Covid-19, our biggest health crisis in a century, has thrust healthcare into the spotlight. Over the course of this week, the Northern Advocate is exploring the role the health system plays in communities across Northland. Today, Adam Pearse finds that Northland's growing population is putting pressure on our health system, and without a solution being found it is likely to get worse. This pressure is already being felt in primary care where there is a shortage of general practice doctors.
As Northland's population grows and ages, its health services will become more and more stressed without appropriate intervention.
The pressure on health services is already evident in secondary care (hospital care). In a Northland District Health Board meeting last month, it detailed how the DHB's target for 95 per cent of patients to leave the region's hospitals' emergency departments within six hours was not met in June - a target which had historically not been met.
NDHB chief executive Dr Nick Chamberlain, who said the percentage of patients staying in ED for less than six hours would sit between 81-86 per cent, explained that target would not be met until Northland received its new hospital to replace the current Whangārei facility - the funding for which had not yet been confirmed but was likely to come.
However, there is a rapidly emerging crisis in primary care (community care) relating to a shortage of general practice (GP) doctors in Northland.
According to data from Northland's primary health entity, Mahitahi Hauora, Northland's population between 2018 and 2028 is forecast to increase by 6.4 per cent. Furthermore, as the population ages, GP consultations are set to grow by 11 per cent over that time.
Despite the clear need for more GPs in the region, data from a Royal New Zealand College of General Practitioners survey ranked Northland fifth in the country for the number of GPs who intended to retire by 2023 (33 per cent).
About half of GPs in Northland intended to retire by 2028. Roughly a third of GPs in the Mid North and Far North were over 65 years of age.
The same survey pointed to the stress Northland's roughly 190 GPs are under currently with 34 per cent, the third-highest number across the country, reporting 'burnout' or fatigue caused by overwork.
"As far as I'm concerned, we have a real GP shortage in Northland," Bush Road Medical Centre GP Dr Geoff Cunningham said.
"We have a really elderly demographic of GPs at the moment, a lot of them are to retire in the very near future."
Cunningham, one of three owners of the Kamo-based practice, said the heart of the issue concerned the inability to attract GPs to work and live in Northland, largely due to the heavy workload which was improperly remunerated.
Cunningham believed the shortage would negatively affect the health of Northlanders while putting unnecessary strain on secondary care.
"I think if we...pour money into primary care, preventative medicine, we can keep people out of hospitals," he said.
"We need to work smarter, just pouring more money into hospitals is not the answer."
Fellow Bush Road Medical Centre owner and GP Dr Andrew Miller agreed but said the shortage was recognised not just in Northland but across the country and world.
"General practice in NZ has been such an unstable place to be for so long that many new graduates don't want to do it because they don't know what the future holds."
The image of general practice was a key factor in the shortage, according to Whangārei's West End Medical Centre owners Dr Moira Chamberlain and Iain Watkins.
"Unfortunately, the image is almost like, 'Oh, you're just a GP', so it's not being acknowledged as a speciality," Chamberlain said.
"Because the money's not as good, because you're, 'just a GP', and not seen as a specialist, those things, I think, don't help general practice at all."
Chamberlain said the stresses in primary care was evident in how people could be waiting up to three weeks to see their GP. In the past, she had even had patients travel to Whangārei from Kaitaia because of the shortage of clinicians.
Watkins, who described the issue as a crisis, believed the shortage required a shift in normal practice by utilising video and phone consultations, something which was used extensively by GP practices during the first Covid-19 outbreak.
While the prevalence of video and phone consults had fallen away since the outbreak, Watkins estimated up to 60 per cent of patients currently wouldn't need an in-person consultation, which would reduce workload significantly.
Northland-based academic for the University of Auckland Dr Kyle Eggleton, also a Ki A Ora Ngātiwai GP, said the GP shortage had been recognised for a decade and its ramifications could be realised within 15 years.
"The consequences are quite significant and there's lot of evidence to show that primary care is the most important speciality there is," he said.
"The more GPs you have in a country or an area, the lower your mortality and morbidity are, in other words, people are less likely to die earlier and less likely to have significant complications from disease."
Eggleton said the cause of the shortage was multi-factorial and required a similar response, including increasing the visibility of general practice as a career choice for medical students and finding ways to attract and retain GPs in rural areas.
Kaitaia GP Dr Kathryn Rollo, who saw patients from some of the most remote areas of the country, said the value of a rurally raised and trained GP was second to none.
"Quite a few of the doctors that I see do well up [in the Far North] are the product of farming families, they are from rural communities, they get it," she said.
"Personally, where I think where we could do things better from a GP perspective is having a rural training programme."
Rollo's thoughts were echoed by Mahitahi Hauora chief executive Phillip Balmer, who said providing rural training programmes would help avoid the consequences should the workforce become too depleted.
"At the moment, we are dealing with the beginning of that [GP] demand trend but you play it forward…and it's just scary," he said.
"We must train more doctors locally because they'll stay. So, what we need to do and continue to do is grow our own medical force."
In secondary care, the demand for more specialised services in Northland was well-recognised.
The construction of the Jim Carney Cancer Treatment Centre in Whangārei in 2014 significantly increased what cancer treatment could be provided in Northland, rather than patients being forced to travel to Auckland.
In 2013, the NDHB had provided 2315 chemotherapy infusions to 290 patients. By 2018, the number of infusions rose 126 per cent to 5521 for 499 patients.
In 2017, a cancer treatment unit was opened in Kaitaia which had seen 321 infusions given to 50 patients in 2020.
By having more specialists come to Northland to work at the centre, the number of specialist appointments for Northlanders held in Auckland had significantly reduced.
Kaikohe's John Masters, originally from Panguru, was first diagnosed with bladder cancer about five months ago and has had three rounds of chemotherapy at the Whangārei centre so far.
Fortunately for the 64-year-old, he hasn't had to travel down to Auckland for any treatment and was confident in his driving ability to travel the roughly 70-minute journey from Kaikohe to Whangārei.
While he acknowledged the difficulty of the situation, Masters believed having a negative mindset would only worsen his condition.
"It was devastating to hear it but at the same time, you've got to be positive about these things," he said.
For 58-year-old Bryce Kereopa, travel was a significant barrier to getting treatment for his liver cancer.
Based on Waipoua Settlement Rd about an hour north of Dargaville, Kereopa has regular blood tests at Dargaville Hospital and scans in Whangārei every three months.
Without a licence, Kereopa has to rely on a Cancer Society funded staff member from Te Ha Oranga o Ngāti Whātua as well as the Kaipara Community Health Trust's health shuttle to receive his treatment.
However, over his three-year battle with cancer, Kereopa has had to travel to Auckland three times - a journey which was incredibly taxing.
"[Afterwards], I just curl up and just crash," he said.
While he believed having more treatment accessible further north would be beneficial, Kereopa was very grateful for the support he received.
"I don't mind [the travel] because it's a necessity."
"I feel privileged to have these healthcare things while I'm staying out here."
Cancer Society Northland manager Jenni Moore said while the centre had significantly improved the state of cancer treatment for Northlanders, there were still barriers to care, especially those who had to travel to Auckland for radiotherapy - something not offered in Northland.
"For Northlanders, [going to Auckland is] a huge ask in that people have to go for several weeks, away from their families," she said.
Financially, patients could receive support from the National Travel Assistance scheme, which provided contributions towards a patient's travel or accommodation costs.
However, Moore said through the scheme using an excessively strict criteria and paying costs retrospectively, there were many cancer patients who could not access the support.
Moore also referenced a national study into disparities in cancer survival between Māori and non-Māori from 2007-2016, which found Māori continued to experience substantial cancer survival inequities - a finding Moore believed was reflected in Northland.
Centre oncologist Dr Vincent Newton said a main contributor to poor outcomes for Māori cancer patients was that Māori tended to present with more advanced cancer than non-Māori.
"When you look at it, each step in the pathway, there are little delays," he said.
"[Māori are] less likely to present early to their GP, may take longer to engage in having a diagnostic procedure done, may take longer from that point to actually come and have the next stage of treatment, which is due to a whole host of things."
Newton said such findings were the reason Māori patient navigator, Queenie Mahanga, had been working at the centre for six years, to help shorten the time from diagnosis to treatment as part of the goal to improve equity.
While radiotherapy was not offered in Northland, the Government had made a commitment to source the necessary equipment, a linear accelerator, to offer the service in Northland and was investigating how it could be joined with the current centre.
Newton said offering radiotherapy in Northland was the next vital step in improving cancer treatment in the region.
"[With radiotherapy] in Northland], there would be a few hundred patients not travelling down to Auckland each year, and they would be able to have treatment but also stay in work and with family."
Similar struggles concerning inequity and patient travel were behind the decision to build a cardiac catheter laboratory (CCL) in Whangārei.
Set to open in May next year, the $7.5 million laboratory will diagnose coronary artery disease - the cause of heart attacks.
At present, Northland cardiology patients were sent to Auckland for treatment. In the 2018/19 financial year, 553 Northlanders were sent to Auckland - a significant increase from the 2014/15 financial year of 444 patients.
With an expectation to treat nearly 700 patients in the 2021/22 financial year, Northland cardiologist Marcus Lee said the rise represented the state of cardiovascular disease in the region.
"That increase really just reflects a high disease burden in Northland which disproportionately affects Māori, we also have a significantly ageing population which has more health needs."
Lee said cardiovascular disease was 66 per cent more prevalent in Māori than non-Māori. He also added it was not uncommon for patients to refuse treatment in Auckland based on past experiences with the healthcare system.
Inequitable access for Northlanders was also shown through the time patients were made to wait for an angiogram - a diagnostic test that uses x-rays to take pictures of blood vessels.
International guidelines dictate someone who has had a heart attack should have an angiogram within 72 hours. Having a delayed angiogram runs the risk of more muscle damage and scarring to the heart.
Taking into account services not being open on weekends and patients being too sick for the procedure, NDHB's target was for 70 per cent to have an angiogram within 72 hours.
However, in July, 16 out of 38 Northland patients didn't get an angiogram inside 72 hours, 28 per cent below the target.
Lee said historically the region's average was around 55 per cent, but admitted it was sad to see some patients go as many as 10 days without an angiogram after a heart attack.
Nevertheless, Lee was hopeful the new facility would work towards reversing the inequitable trend in cardiology in Northland. Of the 553 patients sent to Auckland in 2018/19, Lee speculated at least 400 could be serviced in Northland at the CCL.
Looking to the future, Lee said cardiology care should not be determined by where a patient lived.
"If you live in a rural area, you should have access to equivalent services in Whangārei as you would living in Auckland.
"The development of the [CCL] allows us to say within two to three years, we want to have everyone in Northland having access after a heart attack to an angiogram within 72 hours."
The worker logged 437 hours in five weeks - all of which was unpaid.