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The waiting game

After New Zealand, I have mixed feelings about copayments

Dr Kate Harding

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On my return to general practice in this country after just under two years in New Zealand, I had to make several adjustments. One was to the ten-minute consultation. This came as a rude shock.

A more welcome adjustment was to the removal of the burden of billing the patient for their care. In both New Zealand and Australia, 15 minutes is the normal length of time for a standard consultation. The patient pays for this time, and extra time is (in theory) also charged to them, at the discretion of the doctor.

In practice any extra charges are difficult to enforce, particularly for the (usually) billing-averse NHS-trained GP, and this leads to a constant tension between one’s sense of duty and fairness to the patient, desire to nurture the doctor-patient relationship, and obligation to one’s employer, who is running a business, and understandably keeping a close eye on the practice’s daily income.

To begin with 15 minutes seemed to me an incredible luxury. I soon came to realise that, just as nature abhors a vacuum, patient need simply expands to fill whatever time is allocated to it. The extra time meant that more was brought to the table, or more literally to the examination couch; the day was structured so that patient appointments stretched from 8 am to 5pm, with a nominal hour for lunch, often cut down to a hasty 20 minutes given the usual demands and uncertainties of the primary care clinical workload, combined with the fact that there is no time allocated to paperwork.

Home visits are exceedingly expensive, which puts people off requesting them

The middle chunk of the day that we UK GPs have traditionally used to complete tasks, write referral letters, deal with insurance paperwork and forms of every kind, sort out prescriptions, and visit our patients just doesn’t exist over there. The entire day is spent interacting with patients, in short. Paperwork is done after hours, in my case on my laptop with remote access, and, therefore, for free (an ongoing gripe of mine, and of my colleagues).

Home visits are a rarity, usually pre-arranged, and generally reserved for the terminally ill; any other sort of visit request throws a figurative grenade into the day, and makes the receptionists break into an anxious sweat, as visits of this sort can only be accommodated by cancelling several consecutive pre-booked surgery consultations. They are exceedingly expensive, which puts people off requesting them. A visit to the emergency department is cheaper (public hospital services are free at the point of use, as in Britain) – as long as you don’t require an ambulance, which incurs a hefty charge.

General practice in New Zealand has more similarities to its counterpart in the UK than differences. It remains, broadly-speaking, the same job. The relationship that is built up between doctor and patient is what makes the job so unique and so privileged, but also so anxiety-provoking, to those of a certain personality type. Overall, I did find the job more palatable over there, because of the longer appointment times and the greater efficiencies built into the IT systems.

I appreciated the rarity of home visits, too. I wouldn’t dream of working eight sessions a week here, but managed this with relative ease in New Zealand, dropping to six sessions after a few months once our family situation had stabilised.

As a patient, I loved the accessibility of my own doctor. Yes, I had to pay to see her (the equivalent of about £15). But to an infrequent attender like myself, the charge meant little, and was more than compensated for by her ability to see me within 24 to 48 hours of me phoning up for an appointment. I miss that sense of security.

In theory, I love the NHS. In practice, I can’t get a GP appointment in this country for myself or for my children in under three weeks. That makes me very, very nervous.

Dr Kate Harding is a locum GP and hospice doctor in Herefordshire


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Readers' comments (17)

  • You can always get to speak to a doctor and if necessary see one in the UK as long as it is urgent. Everything else can wait a little while.

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  • Sounds like a great place.I hope you do not regret the move in the wrong direction. I wonder if they have GDPR, child protection and Gross Negligence Manslaughter charges for system failures there. Things that are out of your control.

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  • Nice article - thank you.

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  • when I was there the copayments caused problem s-i patient who wa sin AF needed an ecg but refused as he had had one 8 weeks previously and he wasn't going to pay another $ 20

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    15 pound per patient
    so that's about 60 pounds an hour
    assuming seen 4
    then your employer will want a cut
    and with running costs
    maybe grass is not greener

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  • Mel Fiddly Diddly, does your dictionary go as far as ' Copayment', or is that too complex for your 'mathematical modelling'.

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  • Kate Harding

    Mmh yes the payments are a huge disincentive for people being investigated, that's absolutely true. An ECG at our practice cost $50. Also NZ GPs are poorly paid, compared to their UK counterparts, the job is massively sedentary (you barely leave your room at all, during the day - I HATED that aspect!) and you are a second class citizen compared to your secondary care colleagues, who have a huge study leave budget ($16,000/year) to fly off to overseas conferences with, and are much, much better paid generally. Unless you are a practice owner, it is hard to make comparable money in primary care. But the pace of work is certainly not as insane over there, that's a massive plus! And the country is small, so networking is easy, there are really good conferences and educational events up and down the country, and great peer support groups which meet monthly and are a fantastic source of information and friendship and advice. I haven't even mentioned the infamous ACC! Those of you who have worked in NZ will know all about the byzantine complexity of this system, unique to NZ, which caters to all accidents (even if that's an insect bite!) in order to avoid the all-too-common litigation scenarios common to the rest of the developed world...

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  • One thing is certain: the all you can eat, 24/7 buffet that has created enormous demand cannot go on here in the UK. Something has to give: quality seems to be the current plan of the government, and a non-GP delivered primary care workforce to replace us.

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  • As a NZ trained GP working in Scotland ( for 15 years now ) I prefer the system here. There is variability in how much it costs a patient depending on the area you are in( more subsidy in poorer areas and for poorer patients-means testing),but sending bills to patients who couldn't afford them often felt wrong.Rural practice is better supported here ,it is not surprising that people choose to visit A/E and delay seeing a GP in NZ because of the cost. ACC (set up in 1974 )is an excellent system that benefits patients and doctors( reducing the cost of medical defence fees significantly) and avoids use of lawyers( usually ) with medical misadventure. It also should cover costs of treatment, and compensate for time off work following an accident.I feel the UK and USA would do well to consider such a system but suspect that there are too many lawyers in government to allow this.

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  • |whats the problem | GP|26 Jun 2018 12:21pm

    That's his decision to make though isn't it, and he's a big boy and can weigh up the pros/cons. Why shouldn't the economic impact be taken into consideration in a health decision? Guess what, life is unfair, some have to strive harder than others to reduce their risk in life. Its time we treated people like adults, if we want them to behave like adults.

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  • No idea where the middle chunk of the day for doing admin has gone, UK GP is firefighting constantly now. One big s**t storm getting increasingly unbearable.

    Sorry to hear it’s not much better in NZ, maybe it really is just a cesspit of a job everywhere. 😫

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  • We should do the job for free as it’s a privilege 😂

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  • Thank you for another interesting and well written article. It's refreshing to hear a fairly balanced discussion of UK vs Auz/NZ GP.

    Re your 3 week wait - you of course have the option of changing practice if you're not happy. In my opinion, 2-3 weeks for routine problem and same day phone/surgery rv for urgent problem is not bad considering our under resourced system. More of a problem for me is the 5-6 month wait for physio in my area and 3-4 month wait for a routine specialist appt.

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  • AlanAlmond

    This ACC system sounds interesting and I’d like to know more.

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  • Kate Harding

    UtterFool, here is a link to a reasonably clear explanation of ACC:

    It certainly is unique. It is largely a force for good, but getting it to pay out for non-barn-door accidents can be tricky, and there are constant controversies (often featured in the media) over perceived injustices within the system as it currently stands.

    Saldoc - do you know, I had kind of forgotten that much doctoring these days in general practice goes on by telephone. This was beaten out of me (okay, not quite literally) in NZ, since it is hard to charge patients for phone time! So the incentive of every practice is to see their patients face to face! I have now managed to conduct some patienting (as opposed to doctoring) by phone pretty successfully. I guess the next step will be signing up to one of the doctor apps as a patient! (JOKE!) (I think!)

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  • Chacun a son gout. I worked in NZ and really liked it. There is much less time wasting rubbish and when it does happen - hey one can console oneself with the thought that the punter is having to cough up. The copayments are only about half of the income for gps so the pay is better than some of the above calculations. And there is v little of patients asking gps about investigations done by hospitals - or similar dumped work. And wait to see a GP - I didnt come across it - though their gp numbers were low overall.
    Basically their system limits demand in a very sensible way - and that is what we need.

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  • I worked in NZ recently in a rural practice - real issues about continuity of care as the place survives on locums - co payments are 18$ = 10 pounds approx. as they are lower in the rural areas. 15 minute appointments are pleasant but there is more in some than others just as in the UK. ACC is a lottery and the NZ Government are struggling to fund it so rationing and excluding more [sound familiar?]. The Medtech system is clunky and being generous just about makes it into the 21st century. Oh for EMIS web. Nurses are very variable - in some practices - Prime Contract - they are "it" and do pretty much everything - in others the level of responsibility taken is low - especially around repeat prescribing - where they do less than well trained admin staff in the UK ...I think this may be more evident in the DHB [= PCT] run practices - again does that sound familiar?

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