Nine issues that defined 2022: A year of crisis, reform and bargaining with COVID

Just as we were starting to familiarise ourselves with the Greek alphabet, SARS-CoV-2’s evolution successfully branched off at Omicron and changed everything.

Think back to 14 December 2021, a year ago today, when New Zealand was starting to shake off its Delta headache. The daily COVID-19 update reported 80 new community cases, 62 cases were in hospital and there were no deaths – in contrast to the thousands of daily cases and widespread deaths that were to come.

Auckland’s COVID border lifted the following day, allowing most to travel out of the region if they were double vaccinated or had had a recent negative test, but the international border would open only gradually over the following months.

New Zealand’s moat had largely protected the country from the worst of COVID while vaccination went national. By 14 December, 89 per cent of those eligible for two doses had received them.

Then on 29 December our first Omicron exposures were reported. Within weeks, daily new case numbers had shot up from dozens to thousands and on 25 February peaked at 24,318.

February was also the start of the mostly peaceful, but at-times violent, protests centred on Parliament’s grounds involving hundreds of people who objected mainly to COVID mask and vaccination rules, ructions that were forcibly ended by the police in early March.

That first, abrupt Omicron wave gradually dropped to a point of 4737 daily cases, averaged over seven days, on 25 June. But a new wave was quickly under way, reaching its much smaller peak of around 11,500 daily cases in mid-July.

And by late November, Omicron wave three was on the way up although it appeared its peak would be smaller than wave two’s.

The “traffic light” COVID-19 Protection Framework, which succeeded the lockdown system, ended on 12 September, with prime minister Jacinda Ardern saying: “It’s time to safely turn the page on our COVID-19 management, and live without the extraordinary measures we have previously used.”

Suddenly the country was looking for business as usual, plus a bit of mask-wearing, rapid antigen tests, seven days’ isolation for cases, and occasional updates on booster vaccination.

General practice care in the community became the norm for the moderately unwell, while the many thousands with relatively minor symptoms learned to cope at home without medical support.

Take-at-home COVID antivirals became available from April for high-risk patients and access was later broadened. Like vaccination, these drugs shifted the odds in favour of humans, in our bargaining with SARS-CoV-2.

In mid-September, the Ministry of Health gave up daily case-number reporting in favour of weekly updates and began a series of weekly COVID-19 trends reports.

The reports confirm it has been the year of Omicron. BA.5 was the dominant variant in the weeks leading up to the 18 November edition. Three other Omicron variants together accounted for 26 per cent of analysed cases.

Delta got just one mention in the report: XBC variant, the cause of eight identified cases, is a recombinant lineage of Delta and Omicron variants. It brought no indication of increased disease severity.

Several things this year, in addition to urgent care’s woes, confirmed the severity of the primary care workforce crisis – against the background of RNZCGP survey data released in 2020 and last year, showing more GPs intend to retire soon and that more are experiencing burnout.

This year, the Medical Council’s workforce survey found a net rise of just 15 in the number of practising GP specialists on 30 June when compared with 12 months earlier.

RNZCGP president Samantha Murton said that, between 2010 and 2015, the number of practising GP specialists grew by around 100 a year, so for the annual rise to slump below 50 in 2021 and to just 15 this year was “just shocking really”.

Disappointingly, the number of doctors confirmed to start the college’s General Practice Education Programme next year is down on this year, despite a promise that most trainees will get pay parity with hospital registrars, a key deterrent of GP training. Pay parity’s impact is expected to be felt first in 2024.

Around 185 GPEP1 entrants were by last month confirmed for 2023, down from 193 this year.

The college and the Government want 300 a year and that was the subject of new funding announced by health minister Andrew Little in October.

The changes will from 2023:

• give pay parity to college-employed GPEP1 registrars with their peers in hospital-based specialist training programmes
• pay teaching supervisors for an extra two and a half hours a week, and
• pay $3600 to practices which host 12-week community training modules for early postgraduate (early-postgraduate) doctors.

Another disappointment for general practice was the exclusion of most practices, at least initially, from the Government’s $200 milliona-year pay-parity funding package designed to increase pay rates of nurses in aged-residential care, at some Māori healthcare providers and some other providers.

Mr Little claimed there was a “lack of real evidence of pay difference” between general practice and Te Whatu Ora nurses.

Practice nurses took strike action in October, seeking Government funding to close the $8000 pay gap between the main New Zealand Nurses Organisation primary care nurses’ pay deal and Te Whatu Ora’s nurses’ pay deal.

Primary care funding is now actually under review, five years after this was promised.

The Sapere capitation review released last month found significant unmet need and that a theoretical loss of 7.6 per cent in general practice is masked by unpaid work.

Te Whatu Ora has portrayed the Sapere review, which is considered important by general practice, as just one part of the picture and it has been subsumed into the agency’s broader, ongoing review of primary care funding.

In the meantime, the lifespan of the national PHO Services Agreement has been extended, possibly until mid-2024.

College medical director and specialist GP Bryan Betty, who works at a very-high-needs practice in Porirua, said he agreed with the basic tenet of the Sapere review that general practice is underfunded. “The capitation system…needs to be totally reworked. It’s not fit for purpose.”

The Sapere report found the average practice needs 9 per cent more revenue to break even at the current level of patient care.

Very-high-needs practices needed an extra 34 per cent to 231 per cent in capitation funding, depending on what level of improvement is considered desirable.

It noted the capitation system was based on historical use patterns and costs and recommended a system based on age, sex, ethnicity, deprivation and, importantly, morbidity. Age and sex are the dominant funding variables at present.

General practice representatives walked out of the mid-year capitation funding talks with government officials over the proposed 3 per cent increase – significantly less than inflation – which was later simply imposed.

The inflation/capitation issue came up again later when Te Aka Whai Ora’s interim primary care clinical leader, specialist GP Rawiri McKree Jansen, told the college conference in Christchurch that for the past decade, capitation increases had bettered the Consumer Price Index.

General practice funding negotiator, GenPro deputy chair and specialist GP Angus Chambers, however, said most GPs would disagree with the notion that capitation had kept pace with cost pressures.

GenPro last month appealed for public support in its On the Brink campaign to save general practice. Including a petition seeking better funding of family doctor services and an open letter to Mr Little, the campaign’s nine-point plan includes nurse pay parity, removing barriers for overseas-trained doctors and nurses, removing the disadvantages for doctors choosing to be a GP, and a greater share of health funding going to front-line services.

In another measure of sector stress, two surveys this year found an increasing number of general practices are not taking new patients. In one of those, General Practice NZ found 34 per cent of respondent practices in its member PHOs had closed books, up from 26 per cent in 2021.

In the other survey, by Victoria University of Wellington researchers, 25 per cent had fully closed books, up sharply from 7 per cent in 2019.

The landscape of general practice advocacy changed dramatically in 2022. After 136 years, the NZMA in May began the process of winding itself up, with an overwhelming majority of members voting in favour of liquidation at the annual meeting. In July, that was confirmed at a special general meeting.

Delivering the “heart-breaking” news, the final NZMA chair, Alistair Humphrey, said that despite the efforts of board members and staff, the organisation’s finances had become ever more precarious.

Stagnant membership numbers and the cost of rebuilding its heritage-listed, earthquake-risk headquarters in Wellington had tipped the NZMA towards insolvency.

As the NZMA’s star waned, GenPro’s continued to rise, with the two-year-old organisation campaigning on general practice issues and becoming an established voice in the general media.

GenPro was heir apparent to the NZMA’s role as representative of most employers in the primary care nurses multi-employer pay deal, but was caught off guard by the entry of a new entity called the Primary Care Bargaining Collaborative. With the support of General Practice NZ, the collaborative is led by ProCare.

Another new entrant this year, potentially, is General Practice Aotearoa, which bills itself as an independent voice for all doctors working in general practice. The 25-strong driving force of the group, which hopes to be formally established this month, includes Marcia Walker and several others who were members of the now-disbanded NZMA GP Council, plus Api Talemaitoga, Karl Cole and Justine Lancaster.

Rural excitement came to town at mid-year, with the formal launch of Hauora Taiwhenua Rural Health Network.

The new collective organisation started work on 1 July, following a launch event at Parliament on 28 June. Chair and specialist GP Fiona Bolden spoke at the time of the need for rapid action to address rural health workforce shortages.

More telehealth was welcome, she said, but it wasn’t the answer to shortages: more bodies on the ground were needed.

The network comprises nine chapters: Rural General Practice; Rural Nurses New Zealand; Rural Hospitals; Rural Midwifery and Maternity; Rural Communities; Rural Health Research and Education; Whānau Whanui; Rural Scientific, Technical and Allied Health; and Students of Rural Health Aotearoa.

Innovation is now the hallmark of Māori and Pacific healthcare. If addressing long-standing, entrenched health inequities is a significant driver, you can’t ignore the motivation of a workforce that lives in the community it serves.

But progress hasn’t been straightforward, with providers, particularly those in Counties Manukau, complaining of the wider system’s slow understanding of the need for targeted outreach programmes.

One-size-fits-all has never fitted all, and it took an intensive, flaxroots effort to get marae, churches and others on board to activate communities to get tested and vaccinated, and build trust in the health system.

The depth of need exposed by the pandemic also fuelled the push to widen the definition of healthcare to include the social determinants of health, such as housing, education and employment.

But with the creation of Te Aka Whai Ora, progress towards concluding the Wai 2575 claim, and the planned national network of Pacific healthcare providers, the pieces may be falling into place to deliver on years of talk about equity.

The Pacific plan may be the more easily realised. The network’s tiny workforce, only 2 per cent of the total for healthcare, is already collectivising. Most of Auckland’s practices are part of a formalised consortium, and Te Whatu Ora national director Pacific Health, Markerita Poutas, seems committed to increasing this process to include data and resource sharing.

But such potentially progressive initiatives remain fragile. With 2023 an election year, there is widespread confusion around the role of localities, not to mention how they will be funded, while rumours abound of problems with the formulation of the iwi Māori partnership boards that will underpin and monitor their work.

Waitangi Tribunal claimants’ hopes are high that a resolution is nearing on their Wai 2575 claim of historic primary care underfunding of Māori healthcare providers.

Te Kōhao Health director Lady Tūreiti Moxon and other claimants met Mr Little and associate health minister Peeni Henare last month. Lady Tūreiti later said the ministers had sought a Ministry of Health paper on the underfunding and had given a commitment that progress was being made towards a resolution.

An analysis released last year by Sapere found Māori providers had been underfunded by $530 million since 2003, based on the 2001 Primary Health Care Strategy. Lady Tūreiti said she hoped the issue could be resolved by early 2023.

The inquiry this year also started hearing claims related to Māori with lived experience of disability.

The tribunal has so far heard four of the anticipated eight weeks of claimant evidence with the next hearings set for March. The Crown will then continue presenting its evidence.

The well-publicised overcrowding of hospital emergency departments during the infectious disease outbreaks of winter and beyond, had its sequel in urgent care, one that shone a light on how that sector is staffed.

Pressure from COVID-19 and influenza caused high patient volumes and high rates of staff absence in urgent and after-hours clinics. That situation was made worse by the higher staff requirement with red and green streaming to separate respiratory patients from others, and by the underlying shortage of health workers.

Some clinics reduced their hours to cope, staff have been working extra shifts, and patients at some clinics have faced waiting times of up to six hours.

Shorecare, which operates two urgent-care clinics on Auckland’s North Shore, has maintained its 24/7 service at Smales Farm, but has often reduced hours at Northcross, whose usual hours are 8am to 8pm. This began in autumn and has still been occurring in recent weeks.

During winter, chair Alex Price said the underlying problem at Shorecare was the increasing reluctance of GP-shareholders to work shifts in the clinics. There wasn’t an intention to introduce a contractual shareholder staffing obligation, but that question would be kept under review.

In April, Anglesea Clinic Urgent Care in Hamilton ditched its cooperative business structure and unpopular requirement for GP-shareholders to do shifts. It became a charitable trust in which contracted practices pay a monthly fee per enrolled patient, plus copayments after their patients present to Anglesea.

A health and disability commissioner case of wide interest to GPs and practice owners went to the Supreme Court in March.

At stake is the question of one specialist GP’s vicarious liability for another’s mistake. The court’s verdict was still awaited at this edition’s deadline.

Christopher Ryan and Peter Sparks, trading as Moore Street Medical Centre in Ashburton, were held vicariously liable for a prescribing mistake made by Dr Sparks in 2016. The commissioner found the mistake breached the Code of Health and Disability Consumers’ Rights.

The patient, who suffered an allergic reaction and was hospitalised, was one of Dr Ryan’s, but because he was away from work, she saw Dr Sparks instead.

The appeal was brought by Dr Ryan who, although not personally at fault, was left at risk of being sued because of the liability finding. He had previously failed to have the finding overturned in the High Court and Court of Appeal.

Dr Ryan, who is not currently practising, has argued he and Dr Sparks operated their own separate practices, with separate patient registers and bank accounts.