Executive summary for Series 7: 17-24 September 2020

This is the seventh of the national surveys of New Zealand general practice experience with COVID-19 and its aftermath. It was launched when Auckland was at alert level 2.5, and the rest of NZ at level 2, due to the cluster outbreak.

Policy recommendations based on responses

Variability between DHBs resources practices is a continued theme. We now have ethical approval for practices to indicate DHB so we can report these variations in the next series. Practices and patients need to know that their referrals are being addressed as fast as possible – DHBs should not expect GPs to have to re-submit them.

The Ministry needs to ensure that all DHBs and PHOs support and resource practices to ensure optimal community-based COVID-19 testing takes place, and that testing is sustained through all alert levels.

Clear public health messages on the need for everyone with respiratory symptoms to be tested are called for.

Effects of COVID-19 on practices

The strain on practices from COVID-19 continues, with 77% reporting significant to severe impact (86% in S6), and 2% still reporting no ongoing effect. Only 17% still report ongoing effects of COVID-19 leading to staff layoff or affecting leave arrangements.

Delays

Patients facing delays in diagnosis and treatment for non-COVID-19 conditions is now a major concern.

General practice: 48% report delays for patients attending general practice.

“Increased demand for GP appts causing delays to get in” [PN]

“Issues with some patients accessing a phone for telehealth or not having credit if they need to call the practice. Some older patients too scared to leave the house and come to the GP” [GP]

Out-patients: 79% report delays in outpatient appointments.

“Massive delays for hospital outpatient appointments and booked surgeries. Patients still waiting for appointments that were postponed during initial lockdown” [GP]

“DHB seems to be ignoring referrals and them in a pool ie waitlist to get on waiting list” [PM]

“Delayed appointments, denied referrals” [GP]

Some report having to re-submit previous referrals: “Multiple rebookings… forced resubmissions of referrals to secondary and tertiary care” [GP] and “Some referrals have been overlooked – so re-referral necessary” [PN]

Diagnostic investigations: 68% in investigations such as colonoscopy.

“Long waits for ultrasound scans —> delayed diagnosis ; community laboratories are swamped” [GP]

“Radiology all delayed so diagnosis delayed” [PM]

“Delay in bowel cancer diagnosis” [GP]

“Lots of services delayed like colonoscopy gastronomy” [GP]

Elective procedures 72% report delays in elective procedures such as hip replacements:

“Abscess enlargement, knee joint replacement postponed” [GP]

Delayed treatments: Many others report delayed treatments leading to more serious disease:

“People becoming unwell eg chest pain not dealt with, undiagnosed cancer, bumped off surgery lists” [GP]

“Woman with a delayed diagnosis of melanoma …now had disfiguring facial surgery” [GP]

“Patients in septic shock prior to presentation” [GP]

“A few virtual breast clinic f/u missing pathology when I as a GP examined breast in metastatic breast disease”

“Severe delays in cancer treatment” [GP]

“Facial cancer which may require more extensive excision in retiree beneficiary” [GP]

“Backlog from those referred for ENT over lockdown which has flow on effects” [GP]

Delays may also lead to greater inequity:

“More vulnerable patients struggle more to get to appts, often present later in disease course so referral delays have bigger impact” [GP]

Mental health

Rising mental health issues and difficulty accessing services to address them is also a major concern, and again an area where inequities are increasing.

“Increased need for consults regarding mental health“ [PM]

“Redundancies causing financial problems so people giving up health insurance. There’ll be more demand on public secondary care as a result” [GP]

“Shopping lists so long consults, increasing numbers with job loss, financial and mental health problems”

“Mental health waits disastrous and very worrying” [GP]

“Mental health is the biggest area – where persistence and health literacy help people get to the top of the waiting list for services. Those economically, educationally or demographically vulnerable … most needy but least pushy so may be leapfrogged by those better at advocating for themselves in community provided services” [GP]

”Elderly patients are increasingly opening up about how hard the isolation was. Seeing flares of chronic mental health issues in all ages” [GP]

“Generally increased mental health needs and no ability to access counselling” [GP]

“Youth mental health need has escalated but the system… is well beyond capacity” [GP]

Testing and PPE

34% of practices still report challenges in getting PPE, and 9% say they are reusing or relying on homemade options. One GP comments: “Concern that DHBs are going to stop supplying PPE. The costs to us are still high compared to normal so if we have to pay for PPE it will be on charged to patients or if we are unable to source adequate PPE then red stream patients will be referred to ED.” The rationing of resources appears to be continuing in specific DHBs: “A frustrating gap exists between the DG asking for more testing and what instructions we are given locally. We would like to do more.. but we are asked by the DHB to not do that because they can’t afford to pay us for it” [PM]Only 16% indicate lack of financial recompense for testing (20% in S6), although 1 GP says “still waiting for payment for some of the April COVID swabs”.

Patients not presenting for tests when they have respiratory symptoms remains an issue.

“Ongoing struggle to keep patients with respiratory symptoms out of the waiting room, despite reception asking screening questions. Some people don’t disclose, minimise symptoms or feel reassured with neg covid swab” [GP]

“Very worried about cold flu cough slipping thru [our] triage net ( happens every week ) People often don’t seem to know that all colds and coughs could be COVID, thus message is not getting thru. Public health messaging is too complex: severe covid is more rare, 85% are mild. We need simple widespread messaging to reach all cultures and ages. TEST ALL COLDS COUGHS SORE THROATS – THUS MAY BE NEEDED MORE THAN ONCE. Some think once they have a test they never need another”

Telehealth consultations

64% still report they have patients who struggle with telehealth: “Difficulty with telemedicine – patients with poorer health literacy not calling when they should” [GP]

Video consultations are being conducted in 43%; telephone consults in almost all (99%) – for 45% this is for more than 20% of consultations, and these figures have not changed much since S6.

Method On Thursday 17th September, the seventh of the fortnightly Quick COVID-19 NZ Primary Care Survey was launched. An invitation to participate was distributed to general practice GPs, nurses and managers across the country, disseminated by the RNZCGP, RNZCUC, GPNZ, PMAANZ, RGPN, and NZMA. The survey closed on 11 September.

Sample There were 115 respondents: 82 doctors (GPs or urgent care doctors), 13 practice nurses [PN], 1 nurse practitioner (NP], and 19 practice managers [PM].

74% of practices were GP-owned; 66% had more than 3 GPs; 33% independent and part of a larger group, none were DHB-owned, 15% owned by a community trust, 24% as urgent care / after hours. 28% identified as rural.