Closed books symptom of failing system, not cause

These days, a few metrics are used to indicate a failing system. Often, these point to general practice as the point of failure. I will come back to that…

One such metric is closed books.

I will start by stating that closed books are a symptom, not the cause.

If we look at the reasons why and focus on our patients, then closed books are arguably a good thing for the enrolled population, but not so much for the growing number of people who cannot enrol. It is also a very blunt measure without understanding why.

When GenPro undertook its annual pulse survey last year, three categories emerged:

• open and actively enrolling all comers
• closed and not enrolling
• limited enrolments, for example, taking on relatives of existing patients.

The results showed that about 24 per cent of practices had closed books, 30 per cent were fully open and just under half had limited enrolments. It appears that the number of practices with closed books has increased, and GenPro will be running the 2024 pulse survey in the coming weeks.

If you enrol but cannot service patients in a timely manner, is that better than closing books to maintain quality and deny some people access to general practice?

Some general practices have been accused of over-enrolling and under-servicing to game the capitation formula. Arguably, enrolling more patients than you can serve will create a myriad of issues, from long and growing wait times to increasing levels of unmet need, staff burnout and erosion of the quality of care. But you have open books…

General practices are also accused of denying people access to care by not enrolling patients. The reasons for closing books are to counter the long and growing wait times, increasing levels of unmet need, staff burnout and erosion of the quality of care.

So, if you enrol but cannot service patients in a timely manner, is that better than closing books to maintain quality and deny some people access to general practice?

Demand continues to outstrip supply, the population is growing, services continue to shift from hospital care to GP care, complexity is rising and the funding to deliver care is effectively going backwards as it has been for years.

The undervaluing and failure to recognise the increasing costs of providing high-quality, accessible care by the Government has resulted in fewer doctors choosing general practice, fewer doctors owning general practices and decreasing workforce capacity to meet growing demand.

Returning to the subject of the system failing due to general practice, a successful system is a collection of interdependent parts working together as a complex whole, interconnected and adaptive.

Within a system, the components are not typically homogonous. They typically bring different strengths, and working to these strengths results in the system delivering better outcomes than could be achieved by individual entities.

The strengths of general practice have been acknowledged, and then under-resourced.

Therefore, closed books are another metric that places the blame for a failing health system squarely on the shoulders of general practice. But the blame is on both the political and bureaucratic arms of the Government for the policy settings that have led to this situation. This is despite multiple warnings about the very thing that is coming to pass.

Angus Chambers is a Christchurch specialist GP and chair of the General Practice Owners Association of Aotearoa New Zealand