A recent media report noted that graduate doctors’ interest in working in small towns and provincial cities continues to decline, adding to ongoing concern about the sustainability of rural health services.
The New Zealand Doctor article went on to say that very few medical graduates want to live and work in towns with a population under 10,000, but rural health advocates point out these communities have increasing health needs as residents age.
The statistics were drawn from the latest Medical Schools Outcomes Database (MSOD) report* that shows only 1.6 per cent of New Zealand medical graduates in 2015 saw small towns as places they wanted to practise.
New Zealand has a long history of trying to incentivise doctors to remain and practice in small towns and rural areas. Many continue to call for incentives (for doctors) despite the historical and demonstrable failure of the many forms of incentives tried.
Alongside the increasing struggle to recruit GPs to many parts of the country is the huge amount spent on GP locums over the years. I personally have no idea exactly how big that spend is, but I can confidently suggest that over our history it has run into many millions of dollars.
Currently there is a push to try and increase GP numbers by establishing a new medical school at Waikato University that will produce rurally oriented GPs. It seems to be based on a similar model at Flinders University in Adelaide which has had success at providing GPs for rural areas.
Provocative questions
My questions in response are outspoken and provocative:
- Will producing more GPs actually solve the many problems that confront us in providing primary health care services, be they urban or rural?
- Will more GPs actually change the model of service which, I would candidly suggest, is broken?
- Is an extensive training in biomedicine the best fit with communities’ needs to live well, stay well, die well and to stay out of hospital regardless of income levels, ethnicity and residential location?
These are challenging questions but they need answering if we are to really deliver on the goals of the New Zealand Health Strategy.
We should be very concerned that more and more New Zealanders are experiencing diminished access to health services – or poor quality, poorly co-ordinated care – with different health outcomes for Māori and Pacific, poor or no rural access, rising mental health problems and many other concerns.
We are in danger of becoming inured to such reports as they come so frequently. Whichever way we look, there is a system under severe and growing pressure. Those working in hospitals dealing with the consequences of poor primary health care are under even more pressure.
At least half a million people can no longer afford general practice visits. Many such people in desperation, are currently putting emergency departments under intolerable pressure. At the same time GPs are reporting that their practices are not viable with current funding levels. This situation should not be allowed to continue as it can only worsen under the pressures of an ageing population, increasing levels of long term conditions such as diabetes and kidney disease and the impending threat of anti-microbial resistance.
Stuck record
I feel like a stuck record in noting that one answer is hiding in plain sight.
In New Zealand it costs approximately $600,000 to produce a general practitioner (GP) and $100,000 to produce a nurse practitioner (NP) yet the scope of service is the same.
Registered nurses are widely distributed around the country in rural, remote and urban areas. Evidence shows they are inclined to remain in the areas where they begin practice. Evidence now shows that approximately 4000 nurses have a clinical masters degree and many would not be far off seeking NP registration if encouraged with minimal further investment.
There is a long overdue need to stop the repeated calls to educate more GPs and instead divert substantial investment towards developing some of the existing nursing workforce to nurse practitioner level. Doing so would provide a rapid, cost effective, completely safe and highly accessible solution to the problem.
There are already nearly 300 NPs in New Zealand, half of whom are providing primary health care services.
I would urge more careful consideration of this health workforce solution which is right under our noses.
*National report on students graduating medical school in NZ in 2015, NZ MSOD Steering Group
Author: Professor Jenny Carryer RN PhD is executive director of the College of Nurses. This article will also be published in the next print edition of Nursing Review.
Hallelujah, and thank you Jenny Carryer for talking about the obvious solution – yet again. It is beyond me why heels are being dragged on this issue either, but I might tentatively suggest that possibly it is professional jealousy from the medical profession?
In my (so far, admittedly brief) experience as a PHC nurse, many doctors still see us as little more than cleaners and ‘go-fers’, and in my current role I am working right at the bottom of my scope. Kind of sad for someone who is on a post grad pathway, hopefully leading to NP – but obviously not where I currently work.
Great questions, Jenny. Thank you for raising this issue. It is, after all, about access to health care.
Thanks for your comment and yes it is indeed..yet again!!!
It is really helpful for me to understand exactly how the situation arises where you find yourself working right at the bottom of the scope, as it can be different in different places. If you feel like contacting me I would be grateful. If you look on the Massey University web site you would find my contact details Jenny Carryer
If the ‘scope of service’ is the same, and ‘completely safe’, perhaps a good entry requirement for a NP would be to sit the GPEP clinical and written exam?
Although, there is much scope for NPs in NZ, I would very much doubt if they provide even one twentieth the scope or function of any GP that I have met. In addition, what makes you think NPs are any more likely to live in rural areas than GPs? In reality, they are more likely to have restrictions caused by their family role, their children schooling and social life and, dare I say it, their spouses occupation. These are the same for all individuals and not really discipline related but may more affect women than men (rightly or wrongly). Individuals must also address the limited social life, social isolation, educational opportunities for children and access to a range of consumables that many such urban individuals take for granted. This is inevitably more problematic for all who train in the city and who may have come from urban environments (the majority). Rural medicine (RM) is indeed very rewarding but a challenging primary care environment with greater demands that even urban GPs need to adapt to. The scope of RM is definitely wider, has more limited primary and secondary support and the ‘on call’ far more daunting. One cannot cherry pick. Being a 9 – 5 NP in COPD, Diabetes, Elderly Care – those NPs one mostly have contact with – certainly don’t have a scope remotely comparable to a GP. As for NPs whose scope is primary care, these are still extremely rare and in my experience could never work in isolation – at least for many years in the post – and, in any case are quite expensive to employ considering patients will not pay such consult fees. One day this ay change but at present this is a reality. If NPs are so motivated to work in primary care, why are they not more present in AFTER HOURS? It is here that there is a really great need for NPs dealing with the worried well and minor illnesses. This is not a denegration of their training as it is here where the (quite uncommon) risks occur. Knowing when things are not quite right requires real experience when much of the time very limited skills are needed and the risks of getting things wrong are minimal. The waste of medical expertise here in a world of diminishing ageing doctors in NZ is a travesty. If NPs could show that they could tackle such a workload (15 minutes a patient) I might be impressed. Despite these negatives, I do sincerely support the evolution of nurses to NPs by broadening there scope but cherry picking narrow spectrum specialities cannot really be seen as being a GP.
HI Phillip Your support and interest in NPs is valued but some of your knowledge about NPs in NZ is a little out of date. It is true that early NPs in NZ were authorised in more defined specialist areas but of the nearly 300 NPs in NZ now, and at last count, approximately half have primary health care as their scope of practice. It is the area of most rapid growth and has been for a while. They are working well in general practice settings functioning independently to the extent of owning their own business or working as partners and sometimes as locums or practice employees. No-one should work in isolation and collaboration is essential for all clinicians but they are demonstrating that they are able to deal appropriately with patients in that setting without supervision and handling the same case load on the same basis. We know that nurses are in every community in NZ, already resident and the limited evidence available shows as you suggest that they stay put because of commitments to partners and children (indeed rightly or wrongly!!). This makes them a vital resource to educate to NP level as they remain in their own community but can provide a much needed level of service. There are many rural areas where RNs with PRIME training and using standing orders are doing 24/7 call and are the backbone of that service. Becoming NPs means they will be able to prescribe independently, have an even greater level of knowledge and be a little more appropriately remunerated for what they do. And a final point. NPs are not too expensive to employ. They are able to enrol patients, claim capitation, GMS and use the flexible funding pool and fee for service as do GPs. They are therefore income generating.
This is a vital dialogue as we look to resolve the issue of service sustainability into the future.
Kia ora Jenny and thank you for this opinion piece. As you know, Maria Kekus and I are big advocates of Nurse Practitioners and pleased to see the growth of NPs in NZ. We actively support NP training and the NP pathway.
We had the opportunity to reflect on the debate about training/educating more NPs over GPs and whilst we see there is an opportunity to growing more NPs, we know the value of GPs and having a shared approach based on our experience as a nurse-led independent business.
One area we think is often excluded in the Health Workforce debate is that of the role of non-regulated health workforce and the important role they hold.
Whether we educate more NPs or GPs – we have to acknowledge that in our experience young people coming to see a GP or NP may have brushed up against a non-regulated health worker beforehand. We would also suggest those young people who do not cross the threshold of either an NP or GP are more likely to have come in contact with a non-regulated health worker.
The Health Workforce and its future is a good debate for us to be having which includes the whole of the health workforce is essential. – how we better improve what we deliver, by who and where to achieve better outcomes for communities is key.