Stephen, beware of magical thinking

It’s unlikely there will be any changes other than in layers of officials and complexity

During the Rotorua GP CME session on sustainable funding for general practice, the panel received a question that made me animated.

“Why don’t GPs just get salaried by the new Health New Zealand?” asked Stephen.

I suggested the questioner put up their hand or come to see me after the session, but no one did. So, I didn’t get to explain to Stephen why that’s a terrible idea and why he should reconsider.

Here is my take on this issue: don’t trust them. GPs should hold on to the shreds of autonomy we have.

GPs are largely self-employed. Fewer than one-third of GPs are employed in roles in corporate or iwi-owned practices. The other two-thirds of GPs are either contractors or are owner-operators.

Most employees are on individual contracts, few of which match the Association of Salaried Medical Specialists’ multi-employer collective agreement for senior medical staff in the hospitals.

These realities cannot be overcome by magical thinking, which is what a Health NZ takeover of general practice would represent.

To take over and employ all GPs, Health NZ would have to purchase their practices. Then it would be responsible for managing those practices and for all the associated business costs.

Where DHBs have attempted to run GP practices, they have been financial failures.

For example, the DHB-owned practice in Taranaki had an operational budget shortfall of $1.2 million last year. This reflects business pressures and the fact that, where the GPs are owners, GP practices are more likely to thrive. Doctors working in the practice have skin in the game and work harder than salaried employees. A central agency could not manage this efficiently.

The issue of productivity is important and is an underlying wicked problem in our health system. A higher number of procedures can be performed in a private hospital compared with a public one. This is partly due to nurses “working to rule” in theatres in the public sector.

However, the fact that more income is generated by doing more procedures in private is also a strong incentive to work more. When income is not matched to measurable outputs (or even, in some places, to hours worked), then there is no incentive to work harder.

Health NZ has not signalled interest in investing in general practice. The recent round of funding discussions of the PHO Services Agreement Amendment Protocol (PSAAP) group showed that.

The June meeting was moved so that it would take place after the Health NZ board meeting that followed the Budget announcements.

The day before the PSAAP meeting, Crown representatives sent the contracted providers an email with a draft compulsory variation notice. In other words, the State came to the table with its position set and no room for negotiation.

This heavy-handed tactic showed a level of disdain that GPs should be wary of. Expect no benign overseer role from Health NZ.

The freedom that comes with being privately owned provides benefits to the community and should not be dismissed out of hand. In the face of COVID-19, GPs pivoted to telehealth over the course of a weekend and changed our procedures to allow for triage and streaming of patients. This is because most decision-makers were clinicians and understood the need.

In my local hospital, clinical leaders could not even change the type of chairs (from fabric to plastic) as an infection-control measure. Large bureaucracies hinder flexible operations, while seldom delivering any benefits of centralisation.

Officials in Health NZ have a work programme that is daunting. Even though primary care does the lion’s share of patient-interfacing work, there is a focus for the next two years on secondary care.

The New Zealand Health Plan had not been released in draft form at deadline for this article. In drafts I have seen of some sections, the work required is immense and seems unlikely to be achieved in two years. In addition, interim Health NZ has been populated by the “usual suspects”. It’s unlikely there will be any changes other than in layers of officials and complexity.

If Stephen hopes that Health NZ will provide a magic solution to the GP workforce situation, then he will be disappointed. There is no silver bullet: Health NZ will have its hands full and may not ever achieve any of the expected benefits of transformation.

So far, the signs are grim in terms of the relationship between Health NZ and GPs. Expect no respect, support or solutions to come out of that entity any time soon.

It’s likely that Health NZ will spend the next two years mopping up the mess that its own formation will create, and general practice will be small potatoes.

GPs will be better off doing what we can to make our job appealing to more trainees and looking to our own interests and those of our patients. That relationship won’t change under this set of reforms.

Vanessa Weenink is a Christchurch-based specialist GP