The primary care workforce crisis: defining the problems and finding solutions

We have known for two decades that our general practitioner (GP) workforce is ageing and heading towards retirement, evidenced by annual RNZCGP workforce surveys.^1,2 This shortfall is exacerbated by GPs working less hours, experiencing increasing burn-out, accentuated through dealing with the pandemic and expanding workload as their colleagues depart, and to a smaller degree by leaving Aotearoa New Zealand (NZ) to work elsewhere. It is increasingly difficult to access specialist health care for their patients, further straining GPs who need to manage these complex cases without extra resources.³ Training programmes admit an insufficient number of young doctors to address the shortfall. Patients are experiencing ever longer waits to get appointments, many practices have closed their books, and some New Zealanders are unable to enrol with a GP, especially in rural areas. There are similar workforce shortages of other primary care providers, particularly nurses.

Starfield identified some of the basic tenets of general practice are comprehensiveness, continuity and coordination – first contact care for all people and all conditions over their lifetime.⁴ Traditionally, general practice staff consisted of GP, practice nurse, receptionist and possibly manager, often with a community pharmacist next-door. GPs delivered babies, looked after all initial health needs for their patients, had a gatekeeping role to secondary care services and provided end-of-life care. Today there are many more types of primary care providers. Within the practice this might include regulated workers such as nurse practitioners, health improvement practitioners and clinical pharmacists, those in unregulated roles such as health coaches, practice or physician assistants, vaccinators and kaiāwhina, as well as trainees – medical and nursing students, postgraduate year (PGY) doctors and registrars. Within the community, maternity care is provided by midwives, and patients may self-refer to many other services including family planning, sexual health, pharmacy and physiotherapy. There is also expansion of virtual online doctor services. While this may reduce the pressure on GPs, there is a risk of care becoming fragmented and uncoordinated. Can continuity of provider be replaced by continuity of practice, or by a coordinated integrated health record accessible to all?

This special issue of the Journal of Primary Health Care focusing on the NZ primary care workforce contains research papers, editorials and viewpoints examining this pressing issue. A key theme to emerge is the need for integrated collaborative services. When they were introduced two decades ago, there was an expectation that Primary Health Organisations would enhance the integration of primary health care with both secondary care and with social services. However, Middelton and colleagues have found that collaborative practice is variable and patchwork, and much more is needed to achieve ‘joined-up care’.⁵ In a thoughtful editorial, Keenan and Carryer contend that equitable and sustainable services require collaboration rather than competition between professionals (GPs, nurse practitioners, pharmacists, physiotherapists) and between services (general practices, rest-homes, hospices). They advocate valuing, expanding, extending and better remunerating the contribution practice nurses make to the team.⁶

The role of the unregulated workforce is considered. Murton⁷ and Moffatt⁸ go back to back on the possible safety issues of using unregulated health workers to substitute for GPs and nurses in practices. In a viewpoint, medical student Andrew identifies having unregulated physician assistants as a potential risk to patient health outcomes, but advocates that regulating this workforce would help ameliorate GP shortages and untenable workloads.⁹

This issue includes research papers exploring expanded scopes of practice of different primary care providers. The University of Auckland School of Pharmacy has trialled a free clinic where patients can self-refer or be referred by a health provider (including GP, nurse, physiotherapist or dietician) to a clinical pharmacist for consultations on medicine-related problems. Evaluation by Wheeler and colleagues found referring provider experiences were predominantly positive, but having more regular communication with the pharmacists would enhance interprofessional collaborative relationships.¹⁰ The Advanced Practice Physiotherapist scope of practice may reduce escalating health costs and improve workforce sustainability by triage of primary care referrals to orthopaedic services. A study of stakeholders (physiotherapists, GPs, medical specialists, Accident Compensation Corporation case managers) by Stotter and colleagues found support for this scope of practice, with the potential to improve health care delivery and outcomes, but would require collaborative interprofessional practice, knowing if and when to refer to other health professionals.¹¹

Other members of the primary care workforce are paramedics, providing pre-hospital care. Access to, and quality of, pre-hospital cardiovascular care is inequitable for Māori. Kaupapa Māori research by Penney and colleagues found systemic and structural barriers were resulting in unsafe care for Māori.¹² This has further implications regarding Māori ambulance-based care for other conditions.

Primary health care also involves many community-based social services, addressing needs such as mental health and substance misuse issues. This exacerbates the potential for fragmentation and duplication of services. Tokolahi and colleagues explore the development of an intersectoral and interprofessional workforce to address the mental health needs of children and youth through a community of practice.¹³

The primary care workforce shortage is particularly acute in rural communities, who have worse health outcomes than those living in urban areas, particularly for Māori and Pasifika. During the pandemic, the rural vaccine rollout strategy did not account for additional challenges such as the geographical distance of rural roads, small low-density populations, dire workforce shortages, and limited infrastructure including phone and internet connectivity. A study of rural health practitioners by Blattner and colleagues found that the providers took ownership of the rollout with innovative local solutions that were geographically tailored, culturally anchored and locally driven.¹⁴ The authors conclude that equitable rural health outcomes requires long-term sustained investment and an integrated approach to rural services.

Primary care co-payments result in inequitable access to primary care. The Very-Low-Cost-Access (VLCA) scheme was introduced to address this. Research by Pledger and colleagues concluded that while VLCA practices appear to reach groups with greater need, the high level of unmet need due to cost suggests that fees are still too high.¹⁵ In a further study, Pledger and Cummings explored characteristics of people by their unmet need for a GP consultation because of cost, and subsequent inpatient hospitalisation.¹⁶ Those with unmet need were more likely to be young, female, Māori or Pasifika, the more deprived and those in poorer health. They concluded that lower co-payments may not eliminate cost barriers to accessing care, and needing multiple consultations may contribute to persistent unmet needs. This same group of researchers also found that the 5% of New Zealanders who are not enrolled with a general practice are likely to be socioeconomically deprived and to use the free public hospital emergency department service as a substitute.¹⁷ Private practice can also influence inter-professional collaboration. A qualitative study of physiotherapists in primary care practice by Darlow and colleagues found that the competitive nature of private practice inhibits communication and collaboration between practitioners, reducing collegial interaction and potentially impacting on patient care.¹⁸

Primary care practices have become crowded playing fields, and often have insufficient physical space and other infrastructure to house the increasing number of practitioners providing care, including learners. Medical and nursing trainees require positive experiences in primary care practice to choose these career options. Three-month community-based attachments are mandatory for junior doctors in PGY one or two. Atmore and colleagues explored the benefits and costs to practices of hosting a PGY. While this might increase junior doctors’ understanding of general practice, there is a considerable cost of consulting room provision plus unpaid supervision time.¹⁹ While vertical integration of teaching medical students, PGYs, GP registrars and GPs has considerable benefits,²⁰ the lack of consulting rooms and of available GPs to supervise means that instead medical students, registrars and others compete for available attachments.

In a further Viewpoint, Andrew argues that increasing the number of medical graduates on its own is likely to do little to address GP workforce shortages.²¹ He offers other solutions including tax credits for GPs and student-loan forgiveness for those pursuing GP careers, government subsidies to support teaching practices including provision of physical space, and dedicated places in medical school for students who sign up for future bonded GP training.

We hope this issue stimulates discussion and ideas for ways forward and welcome succinct letters to the editors that further the conversation.