I’m sure it’s crossed all of our minds at some point: “I’m going to jack it all in and move to Australia or New Zealand. It’s a better quality of life and I will feel appreciated”. So, for this post, I decided to investigate what it was really like to work in the supposed utopia of primary care.
My friend Anna, from my VTS, decided to take a year off and travel to New Zealand to work as a GP. “I decided to leave as soon as I finished my training and I wanted to go abroad somewhere and to work somewhere different. I felt it was the time to do it – I didn’t have any contract or any job that I was tied to and it was a good time to go away.” We virtually left within a week or two of each other in November 2016 – Anna to New Zealand and me to Japan. Her experience could not be more further away than our multi-cultural urban training scheme “I work in, technically, a rural surgery – it’s a 2500 patient practice which is run by two full time GPs and the equivalent of two full time nurses. We are 45 minutes away from the closest hospital so actually it’s not that rural for New Zealand but it’s more rural than what I’m used to in East London!”
The preparation for such a trip is obviously not that easy and I remember Anna and I having to consult each other a lot – did you have to do anything for your Performer’s list? Did you speak to indemnity? Despite being part of the JIC, it was not particularly that transparent for me either. I remember getting my hands on the draft copy of the JIC toolkit for working overseas (now published) to try and navigate all the stakeholders which was a little God-send. And I’m generally thinking that this might be a useful post to write soon (press ‘like’ below so that I know that this will be of use to you). “A friend put me in touch with the GP who is now my boss here. I also went through a company called ‘New Zealand locums’ who are a company assigned to the government here. They are a recruitment agency but their purpose is to recruit rural GPs and usually they get them from abroad. I had to have interviews with both NZ locums and with the GP who was in charge of the practice. So it was all quite straightforward. The locum agency did the large part of getting me there and getting my contract etc. It’s easy to get a visa for NZ and I got a full working visa for my partner too who came out as well based on my working contract. That’s because GP is seen as a shortage job so you get your privileges.”
“Getting your visa application in as early as possible is important. We ended up getting medicals which were expensive and it turned out we didn’t need them. It probably would have saved us money if we had an immigration advisor but we could have probably just applied earlier too and just be told that it was ok.”
“So once we got our visa, the locum agency set up an introduction to NZ course for new GPs which are run once a month. It’s basically a three-day course introducing you to the particulars of being a GP in New Zealand so the key things that are different and key points about the healthcare system which was useful. Even small things like how to use the computer system here and they also set us up with bank accounts so we could get paid and they set us up with a meeting with the medical council here so that you could get registered and also with indemnity.”
Indemnity – the bane of every GP’s life in the UK. Anna tells me that the cost of her indemnity in New Zealand for one year is less than half of what she had to stump up for three months in the UK. “It was 800 dollars here plus or minus for the whole year which is about £400 and that’s regardless of whether you work one session or 12 sessions. It’s a fixed amount.” Now this seemed bonkers. When we have such issues with spiraling costs of indemnity in the UK, how can it be £400 for a year?! “It’s because there is something called ACC (Accident Compensation Corporation). Everybody is covered for any accident which includes treatment-related injury. So if you were hit by a car, ACC would pay for that – same if your doctor did something that harmed you. Your indemnity doesn’t need to cover you unless you’ve shown willful neglect and this is very rare.”
I have to wikipedia ACC and it looks like it’s a New Zealand Crown Entity and has been around since 1974. It seems to cover not just your medical and rehabilitation care but also gives you sick pay as well. But your condition has to be caused by an accident or an injury so a heart attack wouldn’t be covered unless it was due to medical negligence. Interestingly, it has a no-fault policy i.e. you cannot sue someone in relation to the injury makes me wonder if the medicine that is practised can be less defensive. “Here, there is a lot more onus on patient choice. You can go more with the probability that everything is going to be ok rather than the remote possibility that something might go wrong. I think that’s a good thing most of the time but I wonder if I carry on practising like this after I get home if I am at risk of running into problems. Defensive medicine is not an enjoyable way to practise so it was a big release being here where you don’t have to worry about that kind of thing.”
New Zealand passed the landmark Social Security Act in 1938, 10 years before the NHS, with a vision for universal health coverage. However, speaking to Anna and reading around the health system, it appears that it’s not as equitable as this would suggest. “I’ve noticed that a lot more people use private healthcare here and have private health insurance. I think that’s something that has changed in the last few years and I think that New Zealand has had similar cuts in funding as we have had in the UK. So the waiting times for the outpatient treatments are very long in the public service such as 18 months for a hip replacement but at least it is available. They are very strict about their referrals.”
“The other big difference is that you pay to see your GP unless you’re under 13. It’s up to the individual practice how much they charge you so in my surgery its 35 dollars if you’re registered and, if you’re not registered, it’s 65 dollars for a 15 minute appointment. We run free clinics in very poor areas but its not the same service as you’d get in the regular clinic.”
“I think there is more marked social inequality where I work now. I don’t know if this is because I’m working somewhere more rural than where I used to work but I’ve not seen poverty like this in the UK. People can be very isolated because they may be living in very poor housing in a very rural place with no access to transport and there are no buses. So if you needed them to go to the hospital for an appointment, they wouldn’t be able to go. People won’t come to the GP when they have a health problem because it costs 35 dollars and that’s a lot of money if you’re not working or on a low income. A lot of people can bypass the public system so there is less pressure on people with money and power to make the public system work better.” I can imagine this will grate Anna, a staunch leftie and a believer of “for the many, not the few”. “I prefer the system in the UK where you pay on what you can afford rather than what you need.” Having just watched Professor Green’s BBC documentary on poverty in the UK (I just really love his documentary series), I appreciate that £20 is a lot of money for people on the poverty line who are barely making ends meet. According to Maslow’s hierarchy of needs, if we cannot meet our basic ‘physiological’ (food and shelter) needs then we we cannot work up the hierarchy to meet our ‘safety’ needs (which includes health and well-being). This surely can only lead to a spiral of physical and mental health issues.
But I’m playing devil’s advocate now. What about the argument that people will only come with real problems if there’s a co-payment? “In terms of sh*t life syndrome, you probably see that less frequently. People might come once for it but then you have to try and do everything in that one appointment for them because I find it difficult to get people to come back for follow-up appointments. Getting people to follow up anything is quite difficult. So this waiting and seeing with a condition that it’s likely to be a self-limiting or saying ‘come back if it’s a problem’ is not something that you can do as much. So I might investigate more or treat more than I would in the UK where it is easier for patients to come back.” Co-payments risk creating another barrier to access to healthcare and goes against the concept of free-at-the-point-of-access. The arguments for include generating revenue, reducing inappropriate use and places financial value on the consultation. Personally, I hate the transactional feeling of a consultation that is paid for which is probably why I would make a rubbish private GP. “I find it very uncomfortable that we charge especially if you’re telling someone that they have a virus and they’re thinking I’ve just paid 35 dollars for that.”
We move onto talking about the indigenous population. Although a more amicable history than their neighbouring Aboriginals in Australia, the relations between the Maori people and the Europeans were not without its tensions. “One of the most striking things that they taught us when we arrived is that the Maori’s and Pacific islanders are much more likely to get rheumatic fever so you see it quite a lot. There are campaigns everywhere saying ‘if you have a sore throat, go and see your GP, don’t delay go today’ and you have to do a throat swab and start antibiotics straight away in every Maori or Pacific islander that you see. Unfortunately, their advertising only seems to reach the Caucasian population much more than the Maori population but some of that trickles through. They think it’s a genetic thing but maybe related to poverty as well and poor housing making you more prone to serious infections. You see much more obesity in the Maori population – probably a combination of genetic and lifestyle things – higher rates of diabetes and metabolic diseases along with that. And smoking is much more prevalent. Largely, there is a higher prevalence of poverty amongst the Maori. There is a lot of effort to try and balance out that inequality. For example, free smears and get to go to university for free if you’re Maori. There are certain benefits to try and balance out that inequality but it’s still very noticeable.
So what is good about New Zealand? “I start my clinics at 8:30 in the morning and my last patient is at 4:30, I generally get a lunch break and I can leave my desk. There’s not as much paperwork to trawl through and after I finish my day, I rarely stay beyond 5pm so in that respect I have my evenings whereas that’s not typical in the UK whereas this is typical in NZ.” Why is there less paperwork? What can the UK learn?? “I don’t know – I haven’t worked it out. We get blood results, I guess we get fewer letters from the hospital but I don’t really know why. The nurses will often action things so you just let them know rather than having to do it yourself.”
Have you noticed any other differences? “Their medicines are regulated by PHARMAC which is a bit like NICE so they decide whether medicine is cost-effective and worthwhile. Obviously this limits you as a GP but I think its also helpful to back you up when you don’t want to prescribe things that you don’t think is going to help.”
Anna and I used to be in the same VTS together in East London/Essex where boy racers would overtake us dangerously on our bikes and a there was a plethora of public transport to choose from. So how is it working in a rural environment? “The main difference is that its a lot bigger deal sending someone to hospital because its no longer ten minutes up the road but its 45 minutes/60km drive. If it’s in an ambulance they have to somehow get back and if not in an ambulance they have to get there somehow and that’s always a problem. People will also walk into the surgery for things that back home they would go to A&E – like yesterday, someone came in with anaphylaxis and I had to give them adrenaline and that’s normal.” Anna says this nonchalantly whilst eating dinner whilst we’re on Skype and I’m trying to figure out if I would be this cool if someone came to see me with anaphylaxis. I can categorically say no.
So was her year away everything that she imagined? What has she learnt from the experience? “I’ve probably got falsely romantic about the NHS and it’s probably going to be a shock to the system when I go home and that its not the perfect thing that I’ve made it up to be in my head. I think my opinion of the NHS has become more favourable because I think that it’s a fairer system. I think patients get a higher standard of care but it’s so hard when you’re away because your view skews and you’ll have to ask me again when I get home.” So this is very interesting because I think it’s exactly this skew that makes working internationally confront our issues with the NHS. Certainly, I don’t think the NHS is perfect and it annoys me in many many ways but perhaps we stop being able to see the wood from the trees sometimes. “There are some positive things about NZ for GPs. It’s very easy to transfer from the UK to New Zealand as your medical degree is instantly recognised. You see a lot more pathology as people wait until they get properly sick. So there’s enough difference to keep it interesting with it being subtle enough that you can transition quite easily. You can also do it for a few months at a time so it’s an easy thing to do.”
You can read about some of the health issues faced in NZ in the infogram provided by the OECD New Zealand Health Policy.