What broke our after-hours healthcare?

After-hours healthcare has long been the stop before emergency departments. But industry leaders say it’s in need of its own urgent care. Rachel Thomas speaks to those on the front line.

It was the 1980s when Dr Les Toop, his moustache and his tired green Mazda 323 station wagon, would cover afterhours patient calls at all hours, when his turn came around. “You had a big bag in the back of your car and you did what was necessary.”

His big bag has morphed into a leather briefcase, which he still uses for the odd house calls to his oldest or immobile patients.

And when the Christchurch Emergency Services centre opened in 1987 in Bealey Ave, Toop was on the first shift.

It was one of the first of its kind in the country, Toop says, established by a group of local doctors and the Royal NZ College of GPs to make care easier to access between 5pm and 8pm on weekdays, and at weekends. It was a team effort between doctors and nurses.

“There would no longer be any need for answering services or vague messages... what we want is an after-hours service that is quick, clean, efficient — then during office hours people could go back to their own homespun service,” then college board member Dr Ian Robertson told The Press in March 1987.

And from the days of tired old station wagons, after-hours care has been the buffer between general practice and emergency departments.

General practices are usually allocated a number of shifts they must fill at their local after-hours clinics, and doctors do a certain number per quarter.

Then something broke, around the time of Covid-19. As surgical wait lists blew out, demand for community medicine grew, doctors closed their books and, ultimately, EDs filled up and slowed down.

Christchurch nurse Tania Thompson is a delegate for the NZ Nurses Organisation (NZNO). She also works in Christchurch’s emergency department.

“We are often met with shifts that have high numbers of patients in the waiting room, patients in the corridor and non-stop ambulances coming in. Unfortunately, we do not have adequate staff [or] resources to deal with the increasing number of patients that need our services and care.”

As family doctor Dr Luke Bradford puts it: “When ED overloads, the hospital stops moving.”

Bradford is now a GP in Tauranga and medical director of the College of GPs, but was an ED doctor before that.

“I don’t think people see the cycle. That link of the whole thing as an organism.

“If you haven’t got a GP, you’re not getting your chronic care. You’re not getting your routine and preventative care. Then you’re going to present, all of a sudden, out of hours. If that overloads, you’re going to present into ED.”

This “overload” is being seen at afterhours centres around the country. Queues of patients 40 people deep can greet doctors at the Lower Hutt After Hours Medical Service at 5pm.

Staffing shortages have seen Marlborough's Urgent Care Centre pull its closing time back to 5pm instead of 8pm. Kenepuru’s Accident and Medical Clinic, which offers 24-hour care for 80,000 residents in Porirua, may need to close overnight from November.

In Christchurch, the 24-hour Surgery, born out of the after-hours service Toop helped launch, is indefinitely closing its overnight service due to staff shortages.

“It’s all going to collapse” - GP

Just as “car boot care” was not sustainable, neither is the current model, according to multiple sector leaders, given its dependence on the already short-staffed and lower-paid primary health workforce taking on more.

Dr Lily Fraser (Kāi Tahu), a Māori GP who works in Māngere and Dunedin, says GPs are unable to meet the complex and acute needs of patients.

“We are trying to see patients who have an urgent health need. Primary care is inadequately funded to be able to do that sufficiently because you need more staff to be able to fluctuate.”

While the after-hours clinics where she works are well-staffed and maintaining hours, funding is still an issue. And with cost already a barrier to some patients, government needs to fill the funding gap.

Her practice in Māngere had extended appointments to 20 minutes and was wearing the cost, she said.

“We need increased funding. If you are short of breath from a chest infection today you don’t want to wait three weeks for an appointment.”

Bradford says rural places are struggling to staff themselves in the day, let alone at 9pm.

“It's a complete lottery as to who's got what services where in terms of after hours and urgent care.”

Nurse Kez Jones, also a Christchurch delegate for NZNO, was seeing the flow-on effects of the 24-Hour Surgery closure on her ED.

“The 24-hour Surgery captures a huge portion of patients seeking emergency care. We have certainly felt the impact in the emergency department when they are closed overnight,” Jones says.

Toop, previously chair of Pegasus Health, said 24-hour clinics were not only difficult to staff but difficult to pay for.

“Providing care after midnight, for instance, is extremely expensive, particularly if you are doing it in a facility. The building, the staff, all the things you need to make it work.”

Wellsford GP Dr Tim Malloy works for Coast to Coast Health Care, the only GP practice that offers after-hours care from the North Shore to Whangārei.

He estimates demand has gone up by between 50% and 100% in the past year.

“If we keep doing what we are doing, it’s all going to collapse.”

Following the Kenepuru news, Health Minister Dr Ayesha Verrall put a stake in the ground: “Rosters have challenges all the time and I don’t expect services to shut down as a result.”

She doubled down on this when approached for this story: “I have made it very clear to Te Whatu Ora that staffing gaps do not justify limiting publicly run after-hours services.”

Very few after-hours services outside of EDs are publicly run, Bradford says.

For privately run clinics, as most after-hours services were, “Te Whatu Ora has contingencies in place to make sure communities aren’t without when privately run after-hours clinics are closed“, Verrall said.

In the case of Lower Hutt’s After Hours Service, Te Whatu Ora was providing funding for locum GPs and triage nurses.

Karl Andrews, chief executive of South Link Health Services, went as far as saying locum staff and contractors were probably “propping up almost every general practice in the country”.

South Link is a general practice network which owns 24 practices across 28 sites, spanning Auckland to Southland.

He says things have worsened since Covid because of the lack of immigration and the recent pay settlements for hospital nurses.

Toop agrees: “Everything everywhere has been made worse by two things: Covid and the pay equity payments creating a vast divide.

“The private facilities, unless they put their fees up enormously, can’t match it.”

Parity important, politicians say, but won’t commit to time frame

Post-election, either Verrall or National’s Dr Shane Reti will be the health minister. Neither had time to be interviewed for this story.

“Fair pay is a key step to attract more nurses, and this will be priority for us if re-elected,” Verrall said in a statement.

“As it stands the funding system for GPs is not fit for purpose.” She said many changes are needed, but did not elaborate and her office said this was tricky given Labour’s health manifesto was yet to be released.

Reti said National supported pay parity for GP nurses, saying Labour was wrong to “refuse to include them in the December pay parity initiative”.

Toop says until parity is addressed, there will continue to be a “flight” from general practice into hospitals.

Maura Thompson is chief executive of General Practice New Zealand, which