GENERAL PRACTICE MANPOWER.

IN

NEW ZEALAND

A DISCUSSION DOCUMENT PREPARED BY THE

ADVISORY COMMITTEE ON MEDICAL

MANPOWER

I110[QI

: GEN

198

STACK, yJ

JULY 1981

GENERAL PRACTICE MANPOWER

IN

NEW ZEALAND

A DISCUSSION DOCUMENT PREPARED BY THE

ADVISORY COMMITTEE ON MEDICAL

MANPOWER

J4867O'

Department oftffngton

CONTENTS

•PREFACE

•ACKNOWLEDGEMENTS

•COMMITTEE

•WORKING GROUP

CHAPTERS

1. Introduction

2. Trends

3. Review

4. Deployment

5. Requirements

6. Supply

7. Wanted - A Basis for Planning

8. District Practice Advisory Groups

9. Locum Service

10. Incentives

11. Prospects

APPENDICES

1. District Practice Advisory Groups

2. Maps Showing Health Districts

3. Projected Populations in Health Districts1976-2001

4. Summary of Incentives Available to GeneralPractitioners

5. Medical Migration Data

6. Designated Rural Areas

Page

1

5

13

17

25

29

33

39

41

43

49

57

60

62

63

69

70

REFERENCES72

PREFACE

This document is based on the findings of a survey of generalpractice manpower started in 1979 and completed in 1980.

It is a discussion document and does not yet have the statusof a formal report. Data are presented, interpretation isoffered, questions are posed, requirements are forecast andplanning action suggested. Some suggestions which would bereadily implementable to improve the availability of generalpractitioner services are made.

It is the committee's wish that this document be dissectedand discussed by all those organisations and individualsinterested in the availability and distribution of generalpractitioners.

The committee would be pleased to receive comment upon -

•the quality of the statistics;

•the questions raised concerning the availability ofgeneral practitioner services and ways to improvetheir distribution;

•the manpower requirements as forecast by DistrictPractice Advisory Groups;

•the suggestions made; and

•any other matters raised in the report.

In the light of the submissions received the committee willprepare a formal report, complete with recommendations, forsubmission to the Minister of Health.

ACKNOWLEDGEMENTS

In presenting results from the 1979-1980 review of generalpractice manpower the Advisory Committee' on Medical Manpowerwishes to acknowledge the achievements of the working groupset up specifically to report on the availability anddistribution of general practitioners.

It also acknowledges the major contribution made by theDistrict Practice Advisory Groups, the Canterbury PrimaryHealth Care Advisory Group and the Northland Primary HealthCare Service Development Group. Without their contributionthere would not have been comprehensive regional feedback onall the issues raised.

The New Zealand Medical Association has been a majorcontributor of opinion and advice, especially an Otago branchworking-party which produced three substantial papers. Thecommittee wishes to thank them and to acknowledge all thosewho have contributed to this task so far. With theircontinuing enthusiasm an improved provision of primarymedical care must surely evolve.

ADVISORY COMMITTEE ON MEDICAL MANPOWER MEMBERSHIP

•H G Lang (Chairman)

•G L BrinkmanD S Cole(Medical Schools)

•B G Jew (New Zealand Medical Association)

•F W E Rutter (Hospital Boards' Association)

•Anne Hall (Colleges' Liaison Committee)

•C H Maclaurin (New Zealand Council for PostgraduateMedical Education)

•N W Harry (from May 1979)(Medical Superintendents' Association)

•A E White (until November 1979)C Wake (from November 1979)(Resident Medical Officers' Association)

•J L O'Donnell (until August 1979)S Brann (from August 1979)(New Zealand Medical Students' Association)

•RABarkerR Dickie (until September 1980)T Lawrie (from September 1980)G C Salmond(Department of Health)

•A H Morris (Research Officer)

•E M Morris (Secretary)

WORKING-GROUP MEMBERSHIP

B G Jew(Chairman) New Zealand Medical AssociationJ R BarnettGeography Department, University of

Canterbury

T Farrar'Royal New Zealand College of GeneralPractitioners

J S PhillipsDivision of Clinical Services,Department of Health

G C SalmondManagement Services and Research Unit,Department of Health

S R WestDepartment of Community Health,University of Auckland School ofMedicine

E M Morris (Secretary) Management Services and Research Unit.,Department of Health

1INTRODUCTION

In May 1979 the Advisory Committee on Medical Manpowerproduced a general report on medical manpower requirements. (1)In that report the committee reviewed the medical manpowersituation in the light of changing economic and socialcircumstances. Based on available information about theexisting workforce, patterns of medical migration andexpected manpower production, and making stated assumptionsabout expected population growth and resource availability,the committee prepared and examined a number of forecasts ofthe manpower likely to be available between 1979 and the year2,000.In the light of this information the committeeconcluded that within 5 years New Zealand could have moredoctors available than are required to operate healthservices at a cost the country is willing and able to pay.

In keeping with this general conclusion the committeerecommended that:

•national health planning mechanisms be developed toenable medical manpower to be planned within thebroader framework of health and health manpower planning;

•the Medical Council be encouraged to improve and developits annual manpower data collection;

•highest priority be given to completion of the surveysof specialist manpower and the availability anddistribution of general practitioners so thatappropriate measures can be taken to ensure that theemerging doctor surplus is used first to meet demand inareas of shortage;

•all immigrant doctors working as resident medicalofficers or otherwise in training be given temporaryimmigration status to cover a specified period and thatcriteria for a long term immigration policy bedeveloped as the studies on the availability anddistribution of doctors make this practicable; and

•tudent intakes to New Zealand medical schools bereduced by the order of 25 percent as soon as practicaland that the matter be subject to annual review.

Significant progress has been made in the implementation ofthese recommendations.

The manpower questionnaire issued by the Medical Council withthe annual practising certificate was revised extensively andissued without problems in March 1980. A greatlyincreasedyield of useful information is expected from the newquestionnaire.

2

Tighter controls have been established on the immigration ofoverseas doctors. All applications for overseas doctors towork in New Zealand are now reviewed by the Department ofHealth.Doctors ..ifl training or wishing to work as residentmedical officers are given temporary immigration permits.Applications for permanent immigration are supported only ifthe applicant has assured employment in a recognised post forwhich there is no suitable New Zealand applicant. Thispolicy applies to the employment of both specialists andgeneral practitioners.

The Government in September 1979 approved reduction by theorder of 25 percent of students to undergraduate medicalcourses to be implemented in two steps:

•a reduction by some 12½ percent in 1980;

•a further reduction in 1981 subject to satisfactoryagreement being reached between the Government and themedical profession on ways and means of overcoming themaldistribution of doctors by field of specialistpractice and by geographical location.

The required agreements have been reached and the 25 percentreduction made.

To assist in resolution of the so-called "maldistribution"problems the committee carried out national surveys ofmanpower in specialist and in general practice. In May1980 a discussion document was released on specialistmedical manpower and submissions called for. A furtherreport will be produced in the light of these submissions.

Of more immediate concern to the Government was the manpowersituation in general practice. Recognising this thecommittee in 1978 established a sub-committee of Dr Jewand Dr Salmond with power to co-opt and with the followingterms of reference:

1. to determine the distribution of general practitionersthroughout New Zealand;

2. to recommend appropriate norms for practice in eachdistrict or suburb of the country;

3. to study the possible use of incentives anddisincentives as a means of better distributing medicalmanpower;

4. to determine ways and means whereby young graduatescould be kept informed about practice opportunities andthe assistance. available to doctors entering generalpractice; and

3

5. to investigate and report on any other matters relevantto the availability and distribution of generalpractitioners.

Those co-opted to the sub-committee or working group as it wascalled were Drs J R Barnett, T Farrar, J S Phillips andS R West.

Working through the New Zealand Medical Association andDistrict Practice Advisory Groups the working group gathereddetailed information about the general practice manpowersituation in all parts of the country. This material hasbeen consolidated and is reported here.

This is a discussion document.It describes the situation,raises issues, and presents options.It does not makerecommendations. The report begins with an examination ofdemographic trends in the general practice workforce.Chapter 3 describes how the working group carried out itsreview. Using data from this review and information fromother sources chapter 4 looks at the distribution of generalpractitioners. Again using information from the review,chapter 5 reports on the estimated requirements for generalpractitioners at the time of the survey and the forecastedrequirements for 1986. Chapter 6 looks at the likelysupply of doctors in the years ahead.

In the light of the review the remaining chapters examinesome of the major issues and options for the future ofgeneral practice in New Zealand. Chapter 7 tries toestablish a philosophical framework which, within the widercontext of health planning, gives due weight to primarycare. Chapter 8 looks at possibilities for the future roleand function of District Practice Advisory Groups. Chapter9 outlines a proposal to establish at national level astanding locum scheme to provide immediate cover forcommunities suddenly deprived of access to medical care.In chapter 10 the existing incentive schemes operating ingeneral practice are reviewed in the light of the changingmanpower situation. Chapter 11 looks broadly at theplanning implications of the information already presented,highlights the unresolved problems and examines the options.The report concludes with appendices and references.

Readers are asked to accept that what has been attempted hereis difficult.In the planning of health services there canbe few easy or unequivocal answers. The social, economicand political environment in which services are provided isconstantly changing along with changes in the health caretechnology. Added to this are the difficulties ofobtaining the reliable data which are essential if planningis to be soundly based. In places the data in this reportare clearly deficient and for this and other reasons many ofthe important issues remain unresolved. But by building onthis effort it should be possible to improve planningperformance and the quality and coverage of our generalpractice services.

2TRENDS

This chapter looks at the demography of general practice.

Reliable fact-gathering about the general practice workforceis difficult for a variety of reasons.There isunfortunately no generally accepted method of accounting forthe workforce. Different investigators have developed theirown methods of defining general practice as opposed to otherforms of primary medical care and of dealing with the problemof part-time employment. This has resulted in varyingestimates of the effective workforce. On the whole these donot vary greatly but may cause confusion.The informationused here is mainly from the Medical Council's datacollection 1973-1979.In places this is supplemented withinformation from other identified sources.

NUMBERS

In the period 1973 to 1979 the New Zealand populationincreased by 161,000 or 5.4 percent.In the same time theactive medical workforce grew by 32.3 percent. Table 1shows that growth in all specialties exceeded the rate ofpopulation growth.

6

TABLE 1 : ACTIVE MEDICAL WORKFORCE, BY SPECIALTY - 1973 AND 1979

Area of practiceActive doctorsGrowth

197319791973-1979

NN

Resident medical officers

General practitioners

Internal medicine

Surgery

Anaesthetics

Community medicine *

Dermatology

Diagnostic radiology

Obstetrics & gynaecology

Ophthalmology

Otolaryngology

Paediatric medicine

Pathology

Psychiatry

Radiotherapy

Venereology

Total (incl. other)

6581,00953.3

1,3251,78034.4

24229321.1

27133021.7

11416746.5

11413821.1

253124.0

911009.9

10113634.6

596815.2

43•467.0

507448.0

10411611.5

12215325.4

111754.5

22-

3,4444,55732.3

Source: Medical Council questionnaire

* Includes public health, preventive medicine and medicaladministration

The supply of general practitioners relative to populationhas changed significantly over the last 20 years. In thefirst decade supply lagged behind population growth but since1973 the situation has improved steadily as shown in Table 2.

7

TABLE 2 : TREND IN THE SUPPLY OF GENERAL PRACTITIONERS IN ACTIVE PRACTICE1959-1979

Year1959 1962 1967 1972 1974 1976 1977 1978 1979

No of generalpractitioners

Population peractive generalpractitioner

1037 1318 1318 1297 1407 1576 1651 1709 1780

1780 1875 2069 2256 2169 1986 1902 1828 1755

Sources: Medical Council questionnaire 1972-1979Where should I practise?1959-1975

•AGE

Table 3 shows the age structure of the general practiceworkforce in 1979.

TABLE 3 : GENERAL PRACTITIONER WORKFORCE BY AGE - 1979

AgeNoPercent

Under 35 years37421.0

35-4440822.9

45-5443424.5

55-6438721.7

65-741206.7

75 years and over573.2

Total1,780100.0

Source: Medical Council questionnaire

Due to the rapid growth in recent years the general practiceworkforce is relatively young. Among the specialties onlyanaesthetics and paediatric medicine have a higher proportionof the workforce under the age of 45 years.

About 10 percent of general practitioners are aged 65 yearsand over. This is close to the average for the wholeprofession.

FA

8

•SEX

Table 4 shows a steadily rising proportion of women ingeneral practice over the decade of the 70s. This is largelydue to the rising proportion of women among local medicalgraduates.In 1971 16 of 118 graduates were women; in1978 the proportion was 61 of 189.

TABLE .4 : GENERAL PRACTITIONER WORKFORCE BY SEX 1972-1979

YearFemaleTotal

Percent

NoNoFemale

197212212979.4

197313313529.81974144140710.21975154150810.2

1976170157610.81977192165111.61978203170911.91979226178012.7

Source: Medical Council questionnaire

•OVERSEAS GRADUATES

Table 5 shows the proportion, by sex, of overseas graduatesin the general practice workforce 1972-1979. For bothsexes the proportion of overseas graduates in the workforcerose steadily over the first half of the 1970s. Morerecently it has stabilised with approximately one-third ofthe males and half of the females being overseas graduates.

TABLE 5 : PROPORTION OF OVERSEAS GRADUATES IN GENERAL PRACTICE BY SEX1972-1979 -

YearMale FemaleNoPercent overseasNoPercent overseas

graduatesgraduates

19721175 24.4 122 43.4

19731219 25.4 133 45.9

19741263 26.2 144 47.2

19751354 30.4 154 51.9

19761406 32.1 170 54.7

19771459 32.3 192 54.2

19781506 32.5 203 54.2

19791554 31.9 226 54.4

Source: Medical Council questionnaire

9

•EFFECTIVE WORKFORCE

Table 6 shows that the total general practice workforce isabout 92 percent effective in terms of full-time equivalents(FTE). A little over 8 percent of the effective workforceis aged 65 and over.

An analysis by sex shows that female doctors under the age of45 years are about 60 percent effective in terms of FTErising to nearer 75 percent in the age group 45-64 years.

TABLE 6 : THE EFFECTIVE GENERAL PRACTICE WORKFORCE BY AGE AND FULL TIMEEQUIVALENTS - 1979

Age

under 35 years

35-44

45-54

55-64

65-74

75 and over

Total

NoFull timePercentequivalentsactive

374337.389.9

408378.092.4

434419.296.4

387364.593.9

12098.381.9

5733.859.3

17801631.191.6

Source: Medical Council questionnaire

•EMPLOYMENT PATTERN

About one-third of general practitioners are in part-timeemployment outside the practice. Table 7 shows in terms ofthe number of attachments and full-time equivalents thegeneral practitioner contribution to other forms of medicalpractice in 1977.

TABLE 7 : GENERAL PRACTICE CONTRIBUTION TO OTHER FORMS OF MEDICALPRACTICE - 1977

Area of workAttachmentsFTEreported

Obstetrics60889.1

Anaesthetics18134.5

Community medicine16432.4

Medicine9423.2

Geriatrics8812.1

Psychiatry3312.9

Surgery336.4

Medical administration81.8

Other12221.2

Total1331233.6

Source: Medical Council questionnaire

Me

In 1977, 1651 general practitioners contributed 1497.1 FTE ofwhich 233.6 FTE or 15.6 percent was in other than generalpractice activities.

The most common employment is as a Medical Officer of SpecialScale (MOSS) in a public hospita],Using data from the1979 Specialist Manpower Surveytable 8 shows the patternof part-time MOSS deployment.

TABLE 8 : PART TIME MEDICAL OFFICER OF SPECIAL SCALE DEPLOYMENT BYHOSPITAL BOARD AND AREA OF WORK

TeachingOtherArea of workcentres*boardsTotal

NoFTENoFTENoFTE

Medicine21

3.7

83 24.2

104 27.9

Geriatrics9

2.0

30.9

122.9

Surgery 3

1.4

72.0

103.4

Accident & emergency4

1.8

62.2

104.0

Anaesthetics13

3.7

87 26.5

100 30.2

Administration1

0.7

144.8

155.5

Dermatology & venereology92.261,0153.2

Psychiatry93.530.9124.4

Other 338.3174.850 13.1

Total 102 27.3226 67.3328 94.6

* Auckland, Wellington, North Canterbury and Otago.

Source: Specialist Manpower Survey 1979.

Relatively few general practitioners find MOSS employment inthe major teaching centres. Those who do are deployed in awide variety of areas.

More general practitioners are employed outside the majorteaching centres. Most either practise general medicine orgive anaesthetics.

•GEOGRAPHICAL DISTRIBUTION

Until it was revised in 1980 the Medical Council'squestionnaire did not record geographical location.Historical series have therefore not been available on thegeographical distribution of doctors. This is an importantmatter which is dealt with further in chapter 4.

11

•CONCLUSIONSAfter being static for more than 10 years general practitionernumbers have steadily risen since the middle 1970s. Much ofthis growth has been due to the recruitment of overseasdoctors, many of whom have entered practice outside the majorpopulation centres.

General practitioners as a group make a significantcontribution to the medical work outside general practice.Most of this is done away from the major teaching centres.

Relative to other groups in the medical workforce theproportion of general practitioners aged 45 years and underis high and rising. The proportion of women is also rising.Given the expected increase in the availability of doctorsin the decade of the 1980s and the likelihood of limitedopportunities for specialist practice these trends arelikely to continue. The general practice workforce of the1980s will be young with an increasing proportion of womenand a decreasing proportion of overseas doctors.

3

REV! EW

This chapter describes how the working-group went about itsreview of general practice manpower.

The working-group recognised the importance to its task ofreliable local information. As a first step a letter wassent to all Medical Officers of Health asking for a completeand accurate list of all active general practitioners withthe address of the principal practice location. The listswere then arranged into order according to geographicallocation. Information on the organisation of practice wasalso requested; that is, whether solo, group or healthcentre, and whether subsidised practice nurses were employed.

The next step was a detailed review of the general practicemanpower in each district. The working-group decided thatthis should be carried out locally by a representative groupconcerned with primary health care. Chosen as being themost appropriate for the purpose were the District PracticeAdvisory Groups (DPAGs) which were set up in 1978 on theinitiative of the Health Centres Advisory Committee. Thesegroups, which comprised representatives from theNew Zealand Medical Association, New Zealand NursesAssociation, Royal New Zealand College of GeneralPractitioners, local hospital board and the Department ofHealth, were primarily charged with the task of advising onlocal health centre development. From the beginning,however, it was expected that groups would become moregenerally involved in the provision of advice on all matterspertaining to primary health care. Further informationabout District Practice Advisory Groups is given inAppendix 1.

DPAGs were asked to undertake a full review of the generalpractice manpower situation in each of the country's healthdistricts. (See Appendix 2 for maps showing health districtboundaries.)The following information was sent to assistthem:

1. a list of general practitioners in the districtaccording to location.Included on these lists was anindication based on General Medical Services (GMS)earnings as to each doctor's level of activity ingeneral practice - precise details were not disclosed.DPAGs were asked to check these lists for completenessand accuracy.

2. population projections for health districts.(Appendix 3).

3. a paper describing the existing incentive schemesoperating in general practice (3).(See Appendix 4for a summary of the incentive schemes); and

14

4.information on the availability, distribution andutilisation of general practitioners based on ananalysis of GMS benefit claims (4).

With the aid of this background information groups were askedto decide whether the information provided gave a reasonablepicture of general practice workloads in their area. Somegroups accepted it as being sufficiently indicative, othersfed in additional detail from their personal knowledge andby obtaining more information from the local doctors.

Comments were sought in particular on ways to achieve abetter balanced distribution of general practitioners:whether zoning - setting general practitioner establishmentsin geographically defined areas - is a possible and desirableoption and opinions on what other options are available.Comments were also sought as to what future developments inthe provision of general practice services would be desirable.Groups were also asked to estimate how many new doctors wouldbe needed in their district over the next 5 years, givenpresent patterns of practice, expected demographic trends andallowing for retirements.

Groups were asked how the stability of services in their areascould be fostered: in particular, what incentives wouldassist and whether an emergency locum scheme would be helpfuland workable.

The groups carried out their task with varying degrees ofenthusiasm. Several groups indicated their intention tocontinue meeting to study the issues because of their interestin obtaining additional information and in providing a moredetailed response than the time-limit for submissionsallowed.Some carried out surveys of local practitioners.Some used the services of an advisory officer to build up amore detailed picture of the manner in which their localdoctors practised; for example, the numbers of servicesprovided in an area, which could then be related to thetotal population of the area.

Replies ranged from two-page statements to lengthy andinformative reports. Most groups attempted to respond toall the issues raised. Analysis of the reports presentedproblems for the working-group. On some issues wherecomparable information was available from all DPAG5 therewere few problems. However, in other areas it was difficultto find a suitable framework for the analysis and thepresentation of results.

In addition to the reports from DPAG5 information wasobtained from other sources.

15

An Otago Working Party of the New Zealand Medical Associationprovided useful material on medical manpower distribution (5),general practitioner distribution and the rural areas (6) andnegative direction (7).

In March 1980 a 3 day conference on "General Practice in the1980s" was held at Pakatoa Island. The conference addressedand reported upon a number of issues with direct implicationsfor manpower planning (8).

A number of projects in Christchurch provided informationof value to the working group. These include:

ereports of consultations, surveys and other activitiescarried out by the North Canterbury Primary HealthCare Advisory Committee;

reports of studies carried out on GMS and other benefitrecords by Dr L A Malcolm and his associates at theHealth Planning and Research Unit; and

•studies of locational choices and historical trends inthe supply and movement of doctors carried out byJ R Barnett and I G Sheerin of the Geography Departmentat the University of Canterbury.

Recently the Minister of Health has spoken on a number ofoccasions about aspects of the medical manpower problem.His speech material and the resultant media coverage hasprovided the working-group with useful information.

In the international medical press manpower is at present E1

major issue. Many western countries like New Zealandcurrently face a sharp increase in the availability ofdoctors at a time when public spending on health services isconstrained. Of particular interest and direct relevance forNew Zealand is the evolving situation in Australia. Anumber of recent reports have been useful (9).

LI

DEPLOYMENT

Mapping the deployment of general practitioners in an area isdifficult. Doctors come and go and alter the extent of theirinvolvement in practice.Lists of doctors are not accuratefor long. Added to this are the problems of definitionmentioned in chapter 2.

The DPAGs used lists giving the names of general practitionerswho had claimed more than $2,000 in GMS benefits during theMarch 1978 - March 1979 year.The sum of $2,000 was adoptedas a cut-off point below which the number of services wasdeemed to be negligible for manpower purposes.

Table 9 shows the numbers of general practitioners in eachhealth district who claimed more than $2,000 in GMS benefitsduring the year to March 1979. These are related to theprovisional population estimates as at 31 March 1979.Thefigures do not include the Department of Health's SpecialAreas. Other omissions from some District Health Officereturns at the time were a small number of doctors workingunder the refund system of claiming for benefits, locums whowere not placed' in a set location and over 30 doctors,providing services through the urgent medical services schemein Auckland. If these are added to the lists provided byDistrict Health Offices, the total of 1654 is readilyreconciled with the Medical Council figure of 1780 activegeneral practitioners in March 1979, which gives a ratio ofone general practitioner to 1755 population.

18

TABLE 9 : NUMBERS OF GENERAL PRACTITIONERS CLAIMING MORE THAN $2, 000 GMSPER ANNUM IN HEALTH DISTRICTS DURING YEAR TO 31 MARCH 1979

Health DistrictGeneral1979RatioPractitionerPopulationDoctor

No Population

whangarei75101,1201:1348

Takapuna161-)558,5701:1526

Auckland205

South Auckland106246,9501:2326

Hamilton159274,1001:1724

Rotorua109189,9601:1743

Gisborne2556,6001:2264

New Plymouth4799,3401:2114

Napier61125,1801:2052

Wanganui4087,0501:2176

Palmerston North63147,1301:2335

Wellington170383,8101:2258

Nelson75122,4501:1633

Christchurch173343,9501:1988

Timaru46109,3501:2377

Dunedin86157,7801:1835

Invercargill53115,7601:2184

Total16543,118,7401:1885

Source: based on lists maintained by District Health Offices.

Because of the omissions table 9 should be regarded as ageneral guide only. When considering small numbers adifference of only one or two doctors in the total can make asignificant difference to the apparent rate of provision.Also, at any one time of the year there would be differencesin the number of doctors active - hence it is alwaysmarginally inaccurate to relate these numbers to populations.

Further there are problems in using GMS data as an indicatorof general practice workloads. Table 7 showed that generalpractitioners make a substantial contribution in other areasof medical practice.

19

No single method of calculating a full-time contribution ofgeneral practitioner services is accepted by all and so othermethods of assessing doctor provision have been devised byvarious investigators. Reference was made in chapter 3 tothe provision of background information to DPAGs. Thisincluded a paper on the availability and distribution ofgeneral practitioners which was based on a method ofestimating full-time equivalents from the amount of GMSbenefit claimed. Table 10 enables some comparison betweendoctor:population ratios based on full-time equivalentsestimated in this way and the ratios established fromDistrict Health Office returns based on doctor numbers intable 9.

TABLE 10 : POPULATION PER 'FTE' GENERAL PRACTITIONER DURING YEAR ENDING31 MARCH 1978 AND YEAR ENDING 31 MARCH 1979

District

Whangarei

North and Cent. Auckland

South Auckland

Auckland (Total)

Hamilton

Rotorua

Gisborne

Napier

New Plymouth

Wanganui

Palmerston North

1979Population

101,120

558,570

246,590

805,160

274,100

189,960

56,600

125,180

99,340

87,050

147,130

RatioFTh doctor:Population

1977-78

1904

1924

2083

2016

2260

2219

2212

2584

2617

RatioFTE doctor:Population

1978-79

1685

1790

2542

1964

2061

1958

2358

2235

2310

2353

2373

Wellington383,81024982384

Nelson122,45020222007

Christchurch343,95021782163

Timaru109,35023392327

Dunedin157,78021011972

Invercargill115,76027382692

New Zealand3,118,74021612120

Source: Malcolm L A, Higgins C S and Barnett J R. The Availability,Distribution and Utilisation of General Practitioners inNew Zealand, 1979.

20

Emphasis on differences in doctor provision between healthdistricts tends to obscure intra-district variations, whichhave been shown in small local studies to be as greater as,or greater than the inter-district differences.

All information received on the provision of generalpractitioner services in New Zealand shows the wide varietywhich exists. Tables 11, 12, and 13 have been included toillustrate this.

Despite the deficiencies, these data enable a profile ofcustomary medical practice in an area to be built up. Thismay well be more relevant than actual doctor numbers todecisions on adequate doctor provision because such provisionis very much' affected by doctors' styles of practice andpatient factors such as agei sex, socio-economic status,geographical dispersion and the like.

Table 11 shows the wide variation in median GMS income ofdoctors aggregated by health district. It must beremembered that this is gross income and does not includeincome from other sources.

TABLE 11 : MEDIAN GMS INCOMES OF GENERAL PRACTITIONERS EARNING MORE THAN$12,000 GMS (FTE) 1978-79

RANKING ACCORDING TO HEALTH DISTRICTS

District

Gisborne

New Plymouth

South Auckland

Whangarei

Christchurch

Hamilton

Timaru

Wanganui

Napier

North and Central Auckland

Wellington

Palmerston North

Rotorua-

Dunedin

Nelson

Invercargill

GMS Income$

31,560

24,444

24,444

23,952

23,553

23,515

23,117

22,882

21,751

21,300

20,910

20,640

20,554

20,435

18,821

18,184

(Figures taken from the report by Malcolm L A, Higgins C S, andBarnett J.R. The Availability, Distribution and Utilisation ofGeneral Practitioners in New Zealand, 1979).

21

The way in which doctors choose to organise their practicehas a direct effect on the type of service provided.District Health Offices were asked to indicate for the surveywhich doctors were in solo practice, which were inpartnership, or group practice in privately funded medicalcentres and which were in health centre practice. Theresults are shown in Table 12.

As ten of the 17 health districts had fewer than 100 doctorsthe proportions shown may be a little unstable but clearlythe pattern of practice between health districts variesconsiderably. -

Thirteen health centres created under the Government's healthcentre programme are now operational. For most theinitiative came from the local general practitioners.Capital costs are financed by grants to hospital boards whomake space available at a reasonable rental to generalpractitioners and other health professionals in the interestsof fostering team care.

TABLE 12 : PRACTICE ORGANISATION ACCORDING TO HEALTH DISTRICT

Reported by District Health Offices - 1979

District

GeneralPractitioners

No

GeneralGeneralGeneralPractitioners Practitioners Practitioners

Soloin Groupin Health

PracticeCentresPercentPercentPercent

Whangarei75 28 72

Takapuna161 49 51

Auckland205 61 39

South Auckland106 61 32 7

Hamilton159 61 35 4

Rotorua109 50 44 6

Gisborne25 92 8

New Plymouth47 62 38

Napier61 69 31

Wanganui40 78 22

Palmerston North63 54 46

Hutt/Wellington170 37 57 6

Nelson75 91 9

Christchurch173 43 54 3

Timaru46 69 31

Dunedin86 34 50 16

Invercargill53 65 30 5

.22

Since it was introduced in the early 1970s, initially as anincentive scheme for rural practitioners, the practice nursescheme has continued to grow. By 1979 the scheme involvedabout900 nurses in both urban and rural areas. Table 13shows the extent of practice nurse support per generalpractitioner in' 1979.Further details of the scheme aregiven in Appendix 4. A review carried out in 1980 concludedthat the scheme had been successful in improving theavailability, the quantity and the quality of care in generalpractice.

TABLE 13 : SUBSIDISED PRACTICE NURSE HOURS PER FTE GENERAL PRACTITIONER -1979

DistrictPractice Nurse General PractitionerPractice Nursehours pernumbers 78/79hours per FThweek General Practitioner

. per week

Whangarei

Takapuna

Auckland

South Auckland

Hamilton

Rotorua

Gisborne

New Plymouth

Napier

Wanganui

Palmerston North

Hutt/

Wellington

Nelson

Christchurch

Timaru

Dunedin

Invercargill

1,055

2,599

2,201

922

2,330

1,359

196

530

637

745

1,197

2,209

657

2,510

639

1,100

709

60

18

410

14

133

18

97

14

24

8

43

12

56

11

37

20

62

19

161

14

61

11

159

16

4714

8014

4316

Note: (FTE general practitioner figures taken from the report byMalcolm L A,Higgins C S, and Barnett J R. The Availability,Distribution and Utilisation of General Practitioners inNew Zealand, 1979.)

23

The data in this chapter show how little we know about thepattern of general practice provision in different parts ofthe country. What is clear is the tremendous variationwhich exists between and within health districts. Althoughmuch more information is required about all aspects of theprovision of care it is obvious that planned improvementcannot occur without the active involvement of practitionersand administrators at the local level.

REQUIREMENTSAny discussion of medical manpower requirements in generalpractice or any other branch of medicine must start with someconsideration of the likely availability of resources.

The availability of health resources has not in the past beendetermined by an objective assessment of need. Theassumption that a centrally planned health care system couldmatch needs and resources has proved so far to be anillusion. Instead, the resources which are made availablefor health care appear to be determined by a variety ofcomplex socio-political systems which are difficult tounravel. To whatever extent health care facilities areexpanded they are generally all used; and at the same timethere is a steady pool of unmet demands.

As a general rule it can be said that the wealthier a countrybecomes the higher the proportion of that wealth devoted tohealth services. Convincing international data can beproduced to show that wealth rather than need seems to be theprime determinant of the availability of health care.

The New Zealand Planning Council was obviously aware of therelationship between the economy and health services when itreported on trends and prospects in health services in 1979.The following is an abstract from its report "The WelfareState?Social policy in the 1980's".(10)

In considering an appropriate rate of increase in Government healthexpenditure the Council had regard to a number of factors including:

(a) the expected slow growth of the economy as a whole;

(b) the desirability of limiting the increase of Governmentexpenditure in terms of gross domestic product;

(c) the rapid increase in health expenditure particularly in thepast 4 years;

(d) the possibility of improving the effectiveness of health caredelivery by using existing resources more efficiently;

(e) the slower rate of population increase and the changingcomposition of population;

(f) the limited extent to which more expenditure on health can infact improve health.

26

Even taking all these factors into account it is extremely difficultto arrive at an appropriate rate of increase in health expenditure.However, having particular regard to the fact that growth in GDP islikely to be 3 percent a year or less, that Government expenditureshould rise more slowly than GDP, and that health expenditure hasrisen rapidly in recent years, the Council recommends that forplanning purposes a rate of increase in real terms of no more than2 percent a year be accepted for the decade ahead.

The Minister of Health The Hon G F Gair has on a number ofoccasions in recent months clearly stated his intention towork towards achieving zero growth in real terms in thehealth sector. At best health can hope to maintain itspresent proportionate share of Government expenditure.

•CURRENT REQUIREMENTS ESTIMATED BY DPAGS

It was against this economic background that DPAGs were askedfor their best estimates of general practitioner numbersrequired in their district now and in 5 years time, givenpresent patterns of practice and existing population trends.Their replies required some interpretation because of thevarious terms they used to express need; for example "wecould use ..., "we want ..., of

would like perhaps ...".However, analysis of their replies did enable a generalassessment to be made of the national requirements.

All groups had difficulty in assessing the present supply andlikely future needs because, as was discussed in previouschapters, there is no generally accepted way to calculate adoctor's workload.In some districts this created less ofa problem due to the DPAG's intimate knowledge of practice inthe area.In some districts it was possible to supplementthis with information gathered by an advisory officer workingwith the group.

Despite the problems, each group arrived at an estimatednumber of additional practitioners required in the districtimmediately. At the time of the survey this totalled fewerthan 40 doctors for the whole country.

A very few, possibly four to six, of these were locations ofabsolute need; that is, a perceived gap in services.Theothers were considered desirable to upgrade services. Atthe same time, several replies indicated that some localitieswere approaching a full, or even an over-doctored situation.

Based on the information provided by the DPAGs there wouldseem to be very few remaining areas of doctor shortage.Most of the gaps identified at the time of the survey havesince been filled.It is however important to recognisethat acute break-downs in service are always possible in areasserved by a small number of doctors. This is a problem

27

mainly of the rural areas and should be helped by the expectedincrease in the availability of doctors. The scheme for astanding national locum service (see chapter 9) should helpto solve this particular problem.

S 1986REQUIREMENTS ESTIMATED BY DPAGS

DPAGs estimated that 100 - 120 new general practitioners, ifappropriately located, would meet the national requirementby 1986. This is in addition to practitioners needed toreplace those retiring or leaving practice for other reasons.Based on this estimate a 1986 workforce of about 1900 doctorsis thought sufficient to take account of population growthand the up-grading of services required in some areas. Givena workforce of 1780 practitioners in 1979, a 6.7 percentincrease is required by 1986.In this regard it isinteresting to note that the Medical Council's questionnairesurvey in 1980 showed 1823 general practitioners, only 77fewer than the estimated requirement by 1986.

These estimates by the DPAGs can be taken only as roughguides to future requirements. On the whole they tended toreport that the existing ratio of general practitioners topopulation in the district was about right with perhaps theaddition of a few doctors in poorly served localities orareas of projected population growth. This is despite thefact that the statistics show wide variation in the generalpractitioner to population ratio in different health districtsas shown in tables 9 and 10.

The working group believed that DPAGs, possibly being moreconcerned with professional rather than patient interests,may have underestimated the requirements for generalpractitioners particularly in economically depressed urbanareas. Recent studies show these to be areas of relativelyhigh morbidity and high health service utilisation. Theseareas often have difficulty in attracting and retainingdoctors and other health workers. Of course, it is one thingto indicate where doctors are needed; it is another toensure that they practise where they are needed.

S NORMS

The question of a desirable general practitioner to populationratio - a "norm" for general practice - is a complex issue towhich there is no easy answer. The few DPAGs whichcommented specifically on norms for their districts eachbased them on current levels of provision and so they variedwidely.

It is important to recognise that the concept of doctorshortage or over-supply is a relative one. An area isgenerally defined as being short of manpower not because thereis an objectively determined need in terms of a doctor topopulation ratio that the area fails to reach but because

28

the ratio is significantly below that achieved in other areas.It follows from this that the basic objective of anyredistributional policies is not the achievement of anyparticular ratio of doctors to population (for that dependsessentially on the overall supply of medical manpower), butrather a narrowing in the range of ratios between the bestand the worst endowed areas. Redistributive mechanisms aimto equalise the distribution of doctors, not to cope with anexcess or a shortage of manpower.

It is thought that the existing variations are the result ofseveral important factors which would have to continue to betaken into account if establishing guidelines for desirableratios.

Firstly, the doctors themselves vary widely in the number ofpatients each is able to care for. The doctor's workloadis influenced not only by the numbers of presenting patientsbut also by the doctor's age and style of practice. Itwould be difficult to take into account the varyingcharacteristics and strengths of doctors. There is somerelationship between doctors' characteristics and thecharacteristics of the patients who choose them. Hencestyles of practice vary widely.

Secondly, characteristics of the population and itsdistribution markedly affect the numbers and types of servicesrequired.It is now well-established that doctor-consultationvaries according to age, sex and socio-economic status aswell as the distance patients have to travel for care. Forinstance, if an area has a high proportion of elderly agreater number of services will be required from its doctors.

Thirdly, the way in which medical services are organised inan area has a marked effect on the numbers of generalpractitioners needed. In some areas greater use is made ofhospital facilities than in others. There is a variety ofhealth personnel available in some areas, while in othersonly the general practitioner is available to provide primarycare. Within some practices tasks are clearly defined asbeing appropriate for provision by the receptionist orpractice nurse; in others the doctor alone greets thepatient and conducts all work associated with the consultation.

To assess the requirements and to plan for the generalpractice services in an area requires an intimate knowledgeof all the relevant local factors. Given guidance from thecentre and adequate advisory officer support the committeebelieves that DPAGs would be the most appropriate bodies toundertake this service planning/service development function.This proposition is further developed in Chapter 8.

on

SUPPLY

If manpower planning is to be attempted, "forecasts" must bemade. In the case of medical manpower, these are based onassumptions about population numbers and assumptions aboutthe available medical workforce.

•POPULATION

Low fertility and net outward migration have recently broughtNew Zealand to a state of near-zero population growth. Forthe purpose of relating doctor supply to population to beserved the Department of Statistics' population projectionmaking "medium" assumptions is adopted.(For technicaldetails readers should refer to the Department of Statisticspublication "New Zealand Population and Labour ForceProjections 1979-2011").

• SUPPLY FORECAST

Details of the basis upon which medical manpower supplyforecasts have been made were given in the Committee's 1979Report to the Minister of Health on Medical ManpowerRequirements. The preferred assumptions and associated"moderate restraint forecast" are summarised below.

Firstly, the assumptions -

1. Production - it is assumed that the graduate output fromNew Zealand medical schools will be 320 per year 1981 -1984 reducing to 240 per year from 1985.

2. Immigration - it is assumed that there will be animmediate reduction of overseas-trained doctors to 100per year.

3. Work-life profile - it is assumed that there will be aslight increase in the active work-life contribution ofwomen and fewer New Zealand graduates emigratingpermanently.

The resulting supply projection together with the expecteddoctor to population ratios are shown in table 14.

TABLE 14 : A MODERATE RESTRAINT FORECAST OF DOCTOR SUPPLY

Year19781986

1991

19962001

Number of doctors4,3775,913

6,460

7,0977,834

Population per doctor719554

530

503472

As a measure of the expected increase in doctor supply it isof interest to note that if doctor numbers were to grow instep with expected population growth, by 1986 there would be4578 doctors and by 1991, 4791 doctors.The preferredsupply forecast exceeds these figures by 1335 doctors in1986 and 1669 in 1991.

30

•RECENT DEVELOPMENTS

Recent population projection information suggests thatpopulation growth is most unlikely to exceed, and may wellnot reach, the rate assumed in the model.

A 12 31 percent reduction in medical school intakes took placein 1980 and again in 1981. This is much in line with theforecast except that the full 25 percent reduction ingraduate output will be delayed to 1986.

Tighter controls on the immigration of overseas doctors wereintroduced in 1979.So far the immigration statistics donot reflect this policy change (See Appendix 5 Table 1).In 1980 the number of overseas doctors coming to New Zealand(271) far exceeded the 100 allowed for in the model. Thereis therefore a continuing accumulation of overseas doctorsin New Zealand.

Until recently New Zealand lost about one-third of itsgraduates by permanent emigration, most of them within 5years of graduation. Although it is too early to define atrend the March 1980 statistics (Appendix 5 Table 2) wouldbe in keeping with a tendency for fewer young graduates toleave New Zealand and for a higher proportion of those whogo to come back. This is in keeping with the model.

•MANPOWER IMPLICATIONS

The effect of the increasing supply of doctors will be feltprogressively over the next decade. Initially the effectmay not be great as it is likely that most graduates willfind employment in their seventh and eighth years given thatthe number of overseas doctors filling house officer postsis drastically reduced.However, once the new cohortsstart to move into the ninth year and beyond there are likelyto be problems.

Given that there is now little if any growth in the resourcesavailable to hospital boards it is doubtful whether boardswill be able to increase their medical establishments in theyears immediately ahead. This means that withoutconsiderable restructuring, growth in registrar andspecialist establishments is unlikely.

With restricted opportunities for specialist training andemployment it is likely that an increasing number of youngdoctors will seek to enter general practice. This comes ata time when on the assessment of DPAGs only modest growth ingeneral practitioner numbers is required. The matter isfurther complicated by a number of other problems. Firstlythe number of general practice training posts will be quiteinadequate to meet the new demand unless new resources aremade available.Secondly, at present there is no way of

31

preventing anyone with a basic medical qualification fromentering general practice. There are no tangible incentivesto encourage vocational training and to reward those sotrained. Thirdly, there is good reason to believe that thecost to the Government of general practice services willincrease in direct proportion to the increasing number ofpractitioners. In the present economic climate it seemsunlikely that the Government would permit this to occur.

7

WANTED - A BASIS FOR PLANNING

General practice, and hence general practice manpower, cannotbe planned in isolation. It is an integral part of primaryhealth care which many claim should be the central focus andmain function of the country's health system. Beforeaddressing the practical problems of planning manpower forgeneral practice it is essential to try to get some feel forwhat the future role and shape of general practice might be.Without some philosophical framework planning is little morethan groping in the dark. A useful place to start is withthe definition of primary health care accepted in theDeclaration made by delegates from 140 nations attending TheInternational Conference on Primary Health Care which wasjointly sponsored by The World Health Organisation and theUnited Nations Children's Fund and held in Alma Ata in 1978.The definition states:

"Primary health care is essential health care based onpractical scientifically sound and socially acceptablemethods and technology made universally accessible toindividuals and families in the community through their fullparticipation and at a cost the community and country canafford to maintain at every stage of their development in thespirit of self-reliance and self-determination.It formsan integral part of both the country's health system, of whichit is the central function and main focus, and of theoverall social and economic development of the community.It is the first level of contact of individuals, the familyand community with the national health system, bringinghealth care as close as possible to where people live andwork and constitutes the first element of a continuinghealth care process."

The Declaration further states that:

"All governments should formulate national policies,strategies and plans of action to launch and sustain primaryhealth care as part of a comprehensive national healthsystem and in coordination with other sectors. To this end,it will be necessary to exercise political will, to mobilizethe country's resources and to use available externalresources rationally."

The thrust of WHO's initiatives in primary health care ismainly directed at the needs of the developing world but theprinciples apply elsewhere. After World War II New Zealand,like most western countries, experienced a period ofeconomic expansion.In the period 1950-1970 people werewealthier every year and thus prepared to pay for more healthcare and, they hoped, better health. Public expenditure onhealth services rose from 3.35 percent of gross domesticproduct (GDP) in 1950 to 3.75 percent in 1960, to 4.11percent in 1970, and is expected to be 5.5 percent in 1980.

34

The people and the Government purchased more health care.The Government also provided more liberal support for medicalresearch and invested heavily in manpower to make medicalservices more accessible and available.

Most expansion in medical manpower and related facilitiestook place in the late 1960s and early 1970s.Medicalschools increased from one (1967) to four (two full schoolsand two clinical schools) in 1977. First-year students grewfrom 120 (1967) to 320 (1976).Faculty numbers increasedconsiderably as did the resources available for postgraduatemedical education.

Over the last two decades there has been a progressiveincrease in the proportion of health resources expended onhospitals.In 1960 56.2 percent of total health expenditurewas in the hospital sector - by 1974 the proportion was61.2 percent (Smith and Tatchell 1979). (11)This movementin favour of hospitals has continued in more recent years andbeen most marked in the public sector.In 1974 the proportionof public health expenditure on hospitals was 71.9 percent;in 1980 it was 73.5 percent.

In the decade of the 70s there was a small decrease in thenumber of average occupied beds in public hospitals(-5.4 percent) a modest increase in the number of inpatientadmissions (24.1 percent) a sharp increase in the number ofoutpatient attendances (56.6 percent) and a sharp increasein the number of junior medical staff (RM05) (97.9 percent).For most of the decade until 1978 medical staff numbers inhospital board employment increased at an annual rate of about6 percent.Since 1978 the rate of growth has slowed and in1980 there was no growth.

The public willingly supported this expansion of services inthe expectation that the hospital would cure illness andremove that burden from the community, organise the newtechnology so characteristic of modern diagnosis and"curative treatment", educate and train the healthprofessionals and provide a wide range of employmentopportunities.It was also hoped that by increasing thenumber of doctors the availability of care would improveboth in hospitals and the community. Based on laissez-fairepolicies it was assumed:

• that a market "flooded" with doctors would make servicesavailable to everyone;

• that the proper mix of specialists and generalpractitioners would automatically take care of itselfwithout interference with public policies in medicaleducation and training or in the financing of care; and

• that the country could afford any number of doctors andmedical services it wanted.

35

In parallel with hospital growth there has been a decrease inresources expended on primary health care. This has been sofor both public health and personal health services.In1961 2.7 percent of total health expenditure was on publichealth services - in 1973 the proportion was 2.4 percent.Similarly in 1961 10.2 percent of total health expenditurewent on general medical services - by 1973 this had fallen to6.9 percent and in recent years has probably fallen further.Certainly public expenditure on general medical services hasdecreased from 4.3 percent of the health vote in 1974 to 3.1percent in 1980.

In recent years some efforts have been made to channeladditional resources into primary care.Of greatestimportance to general practice has been the introduction ofthe practice nurse scheme which now employs about 900 nursesand accounts for an expenditure of $7 million a year.inaddition funds from the health tax on alcohol and tobaccohave been used to support health services in the community.However, not all the funds ($17 million in 1977-78) were usedfor this purpose and it now seems unlikely that the schemewill continue.

It can be rightly claimed that most hospital boards are nowexpending an increased proportion of their resources ondomiciliary services and other forms of primary health care.There would however be very few boards where such expenditureaccounts for more than four percent of the board's annualbudget.

In the quest for funds the hospital has a further importantadvantage over primary care. Whereas the annual financialallocation by the Government to public hospitals isstabilised for inflation there is no automatic stabilisationfor health benefits and other state subsidies.In times ofausterity and rising inflation there is a tendency for thereal value of benefits and subsidies to fall. This hascertainly been so for most general practice-related benefits.To compensate for this practitioners have progressivelyincreased their direct charges to patients. Convincinginternational evidence is available to show that the groupsmost affected by raising user charges are the sociallydisadvantaged, the poor and the chronic sick.

The last 20 years have seen increasing public investment inhealth services with the emphasis on developments in thehospital sector. Public investment in public health andprimary medical care has declined.Largely laissez-fairemedical manpower policies have resulted in some improvementin the availability of both specialist and generalpractitioner services but distribution remains uneven withcontinuing problems in some areas. Within specialist ranksthere has been an increase in the availability ofanaesthetists and paediatricians but shortages remain inpsychiatry, radiology, geriatric and rehabilitation medicine

36

and community medicine. General practitioner numbers werestatic at 1300 from 1962 to 1972; since then there has beensteady growth. However, general practitioners are adeclining proportion of the medical workforce - 42 percent in1968, 39 percent in 1978.There is now good reason tobelieve that as a country we may soon produce more doctorsthan we can afford to employ.

To cut medicine's manpower or its resources may portend adismal future, so accustomed have both the public and theprofession become to decades of continuous medical expansion.Training fewer doctors raises the immediate spectre of lessopportunity to go to medical school and less medical careavailable in society. Also, given fewer resources, thefuture may bring something still worse - imposed limits onusing medical technologies.

Yet economic retrenchment need not produce a loss of doctors'jobs or medicine's technological decline. On the contrary:a more restrained future might still provide work for most ofthe coming cohorts of medical graduates but contain adistinctive new mix of care and technical treatment differentfrom, and less costly than, the technologies so emphasisedby the modern hospital. Medicine could take the form ofmore primary care, namely care outside the hospital usingmore doctors and less complex technologies in promotingprevention and producing better long-term treatment for thedisabled, the chronically ill and a growing population ofaged.Hospital boards, (and if and when they exist, healthboards), could and should be part of this development.

What is needed is greater emphasis on primary health care interms of the Alma Ata Declaration. New Zealand wasrepresented at the meeting and in terms of official policysupports the Declaration.In speeches and preparedstatements in the last 2 years the Government has indicatedits wish to promote primary health care. The message hasbeen echoed by other bodies such as the New Zealand PlanningCouncil in its document "The Welfare State? - Social policyin the 1980's".However, there is as yet no tangibleevidence to show that significant resources are being re-directed into primary health care.

Looking ahead, a more constricted economy and an increasingnumber of doctors may force the present pattern of practiceand training to become more general irrespective of specifichealth care or curriculum policies that promote suchredirection. If the problems of ad hoc development are tobe avoided the Government should spell out, at least ingeneral terms, its objectives and policies for health andhealth services. These should include practical guidelinesfor achieving national objectives in primary health care.Without such guidance health planning, including manpowerplanning, can be little more than speculation. Withoutclearly stated objectives there can be no accountability.

37

The committee believes that it is time to re-think thenational policies relating to general practice and its rolein health services. To be effective such a review wouldneed to be wide-ranging and involve health workers other thandoctors because general practice must be seen in the widercontext of primary health caretIf as a result of thisreview public policies were developed which would involvedoctors in expanded roles in primary health care then theindications are that the required manpower would beavailable. What is less certain is whether there would bethe resources needed to employ them. However, given statednational policy objectives this becomes a matter for politicaldecision on priorities for public expenditure. Overall theobjective must be best value for money in health care.

['1

DISTRICT PRACTICE ADVISORY GROUPSIt has been clear throughout the committee's task that asource of informed opinion on local needs is vital to themaking of appropriate decisions on the delivery of primarymedical care. The DPAGs have provided this source.

Although the DPAGs have in some districts been used to adviseon practice nurse usage, they were originally established toadvise on health centres. However, their terms of reference(Appendix 1) include a provision that their activities couldbe extended to include advising on the availability anddistribution of medical practitioners and allied healthprofessionals.Some groups have been active since theirinception; others had never met until asked to do so for thepurposes of this project. Almost all groups responded withenthusiasm and many suggested that they carry on meeting toprovide the committee with more detailed feed-back on theirareas' primary medical care requirements.

The committee suggests that full consideration should now begiven to expanding the functions of DPAGs to include anactive role in assessing primary health care requirements intheir areas - including the manpower requirements. It isenvisaged that there would be a regular flow of intormationbetween a central administrative focus and the DPAG5.National policy guidelines, statistical and other informationwould be supplied to the groups which would then comment onthe basis of local information and report back. In this wayit is hoped that planning and decision-making at both thelocal and central levels would be facilitated.

If this expanded role for DPAGs is accepted the membership,terms of reference and administrative and support mechanismsfor the groups will need to be reviewed. So far the groupshave been concerned with health centre development,employment of practice nurses and general practice manpower.Reference has been made elsewhere in this report to thedesirability of their functioning as an advisory body on allaspects of general practice including such matters asprescribing patterns and peer review and on primary healthcare issues in general.

On the matter of membership the Committee felt that thereshould be some appropriate "consumer" representation on allgroups. Steps should be taken to ensure regular change ingroup membership. Once constituted, groups should beempowered to elect their own chairman and to set up ad hocworking parties involving outside members. When they wouldotherwise be out-of-pocket as a result of involvement withthe group, members should receive realistic remuneration.Also, meetings should be arranged to ensure that independentpractitioners are able to attend without undue inconvenience.

40

To function effectively, groups should be provided withfinancial resources and administrative and research support.At present these are probably best provided by way of thelocal District Health Office. The levels of administrativeand research support are likely to be key factors indetermining a group's effectiveness.In the absence of adedicated person to organise meetings, gather information,keep minutes, prepare reports and follow up decisions littleprogress will be made. In most areas itwouldprobably bemost appropriate to appoint such a person as an AdvisoryOfficer in the District Health Office.

To provide a central focus for primary health care and thework of DPAG5 the committee believes that a National AdvisoryCommittee to the Minister of Health on Primary Health Careshould be appointed. The committee, which should besuitably representative of the interests if not of theorgañisatiofls involved in primary health care, should concernitself mainly with major policy matters. Matters oftechnical detail or negotiation should be dealt withelsewhere. Basically this should be an advisory group onpriority setting and policy making. The most appropriateadministrative focus for all these activities within theHead Office of the Department of Health would seem to, be theDivision of Clinical Services.

One of the functions of a central. administrative focus couldbe to establish a clearing-house for information aboutgeneral practice, including manpower, and about specificemployment opportunities. There have been many comments onthe need to widely publicise job prospects. At present someinformation is available on enquiry through the New Zealand,Medical Association and the Department of Health but neitherorganisation has a comprehensive and regularly up-dated database.Regular publication along the lines of. the earlierDepartment of Health publication "Where Should I Practise"might be considered.

LOCUM SERVICE

The rural and solo nature of so much New Zealand generalpractice makes it particularly vulnerable to sudden breakdown.This is most apparent in isolated communities where thereare no doctors within a sufficiently small radius to providetemporary cover. Such events occur regardless of currentnational doctor supply. They inconvenience and worry acommunity and are a professional and political embarrassment.

The idea of a centrally administered locum service to dealwith such crisis situations as they arise has met with almostunanimous approval in discussion throughout New Zealand.It is thought that the employment of two or three experienceddoctors should suffice as the need should be quite small.They would be recruited for employment as locums on contractwith the New Zealand Medical Association for not less than6 months and be available to go at short notice to anycommunity lacking the services of a general practitioner.Their assignment to a particular area would normally be for amaximum of 3 months during which time the local communitywould be encouraged to take positive steps to recruit apermanent doctor.

The scheme would be aimed at relieving an emergency communitysituation, not at relieving individual doctors. However,when not required for crisis intervention the locums couldprovide short-term relief, particularly for doctors in ruralareas.

The New Zealand Medical Association has undertaken toadminister such a scheme. The services would be provided atthe association's direction in consultation with theDepartment of Health. However, when priorities have to bedecided the Minister of Health in consultation with theNew Zealand Medical Association would make the requireddecisions.

The salaries of participating doctors would be determined inthe light of their experience and qualifications and basedon salary scales applicable to doctors in hospital boardemployment. Practice expenses such as receptionist's salary,motor vehicle hire, motor vehicle allowance, surgery rentaland insurance would be met by the New Zealand MedicalAssociation but would be partially offset by the receipt ofall patient and Accident Compensation fees and healthbenefits.It is hoped that the scheme should be largelyself-supporting. Personal expenses including travel to andfrom the area and accommodation would be met from practiceincome and the level of reimbursement would be negotiated.No superannuation would be paid but provision for annual andsick leave would be made.

42

While the proposed schemedoctor supply problem thepotential benefits would fscheme should start smallincreases. A Governmentscheme would be desirable.

addresses only one aspect of thecommittee believes that thear outweigh the likely costs. Theand expand as and if demandcontribution to help launch the

10

INCENTIVES

The committee recognises that in the opinion of all whoreported to it a system of incentives will probably always beneeded to encourage provision of continuous, stable medicalcare in certain areas. Overseas experience has shown thatincreasing the total number of doctors is not sufficient toovercome geographic disparities in doctor-provision. Thereis evidence also of a New Zealand trend for the highest netgains in the number of general practitioners to occur in themore affluent, already doctor-rich areas. On the otherhand, with an influx of doctors into general practiceexpected over the next few years the committee is consciousof the need not to make recommendations which might lead toany unnecessary provision of incentives.

Given the considerable restraint on resources available forexpenditure on health care, the committee accepts the needto be realistic about seeking greater expenditure onincentives. All incentives should be regularly reviewedfor their usefulness. After an incentive has been availablefor some time it tends to become an expected fringe benefitand loses its capacity to stimulate change. Certainly underthe present economic circumstances any new incentives willprobably have to be funded by a reallocation within theexisting total allocation of money for primary medical care.

The primary purpose of incentives is improved equity in theprovision of services. To this end, the committee has takeninto account all the suggestions received and has selectedthose which it considers best designed to foster stable,continuous provision of primary medical care while maximisingprofessional satisfaction and minimising professionalisolation.

•URBAN AREAS

Much more thought needs to be given to the provision of carein metropolitan areas which have difficulty in attractingand retaining general practitioners. Typically the peoplein such areas are poor and morbidity levels are high.Knowledge of health and health services is limited despiteoften high use of health and related social services. Newapproaches are needed towards the promotion of health andthe provision of health services in such areas. Newincentive schemes may be needed to encourage desireddevelopments.

Most frequently emergencies involving a complete breakdown ofservices occur in relatively isolated rural areas wheretemporary cover is difficult or cannot be provided. On thequestion of incentives the committee has therefore focussedits attention mainly on the Designated Rural Areas (DRAs) -see Appendix 6 for details.

44

INCENTIVES TO RURAL AREAS

There are reports of increasing dissatisfaction in the DRAs.It is recognised that they differ widely in theirprofessional attractiveness to doctors, some being asattractive as any city location, some being extremelyisolated.It is understood that attempts are to be made tocategorise them more precisely, based on demographic andsocial factors.In the meantime they exist as identifiableadministrative units despite problems associated with theirdesignation. Broadly speaking they comprise areas wherethe central town population is 5,000 or less..

Two schemes initiated as incentives to rural practice have.now lost their effect.The first, the practice nursescheme, although introduced as an incentive to ruralpractice, was extended in 1974 to include urban practicesand hence no longer acts as a rural incentive. The second,which came to an end in 1980 was the scheme for payingpractice grants in approved cases to resident medicalofficers electing to take up private practice in lieu of apostgraduate bursary. Half the grant was payable on takingup private practice with the other half made available oncompletion Of 2 years' service in a DRA.

On the whole rural practice incomes appear to be adequate butthe sources of discontent appear to be threefold:

1. the large capital outlay on equipment and housing neededeven before a doctor can make a final decision to stayin an area;

2. the difficulties of maintaining adequate professionalcontact with other general practitioners andspecialists, and in attending educational courses, dueto problems in obtaining locum cover; and

3. problems in meeting family and social needs; inparticular children's education and a satisfactory life-style for wives.

An apparent improvement in population-doctor ratios in ruralareas may be due largely to de-population of the ruralareas. The present rural practice bonus of 10 percent onGMS benefits and 25 percent on GMS motor vehicle allowanceis not considered a substantial factor in drawing doctors torural areas. However, it may well help to keep them thereand so the committee agrees with its retention. To increaseit to the 25 percent bonus which was suggested in somequarters would be overly expensive and not a sufficientlydiscriminating scheme.

45

To support rural industry and help to .prevent rural de-population it is essential that rural communities have thesecurity which comes with the availability of dependablemedical care.Indeed, it could be in the interests of thetotal economy for the Government to subsidise care in areaswhich would otherwise be uneconomic for a generalpractitioner.

To ameliorate the three perceived sources of discontent thefollowing suggestions are made:

1.Loans

One of the factors which holds doctors in specific areasis their financial stake. The ideal for which to aimis to assist them to achieve establishment while notmaking this so easy that they then feel free to moveaway with little or no warning because they have nofinancial stake to consider.

There is already in existence a scheme wherebyHousing Corporation loan finance is available to localauthorities wishing to provide housing and surgeryaccommodation for doctors in DRAs. Local authoritiesfind the terms quite attractive and there is a fairdegree of doctor satisfaction where accommodation isprovided in this way. The committee thinks it highlydesirable that district schemes should includeprovision for surgeries and that local authorities shouldbe involved in arranging medical facilities for acommunity. Wide promotion of the existing scheme forlocal authorities to obtain Housing Corporation financeto provide housing and surgery accommodation fordoctors in DRAs is advocated.

The committee doubts that there are many appropriatesupervised openings for Family Medicine TrainingProgramme (FMTP) registrars in rural practice but agreesthat there is merit in a suggestion put forward by aDPAG that loans to provide accommodation for FMTPregistrars within an approved rural practice could beconsidered.

Indeed, loan facilities for various aspects of ruralpractice should be considered; for instance, provisionfor assisting a new doctor to buy existing DRApremises and equipment. There is no evidence tosuggest that solo general practitioners provide a lowerstandard of care than is provided by a group practice.As group practice may well not suit all communities orall doctors the committee believes that solopractitioners should qualify for practice loans on thesame terms as group practitioners. The terms of theexisting group practice loan scheme should be reviewedand extended to include solo practitioners. It couldbe renamed simply the Practice Loan Scheme.

46

The priorities for allocating loan funds should be re-set in keeping with the above suggestions.Selective preference should be given to the support ofpractice in vulnerable rural areas and in underservedand otherwise difficult metropolitan areas.

2.professional isolation

Incentives to decrease professional isolation need to beboth substantial and well publicised. The committeeunderstands that the Health Services Research Committeehas provided funds to support an Otago University out-reach programme and believes that such initiativesshould be encouraged on a pilot basis, evaluated and ifsuccessful, implemented widely.

With more doctors becoming available considerationcould be given to placing additional generalpractitioners in rural areas where cover is difficult,so that no doctor has to be continuously on call in a7-day week situation and no community has to be totallydependent on one doctor. This would probablynecessitate provision of a guaranteed minimum income,meaning the acceptance of a more modest remuneration bya doctor in return for a less professionally demandinglife style.

Continuing education needs to be encouraged andfacilitated.The introduction of a rural practiceeducation scheme similar to that available toSpecial Area doctors is recommended.(After 5 years'service Special Area doctors may apply for postgraduatestudy leave on full pay. Two weeks for each year ofSpecial Area service may be granted up to a maximum of14 weeks.)Smaller awards enabling doctors toparticipate in short continuing education programmescould also be considered.

It is suggested that a fund be created to supportcontinuing education in general practice. A committeewould be required to administer the fund and to setcriteria by which applications would be judged. Animportant factor to take into account would besatisfactory service in a difficult rural ormetropolitan area.

The committee is in complete agreement with the commentmade by nearly all groups involved in these discussionsthat "time off" is the most important incentive of allto a doctor. With this in mind it strongly supportsthe idea of increased assistance with the cost of locumservice in DRAs, with provision for 50 percent of locumcosts to be met up to a maximum of $400 pa to assist inthe taking of both study and recreational leave.(Thepresent assistance is 50 percent up to $100 pa forrecreational purposes plus 50 percent up to $150 pa forcontinuing medical education).

47

3.Social and family satisfaction

The committee has received widespread comment thatconsideration of wives' needs - personal, social andoccupational - is the biggest factor in doctors'decisions on location. Country-raised people tend toreturn to the country more readily but the requiredacademic standards and increasing competition for entryto medical schools mean that those educated in the citytend to be at an advantage for selection. They oftenmarry people who also have big-city expectations oflife-style and who are likely to aspire to a city-basedcareer. An increasing number of doctors are likely tobe influenced by the need to provide the opportunityfor work-satisfaction of their spouses.

At conferences of doctors recently the wives presenthave indicated a strong interest in establishing women'sgroups. Possibly a general practitioner wivesassociation could be formed to provide a special focusfor their particular needs in coping with the lifestyledictated by their husbands' profession.

Although there have been many references to theimportance of older children's education to a doctor'slocational choice the committee decided it was notfeasible to single out school fees for rural doctors'children for special tax relief as it would create aprecedent for claims by many other groups for a similarconcession.

The committee does not wish to leave the impression thatbeing a family practitioner in a rural area has everypossible disadvantage and none of the advantages ofcity practice.It clearly has its own attractions andhas the potential for being a highly rewarding choice oflifestyle, as evidenced by those doctors who have been inrural locations for many years. However, there areproblems and without specific policies aimed at theirsolution these are likely to continue despite anincreasing supply of doctors.

11

PROSPECTS

The implications of the information in this report for thefuture of general practice are far reaching.If there is nosignificant change in the current mode of general practice inNew Zealandthe indications are that by the mid 1980s therecould be several hundred doctors struggling to earn a living.This gives cause for widespread concern because of itsimplications for the medical profession, the health services,the economy and society as a whole. This chapter examinesthe practical implications of a possible oversupply ofdoctors.

The consequences of oversupply are likely to affect generalpractice most directly. With the economic restraint nowapplied to hospital boards the positions available forresident medical officers and specialists are not likely toincrease significantly in the years immediately ahead.Ifthe resources available to boards increase by the projectedone percent or less in real terms over much of the nextdecade it is unlikely that the number of established medicalposts in hospitals will grow at a rate greater than this.Given that medical manpower is expected to grow at between3 and 4 percent per annum over the same period it is likelythat large numbers of young doctors may be obliged to seekemployment in general practice.

Based on the reports of DPAGs fewer than 200 additionaldoctors (over and above replacements) by 1986 wouldadequately meet the national requirements. Even assumingthat this assessment is conservative there could well be asignificant oversupply of general practitioners by the mid1980's.This is likely to have both positive and negativeeffects.

On the positive side people may have a greater choice ofdoctors and access to medical services may improve. Doctorsmay spend more time with patients, there may be more homevisiting and the quality of services generally may improve.General practitioners, particularly those in isolated orotherwise difficult areas, may have less difficulty infinding partners and locums and thus the service available insuch areas may improve. In addition the hours of work formany practitioners may reduce, giving more time for rest andrecreation.

On the negative side the increased doctor numbers may resultin over-doctoring in the more popular, mainly urban areaswith little improvement in the availability of care inprofessionally less attractive areas. More doctors may workfrom their own homes or simple premises as solopractitioners to keep their overheads down and direct chargesto patients to a minimum. While this would probably

50

increase doctor accessibility the effect it could have on thequality of care is debatable.It could result in increasingcompetition for patients and ill-will between practitioners.More doctors may work part-time which could give rise toproblems in maintaining professional standards and quality ofcare. Doctors may seek to take back tasks which havebecome the domain of other health workers such as practicenurses and social workers. As well as inhibiting thedevelopment of team work in primary care this could spark offdisruptive industrial disputes. The combined effect of allthis could be unpleasant conditions of practice,deteriorating standards of care and increased health carecosts to both patients and the state.

Cost is particularly important.L A Malcolm (1979) (12)using 1978/79 data showed that the average generalpractitioner was directly associated with an annualexpenditure of $137,000 of public funds.The details are asfollows:

General Medical Services

Maternity

Pathology Investigations

Radiology Investigations

Practice Nurse Salary

Pharmaceuticals

Total

$ 23,000

2,000

13,000

1,000

6,000

92,000

$137,000

Much of this expenditure is largely at the doctor's discretionand not subject to effective outside control. The figureshighlight the relative importance of expenditure onpharmaceuticals. Prescribing patterns and hence the costsof prescribing vary enormously between doctors. In someinstances observed differences defy rational explanation.Clearly this whole area of expenditure warrants furtherinvestigation - particularly expenditure on pharmaceuticals.

Further work by Malcolm et al (13) has demonstrated a closeand direct relationship between the level of generalpractitioner provision in relation to population and percapita utilisation and pharmaceutical costs.It seems thatincreased general practitioner availability is associatedwith rising utilisation rates and increasing per capitaexpenditure on prescribed drugs. While there may be argumentas to whether increased doctor availability results in betterpatient care and enhanced health status there can be noargument about the consequences for health expenditure. Asthings stand each new general practitioner in the systemmeans at least $100,000 of additional public expenditure.If the general practice workforce increases by the

51

equivalent of 500 full time practitioners between now and1986 the additional annual cost to the state could be $50million. The question then which will be asked is - isthis additional expenditure justified?

In the light of these evolving issues it is essential thatthere be an urgent and major review of national priorities,objectives and policies in the field of primary health care.Some of the questions to be addressed are given below,

1. What is the place of general practice in the wider fieldof primary health care?

Society must identify what primary health care it wants andis prepared to pay for. The place of general practice andgeneral practitioners must then be defined in relation toother forms of care and other types of health workers. Onlywhen this is done and the required policy guidelines producedwill there be the required basis for manpower planning ingeneral practice.

2. Should general practitioners restrict themselves to thepractice of episodic curative medical care or should theyseek to be more widely involved in primary health care?

This question is fundamental to the future of general practiceand is one to which no easy answer is possible.Indeedindividual doctors may seek different modes of practice andperhaps this should be encouraged.If practice is to berestricted to curative care then fee-for-service solopractice may continue to be the preferred organisationaloption.If however the concepts of multidisciplinary teamwork, health surveillance and preventive care are to befollowed, then other organisation and remuneration optionsmay need to be considered.

3. What are the advantages and disadvantages of the variousorganisation and remuneration options?

These related issues are best dealt with together. From theoutset it must be accepted that there will always be problemsregardless of how care is organised and paid for. There isno perfect system.Fee-for-service may encourage theincome-maximising doctor to maximise the number of medicalacts he performs regardless of "need" and with adverseeffects on the quality of care. With remuneration on afee-for-service basis the number of drugs prescribed percapita tends to be higher, surgery rates tend to be higherand doctors tend to work longer hours compared to healthcare systems in which payment is on a different basis.However it is the traditional and generally preferred methodof payment in New Zealand.

The principal alternatives to fee-for-service are a salariedservice or a capitation system.

52

For personal and other reasons some doctors prefer to workfor an institutional employer rather than to be self-employed. Salary recipients cannot increase their income byvarying their work rate within their standard (eg 40 hour)week. However they can reduce their workload by pressingfor more colleagues and more numerous assistants. As underany other system of payment some will work harder than others.

Capitation fees may induce the income-maximising doctors tomaximise their list size.If list size is restricted thenthe doctor may seek to get "less demanding" patients andminimise consultancy time in an attempt to maximise leisure.Thus capitation fees tend to be associated with health caresystems where consulting times are short, where doctors workshorter hours, and where, as doctors age, conflict tends toarise between patient load (and hence income) and an abilityto manage that load.

Lest it be thought that the possibilities here raised fordiscussion are departures from existing methods of payment itis important to recognise that the three basic methods andcombinations of these methods already exist in New Zealand.These are:

(1) a fee-for-service system where the doctor sets the feeand the Government agrees to refund part of the fee;

(2) a fee-for-service system in which the Government paysthe whole fee and the doctor has no right to chargeextra, for example the maternity services benefit andthe immunisation benefit;

(3) full-time salaried service, for example Department ofHealth special areas;

(4) combined fee-for-service private practice with part-timesalaried employment in hospitals and elsewhere;

(5) capitation schemes with and without the right to chargepatients an additional fee-for-service.

What is needed is careful study of practice organisation andremuneration in the light of changing social and economiccircumstances, changing needs and expectations on the part ofcommunities, changing professional and life-style expectationson the part of doctors and the changing manpower situation.Mixed methods of remuneration already exist and could beadapted further to meet changing requirements. Differentmethods may suit different doctors and different practicesituations. As long as there is reasonable equity betweenthe various options it should be possible for generalpractitioners to have some choice in these matters.

53

4. Should entry to general practice be controlled?

Based on the information available to the committee there isconsiderable support for the suggestion that something needsto be done to more effectively control entry to generalpractice. There is however little agreement about whatcontrols there should be and how and by whom they should beapplied.

If some way has to be found to limit doctor numbers in generalpractice there would seem to be a number of options.

Firstly, it is generally agreed that overseas doctors shouldnot be permitted to enter practice and settle permanentlyin New Zealand unless they are prepared to work in situationsfor which no suitably qualified New Zealander is available.Recent changes to the Government's immigration policy arealong these lines.

Secondly, the Government could progressively reduce itsfinancial involvement in general practice by continuing toallow inflation to progressively erode the general medicalservices benefit and perhaps by placing direct patientcharges on investigations and pharmaceuticals. This woulddampen consumer demand and reduce costs. In this way marketforces could be used to control general practitioner numbers.To some extent this is happening now. The undesirablefeatures of such a development have already been discussed.

Thirdly, doctor numbers could be controlled by placing allgeneral practitioners on a salary. There is little supportfor this idea in either Government or professional circles.As a method of controlling doctor numbers this is unlikely tobe effective anyway. There is however support for the ideathat more general practitioners could be employed on asessional basis and paid a part-time salary for counsellingwork in their own practices or for involvement in preventiveor health promotion work. This would widen rather thanlimit the employment opportunities for doctors.

Fourthly, numbers could be controlled by the setting ofgeneral practitioner establishments in geographicallycircumscribed areas - so-called "negative direction".Stated simply the idea is that national guidelines would beset for the level of provision of general practice services.Areas in oversupply would be declared closed areas or areasin which only replacement is possible.Intermediate areaswould be open to new doctors wishing to set up in practiceand in areas of shortage, incentive schemes would operate.To claim the GMS and other publicly funded benefits a doctorwould need to be part of an area establishment. Schemes ofthis type already operate in the United Kingdom,Scandinavia and other parts of Europe. Administrativelythere would be problems in dealing with part-time doctors,

54

doctor replacement and in treating patients out of theirareas. Also the concept of goodwill for-practices wouldprobably be reintroduced.

Proposals along these lines found support with some DPAGs,particularly from those in well-doctored areas. Such ascheme would protect established interest from outsidecompetition. Not surprisingly the concept is stronglyopposed by younger doctors aspiring to practise in popularareas. Well trained, many of these doctors believe that byoffering an effective and reasonably priced service topatients they could compete successfully with establishedpractitioners and should be permitted to do so.

A fifth possibility is the combined capitation and fee-for-service method as currently operating in two practices inTauranga and Lower Hutt. Each doctor or practising groupof doctors would accept responsibility for a registeredpractice population. General medical services would be paidfor on an agreed capitation basis with the doctor retainingthe right to charge patients an additional fee per item ofservice. The level of capitation would need to be regularlynegotiated with the Government and could be adjusted to takeaccount of the age structure, dispersion and socio-economicstatus of the practice population, the relative geographicalisolation of the area and other factors. Doctor numberscould be controlled by limiting the number of peopleregistered in a practice.

For doctors interested in a population-based approach togeneral practice the method has the potential advantages whichgo with patient registration. The screening and follow-upof at-risk groups becomes possible, health promotionactivities may be facilitated and opportunities created forplanning, peer review and general practice research.Disadvantages include those associated with any capitationsystem but would be leavened by the fee-for-service component.

5.What could be done to improve the quality of care ingeneral practice?

By international standards the quality of primary medical carein New Zealand is high but improvement is always possible.If steps were to be taken to limit the number of doctorspermitted to practise in an area then reasonable standardswould have to be set for the availability and quality of care.In circumstances of plentiful supply no longer can so-called"doctor shortage" be used as the universal rejoinder to allcomplaints.

The availability and quality of care in general practice isnot simply a matter of doctor numbers. Education and .peerreview are central to the solution of these problems.Efforts are needed to extend and improve the Family MedicineTraining Programme and provisions for continuing education

55

in general practice. The available evidence suggests thatvocationally trained practitioners involved in teaching andcontinuing education provide better quality care at less costthan their educationally less interested colleagues. (14)

While there seems to be general agreement that all doctorsentering independent general practice should be vocationallytrained there is at present no agreement as to how this shouldbe achieved. The Royal New Zealand College of GeneralPractitioners is strong in support of the view that alldoctors entering practice should be vocationally trained.After unanimously agreeing to include general practice/family medicine as a specialty on the specialist register inNovember 1978 the Medical Council of New Zealand in June 1979decided not to implement the resolution, feeling that themedical profession as a whole would not support the move.

The workshop on "The Early Graduate Years" held in Rotoruain August 1980 examined and rejected a. proposal for a twopart medical register. A full description of theMedical Council's proposal was given in the New ZealandMedical Journal by the Chairman (15). Although vocationaltraining for general practice was widely supported majorpractical difficulties were foreseen in making thiscompulsory. Finding the required posts and finance toextend the Family Medicine Training Programme was oneproblem. Possible accusations of professional protectionismand the imposition of unreasonable restrictions upon theprofession as a whole were others.It was clear, however,that there was no practical alternative for ensuring thatrecruits to general practice are adequately trainedvocationally.

Vocational training for general practice has recently beenmade compulsory in the United Kingdom. On 16 February 1980the National Health Services Vocational Training Regulationscame into operation. These require that on and after16 August 1982, a fully registered doctor who wants to becomea principal in general practice will have to gain at least3 years' further experience in educationally approved postsin general practice and the specialties. Provisions aremade to supervise the training and to cope with doctorsalready established in general practice. These developmentswill be followed with considerable interest by many doctorsin New Zealand.

Peer review in primary medical care in New Zealand is in itsinfancy. The Royal New Zealand College of GeneralPractitioners and the New Zealand Medical Association areinterested and involved but to date progress has been slow.Ideally such reviews should involve all community based healthworkers - not just doctors - but well organised and regularpeer review involving doctors would be a good start. Newinitiatives are required in this important field of qualitycontrol.

56

6. What are the implications for general practice of theincreasing number of women medical graduates?

Women at present make up 12.7 percent of the general practiceworkforce.In the years ahead the graduating classes ofNew Zealand medical schools will contain 35-40 percent women.Given that general practice and other forms of primary healthcare may be attractive to women it is reasonable to expectthat 50 percent of future recruits will be women. By 1991one general practitioner in four may be a woman.This must-have far-reaching implications for the future of generalpractice. Many of these women will wish to combineaprofessional life with child rearing. Many will wish totrain and work part-time and are likely to find salariedemployment most convenient. Will such doctors find therequired job opportunities in general practice or is there aneed to explore other organisational possibilities? Inaddition, there are important education implications in thatthe training requirements are greater for a part-time workforce. At present women under the age of 45 are about 60percent effective in the workforce (in terms of full time

equivalents).After 45 this rises to nearer 75 percent. (16)These data together with information about the careeraspirations of women doctors are crucial considerations inmanpower planning. -

These are just some of the issues which need to be addressed.There are many others. The changing social and economic•circumstances together with the sharp increase expected inthe availability of doctors means that the primary healthcare - general practice issue is one which calls forthoughtful and thorough re-evaluation. If the situation isallowed to drift for a further 2 or 3 years we may findourselves with a number of difficult problems which have tobe resolved in an atmosphere of confrontation and crisis..If that happens the chances of good decisions being made areremote. The time for action is now.

57

APPENDIX 1DISTRICT PRACTICE ADVISORY GROUPS (DPAGs)

In 1977 the Health Centres Advisory Committee recommended theformation of a Central Advisory Committee on Health Centresand also: the formation of District Practice Advisory Groups.The Central Committee was to receive reports from the DPAGsand advise the Director-General of Health on policy, reviewand development regarding the establishment, finance, andadministration of health centres,

FUNCTIONSIn 1978 their functions were described as follows:

1.. The group should meet at least quarterly, and more oftenif necessary.

2. It should, of its own initiative, and on the basis ofneed, foster the provision of primary health care in itsarea by encouraging.. the establishment of health centres

- and group practices, and the team approach to healthcare both preventive and curative by a multidisciplinarygroup.

3. It should arrange the provision of essential informationand guidance to parties contemplating the establishmentof group practices, health centres or community-orientated primary health care.

4. It will be invited to make submissions and recommendationsto the Director-General of Health on district proposals,including all new practice proposals where Governmentfinancial assistance will be required, the establishmentof health centres, and assessment of practitioners inregard to their attitude to practice in any form ofintegrated health care or co-operative practice.

5. It should review new health centres approximately 6months after the commissioning, along with a member ofthe Review and Development Section of Head Office. Itshould advise health professionals in their adaptationto integrated practice and assist in the resolution ofdifficulties.In some cases the evaluation mayprofitably be repeated at a later date.

6. It should report to the central committee annually andthrough this committee make submissions andrecommendations to the Director-General of Health onpolicy questions.

58

7, Local authorities should be encouraged to seek its advicewhen considering the erection of practice premises oraccommodation whether using loan finance or otherwise.

8. To assist the appropriate professional bodies if requestedto assess the suitability of any health care group forteaching purposes.

Included in the functions of DPAGs in some areas were theduties of the Consultative Committee on Practice Nurses.

The Health Centres Advisory Committee envisaged that in thefuture, DPAGs activities could extend to include, for example:

1. the availability and distribution of medicalpractitioners and allied professionals in the districtas a whole (including "special areas") and to makerecommendations to the appropriate administrative andprofessional bodies for improvements in the districtcoverage, with particular attention to under-doctoredareas;

2. in areas limited in their requirements to •a solepractitioner, to facilitate the establishment of afamily practitioner and the necessary supportive servicesin: the area; and

3. to develop liaison and coordination amongst all districtagencies - public, private and voluntary - involved inthe provision of primary health care, with the aim ofutilising available resources effectively andeconomically.

MEMBERSHIP

A DPAG was formed in each health district and includes:

Medical Officer of Health (Chairman)A nominee from each of:-New Zealand Medical AssociationRoyal New Zealand College of General PractitionersNew Zealand Nurses AssociationLocal Hospital Board, preferably the Medical

Superintendent, or his nominee, who has an interest inthe extramural services of the hospital

With power to co-opt as required.

Other groups of health professionals have soughtrepresentation on the DPAG5. These have been declined inorder to keep the groups of a workable size but cooperationis necessary wherever their contribution is under discussionor their local profession may be affected for examplepharmacists, physiotherapists,

59

If a conflict of interest arises when reviewing existingfacilities, new proposals or in the arbitration of disputesthe chairman must use his discretion and advise the groupmember of the apparent conflict and seek nomination of asubstitute, should this seem desirable.

Cooperation between DPAG5 and other discussion groups and withcoordinating committees on community care is encouraged. Itmay well be that some individuals are members of more thanone such group and this facilitates cooperation.

In some areas geographical boundaries do not coincide withthose of the New Zealand Medical Association, theRoyal New Zealand College of General Practitioners, theNew Zealand Nurses Association or the Hospital Board.Insuch cases Medical Officers of Health ask the relevantassociation for nominations as appear most appropriate in thecircumstances.

60

HEALTH DISTRICTSAPPENDIX 2NORTH ISLAND.

District Health Offices Shown .

HOK$*NGA SAY OF WHANGAREIISLANDS

WHANGAREI WhangarciHOSSON - -

OTAMATEA j^I.Ikl"AI.BAAMER

\ RODNEY J AUCKLANDTAKAPUNA

All EKLTakapuna --

-THAMESFRANKLIN

SOUTH AUCKLAND

Office PapatoetoeIj OHINEMURI

RAGLAN

Hamilton0ç0RUAPIAKO

TAURANGA

WAIPA MA1AMATA AWAIAPU

0O RotoruaHAMILTON WHAKAIAN&q

-I ROIORUA o

WAIT WAIKOMU GISBORNECOO

0 11

TAUMARLJNUII A U P 0New PlymouthcL' W A I It 0 A

Gisborne

N EW P LYM OUTH

AM 'HAWKS'S¼ HAWtKA BAYNapier

PATEAJ'H /,-(a

WANGANUI WAIPAWA NAPIER

Wanganui- 5-

IijPalmerston North /U

*51*05*

PAUIERSTON NORTH / IKII*HUN*

T, IIASTERTON

Lower Hutt_ __'0 HUTT

FE ATM B SIGN

WELLINGTON

SCALE 14.000000

50050lEO150100 KL I ILOMURES

61

HEALTH I)IS'FR!C I SSOUTH ISLAND

District Health Offices Shown .

NELSON

CHRISTCHURCH

INVE

fCHRSTCHURCH H.D.K Dunedin

DUNEDIN

SCALE 14,000.000

S00501015000.__ _____________1._________ ..J KILOMET005

HEALTH DISTRICTS - PROJECTED TOTAL POPULATIONS 1976-2001HEALTH DISTRICT

Whangarei

Takapuna

Auckland

South Auckland

Hamilton

Rotorua

Gisborne

Napier

New Plymouth

Wanganui

Palmerston North

Hutt

Wellington

Nelson

Christchurch

Timaru

Dunedin

Invercargill-.

New Zealand Total

Census197619811986199119962001

106,730108,360112,660117,680122,360126,300

263,500276,290305,740337,860369,970400,510

292,650287,260287,820287,500286,420284,870

240,550253,770282,810315,870349,570381,740

270,970278,520291,870305,820318,650329,640

187,170192,260207,090223,170238,660252,760

63,63062,76063,04063;66064,04063,950

123,530126,780135,210144,260153,360161,920

99,30099,790101,650103,660105,390106,660

88,16086>39085,36084,52083,28081,590

145,890148,050153,800160,250166,600172,300

188,680193,780202,670212,150220,870228,390

194,690.194,2802014860210,800219,670227,510

130,810133,1701361,830140,370143,290145,250

344,010349,450364,510379,790394,200406,880

109,910107,710106,740107,620108,260108,350

158,370158,860161,570162,020161,930161,010

116,560116,620118,550121,110123,210124,500

3,125,1103,17411003,319,7803,478,1103,629,7303,764,130

-vP1'

><14,

Source: Department of Statistics, March 1980, Urban Areas projections using medium fertility/medium migration options.

63

APPENDIX 4

SUMMARY OF INCENTIVES AVAILABLE TO GENERAL PRACTITIONERS

1. PAYMENT OF BENEFITS

(1) GMS

(a) Service

Built into these benefits are several differentfinancial incentives. For consultations and visitsoutside normal hours the rates are higher. They arealso higher for "special" groups which include children,beneficiaries and chronically ill.

0 $

1.25

3.00

4e00

Ordinary Patients

Consultations at surgery and visits duringnormal hours

Urgent consultations at night, weekendsand public holidays

Urgent visits at night, weekends andpublic holidays

Special Group Patients

- Pensioners, beneficiaries and theirdependants and chronically ill

Consultations at surgery during normalhours

Visits to patients during normal hours

Urgent consultations, night, weekendsand public holidays'

Urgent visits, night, weekends andpublic holidays

- Children and young persons for whomfamily benefit still payable

Consultations at surgery during normalhours

Visits to patients during normal hours

Urgent consultations at nights, weekendsand public holidays

Urgent visits at nights, weekends andpublic holidays

3.00

4.00

6.00

7.00

4.75

6.00

7.00

8.00

64

(b) Travelling Allowance

Current rate 16 cents per km.

(c) Alternative Arrangements to GMS

Special arrangements to remunerate doctors by way offees instead of benefits for GMS have been made with onehealth centre and one medical centre. A monthly fe is'paid for each patient registered at the centre, based onthe annual national average GMS expenditure per head ofpopulation.

(d) Guaranteed Income Practices

Eleven doctors receive guaranteed minimum generalmedical services income for providing medical servicesin specified locations.

(2) Maternity-

Maternity benefits are payable according to scale offees set by agreement between the Minister of Healthand the medical profession,

(3) Immunisation -

The immunisation benefit is payable when -a vaccine isadministered by a doctor or registered general nurse toa person under 16 years of age in accordance with animmunisation programme approved by the Department ofHealth.No charge may be made to the-patient.

2. TAX EXEMPTIONS

Doctors in private practice are classed for tax purposes'"professional business people" and are therefore eligiblecertain exemptions towards the expenses for maintaining ahouse primarily for professional purposes, running coststhe business use of a car, and expenses for equipment.

3. PRACTICE ACCOMMODATION

A rural practice incentive introduced 1970 made loan financeavailable through the Housing Corporation to local authoritiesprepared to provide housing and/or surgery accommodation forrental to doctors in designated rural areas. Approval wasgiven, in 1977, to its extension to urban local authoritiesin areas where there is a particular problem in providingprimary health care facilities.-

asto

for

65

4. GROUP PRACTICE LOANS

General practitioners who are members of a group practicehave their surgeries in the same building, share facilities,arrange a 24 hour cover for their patients and may employ orwork in conjunction with para medical personnel. Two-doctor practices may qualify for the loan only if the areacan support no more than two doctors.

The amount of the loan is a maximum of 90 percent ofapproved costs or $20,000 per participating doctor, whicheveris the lesser.The loan term is up to 20 years with theinterest rate reviewable every 3 years.

Loan applications totalling more than $4,000,000 have beenapproved between April 1970-March 1980.

5. HEALTH CENTRES

The capital costs of health centres are financed by grants tohospital boards who then make space available at areasonable rental to a wide range of health professionals.

The initiative for establishment usually comes from the localgeneral practitioners who make the request to the localhospital board or District Practice Advisory group. If therequest is supported and the department agrees with therecommendation the necessary financial approvals are sought.

A centre's practice nurses are employed by the hospital boardconcerned.

In March 1980 the following centres were operational:

Centre

MangereManukau CityNgateaThamesOtumoetaiWaitangiruaWainuiomataWaikanaeLytte itonMo sgie 1Port ChalmersAlexandraTe Anau

in progress:

Board

AucklandU

Thames'p

TaurangaWellington

I,

I'

North CanterburyOtago

'pVincentSouthland

Upper HuttWellington

66

6PRACTICE NURSES

(1) Urban-General Medical Practice

A subsidy amounting to 100 percent of the nurse 8s salaryup to the salary applicable in the hospital service ispayable for professional duties plus a motor vehicleallowance at GMS rates for domiciliary visits where theemploying doctor would be eligible for GMS motor vehicleallowance.

(2) RuralMedical Practice

The 100 percent subsidy scheme is available oralternatively a 50 percent subsidy plus a subsidy foreach domiciliary visit plus motor vehicle allowance.

(3) Health Centres

Practice nurses may be employed by the board concernedor as under the above schemes.

Expenditure on the practice nurse scheme was around $7,000,000in. the 1980/81 year with the number of nurses at around 900.

7.INCENTIVES TO RURAL MEDICAL PRACTITIONERS

(1) Housing Corporation loan finance to local authoritieswishing to provide housing and surgery accommodationfor doctors in designated rural areas.

(2) Rural practice bonus: 10 percent on GMS benefit and 25percent on GMS motor vehicle allowance.

(3) Telephone consultations: 35 cents for patients located16 kms or further from rural doctor.

(4) Subsidy towards employment of locum tenens: 50 percentup to $100 for recreational purposes and 50 percent upto $100 per annum for continuing medical education.

(5) Motor vehicle allowance.

67

8.SPECIAL AREAS

These are remote and problem areas where special arrangementsfor medical services are necessary. They are set up unders 117, Social Security Act 1964.There are at present 15special areas.

Special Areas

Chatham IslandsDobsonHanmerHokianga -,3 doctorsMiddlemarch - 1 doctor, 2 sessionsMurchisonNgakawau/Granity/WaimangaroaTe AraroaTe KarakaTolaga BayWhataroaWharigaroa - 2 doctors

Estimated PracticePopulation

7002,1651,0004,300

9902,0001,6801,0003,0002,1003,0001,900

Currently with alternative service but not disestablished:

Collingwoôd

1,330Te Whaiti

1,500Runanga 2,000

Medical officers in special areas enter into contracts toprovide general medical services for 1 year, with a right torenewal. They are paid a salary for these services, whichare free to residents in the special area.

Special area doctors are independent contractors but theirsalary increases are related to hospital board increases andare amended on the approval of the Minister of Health.Superannuation is available if desired. They are entitledto 21 consecutive days' annual leave (except for doctors infive areas, who receive 28 days) and 7 days' sick leaveannually. The contract provides for the medical officer tolive in a rent-free house with basic furniture and equipment.

Loans are available for doctors to purchase their own cars -the preferred arrangement; otherwise departmental cars plusrunning expenses may be provided. Travelling fees atpublic service rates are payable in all special areas exceptthe Chatham Islands, where a hospital board vehicle is used.

In several areas the doctors undertake dispensing, for whichthere is a dispensing contract by which the doctor is paidfor wholesale costs of drugs, plus containers, and a servicefee.

68

Where there is such a contract, no charge may be made to thepatients for pharmaceutical supplies unless they areoutside the scope of pharmaceutical benefits.

Where necessary, the De partment of Health contributes towardsthe cost of a locum tenens for a special area. The paynént is$400 per week plus $17.50 if the locum lives in a specialarea house.

After 5 years' special area service, a medical officer mayapply for postgraduate study leave on full pay. Two weeksfor each year of special area service may be granted, up toa maximum of 14 weeks. Return fares are paid, both inNew Zealand and overseas, and there is a subsistenceallowance of $36.50 per day foroverseas study ($10 per dayfor New Zealand study). After the completion of the studyleave, the officer is bonded to serve for 1 year.

9. FAMILY MEDICINE TRAINING PROGRAMME

This is a vocational training programme. Trainees are-employed as registrars with service attachments for 6 monthsin an accredited training practice and 6 months in selectedhospital posts.

Registrars are paid at rates appropriate to their experience.Employment by participating hospital boards ensures thatleave, superannuation and other terms and conditions arepreserved.

In December 1979 the intake was 45 registrars, in December1980 it was about 60.

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APPENDIX 5

MEDICAL MIGRATION 1970-1980

TABLE 1 : MIGRATION OF MEDICAL DOCTORS, NEW ZEALAND NATIONALS ONLY

Years ending 31 MarchQtr year ending

1970 1975 1978 1979 1980 31.12.78 31.12.79 31.3.79 31.3.80

GOING 20-29 yrs467099979436214232

older*585572 1017326233124

male88 109 143 157 12946356140

female16162841381691216

Total104 125 171 198 16762447356

RETURNING Total54 1098073 12536591532

Balance-50 -16 -91 -125 -42-26+15-58-24

* usually over 4/5 are in the 30-49 year old bracket

TABLE 2 : MIGRATION OF MEDICAL DOCTORS, NEW ZEALAND AND OVERSEAS NATIONALS

Years ending 31 MarchQtr year ending

1970 1975 1978 1979 1980 31.12.78 31.12.79 31.3.79 31.3.80

NZ Going104 125 171 198 16762447356

NATIONALS Returning54 1098073 12536591532

Balance-50 -16 -91 -125 -42-26+15-58-24

OTHERGoing45 111 171 161 19951634564

NATIONALS Coming91 303 225 256 2719494.7085

Balance+46 +192 +54 +95 +72+43+31+25+21

Going149 236 342 359 366113107118120

ALL Coming145 412 305 329 39613015385117

Balance-4 +176 -37 -30 +30+17+46-33-3

70

APPENDIX 6:

DESIGNATED RURAL AREAS (DRAs)

The following .areas have been designated rural areas underthe Social Security (Rural Area) Notice 1969 and subsequentamendments.

They are currently being reviewed and may therefore besubject to some changes in the future.

(a) All those parts of the Whangarei Health District notcomprised in the City of Whàngarei:

(b) All those parts of the Takapuna Health District notcomprised in the boroughs of Birkenhead, ..Devonport, -East Coast Bays, Glen Eden, Henderson, New Lynn, orNorthcote, or the City of Takapuna, or the county. townsof Glenfield, Titirangi, Green Bay, or Keiston West, orthe Te Atatu Riding of--the County of Waitemata:

(c) All those parts of the Auckland Health .District notcomprised in .the City of Auckland, or the boroughs ofEllerslie, Mount Albert, Mount Eden, Mount Roskill,Mount Wellington, Newmarket, Onehunga, orOne Tree Hill:

(d) All those 'parts of the SouthAuckland Health Districtnot comprised in the boroughs of Howick, Otahuhu,Papakura, or Pukekohe,' or the cities of Manukau orPapatoetoe:.

(e) All those parts of the Hamilton Health District notcomprised in the boroughs of Cambridge, Huntly,Te Awamutu, or Thames, or the City of Hamilton, or thecounty town of Tokoroa:

(f) All those parts of the Rotorua Health District notcomprised in the boroughs of Mount Maunganui, Taupo, orWhakatane, or the cities of Rotorüa or' Tauranga, or thecounty town of Ngongotaha:

(g) All those parts of the Gisborne Health District not.comprised in the City of Gisborne:

(h) All those parts of the New Plymouth Health District notcomprised in the boroughs of Hawera or Stratford, or theCity of New Plymouth, or the county town of Oakura:

(i) All those parts of the Napier Health District notcomprised in the cities of Hastings or Napier, or theborough of Havelock North:

71

(j) All those parts of thecomprised in the Cityof Otamatea or Putiki:

Wanganui Health District notof Wanganui, or the county towns

(k) All those parts of the Palmerston North Health Districtnot comprised in the boroughs of Dannevirke, Feilding,or Levin, or the City of Palmerston North:

(1) All those parts of the Hutt Health District not comprisedin the boroughs of Eastbourne, Masterton, or Petone, orthe cities of Lower Hutt or Upper Hutt, or the countytowns of Paraparaumu, Wainuiomata, or Heretaunga-Pinehaven:

(m) All those parts of the Nelson Health District notcomprised in the boroughs of Blenheim or Richmond or theCity of Nelson:

(n) All those parts of the Greymouth Health District notcomprised in the borough of Greymouth or the county townof Karoro:

(o) All those parts of the Christchurch Health District notcomprised in the City of Christchurch, or the countiesof Heathcote, Paparua, or Waimairi, or the borough ofRiccarton:

(p) All those parts of the Timaru Health District notcomprised in the boroughs of Ashburton or Oamaru, or theCity of Timaru:

(q) All those parts of the Dunedin Health District notcomprised in the City of Dunedin, or the boroughs ofGreen Island, Mosgiel, Port Chalmers, or St Kilda, orthe county towns of Fairfield, Brighton, orWaidronville:

(r) All those parts of the Invercargill Health District notcomprised in the borough of Gore or the City ofInvercargill.

72

REFERENCES

1. Advisory Committeeon Medical Manpower.Report to the Minister of Health on medical.manpower requirements. May 1979.

2. Advisory Committee on Medical 'Manpower.Specialist medical manpower in New Zealand.Discussion document.May 1980.'

3,Calvesbert EBackground paper on incentive schemes for generalpractice. MSRU, Department of Health 1979.

4. Malcolm L A, Higgins C S and Barnett J RThe availability, distribution and utilisationofgeneral practitioners in New Zealand. HPRU,Department of Health 1979.,

5. NZMA Otago Working Party on Manpower Distribution.Medical manpower distribution. Unpublished report1980.

6. NZMA Otago Working Party on Maiipower Distribution'.General practitioner distribution and the ruralareas.Unpublished report 1980..

7. NZMA Otago Working Party on Manpower Distribution.Negative direction (negative control). Unpublishedreport 1980.

8. Pakatoa Island Meeting of General Practitioners.Report 1980.

9. Leading Article.Medical manpower in Australia. Med J. Aust. 1980,1:194-196.,

10. New Zealand Planning Council.The welfare state?Social policy in the 19801s.June 1979.

11. Smith A G and Tatchell P MHealth expenditure in New Zealand - trends andgrowth patterns.Special report no. 53 MSRU,Department of Health 1979.

12. Malcolm L AWorking paper prepared for conference of medicalbenefits clerks. HPRU, Department of Health1979.

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13. Malcolm L A and Higgins C SGeneral practitioner prescribing in New Zealand.NZ Med J 1981.In press.

14. Vuletic S et al.Evaluation of medical education for generalpractitioners. Exploratory study.Final report.Stampar School of Public Health, Zagreb 1971.

15. Gowland HMedical registration in the future; a basic and avocational register? NZ Med J 1980, 92:18-21.

16.. van Rooyen J CWomen in medicine. Occasional paper No. 9 MSRUQDepartment of Health 1978.

WB 110 [QI GEN

Gener1 Pdtic

ew Ze1 ddiusj.document

Date

WE 886701110[QIGEN1981

LibraryDepartment Of Health'Wellington