Buzz Borrell of the advocacy group General Practitioners Aotearoa delivered an excellent no-punches-pulled interview which highlighted the issues well: inadequate funding and resourcing, intentional destabilizing of the sector, misaligned prioritization of secondary over primary care (which is inconsistent with the evidence base for most effective spend to achieve health outcomes), poor access to health care, felt most acutely in the highest need demographics, all resulting in a deterioration of population health.
The headline of the media article is 'Concept of family doctors in NZ dead': GPs warn of primary care collapse in NZ.
Buzz made a statement that distressed me in particular. "I think it's so close to dead that we might as well call it out for what it is. There are pockets of hope, but they're getting less and less and less." Buzz was talking about the notion of 'Continuity of Care.'
The concept of Continuity of Care can be considered as referring to two paradigms. The most familiar and enduring is its reference to a patient being able to see the same GP with reasonable access to that GP when needed, a GP who has a thorough knowledge of the patient's medical, psychological and social history and needs. The second is broader and somewhat vague and comes from a World Health Organisation document: 'Continuity of care: reflects the extent to which a series of discrete health care events is experienced by people as coherent and interconnected over time and consistent with their health needs and preferences.' Care Coordination is a linked concept: 'Care coordination: a proactive approach to bringing together care professionals and providers to meet the needs of service users, to ensure that they receive integrated, person-focused care across various settings.'
There is mounting evidence for the value of such continuity and coordination. However, there is a gap in the evidence base between an understanding of why it is a good idea, and how to implement it. Patrick Burch and his team describe the significant evidence for better health outcomes through continuity (fewer hospital admissions, lower mortality, and lower costs). The article's introduction states: '...many health systems have chosen to focus primary care policy on access rather than continuity. Continuity has fallen in several primary care systems and this has led to calls to improve it. However, it is sometimes unclear exactly what continuity is and what should be improved.' Furthermore, there is even less clarity around how to improve that which has been identified as needing attention.
Indulge me in an inadequate metaphor. I feel myself as a GP who values continuity caught in a beach rip of survival - the flat water hides sinister currents carrying me out to sea and I have three options: 1. Wave frantically in the hope someone will rescue me; 2. Stop fighting and allow the current to carry me out to sea where I might then find a safer way back to the beach; 3. Swim against the current parallel to the beach towards the waves until I escape the dangerous flow.
The pragmatist in me aligns with Buzz and his regretful suggestion that we should accept that general practice continuity of care is in its death throes, we should 'call it', 'Rest in Peace' to a paradigm of healthcare which served us well for so long, and put our energy into doing the best we can with a broken system. Tread water, conserve energy, let the rip of a health system in crisis do its thing, and eventually its current will diminish, and we will survive.
The idealist in me says 'No!' When I am asked why I remain a full time GP, what I like about my job, I have three responses, always linked. I love the variety and diversity of the work. I love the relationships I develop with patients through some of the most intimate and challenging times of their lives. And I love building those relationships over time, years and decades often. This is Continuity of Care. And I am sure it delivers better outcomes for my patients. If I lose this, I lose the joy and fulfilment of my role - I want to fight against the current in an effective way and to escape its inexorable flow.
But we are tired. And getting more fatigued and burnt out. I know I am pushing this metaphor a bit too much - trying to swim back the beach against the rip current is not only futile, but it may also kill you. Changing direction, harnessing energy to swim towards the waves which appear on the surface to be less inviting than the smooth water pulling you with no effort out to sea, this requires courage.
I know I do not have the answers to the 'How' of resuscitating Continuity of Care - but I know I want to - desperately, and with what remaining energy and courage I have. And at the same time, I will wave my hand for help, because there are some remarkable General Practice leaders who are positioned on the beach Lifeguard towers, in rescue craft, ready to support. People like Buzz Borrell and his GP Aotearoa team.
Another such person is David Beaumont and his initiative Positive Medicine. David's book 'Positive Medicine: disrupting the future of medical practice' is a must read for those wanting to escape the rip current.
Taken from the Positive Medicine website:
Positive medicine enables a radical shift in the way that health is delivered. It transforms the way we see health, life and happiness. This innovation in health and medical practice has two key features: control and empowerment.
It is based on the new definition of health: Health is the ability to control our lives.
Integrating and enhancing the physical, psychological, emotional (relationship) and spiritual aspects of health results in long-term, enriched health and quality of life outcomes. Health, motivated by purpose, joy and wellbeing, is sustainable. Grounded in Te Whare Tapa Whā – the Māori model of health – Positive Medicine champions the synergy and efficacy of a whole person approach.
Such a radical, innovative and transformational shift at the systems level of healthcare delivery is surely one of the tools, a buoyancy device for surviving the rip, that we need to rescue Continuity of Care in General Practice. With apologies to the developers of these models for extending them beyond their intent, Sir Mason Durie and David Beaumont, I want to propose some 'how-to' considerations using the framing of Te Whare Tapa Whā and Positive Medicine.
The whenua - our land and roots - this is the unique place General Practice holds in New Zealand. Having worked in other countries as a doctor, I am proud of our sector in New Zealand, and there is much international envy for what we have achieved. However, as Brian Betty, Jo Scott-Jones and Les Toop iterated in a 2023 New Zealand Medical Journal piece titled 'State of general practice in New Zealand', there is now much to be dismayed by.
How to rebuild then?
Taha tinana - the physical pillar. To extend the analogy, to me this refers to the systems and structures we work with and in. Funding, human workforce, IT support, supply chain resources, and buildings. If these are not robust, adaptive and healthy, we cannot deliver meaningful healthcare.
Taha hinengaro - the psychological pillar. Currently, this would refer to a thorough understanding of the real mood of the healthcare workforce and patients. The parlous state of general practice has been signaled for decades, and, as demonstrated by a recent Minister of Health who denied the adjective 'crisis' in describing the health system, there has been a reluctance from New Zealand's political leaders to engage meaningfully with the mood of the key stakeholders.
Taha whānau - the connections and relationships pillar. There is a mistrust of many leaders in the health sector, in part due to the comment above. Buzz, in his interview, referenced the current Minister of Health Hon. Dr Shane Reti, himself a GP, who garnered hope in the primary care sector that we would have a health minister who would effect meaningful change from his position of coal-face experience. Asked if he felt the Government was prioritising general practice, Buzz said, "absolutely not" and he was disappointed with the minister. Whilst much of health policy has focused on access issues, the notion of quality and longer-term outcomes has been marginalised. Recovering high value connections and relationships through policymakers and implementers engaging with the true stakeholders - patients and clinicians - must be a priority.
Taha wairua - the spiritual, life-meaning pillar. To me, this is the most important of the pillars. A strong sense of purpose and understanding deep motivation is needed to drive changes in the other pillars. Equitable and accessible high-quality healthcare for all New Zealanders - a model that trains, supports, resources its workforce in a way which enables flourishing, a model which empowers patients to be proactive and adaptive to their own health needs, a model which understands that evidence-based investment in effective primary healthcare reduces inequity and improves quality of-life measures for the whole population - this needs to be the spiritual pillar guiding our leaders.
Continuity of Care and Care Coordination, as defined by the WHO above, lacks a personal and pragmatic expression. The General Practitioner and their team should be well-placed to deliver on these concepts with coherence, interconnectedness over time, consistence with the health needs and preferences of the patients, proactive, organised, integrated, team-based, and person-focused care.
This can only be achieved through courageous, intentional, innovative and radical recovery of Continuity of Care in General Practice. It is at risk of dying but not yet dead, there is time for hope to change our direction - let us respond to the alarm call and resuscitate what we know to be worth fighting for.