It was reassuring to hear the Minister of Health (when opening the Education and Research in Rural Health Conference in Dunedin recently) state that “there is no shortage of general practitioners in rural areas in this country.”1 (In fact, he was sick of being told that there was a problem.) It is worrying to know that his opinion is in isolation, however.

Indeed, at the same conference, Professor Paul Worley (Director of Flinders University Rural Clinical School, Adelaide, Australia) after a study tour of the rural teaching facilities of the Dunedin School of Medicine, stated that the situation in rural areas was always one doctor short of a crisis.2

While it is reassuring for the citizens and current general practitioners of Levin, Kapiti, Timaru, Gisborne, Waimate, Twizel, and the entire West Coast to know that the current Minister of Health does not think there is a shortage of doctors in their areas, it is worrying to know that he is wrong, however.

While absolute doctor numbers are static in rural areas, and generally have not declined, the face of general practice as a discipline has changed and will continue to change. With increasing compliance requirements on general practice from the bureaucrats, increasing complexity of presenting illness, increasing age of patients with comorbidities, and increasing patient expectations, the “short” or “one problem” consultation has become a rarity.

The requirements of doctors in the 21st Century have also changed—no longer is it acceptable to be on call 24 hours a day, 7 days a week; no longer is it acceptable to work excessive hours to absorb demand; and no longer is it acceptable to work all night on call, and be expected to work a normal day following.

Yes, the wind of change has blown through, with increased expectations from young doctors of a “normal life” with adequate remuneration. In addition, a change in gender balance in the profession, with greater than 50% of graduates now being female, has added to this stance.

It is generally agreed that the general practice workforce is aging. For example, 73% of rural GPs are older than 40 years3 and 60% of all GPs in New Zealand are over 46 years of age, with 37% being over 50. Even more alarming is the fact that more than 33% of the current workforce intend to move out of general practice within the next 5 years.4

Currently, 12 years are required before a medical student entering medical school today can practise general practice independently, so even if numbers entering medical school are increased, there will be a considerable time lag before any correction will occur.

In addition, there has been an alarming decline in the number of New Zealand students wanting to enter general practice. In the past, about 50% have become general practitioners, but this has declined in recent years, with many students perceiving GPs to have low status and pay, increasing paperwork, and general practice providing less stimulation overall than hospital medicine.5 Large student loans are also a factor.

Current GPs are concerned about never-ending change, bureaucracy, poor earnings, time pressures, lack of adequate resources for patients, threat of litigation, and burnout.6 Thus there is evidence that the general practice workforce is diminishing more quickly than it is being replenished. Indeed, there is direct evidence of this trend, with numbers of practising GPs declining by 249 between 2000 and 2002.4

One critical issue is the number of visits a patient makes to the doctor each year.7 With the evolving Primary Health Care Strategy resulting in lower GP fees, it is likely that the number of visits by each individual patient will rise. If these visits generally rise above an average of four/year, than there will be an enormous increase in workload.

A large number of our doctors, especially in rural areas, are overseas trained and often come from developing countries which can ill afford to lose them. In addition, New Zealand GPs are being wooed across the Tasman with offers of conditions and salary that New Zealand GPs can only dream about.8

The problem is compounded, especially in rural and provincial regions, with GPs becoming too busy to cope, and as a result they leave for the cities with reduced workload.

Is there a solution? Unfortunately there is no quick fix, and denial by the Minister that a reality exists is not part of this. General practice must be made more attractive to young graduates. If it is to compete with hospitals, the status and pay of GPs (although it has been improved over the last 2 years) needs to be addressed as does workload.

As with hospital doctors, paid study leave and sabbatical leave should be available. Relief is required for GPs to take holidays—currently 6 weeks for hospital doctors! The after hours and on call situation also needs to be remedied.

The increase in funding for primary health (after neglect for so many years) is to be applauded, but more needs to be done if a crisis is to be averted.

Author information: James J Reid, Head of Department, Department of General Practice, Dunedin School of Medicine, Dunedin (and a Sub-Editor of the NZMJ)

Correspondence: Associate Professor James Reid, Department of General Practice, Dunedin School of Medicine, PO Box 913, Dunedin. Fax: (03) 479 7431; email: jim.reid@stonebow.otago.ac.nz