An update on Closed Books in general practice in Aotearoa New Zealand
Megan Pledger
1 2 * , Maite Irurzun-Lopez 1 , Jacqueline Cumming 1
1
2
Abstract
People are precluded from enrolling in primary health care at a general practice if it has ‘Closed Books’. This creates barriers to accessing health care.
To examine which Health Districts had the greatest number and proportion of general practices with Closed Books and how this has changed since 2022.
Maps were used to display the distribution of Closed Books general practices and tables were used to compare changes in Health Districts over time.
There were 373 (36%) general practices that had Closed Books in September 2024. Canterbury (n = 56), Southern (37) and Northland (32) Health Districts had the greatest number of Closed Books general practices, while Hutt Valley (73%), Lakes (70%) and Wairarapa (67%) Health Districts had the greatest percentage of general practices with Closed Books.
The problem of Closed Books was felt across the country but has a larger impact in the middle-lower North Island and an increase in impact in Northland and the lower South Island. Improvements have been seen in the worst hit areas since 2022 but, overall, the percentage of general practices with Closed Books has not improved.
Keywords: Primary health care, Primary health care enrolment, Closed Books, Barriers to healthcare access, Health Districts, Aotearoa New Zealand.
| WHAT GAP THIS FILLS |
| What is already known: Closed Books are a barrier to accessing primary health care enrolment. In June 2022, there were 347 (33%) general practices that had Closed Books with the lower North Island being particularly affected. |
| What this study adds: This study looks at how Closed Books are distributed across Aotearoa New Zealand in 2024 and how this has changed at the general practice level since 2022. |
Introduction
In Aotearoa New Zealand (NZ) general practices provide primary health care in a community setting. General practices are partly funded by the NZ government based on the number and type of patients they enrol with the remaining cost generally paid for by the patient. Patients do not have to enrol to access health care at a general practice, but enrolment brings financial and other benefits for both the practice and the patient. General practices can limit patient enrolment either by selecting new patients or by not enrolling any new patients at all, with the latter situation being referred to as having ‘Closed Books’.1
Closed Books has long been a problem, eg enrolment problems in Lower Hutt were raised in the media in 2009.2 In 2022, 33% of general practices were found to have Closed Books with reasons given being the increased workloads due to COVID-19 and border control restrictions that restricted access to NZ by doctors and nurses.3,4 In 2024, with these stressors on the wane, the proportion of practices with Closed Books would be expected to have decreased. However, raised referral thresholds in secondary care, along with the increased complexity of care necessary for an aging and diverse population, continue to put pressure on general practice.5
For unenrolled patients accessing primary health care becomes more difficult as Closed Books practices may also restrict casual appointments, and waiting times for all patients are typically longer.1 An Open Books practice may not be available in the area requiring substitution by other services or may not be suitable in terms of cost or travel time.3
The areas of interest for this study were the 20 District Health Board areas that cover NZ. District Health Boards were administrative units through which government-funded health resources were managed but their role has now been subsumed into Te Whatu Ora Health NZ. However, these areas are still used for reporting purposes due to the long-term knowledge accumulated about these partitions and are now referred to as Health Districts.
The aim of this research was to look at which districts were more likely to have Closed Books general practices and where there were changes between 2022 and 2024. This analysis will provide valuable insights into regional disparities in access to primary health care, helping to inform policy decisions aimed at improving enrolment opportunities across districts in NZ.
Methods
Data and variables
Facilities Database: A database of location information about healthcare facilities including the facility type ‘Enrolling GP Practice’.6 The file was current to 1 September 2024.
Healthpoint Database: A website that gives information about healthcare providers. Information on general practices includes whether the general practice is enrolling patients.7
Each facility in the Facilities Database in the category ‘Enrolling GP Practice’ was searched for on the Healthpoint website and the enrolment information recorded (‘yes’ or ‘no’). Data were retrieved from 5 to 11 September 2024 with the written permission of Healthpoint.8
Practices were excluded if they solely related to aged care or were tertiary education services, which are typically funded and managed by the institution so they always remain open to their serving population. They were also excluded if they were online only, were a nurse-led practice with no general practitioner (GP) or only a virtual GP or had become a community service (health and social care with no GP). The sole refugee integration service was also excluded. Practices were further excluded if they had closed or had amalgamated without keeping their name, were too new to have started consultations, were duplicates or could not be found on Healthpoint or online. Thus, in this analysis, general practices were considered to be an ‘Enrolling GP Practice’ with at least one non-virtual GP, open to the general public and in a physical location. If the enrolment information was missing from Healthpoint then the general practice’s website or their Facebook page was checked for any further information.
GP Fees by Practice Database (2022): A Ministry of Health (MoH) supplied database that gave information on fees and enrolling status for each general practice at 1 June 2022. Enrolling status was a Yes/No binary variable with ‘No’ indicating the general practice had Closed Books on the day the data was collected by the MoH, typically within a fortnight of the report date. The Closed Books status came from information supplied by general practices and Primary Healthcare Organisations, and values for missing data were found via their websites and the Healthpoint website [private communication, Health Planning and Insights, Ministry of Health].
Statistics
Results were presented using maps of districts, ie hexmaps.9 Tables were used to look at changes in the percentages of Closed Books between 2022 and 2024 for general practices that could be linked by a facility ID.
The difference in percentages across time periods does not measure the volatility in those changes. For example, a district may have 50% of its general practices with Closed Books in both 2022 and 2024 but every general practice in that district may have changed status. In order to look at the volatility over time, we compared the general practices that had Closed Books in 2022 and what percentage had kept or changed their status. A similar comparison was made for practices who had Open Books in 2022. Finally, we looked at the percentage of practices who had any change in status, ie churn.
Ethics approval was not sought as the data was administrative and the units of analysis were general practices and districts.
Results
There were 1168 facilities listed in the 2024 facilities database. After searching Healthpoint and online, 122 facilities (10.4%) were excluded (see Table 1). The three facilities who were known to exist but had unknown enrolment status were coded as ‘Yes’.
| N | % | ||
|---|---|---|---|
| Kept for analysis | |||
| Enrolling | |||
| Yes | 670 | 57.4 | |
| No | 373 | 31.9 | |
| Unknown enrolment status | 3 | 0.3 | |
| Not kept | 122 | 10.4 | |
| Age care | 32 | 2.7 | |
| Closed/amalgamated | 22 | 1.9 | |
| Student service | 17 | 1.5 | |
| Nurse lead practice | 17 | 1.5 | |
| Could not find practice | 13 | 1.1 | |
| Community service | 7 | 0.6 | |
| New facility, not consulting | 5 | 0.4 | |
| Duplicates | 4 | 0.3 | |
| Online service | 4 | 0.3 | |
| Refugee service | 1 | 0.1 | |
Note: there were nine virtual care clinics on Healthpoint but only four in the facilities dataset since only four were tied to a physical address.
Number and percentage of Closed Books general practices
Overall, there were 373 general practices with Closed Books (36%). Canterbury (n = 56), Southern (37) and Northland (32) districts had the most general practices with Closed Books. The districts with the highest proportion of Closed Books were Hutt Valley (73%), Lakes (70%) and Wairarapa (67%).
Fig. 1 displays how the number and percentage of Closed Books practices are distributed around the country. The eastern side of the lower North Island appears particularly problematic, along with the lower South Island and Northland.
To look at what changes have occurred at the general practice level, general practices that could be linked by their facility ID in both the 2022 and 2024 dataset were kept. This gave 998 general practices. Of those, seven in the 2022 dataset did not have enrolment information and were coded as ‘Yes’ (0.7%). The statistics are presented in Table 2 by district and in geographic order with values colour-coded so that green indicates a more beneficial percentage and red indicates a more detrimental.
| N | 2022 | 2024 | Difference | ||
|---|---|---|---|---|---|
| % | % | ||||
| Overall | 998 | 33 | 36 | 3 | |
| Health Districts | |||||
| Northland | 56 | 36 | 57 | 21 | |
| Waitematā | 105 | 17 | 24 | 7 | |
| Auckland | 138 | 17 | 20 | 3 | |
| Counties Manukau | 101 | 17 | 18 | 1 | |
| Waikato | 78 | 15 | 21 | 6 | |
| Bay of Plenty | 50 | 30 | 34 | 4 | |
| Lakes | 19 | 16 | 68 | 52 | |
| Tairāwhiti | 11 | 27 | 27 | 0 | |
| Hawkes Bay | 24 | 54 | 63 | 9 | |
| Taranaki | 30 | 80 | 47 | −33 | |
| Whanganui | 14 | 64 | 36 | −28 | |
| Mid Central | 30 | 80 | 70 | −10 | |
| Wairarapa | 6 | 83 | 67 | −16 | |
| Hutt Valley | 22 | 73 | 73 | 0 | |
| Capital and Coast | 59 | 37 | 41 | 4 | |
| Nelson Marlborough | 33 | 52 | 36 | −16 | |
| Canterbury | 111 | 41 | 49 | 8 | |
| West Coast | 13 | 15 | 15 | 0 | |
| South Canterbury | 17 | 47 | 59 | 12 | |
| Southern | 81 | 36 | 43 | 7 | |
Overall, the percentage of these general practices with Closed Books was 33% in 2022 and 36% in 2024, an increase of 3 percentage points. In 2022, the areas with the highest percentages of Closed Books were in the lower North Island and this still continues to be the case in 2024. However, there has been some improvements in these districts, with all but the Lower Hutt district showing large decreases. This is particularly notable in the Taranaki (−33%) and Wanganui (−28%) districts. Of greater concern is the increase in the percentage of Closed Books in the Lakes (+52%) and Northland (+21%) districts.
The churn in each district is presented in Table 3. The districts that had the most success in moving from Closed Books practices in 2022 to Open Books practices in 2024 were Whanganui (56%), Nelson Marlborough (53%) and Taranaki (46%), after ignoring districts with small counts. Out of the practices that were closed in 2022, Northland (90%), Hutt Valley (81%) and Wairarapa (80%) districts had the highest proportion of practices that were also closed in 2024.
| Enrolling (2022 → 2024) | ||||||||
|---|---|---|---|---|---|---|---|---|
| Count | Row % | Count | Row % | Churn | ||||
N in 2022 | N → N | N → Y | Y in 2022 | Y → Y | Y → N | % | ||
| Overall | 325 | 69 | 31 | 673 | 79 | 21 | 24 | |
| Health districts | ||||||||
| Northland | 20 | 90 | 10 | 36 | 61 | 39 | 29 | |
| Waitematā | 18 | 56 | 44 | 87 | 83 | 17 | 22 | |
| Auckland | 23 | 70 | 30 | 115 | 90 | 10 | 13 | |
| Counties Manukau | 17 | 71 | 29 | 84 | 93 | 7 | 11 | |
| Waikato | 12 | 58 | 42 | 66 | 86 | 14 | 18 | |
| Bay of Plenty | 15 | 67 | 33 | 35 | 80 | 20 | 24 | |
| Lakes | 3 | 67 | 33 | 16 | 31 | 69 | 63 | |
| Tairāwhiti | 3 | 33 | 67 | 8 | 75 | 25 | 36 | |
| Hawkes Bay | 13 | 77 | 23 | 11 | 55 | 45 | 33 | |
| Taranaki | 24 | 54 | 46 | 6 | 83 | 17 | 40 | |
| Whanganui | 9 | 44 | 56 | 5 | 80 | 20 | 43 | |
| Mid Central | 24 | 79 | 21 | 6 | 67 | 33 | 23 | |
| Wairarapa | 5 | 80 | 20 | 1 | 100 | 0 | 17 | |
| Hutt Valley | 16 | 81 | 19 | 6 | 50 | 50 | 27 | |
| Capital and Coast | 22 | 68 | 32 | 37 | 76 | 24 | 27 | |
| Nelson Marlborough | 17 | 47 | 53 | 16 | 75 | 25 | 39 | |
| Canterbury | 45 | 76 | 24 | 66 | 70 | 30 | 28 | |
| West Coast | 2 | 50 | 50 | 11 | 91 | 9 | 15 | |
| South Canterbury | 8 | 75 | 25 | 9 | 56 | 44 | 35 | |
| Southern | 29 | 72 | 28 | 52 | 73 | 27 | 27 | |
Of the practices that had Open Books in 2022, Lakes (50%) and Hutt Valley (45%) were the districts more likely to have general practices that subsequently changed to Closed Books in 2024. On the other hand, Counties Manukau (93%), West Coast (91%) and Auckland (90%) districts were the most likely to have remained open to enrolment.
Across this cohort of general practices, 24% had changed their status between 2022 and 2024. The districts with the highest churn were Lakes (63%), Wanganui (43%) and Taranaki (40%), with the two latter having greater beneficial changes and the former detrimental.
Discussion
This study has shown that in 2024 there were a large number (373) and proportion (36%) of general practices with Closed Books across NZ with the number and proportion increasing since 2022. The authors find this somewhat surprising given the reduction in the burden of COVID-19 on general practice and the borders being open for over 2 years allowing for the recruitment of GPs and nurses to plug workforce gaps.4,10 However, ongoing capacity constraints in secondary care are shifting more clinical and administrative responsibilities to general practices increasing workloads.5
When general practices were matched across time points, it showed that 24% of general practices had changed their status between June 2022 and September 2024. However, this is likely to be an under-estimate of the total churn as we did not make observations at time points in between.
Closed Books practices may mean patients have to travel long distances to find a practice where they can enrol.3,4,11 Conversely, those enrolled might feel compelled to stay due to the associated time, expense and travel required to switch to a more suitable option. Closed Books has implications for other health service providers that can substitute for general practices as they deal with the increase in demand with long wait times and having to turn away patients.12
Not being enrolled in primary health care is associated with poorer health outcomes. An analysis of all amenable deaths between 2008 and 2017 across NZ found that those who died were more likely to not be enrolled, after adjusting for age, sex, ethnicity and deprivation.13 From analysis of the New Zealand Health Survey, of those who used an emergency department, the unenrolled (40%) were more likely than the enrolled (26%) to go there for a condition that could be treated in primary care.14
A limitation of this study is that it relies on general practices updating their Healthpoint profiles in a timely and accurate manner. When a practice can only take on a few new patients or is very busy this may not happen.15 The original data were collected in 2022 by the MoH from multiple sources while the data in 2024 were collected by the authors mainly from the Healthpoint website. There is a possibility that some of the differences in the collection methods could explain the differences seen.
The problem of Closed Books was felt across the country but has a larger impact in the middle-lower North Island and an increase in impact in Northland and the lower South Island. Improvements have been seen in the worst affected areas since 2022 but, overall, the percentage of general practices with Closed Books has not improved.
Data availability
Administrative data are publicly available (citations provided) or available on request from the MoH. The data from the Healthpoint website are available under Healthpoint’s terms and conditions of use.
Acknowledgements
The authors thank the MoH for their diligence and care in finding and preparing the 2022 enrolment data.
Author contributions
M. I. L., M. P. and J. C.: conceptualisation. M. P.: methodology, software, data curation, formal analysis, project administration and visualisation. M. P. and M. I. L.: writing – original draft. M. P., M. I. L. and J. C.: writing – review and editing. All authors have read and agreed to the final version of the manuscript.
References
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