A day in the life of a doctors’ general practice 

It’s 9 am on a recent Tuesday and just over half of Te Mata Peak Practice’s 42 staff (many part-time) are gathered in the downstairs meeting room. 

Everyone is wearing navy blue scrubs (a routine continued since the first Covid lockdown) so it’s nigh impossible, at a distance, to view name badges and work out who is a doctor, a nurse or administrator – not to mention a whole lot of other new roles I will encounter as the day progresses. 

“Right! First up, we have on duty this morning …” Vikki Bond, Medical Support Facilitator, with a distinct Scottish burr and glistening pink-shaded hair, is running the meeting. She has only been at the Te Mata Peak Practice (TMPP) since January, but she has 30 years’ experience as a certified dementia practitioner, has been a military police officer in the British Army, and is a trained facilitator. 

Vikki is one of a wave of new staff who are part of a major gear change for this GP practice. 

More on that to come. I am here to witness the Practice in action, so back to the morning hui – a 15-minute daily start to the day. 

“We’ve got three nurses completing training on ear suctions looking for ears to examine.” Vikki surveys the wide circle of staff. “Any volunteers?” 

Several people raise their hands. “You can try me,” says the Practice’s Managing Director Kunjay Patel, known as KJ. 

The hui continues with a discussion on how best to define, for patients who are unsure, the roles of the two nurse practitioners on staff. 

“These are nurses with advanced education, clinical training and the demonstrated competency. They have the legal authority to practise beyond the level of a registered nurse and prescribe medicines,” Vikki offers. “Or I like this simple definition: nurse practitioners have the brains of a doctor and the heart of a nurse.” 

There is much laughter and then all eyes are on a video as it runs through pronunciation of Māori greetings and farewells as part of TMPP’s ‘Te Reo Tuesday’. 

Keita Rasell, Ngāti Kahungunu, Ngāti Porou, and a health coach at the Practice, turns to her colleagues. “If anyone has a query about pronunciation in real time, I am happy to go through things with you.” 

And then the daily hui is over and the staff (mainly female) ranging in age from 18-70 and comprising mixed nationalities – UK, Māori, Indian, Scottish, Danish, German, South African and NZ European – leave to get on with their day. 

“Ata mārie,” calls someone. 

A little over a year ago this GP practice, like many around the country, was struggling with a crushing workload and staff burnout, highlighted by Covid. 

To hear more about this and big changes in response, I sit around the table in the meeting room with TMPP’s three directors. Interestingly, they are all second-generation doctors. KJ, 47 years old, is the son of an anaesthetist and a gynaecologist. He came from the UK to NZ in 2006 and to this practice in 2008. As well as being the current Managing Director, he is a GP and medical educator. 

David Doig, 49, whose father was an obstetrician and gynaecologist in Christchurch, began at Te Mata Peak Practice nearly 20 years ago and now specialises in nutritional and environmental medicine and patients with complex conditions. James Newman, 37, also hails from the UK where his father was a GP and his mother was a nurse. James is late to our meeting because he has been on a house visit to a dying patient. 

“Yes, we all do house visits,” the three doctors chime when I look slightly incredulous remembering my own 1960s Havelock North childhood and the GP arriving at the front door with his brown leather bag. 

“We do most of our home visits in lunch hours or after hours,” says James, who looks after a lot of the Practice’s older population. Nearly one-tenth of TMPP’s enrolled patients are over 80 years old.

Some history

Wind back just a few years and there were six doctors working here, all siloed as independent businesses. As one-by-one three left, KJ, James and David continued on with long waiting lists – up to three weeks – and with little chance of employing another GP with such a severe shortage in the country. They were also drowning in ever increasing amounts of admin, plus dealing with their own frustration at the ongoing lack of government funding for primary health care. “Nine percent of the health budget while 70 percent of the interactions, consultations and work is being done in General Practice across NZ,” they claim. 

Plus more and more of the workload from Secondary Care seemed to be falling into Primary Care’s lap. For example, no surgical spaces in hospitals, resulting in GPs managing chronic pain; support services at home falling back to the GP; increased workload for palliative care; more drug addiction and hepatitis being handled in the community; a lack of cardiologists meaning more appointments needed at GPs; gastroenterology being managed in the community; elderly care being done at a local level rather than secondary. (“General Practice’s increasing workload comes from our ageing population.”)

And an overwhelming amount of a GPs resource being absorbed into mental health. “And not just depression and anxiety but also bipolar, schizophrenia and mental illness that hasn’t been categorised,” explains KJ. “The hospital end of the system is getting screwed on this too, so we’re not blaming them but it’s a big problem.”

Mindful of staff burnout, and their own – James’s GP father died at work, age 64, of a haemorrhagic stroke, David’s father at 66 of a heart attack and KJ’s father had a stroke at work six months before he retired – the three directors literally decided to take matters into their own hands.

Break and fix

“A year ago we broke so many systems,” says KJ. “We re-formatted, re-developed and changed them and we all invested a lot of money in upgrading the Practice.” 

First, they doubled their nursing team from three to seven and in a nod of acknowledgement at the dispiriting lack of pay parity for nurses between primary and secondary healthcare, gave their nurses a five per cent pay rise, taking a pay-cut for themselves. 

Then they began tackling the load of admin pouring into the Practice. 

“We were processing hundreds of pieces of health critical data every day,” says KJ. “There is so much over-sharing by hospital disciplines. We’d get a notification that a person’s referral had been received, then what priority it’s been assigned, then a letter, then a notification that the referral has closed – just give me the clinic letter and the plan. Just tell me when the booking is. We’d get a notice that the referral was going to be triaged. We don’t need to know that. 

“There is just such nonsense stuff that comes in – this patient had a fluoroscopy and we’re letting you know, but no clinic details are included – what’s the point? Hospital doctors can order a test and expect us to follow them up without cc’ing us into the result, then we have to ask our nurse to chase it and then action it. We’ve become secondary care’s secretaries. We can’t order MRIs without jumping through hoops. 

“The system is so stupid that sometimes hospital doctors will request that we do a referral to another discipline because they’re not allowed to do it themselves. 

“So one of the biggest re-focuses we’ve had is getting our admin team to function in broader roles. They’re doing much more, for example, recall management and enrolling and processing new patients. TMPP’s nursing team have had changes to their clinical roles and now provide admin support too. 

“In the last year we’ve got our waiting list down from three weeks to one and we want to get it down to sub one.” 

The Practice is also one of the first in New Zealand to employ Extended Care Paramedics (ECPs). These are top tier paramedics who have been trained in General Practice so they can do the day-to-day call backs and review of patients with acute medical issues. 

“This has freed our GPs because we’re not dealing anymore with coughs, colds, cuts and sneezes and increasing amounts of the urgent general practice workload, and can deal with more complex non-urgent stuff,” says KJ.

“The medical conditions GPs are dealing with on a daily basis are becoming more complex,” adds David. “People are living longer and they have multiple co-morbidities or conditions at the same time. With the elderly a lot of the warning lights don’t go on, they don’t get the symptoms that tells them something is wrong. They don’t cough and don’t have a fever, but they’ve got pneumonia. We play a lot of ‘spot the cancer’ here too and it’s not always easy.”

Another significant change here is setting the Practice up as a company with 10% of profits going to an employee trust, so staff can all have shares in the company. 

“We’re still finalising the paper work,” says James, “but we’ve told the staff and we’re going to set up a Board.”

“We want to empower as many people as possible and build it into the DNA of the company,” adds KJ.

Traditionally this Practice has been a holding and distribution company for six individual businesses with shared investment in the premises while each individual business would make its income depending on how much work the doctor was doing.

“Now we’re less territorial; we’re working as a team and together we can hold each other to higher clinical standards.”

Practice stats

I finish talking to the three directors and leave them to their monthly strategy meeting with Practice Manager Sharee Fawlk, who has been instrumental in helping TMPP re-structure its internal systems.

The TMPP waiting room upstairs is pin-drop quiet. It is hard to believe there are currently some 8,700 enrolled patients here with the directors aiming for a maximum enrollment target of 12,000, dependent on GP recruitment (they have just brought on two part-time GPs). 

On average, the practice has 540 scheduled appointments per week spread across the GPs, nurses’ clinics, a health coach, health improvement practitioner and clinical pharmacist, with another 80 people per week on average walking into the Practice, without an appointment, for urgent care.

The patient make-up of TMPP is 89% European with just under 10% of patients over 80, and 28% 65-plus. Of the rest 29% are under 25 and they usually come for things like contraception, pregnancy, endometriosis. 

Bulk government funding for GP practices is paid monthly on a capitation basis (i.e. per patient enrolled) with differing factors such as age, gender, quintile and ethnicity factored in for every person enrolled, so that there is not one set per capita rate. Rates are generally higher for patients at either end of the age spectrum – under 5 years and over 65s. 

In August this year the TMPP directors wrote to their patients explaining that they had to increase fees as a direct result of the government imposing what amounted to a significant funding cut in real terms. 

“As of 31 March 2022, national inflation rises were running at 6.9%,” they wrote. “Additionally, general practice has experienced a range of further cost pressures which has meant our total costs have risen by over 10 per cent compared to this time last year. The government has imposed a funding increase of just 3%….“We think this is unfair.” 

The letter suggested patients lobby their local MP and the Minister of Health – one of several signs this Practice is not hanging back in the shadows. Earlier I had noticed a laminated poster on a wall, Patient Participation Group: Do you want to help improve our services?

“That’s something that’s been around for a couple of years,” says Sharee Fawlk. “If we are going to change something or introduce a new service we ask the participation group for feedback.”

Practice at work

One of the heart beats of TMPP, is the ‘Treatment’ room, which includes a Nurses Station and is set up to handle emergencies. It has an ECG machine, defibrillator, oxygen, suction machine/aspirator for clearing obstructions from airways, a plastering station, suture kits, and equipment to take bloods and specimens.

Adjacent to this is the new and ground-breaking tele-consult room (nicknamed the ‘goldfish bowl’) where Emergency Care Paramedics (ECPs) deal with acute patients over the phone. 

Every call that comes into TMPP is fielded first by a three-person Call Centre down in the basement, colloquially-named the ‘Mushroom Room’. If calls are acute, they are logged with the ECPs who will do a fast call-back and assess whether to forward on to outside emergency services, to a TMPP GP, or carry out their own phone or face-to-face consult – both of these charge the usual GP-visit fee. 

“I used to work at the bottom of the cliff dealing with emergencies,” says Dale Walters, one of the three paramedics (two are on duty each day). “Now I am at the top of the cliff doing a lot of preventative medicine.”

Dale has 35 years experience as a trained paramedic with St John Ambulance. Keen to broaden his skill set and be part of a new direction for paramedics, Dale did a postgraduate diploma in health sciences at Auckland University of Technology. This has enabled him to move into General Practice work.

Most of the 20 to 60-odd calls a day fielded by the ECPs are for things like coughs, colds, parents worried about sick children, chest pains, fractured ankles, head injuries, mild asthma attacks and viral illnesses. The paramedics can issue basic medicines such as pain relief, antibiotics and Ventolin, which are listed in Standing Order guidelines developed in conjunction with TMPP’s clinical pharmacist, Steph McAllister.

The paramedics are also on hand if an emergency patient arrives at the clinic.

“The other day a man collapsed in the surgery and I was able to resuscitate him quickly in the Treatment room,” says Dale.

He has only been at TMPP for four months and is still finding his feet. “I’m going to enjoy this immensely,” he says, “but I am not yet. I am so used to dealing with trauma – car accidents, cardiac arrest, major asthma attacks, temporising them and moving on. Now I am dealing with things like skin rashes and working with patients in a whole new way.”

On a busy week the ECPs can return 190 phone calls with the majority being resolved over the phone without the patient needing to come in. That’s a big circuit breaker to the GP workflow.

“And that’s what I am already enjoying,” says Dale. “I love being part of a bigger functioning unit and a multidisciplinary approach.”

Adjacent to the ECPs, Penny Rhodes looks busy at the Nurses Station. She is the Practice’s Nurse Manager and has been here for nine years. She is in charge of the clinical flow day to day, rostering nurses to work either in the treatment room, be on duty to support patients and the doctors, or help with practical work such as giving immunisations, taking blood pressures and assisting in a small day-surgery room.

A new nurses’ role at TMPP is the ‘Inbox Nurse’. Each nurse is now regularly rostered on to help with the overflow of information coming into the clinic. Says Penny, “The Inbox nurse deals with hospital notifications, test results, discharge summaries – things that we as nurses understand, but are not going to impact on patient management.”

The Inbox Nurse is another TMPP innovation that has had a huge impact on GP workflow, at the same time extending nurses’ skills. 

Most GP practices in NZ now have a registered nurse with mental health credentials on staff to whom doctors can refer patients for free appointments (in TMPP’s case funded by Health Hawke’s Bay.)

I catch Sarah Heke, one of two mental health nurses working part-time, on a break between appointments. She has been here seven years, three working in mental health, and says she is mostly dealing with depression and anxiety. Sometimes her job is simply to refer a patient on or she will work with them building a care plan and setting goals. “We all have a cognitive brain and an emotional brain,” she says, “and it’s often the emotional brain I am working with.”

Sarah is also running two nurse-led clinics a week at St Andrews Church in Hastings where her husband Warren Heke, the church pastor, had already established some support for a homeless community. 

Next, I pop my head around the corner of Dr Katie Goatley’s room. She arrived from the UK in mid-July and says the main difference she is noticing here from her UK GP role is the team support. “Everybody has got each other’s back.” 

Down the hall I find Health Coach Keita Rasell and her colleague Health Improvement Practitioner Shannon Houston. Keita has a degree in natural medicine and has worked in a variety of organisations including Kaupapa Māori Health. Shannon is a trained occupational therapist. Both provide support to patients who want to make changes to their physical and/or mental health. Says Keita: “Shannon might work on a behavioural change plan with a patient and I can then follow up with more repetitive engagement to help them stay on track.” 

As the day goes on, I meet and talk with many staff at Te Mata Practice and watch as a steady flow of patients come and go through the front foyer. The atmosphere remains calm and quiet and belies what is going on behind the many closed doors. This prompts me to ask Practice Manager, Sharee Fawlk, whose idea it was to let BayBuzz in for a peek behind the scenes.

“Mine,” she laughs. “When I started 12 months ago, I had no idea how complex this place was. Everything happens at the back-end and this seemed like an opportunity to lift the veil a bit…”

I wait until director KJ has completed his last consult and then step into his room where his electric guitar hangs on the wall next to his desk – a reminder of the hobby he will get back to one day.

Not that he is complaining. He is already thinking about his next project: to get a young Registrar on board. “Someone that we can show the joys of General Practice to and they can in turn stimulate us with new ideas and new evidence,” he says.

In fact, KJ is off to Auckland the next day to brush up on some of his medical educator skills.

He says he aims to be in General Practice for the long haul. “I hope when the time comes to retire that I feel torn about leaving,” he says.

“I love General Practice.

“And teamwork is the panacea to all ills.” 

Public Interest Journalism funded through NZ On Air

Photo: Jack Warren