Aotearoa New Zealand general practice workforce crisis: what are our solutions?

Introduction

It is not news that Aotearoa New Zealand is in the midst of a general practitioner (GP) shortage. The recent GP workforce documents released by the Royal New Zealand College of General Practitioners (RNZCGP) paints a worrying picture; its notable findings include worsening levels of burnout and a rapidly ageing workforce, with 57% of GPs aged ≥50 years, and more than one-third of the country’s GPs planning to retire within the next 5 years.^1,2 Unsurprisingly, this shortage is expected to be particularly acute in rural and high-needs urban areas.^3,4

Primary health care (PHC) is often recognised as an important determinant of population health and addressing health inequities.^5,6 Having a strong and well-resourced PHC is essential in improving health outcomes for all through timely access to appropriate medical care, the mitigation of preventable diseases, and preserving the viability of health systems.^7,8 GPs are crucial players of a multidisciplinary primary healthcare team as they are pivotal in the organisation of PHC services, including ensuring the continuity of care and acting as ‘gatekeepers’ to patients’ access to specialist (secondary) care. Considering the vital role GPs have on the health and wellbeing of the communities they serve, the reported high levels of burnout and intentions to leave the profession highlights the pressing need for novel solutions to tackle the workforce crisis. So what exactly are our solutions? This viewpoint examines current and proposed strategies aimed at tackling Aotearoa New Zealand’s general practice workforce shortages. Additionally, it explores alternative interventions that could be adopted to further strengthen the sustainability of our general practice workforce.

Strategies for addressing GP workforce shortages: current initiatives and proposed solutions

The current Government’s plan to increase the number of primary care physicians is essentially a two-folded strategy.

The first part of the strategy focuses on increasing the annual number of graduating doctors through increasing current medial school enrolment quotas and the establishment of a third medical school at the University of Waikato by 2027.⁹ Currently, around 25 percent of medical graduates annually choose to pursue a career in general practice, a figure that falls considerably below what is needed to address the shortage of primary care doctors.¹⁰ It is hoped that by opening a new medical school, characterised by an innovative curriculum emphasising primary care career pathways and early clinical exposure to general practice, it would encourage a larger proportion of graduates from this third medical school to pursue specialised training in rural medicine and primary care.

The second part of the strategy focuses on making a career in general practice more attractive by offering financial incentives to those who chose to practise general practice in remote areas or areas with high health needs. This initiative is more commonly known as the voluntary bonding scheme (VBS). Under this scheme, newly qualified healthcare professionals who practise in certain areas of need for a designated period of time would receive a fixed monetary payment. Currently, only doctors in postgraduate training years 3–6, who are either starting or already involved in general practice training, are eligible for a $30 000 lump-sum pay-out (after-tax) upon completing 3 years of service.¹¹

Potential issues with current and proposed solutions

Although it might seem intuitive that the solution to address Aotearoa New Zealand’s primary care doctor shortage is to train more doctors, the solution is not as clear-cut as it is made out to be. In order for New Zealand medical graduates to attain full registration with the New Zealand Medical Council, allowing independent practice in a hospital or private practice setting, they must first undergo 2 years of prevocational medical training upon graduation. However, due to limitations on hospital resources and the availability of adequate clinical supervision, securing prevocational training poses a challenge for some New Zealand medical graduates. In recent years, 22 and 23 New Zealand medical graduates were not offered prevocational postgraduate training positions in the 2022 and 2021 training years respectively.¹² In its current form, the Government’s plan to increase the number of medical graduates is being done so in a setting of insufficient prevocational postgraduate training positions and thus is counterproductive and morally irresponsible as it would result in an excess of graduates who, despite completing their education, face obstacles at the final stage and are consequently unable to contribute to patient care. Without completing the required 2-year prevocational training, graduates are unable to participate in any subsequent vocational training programme, including general practice. Hence, it is imperative for the Government to provide assurance that, at the very least, every graduate from a New Zealand medical school will be guaranteed a position for prevocational training.

Moreover, it is uncertain whether establishing a medical school that has a curriculum focused on primary care medicine would actually favourably affect the career intentions of medical students. Although evidence indicates that increased exposure to general practice teaching during medical school is linked to a higher likelihood of choosing a career in general practice, it is worth noting that the influence of medical school curriculum is just one of several factors influencing medical students’ postgraduation career choices.^13,14 Unfortunately, general practice is often perceived as being inferior to other medical specialties, when considering other factors such as intellectual stimulation, societal perception, self-perceived occupational prestige, and remuneration.¹⁴ Furthermore, it remains uncertain as to the extent to which general practice exposure at medical school influences future career choices.¹⁵ For instance, do graduates prioritise remuneration over intellectual stimulation and clinical exposure when deciding their future career pathways? Which factor(s) carries more weight in their career decision-making process? Certainly, as Fodeman and Factor have indicated, early exposure to general practice would help, but additional actions are needed to adequately address this issue.¹⁵

Introduced in 2009, the VBS was designed to enhance the income potential of primary care to encourage more graduates to pursue a career in general practice. However, the uptake of the scheme has arguably fallen short of expectations, reportedly with a high attrition rate for doctors in 2012.¹⁶ Interestingly, Te Whatu Ora has not provided data on the current retention rate for doctors under the VBS scheme. Nevertheless, I believe that the primary reason for this poor historical retention rate could be due to the unappealing payment structure and option. Currently, eligible individuals receive a lump sum of $30 000 (after tax) at the end of 3 years, credited to either their student loan balance or directly to their bank account if they do not have a student loan balance.¹¹ However, the current payment method is considered unfavourable because participants are unable to practically use the money for various essential purposes such as relocation costs or contributing to their day-to-day living expenses. Perhaps the effectiveness of the scheme would be improved if payments were distributed regularly (preferably weekly) over the duration of the scheme rather than provided as a lump sum. Additionally, directing the payments straight to an individual’s bank account, instead of crediting it to their student loan balance, would allow clinicians to use the funds more flexibly. This approach would enable clinicians to use their payments in a manner that aligns better with their evolving financial needs and circumstances.

Other solutions

In this section, I explore alternative solutions that could be adopted to further increase GP recruitment and retention.

Conclusion

Although it is positive to see ongoing and proposed solutions aimed at tackling Aotearoa New Zealand’s general practice workforce crisis, it is crucial to recognise that certain implementation issues are hindering the full efficacy of these solutions. Nevertheless, there are other strategies that merit deeper exploration as additional solutions to further strengthen the recruitment and retention of primary care doctors.