Executive summary for Series 8: 14-22 October 2020
This is the eighth of the national surveys of New Zealand general practice experience with COVID-19 and its aftermath. It was launched when the whole country was back down to Alert level 1. Surveys are now monthly.
Policy recommendations based on responses
Care needs to be ensured that telehealth is only used for consultations where appropriate, and that barriers to its use by vulnerable patients are identified and addressed, to prevent increasing health disparities.
Effects of COVID-19 on practices
The strain on practices from COVID-19 is waning, with only 31% reporting significant to severe impact down from 77% in S7), and 36% reporting mild or no ongoing impact. However 22% still report ongoing effects of COVID-19 leading to staff layoff or affecting leave arrangements.
53% report they have patients who struggle with telehealth. 41% are still using some video-consults, whereas 96% are doing some phone, and 43% other forms of e-consultation. This survey focused on barriers experienced by vulnerable patients to telehealth, and some of the solutions implemented by practices.
Specific barriers encountered with telehealth use with socio-demographically vulnerable patients
COVID-19 lockdown was seen to increase the disparity gap for socio-demographically vulnerable patients:
“Some of them didn’t even call or know we were open”
A common theme was patients not having access to the technology, either the physical devices or the paid minutes and data to use them.
“Increased need for consults regarding mental health“ [PM]
“Really deprived patients just don’t have phones. The whole Covid telehealth plan excluded these people“
“Poverty, frequent phone number changes“
“Those who cannot afford a phone or the phone plan costs for anything more than texting.“
“Devices shared among several people so significant privacy issues ability to use phones/ tablets”
“Financial barrier paying for said data or minutes for telephone calls”
One GP said that patients are
“frightened to pick up phone with no caller ID as think it is police or govt dept”
A number identified English as a second language as a major issue.
“Difficult to understand accents including those of interpreter over the phone, loss of being able to read body language is huge.”
“Language barriers in refugee and migrant families. Cannot have interpreter easily available”
“Mostly my refugee patients held off till after lockdown”
Deafness was a similar problem:
“Very difficult for deaf patients requiring sign interpreter“
A number also mentioned difficulties engaging with the elderly and cognitively impaired.
“Elderly patients hard of hearing and worried about the changes to routines“
“Spent ½ hour instructing a patient how to install the app on his phone. He then wanted to show me his toe and I had 15mins of his face moving about. I just couldn’t explain to him how to turn his camera around. Sigh. Elderly quintile 6 Maori. I love it that he really tried“
Several mentioned that it was difficult for patients to take calls while at work
“Jobs make them unable to answer their phones during the day“
and others that patients chose telehealth when it was not suitable
“They are using telehealth rather than coming in as not mobile with transport. Often inappropriate problem for telehealth“.
Specific barriers encountered with telehealth use with rural patients
Telecommunication access was often a major concern with rural patients
“Rural patients often have a cellphone but isn’t always able to get reception”
“Rural connectivity can be challenging, no fibre for 95% of our patients so lag can be terrible”
“Patchy broadband and mobile reception, sometimes have to do consult while they stand on a hill on their property!”
A number of other issues were also identified
“Age is the biggest barrier, they are not techno savvy, we are a rural practice, a phone call is fine or house visit”
”Prison workers are not allowed to carry mobiles”
”Challenge has been getting DHB services to use telehealth that’s not dependent on receiving text messages (eg using emails to patient), and using telehealth more regularly”
Several practices however commented that telehealth suited their patients
“My rural patients love not having to leave their farms to come in”
Solutions implemented to overcome any of these barriers
Practices have come up with a variety of innovative solutions to these various problems.
“See refugee and migrant families in-person with phone interpreters”
“Have a Facebook page so those who do not have cell phone reception can access us via messenger“
“Send text msg to ask pt to contact us (works if cell coverage poor, can call us back when working, but doc not always available)”
“Local hub in the community lounge of a retirement village to help people with technology for tele-consults“
When mobile coverage is an issue rural patients may still have access to data so using alternative messaging options like MMH, What’s App and messenger“
“Started weekly nurse-led home visits targeting those with LTCs & elderly for BP checks, overdue labs, flu vac, Covid swabs“
“If we have a patient who is due for a blood pressure check, for example, and they do not want to travel into the clinic then we would arrange for them to have one at a local pharmacy and then have a telehealth consultation with the doctor.“
Testing and PPE
33% of practices still report challenges in getting PPE, 12% s are reusing or relying on homemade options and 12% also report finance as a barrier. “DHB not paying PHO for COVID reimbursements was a disappointment” [GP, Tairāwhiti DHB]. On the other hand, another practice reports “Income from covid swab meant we were able to give reception and admin staff a much deserved bonus, they have stepped up in a way not trained for“ [GP, Southern DHB]. Other comments include
“We have good supply of PPE through WDHB which helps ease stress” [GP Waitemata DHB]
“CBACs need to remain open to maintain surveillance” [GP, Hutt Valley DHB]
26% of practices still report a decrease in patient workload. One reports “We are in the CBD and there are many fewer people coming into the city for work“ [GP, Auckland DHB]
For many others there are concerns about increased workload “I have enjoyed the new tech with eprescribing/ emailing the lab, things I have wanted for years. I am now booked up around 6 weeks ahead due to “catch up”, despite my nurses doing a lot of consults also” [GP Hawkes Bay DHB]
Concerns about the non-COVID-19 effects on patients still feature frequently, including worrying delays in getting specialist care “Woeful level of support from secondary care in cancelling OPC appts that were delayed bc of Covid & expecting GPs to re-refer them back to the start of the queue“ [GP, Counties Manukau DHB]
On Wednesday 14th October, the eighth of the 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 22 October.
There were 129 respondents: 112 doctors (GPs or urgent care doctors), 8 practice nurses [PN], and 9 practice managers [PM]. 76% of practices were GP-owned; 71% had more than 3 GPs; 26% independent and part of a larger group, one DHB-owned, 10% owned by a community trust, 19% as urgent care / after hours. 24% identified as rural.