Health Minister Dr Shane Reti and Health NZ Commissioner Professor Lester Levy say the new roles are aimed at reducing waiting times. Video / Denise Piper
Opinion by Bruce Cotterill
Bruce Cotterill is a professional director and adviser to business leaders. He is the author of the book, The Best Leaders Don’t Shout, and host of the podcast, Leaders Getting Coffee.
Despite a $16.68 billion funding boost, waiting times and staffing shortages persist, with 500 doctors and 1817 nurses short.
Proposals for reform include bonding medical graduates and redesigning the health system to improve efficiency and outcomes.
Health New Zealand continues to hit the headlines for the wrong reasons. Fortunately, the latest complaints are about creative accounting rather than any misstep in the operating theatre.
Sadly, our health system keeps getting worse, not better. Despite different governments, restructuring programmes, name changes, independent reviewsand health ministers of varying competence and quality, things don’t seem to get better. The unfortunate part is that, the worse it gets, the lower our expectations become, and the lower the standards we are prepared to accept.
I had a reminder the other day. A friend of mine had a medical event while in Sydney on business. He thought it might be his heart and managed to get in to see a doctor that same morning. He was sent for a scan which was done immediately and the results were shared with both the doctor and patient, that afternoon. He was immediately booked in to see a specialist at the end of the day.
He stayed on in Australia for a few days before being confident enough to fly home. By his own assessment, when he returned to New Zealand, his treatment programme was a year ahead of where it would have been if the issue arose at home.
It’s easy to forget that, that’s what it used to be like here. And like any improvement programme, we need to have goals and aspirations before setting out to change things. That experience, in Australia, is a good standard of delivery to aspire to. But we have a long way to go.
My most recent appointment with a GP came after a four-week wait. Another friend of mine with a dodgy knee is in the middle of a six-month wait to see a specialist. Elsewhere, my ageing mum takes three months to get a response from a specialist. And as for a scan, well hold that thought.
We’re told that we don’t have enough frontline medical staff. According to a recent briefing to Health Minister Reti, we are 500 doctors short. That’s slightly less than the annual number of new doctors coming out of Auckland and Otago medical schools each year.
And according to Health NZ, we had 1817 nursing vacancies at the end of 2023.
Like most things, our health system is probably best measured by the outcomes we deliver for our patients. Right now, those outcomes aren’t good enough or fast enough. It’s not for the lack of money. Earlier this year, the Government announced a funding boost of $16.68 billion across three Budgets for frontline services. But like many government enterprises, too much money goes into the back office. Big bureaucracies full of people doing business with themselves, having meetings with each other with no outcomes, going to conferences and courses, the outcomes of which are often vague at best.
It wasn’t always like this. We once had a health system that was the envy of many countries. At its heart was the local GP, who usually operated out of his own practice, and worked long hours at the clinic, often from 7am until 7pm. That same doctor would then do house calls on his or her way home in the evening if required. They knew their patients, their families and their state of health.
Alongside other GPs from around the neighbourhood, they would jointly co-ordinate their efforts to ensure that weekends were covered for those owner-operators who needed medical help after hours. And we didn’t need after-hours clinics because if it was serious enough, we could call the doctor outside of hours.
But time has moved on and work has changed.
Since then, the corporatisation of doctors’ clinics has changed the way our health is serviced. These “corporate-style” GP operations are based in bigger premises and have a number of doctors on their roster. None of those doctors are “owner-operators”. Some will work fulltime while others are part-time. Most work from 9am through until 5pm. Very few make house calls.
I know a young doctor who has recently entered public practice working as a GP for one of these services. She works from 9am until 4pm, four days a week. She’s quite happy with that workload.
As a result, in many cases it’s not possible to build a relationship with the doctor. You might see a different person each time. They’re more mobile than the old neighbourhood doc. So they will move on without you knowing.
Health NZ Commissioner Professor Lester Levy during the Health select committtee hearing at Parliament, Wellington, 04 December, 2024. NZME photograph by Mark Mitchell
I’m no expert on what is going on in our health system. But when things are as bad as they are, we need to change the way we do things. For example, think about the process of having an annual check-up. We all know that a blood test is going to be a part of that. Ideally, we’d have the blood test before we see the doctor. But we can’t get a blood test unless the doctor requests it. The doctor won’t request it until they see us. Why can’t a nurse request a blood test in advance of the doctor visit? That way, if there’s a problem the doctor can deal with it rather than wait for a second appointment.
It’s the same with the hideously long waiting times to see specialists. Another mate of mine, this time with a bung hip likely needing replacement, waited four months to see a specialist. Once there, the specialist spoke to him briefly and ordered a scan. The appointment lasted four minutes and cost $375. The patient had asked his GP if he could get a scan before seeing the specialist and was told only the specialist could order it. He then waited a month for the scan and another two weeks for the results. The specialist then booked another appointment, this time two months out.
You don’t have to be an expert in time and motion studies to see that this is nonsense. It’s no wonder our country’s productivity is so bad. Let the doctor order the scan before we see the specialist and you eliminate the need for an appointment three or more months after the first.
There must be hundreds of other relatively simple processes that we would change to make things more efficient. In all of those restructures and reviews, I’ve never seen anything change at the coalface. And that’s where change is most required.
That aside, there is no question that we need more medical professionals in the ranks in New Zealand. It’s great that the Government is looking at adding a third medical school. But we should also be pushing the capacity of the two we currently have.
Otago and Auckland say that, given funding, they could increase capacity by 50%. That would give us another 300 or so doctors a year. We need to try harder to keep them too. What if we bonded them for five years in return for paying a portion of the education and accommodation component of their student loan?
We attract plenty of overseas students to our medical schools, and the good news is that those numbers are gradually growing again. But many of those students, whom we educate, return to their homelands post-graduation. What if we bonded them too, and in addition, offer them citizenship if they graduate and stay?
It’s the same with nurses. We need to encourage young people to pursue a career in nursing and we need to motivate them to stay here. Bonding, work visas and citizenship offers all have a role to play in fixing these problems more quickly.
Recently we learned that just 844 of a total of 1619 nursing graduates were offered jobs. That means 775 missed out. Someone should be asking why that is. Are we recruiting the wrong people or teaching them the wrong things. There is no question that we need nurses. So we train them, but fail to employ them? It doesn’t make any sense.
It’s not going to get any easier either. Most of us understand that we have an ageing population that will only become more needy in the next 20 years.
I recently watched a speech given by an Australian doctor and medical professor speaking about the likely downstream impacts on health as a result of the rushed Covid vaccination scheme. If what he is saying is accurate, and I have no reason to believe that it’s not, then we are going to have even greater pressure on our health system over the next 20 years than historical evidence might suggest.
So we need to get on a path to recovery, and we need to do so quickly. I met the new Health Commissioner a number of years ago and found him to be a good and highly competent person. But I wonder if his hands are bound too tight.
Perhaps we should seek to start again. Our health system is currently operated by not one, but two government departments, the Ministry of Health and Health NZ. What would happen if we set a target to close both down completely 12 months from now?
We could then appoint a highly qualified and small team to spend the next year designing and establishing a new organisation appropriate for today’s needs. They should be excluded from employing bureaucrats who currently serve in the existing system. They should also be targeted with maximising the talent at the front line and minimising the size of the back office. And in 12 months’ time, all necessary assets, equipment and the employment contracts for those critical doctors, nurses and other mission critical personnel at the front line would switch to the new organisation.
It might sound risky. But the status quo isn’t working any more. We have to try a new way. And in 10 years’ time we might get a doctor, a scan and a specialist in one day.
