AUGUST 10 2019 LISTENER 21
and Nelson-Marlborough). Auckland has
not only the most doctors (82 per 100,000
people) but also 29 of the country’s 36 after-
hours clinics.
PHONE TRIAGING
Apart from fundamental changes to the
way general practices are run, and a rise in
the number of salaried as opposed to busi-
ness-owning GPs, we can expect increasing
diversification of the primary-care work-
force. More work will go to nurses, nurse
prescribers, clinical pharmacists, health
coaches and “HIPs” – health improvement
practitioners. “Just seeing a GP is so yester-
day,” says former Pinnacle Midlands Health
Network chief executive John Macaskill-
Smith, who introduced the US-pioneered
Health Care Home (HCH) model in 2011
that has since been adopted not only in Te
Aroha, but also in another 160 practices
covering 1.2 million patients nationwide.
“People have been trying to pour more
money into the old model and put stick-
ing plasters over it and say, ‘Let’s train more
doctors’, but it’s not the right answer,” says
Macaskill-Smith, who now heads Midlands’
innovation arm, Ventures.
He says general practices have until now
been run on a first-in, first-served basis.
In Midlands, where 114,000 patients are
enrolled in HCH practices, a 2017 evalu-
ation by Ernst & Young credited the new
model with a 14% decrease in hospital
emergency visits (down 24% for Māori and
32% for over-65s), fewer referrals to special-
ist care and 20% fewer preventable hospital
admissions.
When assessing how many patients full-
time GPs should have on their books, a figure
of 1:1500 is often suggested as an appro-
priate norm. It’s a crude figure, depending
on the demographics of a practice and the
ability for GPs to call in or rely on related
support services. In Taranaki, where that
figure has blown out to 1:2500-3000 – one
of the worst in the country – it’s very dif-
ficult to get a same-day appointment.
Some GPs are worried that phone triag-
ing and the patient portal are potentiallyrisky options for patients who may not
be able to adequately communicate their
problems. What if serious ailments are
missed? Macaskill-Smith and former Ven-
tures general manager Helen Parker, recently
appointed Midlands’ chief executive, have
heard all the what-ifs, to the point of
despair. “Helen and I spend our lives with
the owners of practices. I used to be skinny
and have lots of hair,” says Macaskill-Smith.
“We spend many, many evenings having
philosophical discussions with them and
say, ‘What does the future look like? It’s not
sustainable. How are you going to attract
the next generation – who are you going to
sell to? What’s going to make this work?’”
They’re also frustrated that some district
health boards, through which primary-care
funds are channelled, can’t see the sort of
benefits the Ernst & Young report highlights.
“DHBs generally don’t understand primary
care and I don’t think they feel as if theyhave a responsibility around primary care.
There is often a sense that GPs go home at
five and don’t work weekends, so by default
everything ends up at the ED [emergency
department]. They are quite focused on
hospitals, and primary care is this private
enterprise that happens outside. Some of
them have a belief that GPs just take the
money and buy a new BMW.”
Parker says the planners commissioning
health services tend not to come from a pri-
mary- and community-care background. It’s
helped to make DHB support for, and buy-in
to, the HCH model patchy.
In Counties Manukau, where the biggest
primary health organisation, ProCare, has
12 practices and 107,000 patients converting
to the HCH model, the organisation’s chair-
man, Ōtara GP Harley Aish, says patients
readily adapted to the changes. “When there
is a lot going on, Māori and Pacific patients
and their whānau use the portal to the
maximum. They are messaging us, check-
ing their notes, ordering repeat prescriptions
and making appointments. I didn’t expect“People have been trying
to pour more money into
the old model and put
sticking plasters over
it and say, ‘Let’s train
more doctors’, but it’s
not the right answer.”Pinnacle Midlands
Health Network chief
executive Helen
Parker and Ventures
chief executive John
Macaskill-Smith.