Being a GP in the land of the long white cloud

Authors: Andrew Fisher 

Publication date:  03 Sep 2011


Andrew Fisher offers some pointers for those considering a move to New Zealand

Fresh from completing the membership examination for the Royal College of General Practitioners, many fledgling GPs consider heading to Australasia to sample general practice overseas. I was among those in 2010—with the added obstacle of convincing my pregnant wife to come and give birth to our first child in an unknown country. Twelve months later a return to the United Kingdom was on the cards. As I considered why we chose not to make our move to New Zealand permanent, I realised that our reasons were cultural as much as professional. It also dawned on me that it would be useful for any GP considering a move to the country if I shared my experience of Kiwi primary healthcare.

Having successfully dropped off the end of the GP training conveyor belt in the UK, I was tempted by the lure of the surf and an outdoor lifestyle on the doorstep to try life on the other side of the world. We had come with open minds and few ties other than family in the UK, free to consider the possibility of staying for good.

Working in Aotearoa (Maori for New Zealand, “the land of the long white cloud”) is satisfying in many ways: from the welcoming, easygoing manner of the locals to the greater exposure to practical procedures as the line between general practice and small emergency department becomes increasingly blurred in rural practices. What follows are my personal views of working in New Zealand general practice and the notable differences from the UK system.

“Man, you’ve got soft hands”

The third local miner who opened our consultation with such a line prompted me to consider whether it may be a good idea to stop shaking hands at the beginning of appointments in New Zealand. Either that or take up some form of manual work in the evenings to toughen up my hands. I had brought with me only one of my collection of three pink shirts, such a staple of my GP outfit back in Wiltshire, but even this was relegated to the back of the wardrobe two days after starting work in Waihi.

Waihi is a gold mining town at the bottom of the beautiful Coromandel coast in New Zealand’s North Island. Although only a couple of hours’ drive from Auckland, the area’s landscape and social climate are very different from the city. This is an area of dairy farmers, hunters, miners, fishermen, and builders. It is frowned on to drink any other beer but the local Waikato draught at barbeques. Here was certainly no place for pink shirts and soft hands.

General practice in New Zealand has many attractive aspects: a standard appointment length of 15 minutes is a real luxury, and there are no QOF points to worry about. Fascinating cultural insights are common: when working a clinic at the local marae (Maori village) I quickly learnt that it is considered “tapu” (forbidden) to touch somebody’s head unless they have asked you to. Other interesting memories include working in a rural practice that kept a thrombolysis kit. This certainly made for interesting referral discussions with the cardiologists over the phone.

It is important to be aware of the differences in healthcare organisation that you will face as a GP outside the UK. Here I list several differences in New Zealand, the combination of which inspired in me unexpected sentimentality for our own NHS.

Charging for consultations

This is a concept completely alien to most young GPs who have trained and worked only within the NHS. Most surgeries charge around £20 ($NZ40) for a normal consultation, rising to £80 for excision of a skin lesion.

Quite simply put, I didn’t like charging. I disliked the way it prompted patients to store up problems and present with “shopping lists” to an even greater extent than occurs in the UK. Then there was the obvious problem of patients with less money consulting less often and being less likely to turn up for follow-up appointments. The health outcomes of the poorer Maori and Pacific Islander populations are similar to those of a third world country, which is probably due to many reasons, but I think that the cost of seeking healthcare advice ranks highly.

My greatest problem with charging for consultations lies in the fact that I am soft. I would often charge patients half price for “quick” consultations during the daytime, as this just involved a scribble on their appointment slip, the payment then being processed by the receptionist. In reality they had usually been in my room for well over 20 minutes. Even worse, I once undercharged a patient who called me out at 3 am for a dubious emergency, even though I had been cursing the patient minutes earlier as I shuffled through the rain to their doorstep. I can’t think of a reason for this, other than my wish to avoid the look of consternation on their face and possible confrontation when they found that the standard charge for an overnight call was double what they were expecting.

Charging for GP consultations has also caused hospital emergency departments in many urban areas to become overloaded with minor complaints, as “emergency” hospital consultations are free.

Most surgeries don’t charge for children under 6 years old (the fees being subsidised by the government). This also causes some difficulty, however, as many adults try to sneak in their asthma review while you take a look at little Billy’s warts.

Lack of home visits

Some GPs would see this as a positive aspect. Charging excessively for home visits seems to have been a very effective way of phasing out all but the most essential of these. It is amazing how relatives can suddenly appear from nowhere to provide transport to the surgery to avoid a greater charge. I actually quite missed the variety of being able to nose around patients’ houses and gain an extra insight into their life and health.

Payment for investigations

New Zealand has a mixed public and private system of investigation and referral to secondary care, quite similar to that in the UK. The big difference is that public referrals to specialists have much longer waiting times than those found in the UK in recent years; the same also goes for ultrasonography and other radiological investigations. After a squeeze in their finances, many health boards have stopped doing varicose vein or simple elective hernia operations at all in the public health system.

Less freedom in prescribing

As a GP in the UK I did not appreciate the vast range of drugs at my disposal until I had them taken away by moving overseas. New Zealand’s national system for prescribing, called Pharmac, subsidises a comparatively small range of drugs, but the patient pays only £1.50 per prescription for any of these. The government often makes new deals with drug companies, resulting in rapid changes to the brand name drugs you can prescribe. Unfortunately the list of drugs that the regular GP can prescribe has some notable omissions: no topical antibiotic acne treatments are available, for example, and only a few combined oral contraceptives. For some more expensive drugs you have to fill out a “special authority” form online, which can be arduous and frustrating.

The accident compensation system

The Accident Compensation Corporation (ACC), a government run organisation, pays for the healthcare of anyone who has an accident, and the system is run on a no fault basis. This is a big problem in New Zealand healthcare, as it is a drain on resources and needs an overhaul. Mistakes made by doctors are also covered by ACC, which is why New Zealand has a low level of medical litigation.

ACC is comprehensive to the extent that it covers any tourist who sets foot on New Zealand’s shores. If such a tourist should fracture an ankle, the government will subsidise the cost of the GP consultation and then the subsequent radiography, plaster cast, and orthopaedic follow-up. All ACC referrals are put in the same bracket as private referrals for specialists, so these patients get seen a lot quicker than those referred from the public system.

ACC is regularly frustrating for GPs for two reasons. Firstly, patients may give you false information—“My knee suddenly hurt when running” rather than “My knee has been aching for the past year”—so they can be referred on ACC. This is understandable on the patients’ part, but it doesn’t help diagnosis in primary care. Secondly, as you would expect, a substantial form needs to be filled in for an injury to be registered and then an extra form should the injury prevent the patient working. The patients need to take the paperwork with them at the end of the consultation, so you typically spend a lot longer staring at the computer than at the patient during injury based consultations.

Working abroad can help sharpen your GP skills through exposure to new cultures and different ideas about how healthcare systems should be organised. With the advent in England of GP commissioning and other changes proposed for the NHS, it is worthwhile to see whether other countries are using models from which it would be beneficial to borrow. Sometimes, however, looking at other systems makes you realise that things aren’t so bad on your own doorstep after all.

BMJ Careers Fair

If you are considering a job overseas, these organisations will be exhibiting at the BMJ Careers Fair from 30 September to 1 October at the Business Design Centre in Islington, London:

Africa Health Placements

Alberta Physician Link

AMA Recruit

Aramco

Physician Recruitment Saskatchewan

Health Match BC

International SOS

Med Recruit

New South Wales Health

Queensland Health

Rural Doctors Workforce Agency

Rural Health West

Rural Workforce Agency Victoria

Triple O

Western Australia Health

Competing interests: None declared.

Andrew Fisher sessional GP Bath, UK

 andrewfisher@london.com

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