Addressing closed and limited enrolments in general practices in Aotearoa New Zealand: a mixed-methods study 

In Aotearoa New Zealand, primary care (PC) is delivered principally in community-based general practices by general practitioners (GPs), practice nurses, nurse practitioners and other healthcare professionals, both from the regulated professions (such as pharmacists) and non-regulated professions (such as health coaches).¹ There are approximately 5,600 GPs and around 1,000 general practices in Aotearoa New Zealand, providing about 14 million consultations every year.²

Patient enrolment with a general practice is fundamental to the funding of PC, as practices are largely funded by the government, based on the numbers and characteristics of their enrolled populations.^3,4 Enrolling with a general practice also has many benefits for patients, such as reduced consultation fees (resulting from higher government subsidies), centralisation and management of patient data and of recalls for preventive care, and GPs taking responsibility for prescription, referrals to specialised care and subsequent follow-ups.³

PC providers serve as the entry point to the broader healthcare system in Aotearoa New Zealand. Consequently, limited access to PC translates into challenges in obtaining referred services such as prescriptions, diagnostic tests and specialist consultations. A robust PC system is seen as the path for the effectiveness, equity and efficiency of the overall healthcare system.⁵ Amidst a growing burden of non-communicable diseases, PC is central for both preventive measures, as well as coordinating the long-term management of chronic conditions. Additionally, PC plays a crucial role in executing key public health tasks, exemplified by its response to the COVID-19 pandemic.⁵

However, general practices in Aotearoa New Zealand are increasingly having to limit or cease enrolments of new patients, with the latter being known as “closed books.” Closed books have been reported in the media for some time.⁶ In 2017, it was estimated that 10% of general practices were closed to new enrolments, rising slightly to 11% in 2018.^7,8 We have more recently estimated that 27% of practices had closed books in 2022, and 79% of practices were closed to new enrolees at some point between January 2019 to August 2022.⁹ Previous research identified workforce shortages as a key reason for closed books,¹⁰ Aotearoa New Zealand being highly dependent on overseas-trained staff, with around 50% of doctors working in Aotearoa New Zealand trained in other countries^10,11 and 27% of nursing staff having also trained overseas.¹² The long-term emigration of medical professionals to Australia continually contributes to workforce shortages in Aotearoa New Zealand.¹¹

While previous studies have quantified the problem, few have looked at the issue in depth.^7,8,13 This study aimed to explore the reasons and impacts of closed books based on the perceptions of primary care experts and general practice healthcare professionals, and to elicit recommendations for improvement.

Methods 

This research was a part of a larger study about the challenges of closed books for PC access, health outcomes and equity in Aotearoa New Zealand.⁹ The larger study used a mix of qualitative interviews and quantitative and qualitative survey methods. This article focusses primarily on qualitative data from interviews and open-ended questions in the survey.

A first round of interviews was conducted with informants to better understand the key issues relating to closed books and to refine the survey questions. A survey of general practice healthcare professionals was then launched. It included the recommendations that informants gave to end the problems of closed books in order to gauge the level of support for these recommendations among general practice health professionals. Subsequently, after analysing the preliminary survey findings, a second round of interviews took place, focussing on clarifying emerging issues from the survey and further exploring recommendations.

Participation in this study was voluntary. A participant information sheet and consent form were sent to all potential interviewees. Interviewees received a brief introduction about the study before their interview. An interview guide was used to structure the interviews, allowing data gathering through a consistent set of questions, as well as the ability to explore new insights as they emerged. The interviews were conducted either virtually via Zoom or face-to-face, according to the preference of the interviewee and feasibility. Interviews were recorded for data analysis with interviewees’ consent; they were not transcribed, but notes were taken while the audio recordings were played back repeatedly. The audio recordings were named according to de-identified participant numbers and stored in a password-protected computer, with attention to protecting interviewees’ privacy and data confidentiality.

We used a mix of inductive and deductive approaches. The first round of interviews was analysed using a general inductive approach. This approach aimed to develop categories for a model or framework that can highlight the most important key themes arising from the data.¹⁴ These themes were then organised, categorised and combined to give meaningful explanations relating to the research questions. The analysis of survey data reported here primarily followed a deductive approach, where pre-defined options (based on informants’ responses) were given to respondents to react to. The second round of interviews used a mix of inductive and deductive approaches to expand on key emerging issues from the survey, as well as explore ways forward.

The survey was primarily advertised to practice managers and GPs through newsletters of the Royal New Zealand College of General Practitioners (RNZCGP) and the Practice Managers and Administrators Association of New Zealand. The survey was administered through Qualtrics.¹⁵ The key questions in the survey touched on whether the practice had closed books, the reasons for closed books and its impacts, and recommendations to resolve the issue. The 227 survey respondents comprised practice managers (n=119), GPs (n=85), practice owners (n=52), administration staff (n=10) and other management staff (n=10), with some having multiple roles.⁹ Further details about the survey, including a copy of the questionnaire, are available elsewhere.¹¹

The Victoria University of Wellington Human Ethics Committee provided ethical approval for the study (Number: 0000030193).

Results

Altogether, 17 key informants in the PC sector were purposively selected and interviewed for the study: nine GPs, four practice mangers, two academic PC researchers, one nurse practitioner and one staff member of RNZCGP. GPs or practice managers from four practices with a high proportion of Māori users were intentionally included in the study. Māori have higher health needs, under-utilisation of healthcare and lower rates of enrolments with PC compared to other groups.³

We delineate below the key findings across three topics: a) reasons for closed books, exploring the causes leading to limiting new enrolments, b) impact of closed books, focussing on the effects and consequences observed, and c) recommendations in moving forward, discussing proposed measures and strategies to address the challenges identified.

Reasons for closed books

1. Workforce shortages: Interviewees most frequently cited staff shortages as the reason for practices closing their books to new patients. They mentioned that a shortage of GPs or nurses compelled practices to stop taking new patients.

“We closed our books because one GP resigned, and we couldn’t recruit one.” – Interviewee 4

“Recruitment and staff retention, especially GPs and nurses, has been the key issue. Almost no job applicants, and those few that do, have multiple offers to pick between because there are so many vacancies around.” – Survey respondent

Interviewees and survey respondents pointed to a variety of factors contributing to the workforce shortages, including:

1.1 Retiring GPs: The growing proportion of GPs who are approaching retirement age exacerbates staff shortages. Staff shortages are worse in rural areas; one interviewee noted that there were no replacements for retiring GPs from high-needs practices in their rural location. Another pointed to the particular problems of recruiting in rural areas, including the trouble obtaining suitable employment for GPs’ partners and locating schools of choice for children.

“Thirty percent of the GPs are going to retire in [soon]. That’s adding to the problem.” – Interviewee 2

1.2 Difficulty in recruiting overseas-trained staff: Interviewees commented that Aotearoa New Zealand relies heavily on medical staff trained abroad. The recruitment of medical staff was limited between 2020 and 2022 because of COVID-related border restrictions.

“[Staff shortage] seems to be worsened during the last couple of years from 2019. I think that’s a direct consequence of the GP workforce issues we are having. Certainly, it’s been exacerbated by the borders being closed.” – Interviewee 1

1.3 Pay inequity compared to secondary and tertiary care: Pay inequity in PC compared to secondary and tertiary care came up as another reason for staff shortages in PHC. Hospital staff receive a higher salary than PC staff, which makes more professionals attracted to specialised care.

“The pay equity stuff is really significant, a nurse working in a hospital earns an average NZ$20,000 more than a nurse practitioner.” – Interviewee 1

1.4 Fewer medical students choosing general practice as a career: During medical training, students get less exposure to general practice compared to secondary care, and medical students are thought to frequently regard general practice as a less appealing option than hospital medicine due to its lower remuneration.

“We are expecting our medical students to go into something they don’t have exposure to.” – Interviewee 3

“Medical students are choosing specialities: better pay and status.” – Interviewee 14

2. Under-funding of general practices: Another major reason provided for closed books was insufficient funding for general practices. General practices are partially funded through capitation formula based on the number of people enrolled and their characteristics. As the capitation funding model is generally not seen to adequately account for the complexity of conditions that patients have, there is a perception that high-needs patients are being passed along.

“Funding per patient does not reflect the workload that is required. It is problematic especially for high-needs patients.” – Interviewee 2

“We take all comers whether high needs or not. Other local practices seem to refuse high-needs patients, so we get more than our fair share.” – Survey respondents

3. High workloads and staff burnout: The pressure of under-funding and staff shortages causes a higher workload among existing staff, resulting in staff burnout in general practice. Professional staff reported having to increasingly conduct administrative tasks in addition to clinical work, further leading to higher workloads and burnout among staff. Higher levels of patient concerns, and staff sickness during the COVID-19 pandemic period, also added to the workload.

“The pressure and stress of under-funding and insufficient workforce are causing existing staff to resign, which further worsens stress on existing staff.” – Survey respondent

“General practices are asked to take on more and more work, including work that was previously performed in hospitals. The paperwork has also increased. So, there is more work but a seriously declining number of healthcare workers (most particularly, GPs) to carry out this work.” – Survey respondent

4. Impacts of COVID-19: The COVID-19 pandemic was seen to have both direct and indirect impacts on the PC sector. The workload of general practices increased as the number of sick patients increased, along with an increase in patient demand, and with the added precautions needed to treat COVID-19 patients. The pandemic also resulted in staff shortages due to staff or family sickness. The border closure enforced during the COVID-19 pandemic had an impact on workforce shortages in Aotearoa New Zealand due to the reliance on overseas-trained medical professionals and the inability of new health professionals to enter the country.¹⁶

“[Our] high-needs practice was hit hard with COVID-19, both staff and patients, and [we were] required to support patients 7 days per week, with up to 40% of staff away at any given time.” – Survey respondent

5. Concerns about quality of care: High ratios of patients to staff can increase waiting times, cause delays in patient care and decrease quality of care and patient satisfaction. PC staff worry about the quality of care they can offer when there is more demand for healthcare than can be managed. Therefore, general practices may choose to limit or close the number of new patient enrolments to manage the workload and thereby retain quality of care. They may choose to do this despite the revenue new enrolees would bring to the practice.

“From a business point of view, there is a disincentive to close your book but at some point, patient care has [to] take priority over financial benefit.” – Survey respondent

6. Insufficient physical space: Insufficient physical space was another reason given for closing books to new enrolments. Respondents noted that there may not be sufficient rooms for examination and treatment, and in some practices, patients’ waiting areas are also limited. One interviewee mentioned that in some general practices, staff are working in shifts to occupy the working spaces available to them. Interviewees noted the need for plans to extend or upgrade the existing space to meet demand.

“We are limited in terms of funding, staff and space to accommodate patients in our waiting areas, and consultation rooms.” – Interviewee 8

Impacts of closed books

Study respondents noted that all three dimensions of PC—preventative care, acute care and chronic care—are affected by closed books. When people cannot get an appointment when needed, they are forced to seek care at after-hour services or hospital emergency departments. After-hours services are expensive, while free hospital emergency departments can get over-loaded and people can face long waiting times. People may also choose not to access care at all, which can lead to delays in treatment and diagnosis. Consequently, people’s health may worsen. They may also not be able to access preventive care such as cancer and cardiovascular disease screening, and continuity of care may be lost if they are not enrolled. The increasing prevalence of closed books may also affect care for those who can get a general practice visit by putting pressure on the ability of practices to maintain clinical standards of care and continuity of care.

“Patients need someone who knows their health needs. These kind of relationships and trust in medical staff will be compromised because of discontinuity of care.” – Interviewee 4

The impacts of closed books can also compound; when one general practice closes or closes enrolments, it increases the burden on other practices. It can also induce gridlock when multiple patients, across different localities, do not want to relinquish enrolment in one place because they cannot enrol in their new location, as well as issues of excessive travel or problems of managing distant patients via telehealth.

“[We have] patients trying to enrol from outside our community because they have been unable to enrol in their hometown—these are people who are one and a half hours from our practice.” – Survey respondent

Recommendations

To address the workforce challenges, interviewees and survey respondents proposed several strategies. Recommended actions included: to recruit more staff, establish pay equity between primary and secondary care staff, increase the number of places at medical schools, include longer placements in general practice for medical students, relax immigration rules to ease overseas staff recruitment and increase remuneration in PC to attract and retain staff.

Recruiting more staff from overseas was seen as a short-term solution. It was argued that there is not enough GP training in Aotearoa New Zealand to meet current and future needs. Increasing the number of places for medical training in Aotearoa New Zealand was seen as a long-term solution that could lead to an increase in the number of medical students choosing general practice as a career. It was also felt that there was a need to make general practice more attractive to new graduates and that the medical curriculum needed to be reorientated to increase its focus on PC, including having more student placements in the community, especially in rural areas.

“We rely on overseas-trained doctors; the immigration department needs to make the rules more relaxed to let more medical professionals come and work here.” – Interviewee 4

“Please encourage the New Zealand government to create incentives for people training as a GP and also incentives to bring more doctors to New Zealand from overseas.” – Survey respondent

Recommendations to manage the workload of staff were to recruit multi-disciplinary team members in general practices, recruit more nurse practitioners and appoint more administrative staff to support the work of existing staff.

“There should be an understanding about the workload of GPs and nurses.” – Interviewee 6

“Rearrangement of paperwork management so doctors can see more patients.” – Interviewee 5

More funding and revision of the capitation formula were repeatedly suggested by most of the interviewees as key means of reducing general practices closing their books. Some general practices were also seen to need funding for expanding or building new spaces and facilities for patient care. Finally, it was felt that the government needs to better understand the problems and, in particular, the workload of general practice staff.

“More space, improved funding to pay GPs and nurses, improved communication from the Ministry of Health in advance of changes.” – Survey respondent

The main recommendations compiled from the first-round interviewees were put to respondents in the survey to assess respondents’ agreement with key recommendations. Table 1 reports the proportion of survey respondents who agreed with each recommendation, listing recommendations from those with the highest to those with less support. Overwhelmingly, survey respondents wanted more funding for PC and pay equity with other sectors. Other recommendations with high levels of agreement revolved around staffing, specifically the ability to attract and retain staff, and improved training pipelines.

View Table 1.

Discussion

The results of this mixed-methods study show that the key reasons for not enrolling new patients included workforce shortages, under-funding, high workloads and staff burnout, the desire to preserve quality of care and having insufficient physical space. The results suggest that the situation has worsened due to the impacts of the COVID-19 pandemic, resulting from higher demand for services for COVID-19, staff getting sick and border restrictions preventing the inflow of medical workforce, adding to the already existing shortage of GPs and nurses. The interviews highlighted a critical shortfall in the capacity of Aotearoa New Zealand’s general practice workforce to meet the demands of PC.

Other studies have reported similar findings. A RNZCGP survey conducted in 2021 showed that about 31% of the informants reported being burned out.¹ Staff shortages have also been previously recognised as an issue in the PC sector and are expected to worsen due to the increasing number of GPs approaching retirement age: approximately 31% of GPs are planning to retire in 5 years and half of the current GP workforce will have retired in 10 years.¹⁷

A shortage of GPs also affects other countries. In Australia, the New South Wales Rural Doctors Network found that 40% of GPs in rural areas are planning to leave their career in 5 years and 70% of rural general practices in New South Wales (NSW) are trying to recruit staff.¹⁸ Equally, findings from a 2022 Commonwealth Fund survey, conducted among physicians, showed that at least half of the physicians aged 55 and older in most of the countries surveyed would stop seeing patients and leave the PC workforce within 3 years.¹⁹

Healthcare workers migrate internationally for better working conditions and better pay. To confront these challenges, New South Wales is planning to recruit 10,000 nurses and has put up AU$4.5 billion for the move.²⁰ Experts in the Aotearoa New Zealand healthcare sector fear that many New Zealand nurses will be attracted to Australia from an already over-stretched workforce.²⁰ Te Whatu Ora – Health New Zealand started an immigration service in October 2022 to offer overseas-trained healthcare professionals immigration advice for free, a one-way airfare, moving costs and temporary accommodation. GPs were the key group for recruitment.²¹

Besides the short-term strategy of recruiting international medical professionals, those participating in this research demonstrated a consensus about the need for training and recruiting more medical students for general practice, to meet its demands in a sustainable manner. To address this, the RNZCGP has recommended an increase in the annual number of medical students from 200 to 300 each year.¹⁷ While the Labour Government committed to 50 new placements in the 2023 budget, the National Party, in the run-up to the 2023 election, promised a further 50 new places in 2025, as well as opening a medical school at the University of Waikato by 2030, although the National–ACT coalition agreement required a cost–benefit analysis for the latter before making a final decision.^22,23 If these plans were to come to fruition, it would mean 759 medical graduates in 2030, up from 539 graduates in 2023.²²

Extended placements of medical students in general practices, especially in rural areas, was a recommendation from the study participants. A study conducted in Australia found that placement of medical students in extended short-term training in rural areas was associated with a higher proportion of students selecting to work in regional and rural areas.^24,25 Similar evidence was also found in the United Kingdom, which suggests that more immersive and longer placements in community care make medical students more likely to select general practice as a career.²⁶ However, general practices already working at capacity may feel the need to close their books, even if temporarily, if they have to take on more medical students requiring longer placements.

Another key recommendation from the research was for more and immediate government funding, especially for high-needs practices and to resolve pay disparities between general practice and hospital staff. The proportion of government health funding allocated to PC is notably low, estimated as about 14% on average across 22 OECD countries (2016), and in the case of Aotearoa New Zealand, about 6% of Vote Health going to general practices.^27,28 The way in which the money is allocated could also be improved, adjusting capitation payments to reflect the complexity of providing care for high-needs populations.²⁹ A study of the capitation formula commissioned by the Department of the Prime Minister and Cabinet in 2022 reported that a 9% rise in funding was required for general practices to maintain their current operations.³⁰ Following this analysis, Te Whatu Ora – Health New Zealand offered a 5% increase in funding for PC from 1 July 2023, but general practice organisations rejected it, arguing that they required at least a 14% raise.³¹ In April 2023, the previous Labour Government announced an NZ$44 million fund for PC services, particularly for Māori and Pacific populations, an additional NZ$4.9 million for workforce training and NZ$37 million for high-needs populations’ practices, to address funding inadequacies.³²

Key strengths of this study included collecting data from key experts in the PC sector, combining in-depth interviews with quantitative and qualitative data from a survey, and timing interviews in two rounds to maximise information available, in particular integrating survey findings. Limitations of the study included the small sample size and the self-selection of survey respondents. It would be useful in future research to look at the service user perspective by interviewing patients who were not able to enrol.

In summary, the challenges facing the Aotearoa New Zealand PC sector are both multifaceted and pressing, exacerbated by the COVID-19 pandemic and an ageing workforce. The study illuminates the critical issues of workforce shortages, under-funding and systemic inefficiencies that imperil the accessibility and quality of care. While initiatives have begun to address these challenges, they remain insufficient to meet the escalating demands. The study participants’ recommendations, including the re-evaluation of funding models and the expansion of medical education, suggest steps to move forward. Failure to act promptly risks not only the exacerbation of closed books in general practices, but also the erosion of the healthcare system’s overall efficacy. We hope that this study will encourage debate and accelerate actions for the necessary improvements in general practice care in Aotearoa New Zealand.