Equitable access to primary health care: better availability of GP appointments is only one piece of the jigsaw

Timely access to general practice in Aotearoa New Zealand (NZ) is not a reality for increasing numbers of New Zealanders, with ‘time taken to get an appointment was too long’ being the most commonly reported barrier to visiting a general practitioner (GP) in the 2023/24 NZ Health Survey.¹ Although the government has recently announced it is investing in general practice and strengthening the primary health care workforce to address this issue,² there remains a need to ensure equitable access to health care. Access, it needs to be emphasised, is more than just timely availability of services. Accessible health services also need to be approachable, acceptable, affordable and appropriate.³ Further, it is those with the greatest need who have the most difficulty accessing care.⁴ Such patients are often clustered in general practices which have a ‘concentration of complexity’: where adverse social determinants of health and multimorbidity combine.⁵

Multimorbidity, complexity and equitable access to health care feature in this issue of the journal. Askerud carried out an evaluation of Client-Led Integrated Care (CLIC) which was implemented in general practices between 2018 and 2022 in NZ’s Southern region.⁶ CLIC was intended to be provided to patients with complex care needs associated with multimorbidity. The study sought to determine whether CLIC supported self-management ability and assessed its alignment with current priorities for multimorbidity management. She found, however, that CLIC did not uniformly address the needs of all patients, nor did it target those with the most ability to benefit. Her conclusion was that programmes for multimorbidity in primary care should be implemented in ways that prioritise equity and address the social determinants of health. Tane and colleagues explored the barriers and facilitators of accessing heart health care for rural Māori living in Te Tai Tokerau Northland.⁷ They used Kaupapa Māori Theory to inform the study design and analysis. They found that participants experienced multiple barriers to accessing quality heart health care. Participants desired heart health care that was close to home, culturally responsive, included a representative Māori workforce, involved their whānau, and valued partnership. They conclude that health system level action is needed to adequately address inequities in health care access and outcomes in rural Māori and to meet obligations under Te Tiriti o Waitangi.

Type 2 diabetes (T2DM) is one of the most common chronic conditions managed in primary care and disproportionally affects Māori. The need to develop models of T2DM care that are tailored to the needs of this population is the subject of two short research reports. Chepulis and colleagues⁸ conducted a pilot study to evaluate the use of technology (continuous glucose monitor) and culturally-informed education and ‘wrap-around’ care to improve T2DM biomarkers and self-management in a high-needs, majority Indigenous (Māori) population in the Waikato. Their results are promising, with the intervention improving biomarkers in the short term, with improvements maintained by most for at least 12 months. Mustafa and colleagues⁹ evaluated the impact of the Piki te Ora service in Pare Hauraki. The Piki te Ora service adopts a multi-disciplinary approach, with cultural safety as a key element, aiming to provide comprehensive support and care to whānau (enroled patients) living with long-term conditions, including T2DM. They conclude that The Piki te Ora service appears to provide effective support for T2DM management.

Children and young people feature in a third group of research papers, which also have a strong Māori and Pacific focus. Māori and Pacific children in NZ have longstanding inequities in respiratory health outcomes. Matenga-Ikihele and colleagues therefore conducted a systematic review to explore the characteristics of respiratory research in this population.¹⁰ They found a lack of research on the lived experiences of whānau and their children who endure these conditions with few studies incorporating culturally relevant approaches. They conclude that further research using such approaches is urgently needed to help improve health equity for these children. Pokorny and colleagues explore the perspectives and experiences of families/whānau and GPs regarding grommet services for children.¹¹ The rationale for this research was that a large public outpatient ORL service in Auckland (Counties Manukau) had devolved post-surgery follow up to local GPs. They found that while families/whānau valued follow-up services and hearing evaluations after grommet insertion they experienced multiple barriers to receiving the desired care. The final paper in this group explores the well-being of Pacific students at the University of Otago during the COVID-19 pandemic. Sopoaga and colleagues conducted a cross-sectional survey¹² and found that almost all students received a healthcare pack (included medical supplies and Pacific blessing cards). A majority received additional support from the university, which was highly valued by the students.

Oral health should be an important aspect of primary health care (PHC), however, the delivery of such care in NZ is hampered by the siloed nature of general dental and general medical care. Two research papers explore this issue. Smith and colleagues highlight that PHC teams are well positioned to promote and protect patients’ oral health. They thus explored the views of doctors and nurses on the place of oral health in PHC.¹³ They found that while primary care practitioners are open to incorporating oral health into their clinical practice significant barriers to the provision of oral health care exist at individual, professional and health system level. Guan and colleagues sought to explore the nature of interprofessional communication between dentists (general dental practitioners) and GPs and to identify strategies to bridge the gap between the two groups.¹⁴ Both GDPs and GPs reported a lack of efficient interprofessional communication, particularly with respect to complex medical conditions and polypharmacy. Participants suggested a range of strategies to improve matters, including implementing interprofessional education and developing effective referral guidelines.

Our final two research papers illustrate the breadth of primary care research. GPs find examining the retina with direct ophthalmoscopy challenging and have low confidence in their interpretation of findings. Non-mydriatic fundus photography (NMFP) has been shown to have a higher pick up of fundal pathology in non-GP settings. Davidson and colleagues¹⁵ compared the use of direct ophthalmoscopy with smartphone NMFP in patients presenting with ‘red flag’ ophthalmic presentations a large rural general practice in Northland. They found that GPs using NMFP were better able to visualise the fundus compared to direct ophthalmoscopy and inter-rater agreeing between the referring GP and the ophthalmologist was good. In contrast, Ghosh and Blair¹⁶ address a core aspect of being a GP: how you deal with clinical uncertainty. Their qualitative research with GPs and patients identified four overarching professional attributes: collaboration, compassion, insight, and unconventional thinking.

We conclude this issue with a Cochrane Corner on ‘do antidepressants help people with low back pain?’¹⁷ and a Charms and Harms exploring the benefits and harms of Horny Goat Weed/Epimedium¹⁸ (used in traditional Chinese medicine).