arrangements: The majority of GPs work as owner operators. Almost one-third of GPs work as permanent employees or long-term locums. Owner operators are more likely to be male and older, while permanent employees and long-term locums are more likely to be female and younger.

Time in Current Practice: The average length of stay in the current practice is much longer for male than female GPs. Rural GPs tend to have been in their current practice longer than urban GPs.

Doctor/Patient Ratio: The ratio of patients per FTE GP seems to be higher than in any of the national benchmark scenarios, especially for rural practices. However, direct comparisons are difficult due to different parameters being used for measurement.

Work Load: Across the Network, three-quarters of GPs work full time (eight or more four-hour sessions per week). Male GPs are more likely than females to work full-time. A significantly higher proportion of male GPs work eight or more sessions per week: 92% as compared to only 38% for female GPs. On average, female GPs work significantly fewer sessions (6.4) compared to male GPs (8.9).

Work Load - Rural vs Urban: On average, rural GPs work 8.5 four-hour sessions per week, which is slightly higher than the 7.9 sessions worked by GPs in urban practices. GPs in urban practices are more likely to work five or fewer session that those in rural practices: 18% compared to 9%. The proportion of GPs working eight or more sessions per week is higher in rural practices: 85% compared to 71% in urban practices.

Rural vs Urban: Regardless of the definition of rurality used, a far higher proportion of Network GPs work in a rural setting compared to GPs nationally. Male GPs are more likely to practice in rural areas compared to female GPs. The proportion of male GPs working in rural practices is more than double the level found among the North Island GPs surveyed by the RNZCGP. GPs working in urban practices are generally younger than those in rural practices, with 65% of urban GPs under age 50 compared with 57% of rural.

PRACTICE NURSES

Gender: The practice nurse workforce is almost exclusively female, with only one male nurse out of 353 surveyed.

Age: The Network practice nurse workforce is older than the national nursing workforce, with 40% over the age of 50 years compared to The Network practice nurse workforce is clustered in the 40-54?30% nationally.  About?age range with well over half (57%) of the workforce in this age range.  12% of the workforce is aged less than 35 years, which is almost half the proportion in this age group nationally.

Race: Maori and Pasifika practice nurses are significantly Only 4% of the practice nurse workforce recorded their?under-represented.  There are no Pasifika practice nurses in the?ethnicity as Maori.  Network.

Work Arrangements: The practice nurse workforce predominantly works part-time.

Practice Nurse/Patient Ratio: The number of FTE practice nurses per 100,000 enrolled patients is 52, which is slightly lower than that for GPs (56 FTE GPs per 100,000 enrolled patients). The number of patients per FTE practice nurse is 1,927, which is higher than that for GPs (1,794 patients per FTE GP).

Work Load: The average sessions worked per week by nurses in the Network is very similar to that for female GPs. Practice nurses in urban practices are more likely to work eight or more four-hour sessions per week than nurses in rural practices - 44% compared to 27%. The average number of sessions worked by nurses is slightly higher in urban practices: 6.8 compared to 6.0 in rural practices. Interestingly, this pattern is the inverse of that for general practitioners, where rural GPs are more likely to work eight or more sessions per week.

About Pinnacle
The Pinnacle General Practice Network represents 100 medical practices working across five Primary Health Organisations (PHOs) in the Midland region, providing primary care services for about 420,000 people. It serves a diverse population encompassing rural and urban areas, retirement zones, a high proportion of Maori and many socio-economically disadvantaged communities.

The PHOs served by Pinnacle include:
Kawerau PHO (representing 100% of the Kawerau population within the Bay of Plenty DHB);
Lake Taupo PHO (representing 100% of the population in the Lakes DHB);
Pinnacle Taranaki PHO (representing 55% of the population in the Taranaki DHB);
Turanganui PHO (representing 75% of the population in the Tairawhiti DHB); and
Waikato Primary Health (representing 90% of the population in the Waikato DHB).