AUGUST 10 2019 LISTENER 23
Māori women in their fifties to be the power
users, but when they have chronic condi-
tions, they know how to use it.”
Phone triaging has also allowed about
20% of patients booking at his practice, the
Ōtara Family and Christian Health Centre,
to be seen not by a GP, but, “more appropri-
ately”, a nurse. “If they’d rung up and been
told all the GPs are booked, they might have
gone to the ED. Instead of thinking about
the GP and saving time, you think about the
patient experience and they just think it’s
fantastic.” The practice sees many patients
with infections, and a nurse can manage
that by providing standing-order antibiotic
prescriptions already signed by the GP.FIT FOR PURPOSE
In a discussion paper released in April,
General Practice New Zealand (GPNZ) con-
cluded increasing use of nurses was one of
the key solutions to the GP workforce crisis,
although GP-nurse ratios would change
in favour of doctors in high-need patient
populations.
“We are not seeing the death of general
practice, but an evolution,” says GPNZ
chairman Jeff Lowe, a Wellington GP. “We
are trying to describe a workforce that will
be fit for purpose for the challenges ahead.”
In his practice, nurses now do iron transfu-
sions and intravenous (antibiotic) treatment
for cellulitis – procedures previously done
by GPs.
He says the traditional model in which
patients call up to book consultations
is unsustainable. “It’s causing burnout,
because there’s a finite number of 15-minuteappointments. We need to make sure we
are using those for people who really need
to be seen face-to-face. Let’s say you have
someone time-poor in Wellington who has
a simple urinary tract infection such as cysti-
tis. They’ve had it before, they know exactly
the symptoms and they’re not unwell, but
they need a prescription for an antibiotic
or it’ll get worse and may develop into a
kidney infection. With a few simple ques-
tions, we can safely deal with them over
the phone and say, ‘Okay, you can have a
prescription, but if you get worse, we want
to see you.’ We can save that person a couple
of hours driving from town, sitting in our
waiting room next to someone who might
have the flu, and then save another appoint-
ment for someone who really needs to be
seen that day.
“The biggest part of the workforce who
need to lift their game are patients them-
selves – we need them to be self-managing
far better. We can equip them with the
knowledge, data and advice they need, but
we do need patients to take ownership of
their own health.”
His practice’s patient portal gets 75,000
hits a year. “Patients are demanding it, and
they are starting to choose a practice based
on whether they have a portal or not. People
are voting with their feet, saying it’s some-
thing they want and value.”
Lowe says when Sir David Haslam, then
chair of the UK’s National Institute for
Health and Care Excellence, visited New
Zealand in 2017, he estimated that 75% of
patients seen in general practice didn’t need
to be seen face-to-face. “What we need to
know at the beginning of the day is which
75%,” says Lowe.PRACTICES AREN’T COPING
The April discussion paper, written with
input from health economist Tom Love
of the Sapere Research Group, proposed
increasing the ratio of nurses to doctors in
general practice to 2:1, and suggested the
primary-care team should include a coun-
sellor, social worker, healthcare assistant,
clinical pharmacist and physiotherapist,
with the distribution of those roles
depending on the community it serves.
The estimated cost of its two models –
for high-need and general populations- was about $2.2 billion, $500 million
more than the current system. GPNZ
“The biggest part of the
workforce who need
to lift their game are
patients themselves- we need them to be
self-managing far better.”
patients to one problem per consulta-
tion or charging more for an extended
appointment. “That’s the worst deci-
sion you could make. I hate that world,
because we are disincentivising people
to raise things and eroding holistic
care. You start to partialise patients, and
that’s what we criticise specialists for.”
And in an ageing population, the needs
were more, not less, complex.
The practice shifted to a Health Care
Home model about five years ago, but
Nixon doesn’t believe it helped, saying
predictions of 20-30% of patients who
could be diverted to other services or
have their appointments delayed by
phone triaging weren’t realised. And,
he says, the model has risks, particu-
larly if the triaging is being done by a
doctor who doesn’t know the patient
well.
“If you’ve got a patient who is elo-
quent, educated and able to represent
their history really well, you’ll get a
more accurate assessment of what is
going on. If you have someone who is
not as well educated or articulate, then
you might not get the full story. The
burden is on the doctor to make sure
they are not missing something. There
is definitely risk, because the doctor is
saying, ‘I don’t need to see you’, but
you are the last cab on the rank, so you
take the responsibility.”
After a year away, part of which he
spent developing palliative care in
Bhutan, he’s now working part-time in
Tūrangi.
So, are we all just pining in vain for
a return of the long-gone Dr Finlay’s
Casebook days, when the GP arrived at
our bedside with his Gladstone bag and
stethoscope to soothe our fevered brow
while he drank a freshly brewed cuppa?
Nixon says not. “We can’t practise
like we did in the past and we do have
to make changes. But the GP-style
consultation is the most efficient use
of health resources. We are trained to
be the gatekeeper and filter. The best
way of channelling those resources is
through a funnel that is wide at the
top, through a very narrow tube at the
bottom, so we filter out as many things
as possible. That’s the most efficient
and best for patients to keep them out
of secondary and tertiary care. And that
requires GP-level skill.” Dr Jeff Lowe, far left, and
Dr John McMenamin.