Not one cent more. How primary care lost the plot in talks on low-fees deal


Not one cent more. How primary care lost the plot in talks on low-fees deal

Bryn Jones

Not everyone was happy after primary care funding talks ended for the year

Looking back on months of talks, Angus Chambers wonders why the Primary Health Alliance was alone in wanting to negotiate hard with the Government on funding

This year’s primary care so-called “negotiations” have ensured welcome relief for a large number of low-income patients. That’s a win. These are t


In my view this is a case of 1 marshmallow now or 3 marshmallows later.

Angus and I will continue to disagree on approach. His view is that we could have held out for an allocation of money that was not identified in the Budget. I doubt that would have occurred and that any across the board payment to recognise increased compliance cost would have come out of the money that was allocated to the reduced co-payment which has indirectly gone to practices. 

I believe having agreed to implement the increased subsidy to CSC holders (which the sector had called for to at least partially reduce the inequity created by VLCA) we are now in a very strong position to negotiate for a significantly higher contribution to compliance costs which will be budgeted for. This message has been given loud and clear to the MOH and the Minister himself.

Sorry Mark, Angus is 100% correct, we have been totally shafted in this deal!

NO Government has increased capitation at the same rate as inflation let alone health inflation, in a fees review region like Whangarei over the last 15 years your co-payments are linked to this pathetically low percentage also, the result being your profitability sinks at an exponential rate. 

How we could have agreed to a bigger sinking lid with the Government that NEVER values General Practice or keeps their side of the bargain beggars belief. What is more concerning is a Polly Anna view that the leopard will change it's spots, value General Practice, correct 15 years of serial underfunding, put the protections back into the agreement that have just been removed (!!!) and start funding us annually at health inflation etc etc. 

This sort of stuff has to be negotiated. It has not been. It has been given away. 

Probably one of the most important articles published on this site.

When Mark states “This message has been given loud and clear to the MOH and the Minister himself” I don’t know whether to laugh or cry.

If I were in any way responsible for this deal I would hang my head in shame. How is even vaguely acceptable to make providers work harder for less? As I have said before you can only martyr yourself once. Thanks for that Mark. Not.

Patients will have no certainty about what they will pay when they are seen. Everything will be "extra". There are a lot of "extras". Did General Practice want this for our patients? NO. Unfortunately this is the only way to try to remain sustainable.

Government does not value our services above that of a packet of cigarettes. It appears that you do not either Mark.

So Mark, I think the reality is that you and PSAAP have not achieved anything you set out to achieve. Patients will not have certainty about what they will pay. This increased uncertainty will reduce attendance. It will increase disparities. General Practice will not be sustainable as there is no way that the eroding of the value of Government funding, the reduced income from services and reduced service utilization lead to economic sustainability. 

If you think that VLCA practices will be better off you are simply wrong. They depended on an uneven playing field for survival. They field has been leveled for CSC holders. There will be shifts in patient enrollments and VLCA practices will lose income.....and add in even more "extras"

So well done Mark, PSAAP. As Flanders and Swann said to the Ostrich: "Here in this nuclear testing ground is no place to bury your head"


Agree re increased complexity and disparity. It might all seem ok right now, but I'll wager in the years to come the "standard" consult will be shorter, the "menu of extras" will grow (eg charging for referrals / forms), as will the complexity of systems to cope with it all - which in turn adds costs. We are already seeing increased utilisation because it is now cheaper to come in than it is to order a telephone script. Makes all of the work we have done on trying to keep well patients at home to generate capacity for those with clinical need all a bit in vain. Well done Angus for your openness. A very interesting article which should be shared widely.

What  is    the reality  of  practices  utilisation  for   Under  6s  ? Is it  an  average  4 visits a year  + the   6 week  check  funded from  the  Tamariki  Ora  Budget? 

 Or is it  an average  6 visits  a year  , or 8  visits  a year  or 10  visits  a year ?

 What is  the   reality  of  utilisations   for  over  65s? is it   10  visits  a year   ?  Is it 8  visits  a year  ? IS it  6  visits a year . It IS  more than  4 visits  a year . 25- 50 year olds   don't  average  2 visits  a year  on  the  whole   for  medical    visits .

What  is  the  national  utilisation   for    NZ  is it  12million  2.5 visits  a year ? Is it  15million    2.9  visits  a year ?

  Is it   20million ~ 4visits a year ?

 How many scripts   are  charged a  script fee for  and  not   registered  as   a  GMS   type   equivalent  visit ? 1/4   of the  visits   4million   year ???

 1/2 scripts     9 million  script  fees  a year . ???

 Does  the  Ministry   know  >>

 Is  the  ration  of   GP  utilisation   to    Nurse  utilisation  still   5: 1  or is it  now 4 :  1 ????

A&M clinics   are seeing  millions  of  GP  patients    a year  at far  better  accident  remuneration  per visit  than  most  GPs  .

How  many   docs  worked   public  holidays  in  an a&M clinic  anfd  got  paid  penal rates  or did  call   in  their   rural practices  and  got  paid  penal  rates and  an extra paid day  off and  1.5x  normal  pay . ????

 In  Whanganui  the   Emergency   dept  doctors   were all  paid  award rates but   the GPs working in the  same building   doing the  same   hours  were unlikely   to  be  paid  by    the  PHO   that  owns the A&M clinic   any   extra .The PHO prides itself on being  clinically    led  and  clinical leaders and directors   seem to  quite  happily  eviscerate  their  own GPs  after hours  terms and conditions    to   save  money  for  PHO  coffers !Top  4  managers  in    the  PHO   average $200,000  each   for  the  last  4 years .

 How are numbers  stopping  smoking    with  the   Ministries  realigned   stop  smoking  services  ? Whanganui  is  about $2,000  per  smoker Quitting for  the  PHO    run  service  . GPs  are still  paid  about    $30-$50   total  for smoking  cessation services per attempt.  in Whanganui.

 Docs   could  try   bringing  the  rortes  to  the  attention  of  the Office of the Auditor General . who  is  quite interested  in  the   cost effectiveness of    some of the    crappy  contracts   ministries seem to  give  out .




It is in the best interest of DHBs and PHOs to give GPs less money from the health budget - it means more money for them. The sustainability of General Practice does not concern their Mr Magoo myopia one bit. If it did, their actions would be the polar opposite of what they have done here.

Thanks for the transparency Angus. You are a breath of fresh air, I just hope you stay in the fight. You vs PSAAP - it’s bullshit.

I agree with Angus, as it looks like we have forgotten how to negotiate. As GPs are compassionate helping people we don't like the stress of batting for our own corner. Owing a practice myself I have watched the eroding of funding in our practice over the past 5 years- loss of a mental health contract for methadone services in primary care-the money now sits in secondary care. Then reduced care plus allocations. Despite being the cheapest and most efficient service in town, we lost the right to do immigration medicals due to not having an X ray service on site. We have concerns about GP staffing levels in the future, so there is pressure on salaries and conditions.The nurses deal is looming, and compliance for cornerstone ( mandatory for our PHO contract) , health and safety ( e.g we pay 1000 dollars per year to have our electrical plugs checked) and many other administrative costs are all expanding. Now our ability to charge and recover costs via co payments are shrinking, thanks to the indolence of our "negotiators" . It looks like primary care has assumed all the risk here, with the funders, DHBs and ACC all being winners.  How about we stand up for ourselves? Why do our specialist colleagues get 3 weeks paid study leave while we pay for our education, doing it after hours and during weekends? And they say there are concerns about burnout..... 

How many specialists have caps on their copayments? Why is access to care always a primary care duty and not the duty of the whole profession.?

As an overview, we are always told health is an ever expanding demand on resources. This allows for our funders to practice a type of austerity- and primary care is an easy target - fragmented, disjointed and full of conscientious caring and helping people. On the other side, Berl estimated that our country spends 7.85 billion dollars per annum ( over 5600 per family ) on alcohol related harm. We have the public health evidence on how to reduce that harm and save resources and increase economic productivity . So I am indignant that we get scraps to resource our businesses ( remember disrupters are coming- telehealth, genomics robotics etc ) while those in charge of health policy piss almost half the health budget down the drain. I suggest that our representatives need to wake up- we are being screwed long term, and our future is far from certain. Thanks to Angus for pointing this out. 

The definition of stupid is making the same mistake over and over and expecting a different result. Pretty much sums up our negotiations over the years.