The health gap: How living in the regions can be bad for your health
Regional New Zealand may offer better ‘‘lifestyle’’ opportunities, but it could be worse for your health. Helen Harvey reports on the regional healthcare gap.
In January a Taranaki mother was told she would have surgery within six weeks to relieve the intense pain she was suffering.
That six weeks stretched to 32, her operation cancelled four times before finally happening on Thursday.
The woman, who has asked to remain anonymous out of anxiety she may be penalised for speaking out against the health system, says her sciatic nerve is jammed in her spine and she has to take pain medication or end up on the floor screaming with pain.
The hope she felt in January quickly turned to despair when her surgery was cancelled again and again and again. Usually at the last minute and often because of a ‘‘shortage of beds’’. Her story is not uncommon in a health system that at times seems acutely ill itself.
Taranaki, it turns out, is one of the worst places to be sick in New Zealand. When it comes to waiting for specialist appointments and later for the actual surgery those in Taranaki are waiting longer than anywhere.
But it’s not just Taranaki. There is an inequality of health care between the main centres and those of us who live in the regions.
If you live in Auckland, Wellington, Tauranga, Hamilton, Christchurch or Dunedin you have greater access to GPs and specialists, shorter wait times for surgery and a greater range of medical experts when needed. In the regions even skill sets considered common can be hard to find.
The shortage of midwives in Taranaki has been worse than anywhere else in the country. At the end of March there were more midwife vacancies than there were midwives. So severe was the shortage some try and secure a midwife before they conceive.
There is also a shortage of ear, nose and throat specialists, so patients have to travel to Whanganui or Palmerston North for treatment.
Waiting times at the region’s two emergency departments are among the worst in the country, with more than one in five people waiting at least six hours for treatment. The stories may not be exactly the same in other regions but many are similar.
Whichever way you look at it accessing timely and appropriate healthcare is more difficult if you live outside the main centres and, no surprises here, that can be bad for your health. People are in pain for long periods of time, or their condition worsens or becomes more complex leading to longer treatment and recovery times.
Stratford woman Shirley Bielawski had to travel hundreds of miles to get treatment for her throat problem.
And the length of time she had to wait to get surgery for a cancerous growth may have contributed to her losing an eye.
When announcing the major health system shake-up, Health
Minister Andrew Little said the changes were designed to end the ‘‘postcode lottery’’, the euphemism often used to describe the imbalance in health outcomes between metropolitan and regional areas.
On July 1 the country’s 20 district health boards were replaced by one national body, Te Whatu Ora Health NZ, which will work alongside a Māori Health Authority.
A Te Whatu Ora spokesperson said they had been asked about the inequalities in health across the country and had a statement to make about the ‘‘postcode lottery’’.
Te Whatu Ora is working through ways to address any variation in healthcare access across the motu, the spokesperson said. The work is ongoing and further updates are expected in due course.
In the next few months, they will implement national initiatives to support catch-up on specialist services and strengthen public health services, and will be working on initiatives to expand the workforce.
It certainly can look like that’s already happening. Earlier this week Te Whatu Ora Taranaki was advertising 42 clinical jobs on its website, Lakes has 45 vacancies, MidCentral 100 and Northland 71. But against the thousands who work in the health sector, the numbers are the proverbial drop in the ocean.
‘‘Only 1.5% [of GPs] want to work in communities with less than 10,000 people.’’
Ross Lawrenson, professor of population health, Waikato University ‘‘It’s always been difficult in smaller rural areas, where the patient population is smaller.’’
Dr Bryan Betty, medical director of the Royal New Zealand College of GPs
Not training enough health professionals has been one of the issues impacting the country’s under-fire health system for years. Then the borders closed during Covid-19, stopping the arrival of those trained overseas to help fill gaps.
Those gaps are more accurately described as gaping holes. Without immigrants it’s not hyperbole to say the whole system would collapse.
About 27% of the nursing workforce in New Zealand are internationally qualified nurses – higher than any other OECD country.
According to the New Zealand Medical Workforce in 2021 report, overseas trained doctors make up 42.1% of the workforce.
In New Zealand 62.7% of psychiatrists, 57.1% of doctors working in obstetrics and gynaecology and 56.4% working in emergency medicine are from overseas.
Before Covid hit about 40% of the national GP workforce came from overseas.
The shortage of GPs has been discussed and reported on for years. And again, the situation is worse is rural and provincial areas.
Dr Bryan Betty, medical director of the Royal New Zealand College of GPs, says the GP situation is especially grim in places like Taranaki and Northland, but it’s getting bad in urban areas as well.
‘‘It’s always been difficult in smaller rural areas, where the patient population is smaller. It’s hard to get locums and GPs have a sense of isolation if working alone.’’
These issues impact on the ability to retain specialist general practitioners, he said. And he gets ‘‘a sense’’ that GPs are not supported by the system as well as they could be, especially in areas of high deprivation, like where Betty lives in Porirua.
Health NZ and the Government need to develop strategies to make the workforce sustainable in the long term, he says.
The outcomes of GP shortages have a flow on effect resulting in poor outcomes for patients.
Such as an increased number of ambulatory sensitive hospitalisations (ASHs) – avoidable hospitalisations that could have been prevented with earlier interventions. In other words that expensive hospital stay you needed simply because you couldn’t get help from a relatively cheap GP early enough.
The situation is bad enough in the regions that some organisations are looking at where they can support the health system to be better.
Taranaki’s cashed up community trust – The Toi Foundation – commissioned research to find the greatest needs in the region. It showed in 2020 Taranaki had the highest rate of avoidable hospitalisations in New Zealand – 34.2 ASH events per 1000 people, considerably higher than the national rate of 23.8 per 1000.
Not surprisingly the research also showed a smaller proportion of Taranaki’s population attending a GP visit compared to the New Zealand average.
The situation isn’t helped by how difficult it is to get into see a doctor, with only about five general practises in Taranaki still taking new patients.
One mother, who was worried about being named in case it negatively impacted her ability to access healthcare services, just moved to Taranaki with two children aged two, and seven months.
The 2-year-old has asthma, but she has been unable to get into a GP for his ‘‘continuing care, to make an asthma care plan and examine him’’, she said.
‘‘I’m on the waiting list, just like everyone else. My only option is to go to the urgent care centre in New Plymouth in the meantime, kids in tow, to wait who knows how long for a condition that is ongoing and not immediately life-threatening. The exact kind of case the ED doesn’t need to deal with.’’
Her baby will be due his next lot of vaccinations soon, she said. ‘‘I’m not confident that I’ll easily get him booked in on time.’’
The lack of GP access can also impact on mental health.
In Taranaki psychologists are seeing patients who have more complicated medical problems because they have not been to their GP and issues have built up. These often exacerbate their existing mental health conditions.
It’s the same in other regions. There are at least 3000 people in Invercargill not enrolled with a GP, but the number could be as high as 7000, for the population of 57,100.
In August Health Minster Andrew Little rolled out a plan to train more medical professionals, including GPs.
This is a joint project with the Royal New Zealand College of General Practitioners to increase the number of GPs trained each year to 300, and to get more Māori and Pacific GPs.
The overall package to boost the health workforce also includes the establishment of a one-stop-shop for international recruitment within Health New Zealand and removing significant cost barriers for professional registration.
Other initiatives include expanding a successful programme piloted this year that provides $5,000 in funding for every non-practising nurse in New Zealand who wants to return to nursing to help them get reregistered.
But even if more health professional were trained, while at the same time others moved to New Zealand en masse – there is still the struggle to get them out into the regions.
Ross Lawrenson, Professor of Population Health at Waikato University, said people from overseas come for the lifestyle, so some are happy to move to the regions.
That’s what New Zealand is selling. And when they do come people need to look out for them and welcome them, he said.
But there were a number of reasons Kiwis didn’t want to move to the regions and it could be as simple as their partners having good jobs and not wanting to move. Regions, because of their size, cannot offer the same professional opportunities as bigger population centres.
Changes needed to be made to the way doctors were trained to encourage more to work in rural and regional New Zealand, he said.
There needs to be a pathway for young people in rural areas and the regions to go to medical school. And students should have more access to generalist programmes, as well as working in the community earlier in their training and for longer.
But even if these issues were addressed now, it would still be 10 years before it would make a difference, he said.
‘‘Only 1.5% want to work in communities with less than 10,000 people. But places like Stratford and Hāwera need doctors too.’’