Doctor shortages: Community care is the solution for our burned-out medical workforce - Dr Art Nahill

THREE KEY FACTS

• New Zealand is currently 485 GPs short and “will struggle to train or bring in enough international medical graduates to meet this demand”, a briefing to Health Minister Dr Shane Reti has warned.
• A survey of 220 general practice staff found four out of five had stopped or limited their enrolments over the previous three years.
• After-hours medical services in some regions are on the verge of collapse, as overworked GPs signal they can no longer provide cover or the funding falls short.

Dr Art Nahill is an Auckland-based specialist general physician, medical educator, and writer with 30 years of experience. He has worked at Auckland, Middlemore, and Whāngārei hospitals.

OPINION

The news these days is full of stories about the ways the New Zealand healthcare system is failing.

The stories come from every stakeholder group including patients, whānau, doctors, and nurses. The medical workforce is burned out, retiring early, and increasingly giving up on the public health system and moving to Australia, or the far more lucrative private system right here in Aotearoa.

In many rural and remote areas, patients can no longer see a GP because the doctors have closed up shop and moved away or given up practice altogether. In other areas the waits are far too long or the visits much too expensive.

Emergency departments, urgent care clinics, and hospitals have become dangerously overcrowded, though for many there is no alternative but to wait and wait and wait some more. Māori, Pasifika and other vulnerable communities suffer from inequities baked into the system and fare much worse than other groups in many measures of wellbeing.

As a hospital specialist in general medicine for nearly 30 years I have dearly loved my work but have taken an early retirement because I can no longer bear to patch people up, only to discharge them back to the same toxic environments, unhealthy lifestyles, and ineffective health systems, waiting for them to get sick again.

And there are plenty of stories and opinion pieces in which successive governments have politicised their failings to avoid acknowledging how bad things have become and how few solutions they have to offer. We’ve either spent too much money or not enough, have hired too many managers or too few, all depending on one’s political ideology.

No one in government is prepared to admit the current healthcare delivery model is no longer fit for purpose and needs to be radically redesigned, probably because such a makeover would require the active listening, imagination, hard work, and co-operation which no government is especially good at.

But there are alternatives to the current mess in which we find ourselves.

I often think of our current healthcare system as a top-heavy tree whose roots can’t extend deep enough or far enough into the surrounding soil (the community) to support its weight in a storm. What is needed is a system that functions more like a river, its headwaters bubbling up from small springs and aquifers far away that coalesce into bigger and bigger tributaries capable of flowing around obstacles.

What is needed is a health system comprised of true community-based care, small interactions offered in people’s homes, marae, and places of work and worship.

What is needed is not a health system designed to treat disease but rather to promote health and wellbeing.

'I can no longer bear to patch people up, only to discharge them back to the same toxic environments, unhealthy lifestyles, and ineffective health systems, waiting for them to get sick again.' Photo / 123rf

So how could such a health system be achieved?

One solution, which I will call “Te Awa” could involve the creation of a new kind of health workforce, one that is easier, faster, and less expensive to train than the many hundreds of doctors and nurses we would need to fill the gaps in our current system.

It could involve an army of community health workers chosen from the communities they would serve, where they have lived and worked and about which they have in-depth local knowledge.

These workers could be specially trained over a year or two to offer education and support around diet and healthy living, addictions, and basic mental health issues, immunisations and cancer screening.

They could also be trained in the treatment of some acute and chronic conditions that currently require a person to go to a GP practice or urgent care facility. That is, if they can find one, get an appointment, find someone to mind the kids or get time off work, and pay the resulting fees.

This workforce could be supervised by and integrated into the more traditional parts of the system (nurses, GPs, specialists and hospitals) via existing communication technologies, creating a wide watershed of care. Community health workers could also provide support and advocacy as required by people needing to negotiate the swift-flowing, often bewildering currents of hospital or specialist care.

This may sound like a radical idea but it’s really not.

Doctors have already begun (though slowly and often unwillingly) to give up their monopoly on providing healthcare; some nurses, and even local pharmacists, are now able to provide treatments for issues such as Covid, urinary tract and sexually transmitted infections.

Māori community health workers already do great work throughout New Zealand and their training and the healthcare services they provide could be greatly expanded.

Other countries around the world use such workers and find them extremely valuable and cost-effective. International research has shown that true community-based care can lessen the load on emergency rooms and hospitals and significantly improve the health and wellbeing of communities.

The time is long overdue to stop pointing fingers of blame for the healthcare crisis we now find ourselves in.

What we need to do now is start talking about what we want from our public healthcare system and how to achieve it. Simply throwing money at training more doctors and nurses who will burn out, quit, or move away is not an effective long-term solution by itself.

The river model (Te Awa) is just one possible solution, but one which places care and control back where it most belongs: in local communities.

Te Awa also shifts the model of care from the treatment of well-established diseases to one which focuses on prevention, early intervention and treatment, and addresses many of the drivers of health inequity.

It’s time for a kōrero about innovative solutions.

While it may be hard to watch an old, familiar tree fall over, it sometimes allows just enough space and light to grow things never before imagined.