Opinion: Local GPs will be required to see more than 80 percent of patients within a week, to meet a new target set by Health Minister Simeon Brown. It comes into effect in July, and is potentially linked to a government intention to amend the capitation (largely population-based) funding formula for general practices’ enrolled patients, by making part of it ‘performance-based’.
The reaction from GPs, including their representative bodies, has ranged from scepticism to blunt condemnation. Dunedin’s Helensburgh Medical Centre GP Dr David McKay told NZ Doctor the health minister is “dreaming” unless he first addresses the serious workforce shortages, at the heart of patients’ lengthy waits.
“Where do we get the extra people to meet the target? We’re now going to have to jump through hoops to get it and that seems wrong to me. To fulfil that 80 percent target I would have to fit in more patients.”
Dr Orna McGinn of Waiheke Island’s Ostend Medical Centre put it another way: “It’s a simplistic solution to a complex problem.” She acknowledges the importance of patients being seen in a timely manner, but says this in itself doesn’t necessarily ensure good health outcomes.
Potted history of health targets
The first health target (waiting times for non-acute planned surgery) was introduced by Helen Clark’s Labour-led government in the late 2000s. Targets were extended by John Key’s National-led government following the 2008 election.
Under the subsequent Labour government they were eventually replaced by more nuanced and comprehensive health indicators but restored and further increased in number by the coalition’s health minister Shane Reti following the 2023 election.
Aside from some population health based ones, such as anti-smoking education and immunisation rates, the targets were hospital based. None was in primary healthcare. With one notable omission, they all focused on what could be readily counted. They are confined to non-acute care even though acute hospital discharges are already routinely counted.
Because so much in hospital and related non-acute healthcare can’t be readily counted, such as chronic illness and much of mental health, these metrics are not indicators of productivity – despite politicised claims to the contrary.
There is another important lesson to be learned from this hospital-based target experience that is instructive for what is being proposed for general practices. Target achievement is dependent on factors beyond the control of health professionals and managers working in the areas covered by them.
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The three most prominent and publicised targets involve wait times for planned surgery, emergency departments, and cancer treatment assessment. Achievement is dependent on two critical factors – workforce capacity and the rate of acute hospital demand.
Serious workforce shortages first became evident for hospital specialists in the late 2000s. Now they are widespread and entrenched across the full range of hospital based health professionals, including nurses (the largest group). Predictable outcomes include fatigue and burnout.
Since 2014 the rate of acute hospital discharges has increased at a greater rate than population. Acute cases are those that can’t be deferred without serious harm or death. Consequently they take priority over non-acute cases which can be planned. This includes priority for hospital beds.
Flow-on effects include ‘bed blocking’, overcrowded emergency departments, and precariously long wait times. It also ensured non-achievement of the countable targets. This started to become evident in the mid-2010s.
Implications for GP access health target
The key hospital based health targets were not achieved because of factors beyond the control of the hospitals. The proposed GP access target is more likely than not to suffer the same fate, for the same reason.
The health minister has yet to answer some key questions: will the target be a national benchmark, or will it be a regional or district benchmark? Will it be conditional for receiving the new performance-based funding?
Will it be applied to individual practices? Given the health targets apply to individual hospitals, many GPs are assuming that it will apply individually to practices. If they are right (and certainly the General Practice Owners Association believes they are) then practices that don’t meet it would be exposed to misplaced criticism.
Primarily this would be because the workforce capacity (GPs, nurse practitioners and registered nurses) isn’t there to make it achievable.
The association says all GPs would like to see greater patient access, but these sorts of targets for GPs have led to “gaming and perverse incentives” where they’ve been applied in the UK, in order to technically meet the target.
Risks for patients and general practices
In addition to having sufficient workforce capacity, much will depend on how the target is designed. Ideally it could be used to inform government health policy including how practices are funded. But the history of health targets in hospitals suggests that this is unlikely.
Designing the target, which lends itself to arbitrariness, doesn’t just come down to how it is measured (including the reliability of practice data). It also must anticipate and prevent perverse and unintended consequences.
There is a complex mix of factors that contribute to general practice access that don’t lend themselves to a blanket appointment time target. That type of target assumes a generic ‘one size fits all’ timeframe.
The access time for acute conditions (such as those that might require antibiotics) is substantially different to the quality management of patients’ long-term chronic conditions, for whom longer-term booking is more practical and beneficial.
But to enable this level of differentiation general practices would require a much more finessed data coding and extraction system. This complexity on its own could generate perverse consequences despite the health ministry stating that it will make sure the process isn’t onerous.
A further likely perverse outcome is the pressure it will place on general practitioners to reduce their time spent on patient consultations. The shorter the ‘face-to-face’ time a GP spends consulting with a patient, the more patients that can be seen in a busy practice. Quality of diagnosis and treatment becomes the casualty.
If the target were to be used as a barometer for systems performance, rather than as an erroneous and judgmental call on the performance of individual general practices, then potentially it could be beneficial to primary healthcare.
It would be nice to believe this will be so. But the experience of health targets in hospitals suggests shows hospitals are judged harshly even though non-achievement of these targets is due to the factors discussed above that are beyond their control.
If the government were serious about using targets to achieve hospital systems improvement it would have ensured that reducing acute hospital discharges was a key target, given that usable data is already collected.
But politically it chooses not to. This is because even if hospitals were better funded, the driver of rising acute demand does not come from within the health system. Instead it comes from what is known as external social determinants of health. The main determinant is low incomes but there are others such as poor housing and limited educational opportunities.
The effect of these social determinants is to increase impoverishment which, in turn, increases poor health which, in turn, increases acute demand on both general practices and hospitals.
The government could address this through policies focussed on addressing these social determinants. Unfortunately, its ideological paradigm does not allow for this. This leaves the proposed target for GP access in the sphere of politicised rhetoric rather than systems improvement.
Dr David McKay is right. Health Minister Simeon Brown is dreaming.