Time for a change? Unity not competition for the sake of our communities

We write this editorial at a time when political decisions look set to substantially increase the demands on health services in Aotearoa New Zealand (NZ). The disestablishment of Te Aka Whai Ora, the Māori Health Authority, repeal of smoke-free legislation, changes to disability support and removal of fair pay agreements are some of many policy changes that will directly impact the socioeconomic influences on health quality and equity.^1–4 Attacks on the long slow recognition and meaning that Te Tiriti o Waitangi has in our society are a tragic development in our history. At the same time the primary health care workforce, and resultant issues on access, are a source of long-standing and escalating concern.^5–7

Our initial brief was to consider the roles of general practitioners (GPs) and nurse practitioners (NPs) in primary health care workforce development. We write as respective leaders in the domains of nursing and medicine. We write from a basis of significant mutual respect and previous shared experiences around the tables of various workforce advisory groups and leadership positions over long years. We have no interest in perpetuating old arguments about the relevant merits of GPs or NPs. Rather we are keen to stress how important it is to best utilise whatever workforce we do have (or could have). We are not sure who benefits when we expend energy in competing rather than sitting down to develop processes for maximising our various contributions.

Perhaps it is well past time to metaphorically ‘get over ourselves’ and focus together on ensuring that services are equitable and sustainable and that we address the current and increasing threats to primary and community health that range from growing racism and climate change, to right wing politics and enduring poverty.

In many ways, the bureaucracy and funding models have fed and fostered the debates around role substitution. It has allowed such debates to predominate rather than focus on the collaboration and teamwork that is required. The bureaucracy has frequently alluded to or stated the need for new kinds of worker, greater teamwork, an increased multi-disciplinary or interdisciplinary focus and so forth.⁸ There has been little acknowledgement of the role policy has in influencing such changes. Despite the rhetoric of primary care being central to Pae Ora, the policy and budget allocations have not further developed since the initial 2001 primary health care strategy.⁹ It must be noted though that policy and funding can influence these hugely and we reiterate calls for a planned approach to primary care with a focus on outcomes.^10,11

General practice clinics (with or without GPs or NPs), pharmacies, rest homes, physiotherapists and hospices are all key parts of the health services people expect. They are though, primarily businesses (as a necessity) or occasionally not-for-profit.

This free-market approach may appear to give wider access and choice, but it then creates multiple providers all looking to deliver similar or the same services in competition rather than collaboration. These are services that are fundamentally needed by whomever walks through whichever door to the health system. For a business to be viable, they are forced at some level to compete for scarce resource of staff, particularly nurses.¹²

JC was a team member of the HRC funded study ‘Evidence to guide investment in a model of primary care for all’ which concluded in 2021.¹³ One enduring memory of that study while visiting multiple practices, was that the model of ownership seemed less important than the impact of the individuals who owned or led the practice team. We saw enormous variation in how roles were deployed, how continuity of care was managed and how multi-disciplinary teams worked. This provides hope that we can make the best use of workforce capacity despite the strictures of business models, business rules and professional anxieties about competition. Perhaps local leadership and connections between providers of all types with a singular focus on their community’s health and equity is a critical factor.

One notable difference was the deployment of practice nurses which varied significantly across different practices. The value of practice nurses lies in their constant presence and their ability to provide and extend continuity of care rather than the fragmentation of care that occurs with the increasing use of different roles and different players providing different services.¹⁴ We would argue that greater attention needs to be given to properly valuing, expanding, extending and remunerating the contribution of practice nurses to the primary health care team.

At this point, every health professional of any ilk should be regarded as a precious resource and intending candidates should be resourced and supported, particularly Māori and Pasifika candidates who are vitally needed. Pay parity for all health care providers, but especially our practice nurses, is urgently needed. It is beyond comprehension that student nurse attrition is at an all-time high.¹⁵ The intention to review the Māori and Pacific Admission Scheme (MAPAS) also seems ill considered in the extreme. If anything, such programmes should be more universal to all health degrees.

The running of health as a business rather than core service has led us to a place where years of making do, limited back-end planning and a lack of clear policy development are catching up with us. There simply isn’t the capacity in the system and the lead time to do more is long. Perhaps if the wider community care sector, particularly medicine, nursing, pharmacy and physiotherapy worked together more powerfully, greater pressure could be brought to bear on political and bureaucratic decision-making.

The extreme right turn in our political culture and the associated challenges to community health should unite us in a shared passion for protecting the most vulnerable and ensuring access and quality for all regardless of where they live or who they are. Health care professionals need to work together, combining the wisdom of our respective clinicians, clinical leaders, academics and public servants. We need to let go of our professional and business anxieties and become a powerful force of both resistance and action. Primary health care clinicians provide a brilliant generalist and specialist service that is foundational to the quality of life of our communities, which has never been more important.