Urgent-care clinics on a knife edge

Many patients come to the centre because they face a wait of many weeks to see their own GP

After-hours shifts are unpopular with many GPs, leading to pressure for change.

At least one urgent-care clinic wants to scrap the requirement, while anoth­er has it under review to mandate these shifts.

Urgent and after-hours clinics use a variety of staffing models for the doc­tors needed to open for extended hours.

Staffing models may be diverse but clinics are unanimous in saying they are under great pressure this winter. That pressure is from COVID-19 and influ­enza causing high patient volumes and high rates of staff absence; the higher staff requirement with “red” and “green” streams that separate respira­tory and other patients; and the under­lying shortage of health workers.

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

Alex Price, chair of Shorecare, which operates two urgent-care clinics on Auckland’s North Shore, has previous­ly said in an interview the business has an additional underlying staffing prob­lem: the increasing reluctance of its GP-shareholders to work shifts in the clinics.

The Northcross clinic – where hours have often been reduced this autumn and winter – is usually open 8am to 8pm and the Smales Farm clinic, 24/7.

Mr Price says the shareholders are not formally required to work in the clinics. “It’s always been an idea of social obli­gation and how it all fits together.”

In a later email response to New Zealand Doctor Rata Aotearoa, he adds, “We don’t intend to introduce a share­holder staffing requirement as a con­tractual obligation at this stage, but it is something we keep under review.

“A lot depends on how primary care funding and the attendant require­ments shake down with the new [Te Whatu Ora – Health New Zealand] model.”

In Napier, City Medical’s urgent-care clinic wants to quit its requirement for GPs to work shifts there but can’t yet, because of the workforce shortage.

At our deadline on 22 July, the entire clinic closed for most of the day, a no­tice on the website pointing to “staff illness impacting already critical staff­ing levels”. A limited service for urgent presentations would be offered from 5.30pm to 9pm, the notice said.

General manager Leanne Mandeno tells New Zealand Doctor: “It’s loud and clear we need to address our model.”

Owned by the majority of the area’s GPs in a cooperative, the clinic’s hours are 8am to 9pm every day, having been 24/7 until about five years ago. Now, from 9pm to 8am Te Whatu Ora Te Matau a Māui Hawke’s Bay (formerly Hawke’s Bay DHB) operates the prem­ises with its own emergency depart­ment nurse and healthcare assistant, with on-call support from a group of GPs through the local PHO.

Ms Mandeno says the shareholder GPs, who have their own practices, gen­erally don’t like the after-hours and weekend work as it is an extra burden. The plan is to convert to the clinic hav­ing all its own staff when there are enough available, but currently there aren’t enough to recruit even for day­time hours.

In Christchurch, Pegasus Health owns the 24 Hour Surgery urgent-care clinic. It is staffed by employed medical officers alongside staff from member practices working rostered shifts.

Pegasus acting chief operating officer Lisa Brennan says in an email response to New Zealand Doctor that Pegasus member practices can choose, as part of their contract with Pegasus, to use the clinic when they are at capacity or closed.

Those that do, agree to complete shifts based on one shift per 140 en­rolled patients, Ms Brennan says. “A shift is generally six hours and we pay members a minimum of $100 per hour plus allowances and we are currently re­viewing these rates.

“GPs can swap shifts or make ar­rangements for other doctors who have a contract with 24 Hour Surgery to do them.”

The clinical director of the clinic, Jasmine McKay, has previously said of the staffing model: “I believe the collab­oration works well so we can provide an important service 24 hours a day, which isn’t an easy task and we know is a struggle for similar-sized clinics.”

Christchurch specialist GP Angus Chambers, a co-owner of the 8am–8pm, seven-day urgent-care provider and general practice Riccarton Clinic, says it is debatable whether general practices are required under the PHO Services Agreement to provide after-hours care.

Dr Chambers’ clinic contracts its own medical staff rather than relying on any other practices. It uses the 24 Hour Sur­gery for overnight cover in exchange for working some shifts there.

“A lot of places do that kind of coop­erative arrangement where they work together to provide the after-hours care,” he says. “A bunch of other places will employ people to provide after-hours care but also have roster support from their surrounding GP [clinics]. “Sometimes GPs own the after-hours clinic, sometimes they contract with it, sometimes it’s a loose arrangement. I think there is a variety [of models].”

The Dunedin Urgent Doctors and Ac­cident Centre’s general manager, Della Henderson, says it is based on a guild that includes most Dunedin practices. This formed the company that operates the centre, seven days a week, from 8am to 10pm.

The centre engages GPs or ur­gent-care doctors for its day service and employs nurses, administration and re­ception staff for all hours of operation, Ms Henderson says in an email re­sponse. After-hours medical staffing is covered by using a roster system of the member practices.

She says the after-hours roster ar­rangement is generally operating satis­factorily, although the doctors are tired from their already heavy workloads.

Many patients come to the centre because they face a wait of many weeks to see their own GP. Others come be­cause they can’t enrol in a practice. Staffing is stretched, there are vacancies for nurses and day doctors; the doctor shortage sometimes limits the number of daytime consultations.

The Lower Hutt After Hours Medical Centre, owned by Hutt Valley practices, is open from 5.30pm to 10.30pm on weekdays and 8am to 10pm on week­ends and public holidays.

Most shifts are covered by its own doctors. The balance are staffed from a roster under a contract with Hutt Valley practices. General manager Mark O’Connor says the contract is separate from the shareholding.

There is a “mixture of views” among the contracted practices’ doctors about working shifts at the centre.

“We are struggling to staff our oper­ation due to COVID and flu and having to run red/green [respiratory stream­ing] means we almost have to double our staff level,” Mr O’Connor says.