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Your guide to

New Zealand
general practice

1
Acknowledgements
Thank you to Martin London for the work he has contributed to this re-
source. Compiled originally by Lynn Saul and reviewed by Dr Sue Crengle,
Shahrazad Abdul-Ridha, Ian St George, Iain Hague, Sue Hancock, Joe
Scott-Jones and Dene Egglestone. Revised in 2005.

Cover Photo: Lawrence Smith/PhotoNewZealand.com

Version 3, July 2005

Published by The Royal New Zealand College of General Practitioners,


New Zealand, 2005.

ISBN: 0-9582429-1-7

© The Royal New Zealand College of General Practitioners, New Zealand, 2005.

The Royal New Zealand College of General Practitioners owns the copyright of this
work and has exclusive rights in accordance with the Copyright Act 1994.
In particular, prior written permission must be obtained from the Royal New Zealand
College of General Practitioners for others (including business entities) to:
• copy the work
• issue copies of the work, whether by sale or otherwise
• show the work in public
• make an adaptation of the work
as defined by the Copyright Act 1994.

2
Contents

Introduction .............................................................................. 4

Section 1
Requirements to work in New Zealand
as a general practitioner ........................................................... 6

Section 2
General practice overview ....................................................... 15
Professional development ........................................................ 20
Doctor/patient relationship ...................................................... 24

Section 3
Health of New Zealanders ....................................................... 29
Health care sector overview ..................................................... 35
Regulatory requirements .......................................................... 39
Orientation to general practice ................................................ 45
Practice orientation ................................................................. 58

Appendices
Appendix 1: Subsidies ............................................................. 66
Appendix 2: Glossary .............................................................. 69

References ......................................................................... 70

3
Introduction

Intending immigrant family doctors or general practitioners (GPs)


overseas who may be considering New Zealand as an option may
find it difficult to access advice or information on how to get started
in New Zealand general practice.

The Royal New Zealand College of General Practitioners has brought


together in this resource the sort of information you will need. We
intend it to be a living document, and it will be updated as the sector
changes or regulatory requirements alter.

The College provides advocacy and support for general practice


and practitioners, delivering post-graduate education, professional
development and quality tools – all aimed at supporting and strength-
ening our members’ practice.

We set out in this resource first, the requirements you will need to
work as a GP in New Zealand. Second, a general practice overview
includes the sort of professional development a GP is expected to
maintain, and what is expected in this country of the doctor/patient
relationship. Third, the New Zealand health environment, with detail
on how the sector is structured, including the regulatory require-
ments that face each GP. Finally, templates which you may use when
your planning becomes more detailed. These offer questions you
will need answered.

4
The Medical Council of New Zealand provides resources that cover
important information for doctors. If you do not already have a copy,
we suggest you contact the Medical Council to obtain a copy of:

• Cole’s medical practice in New Zealand (2005)


• Good medical practice.

5
SECTION 1
Requirements to work in
New Zealand as a general
practitioner

Work in the medical profession is covered by legislation entitled “The


Health Practitioners Competence Assurance Act 2003.” This deter-
mines the registration and scope of practice of a general practitioner.

To work in New Zealand as a general practitioner you will need:

1. Medical registration
2. Confirmed job offer
3. Work permit
4. Either work with a practice as part of a Primary Health Organi-
sation (PHO), or a Section 88 notice entitling payment of subsi-
dies for some patients.

Under the legislation, the Medical Council of New Zealand is the


authority that determines the scope of practice and the registration
of general practitioners. The College advises you to contact the Medi-
cal Council for information on this as soon as possible.

6
Medical Council of New Zealand
Level 12
Mid City Tower
139–143 Willis St
P O Box 11 649
Wellington
Website: www.mcnz.org.nz
Email: If this is your first enquiry, firstenquiry@mcnz.org.nz
: Enquiry regarding current application, registration@mcnz.org.nz
Tel: +64-4-384 7635

The Medical Council has specified three broad scopes of practice in


which general practitioners may be registered.

• General scope of practice

• Vocational scope of practice

• Special purpose scope of practice.

Particular conditions may also be placed on these differing types of


registration. Which one is right for you will depend on a number of
factors, including:

• Whether you intend to reside permanently in New Zealand

• Where you trained and qualified as a doctor

• What experience and/or training you have in general practice


and in which country that experience and training was obtained

General scope of practice


A medical practioner registered within a general scope of practice is
authorised to work within the Council’s definition of “the practice of

7
medicine”, but must work within a collegial relationship and also
ensure appropriate continuing professional development takes place.

Provisional general scope of practice


This requires the medical practioner to work in a position approved
by the Council for a minimum of 12 months under the supervision of
an approved registered medical practitioner, in which time the medical
practitioner must complete the Council’s requirements for registra-
tion within a general scope.

Vocational scope of practice


A medical practitioner registered with a vocational scope of general
practice works within that scope as defined by the Medical Council
(“General practice is an academic and scientific discipline with its
own educational content, research, evidence base and clinical activ-
ity, and a clinical specialty oriented to primary care. It is personal,
family and community oriented primary care that includes diagno-
sis, continues over time, is anticipatory as well as responsive”), has
the qualifications, training and experience to obtain Fellowship of
the Royal New Zealand College of General Practioners (FRNZCGP)
and must participate in an approved Continuing Professional Devel-
opment (CPD) programme to maintain competence.

Provisional vocational scope of practice


A medical practitioner applying for registration within a vocational
scope of practice must, if not registered within a general scope, work
under supervision for a minimum of 12 months, and during this period
complete the requirements for registration with a vocational scope.

8
Special purpose scope of practice
Medical practitioners who are in New Zealand for defined or limited
reasons, including teaching, sponsored training, research, working
as a locum tenens for up to six months, or assisting in an emergency
or other unpredictable, short-term situation, will be registered within
a special purpose scope. This scope does not lead to permanent
registration. The practitioner must work under supervision, and the
Council must approve the institution where the practitioner works.

Qualifications
The Medical Council has prescribed in detail the qualifications for
the various scopes; the recognised academic institutions, and the
necessary training and experience for registration. There may also
be a requirement for an English language test. The full description
of the scopes and the details of the qualifications are obtainable
from the Medical Council, and are laid out in the New Zealand
Gazette No 120 of 15 September 2004, pages 2920 to 2928. All
medical practitioners must also hold an Annual Practicing Certifi-
cate (APC) issued by the Medical Council.

These registration requirements came into effect on 18 September


2004, and there are some transitional provisions that apply until 19
September 2006 for some practitioners who held registration under
the now repealed Medical Practitioners Act 1995 at the time the new
requirements came into effect.

Work Permit
After a confirmed job offer has been obtained, a practitioner must obtain
a work permit from the New Zealand Immigration Service, which will
also require evidence of medical registration. The Immigration Service

9
has branches in New Zealand and around the world. Medical practitioners
are on a priority list for immigration into New Zealand to address long-
term skill shortages. For questions, including assistance with locating a
branch nearest to you, call the National Contact centre on:

• 914 4100 for callers with the Auckland toll-free region


• 0508 558 855 for callers outside the Auckland toll-free region.
The immigration website (www.immigration.govt.nz) provides com-
prehensive information and will help locate the branch nearest to you.

Confirmed job offer


The confirmed job offer must meet Medical Council requirements
for supervision and collegial relationships.

Most vacancies for GPs in New Zealand are advertised in at least


one of the following two medical publications. You may also wish to
place your own advertisement.

The New Zealand Medical Journal


New Zealand Medical Association
P O Box 156
Wellington
Tel: +64-4-472 4741
Fax: +64-4-471 0838
Email: nzmedjnl@nzma.org.nz
Website: www.nzma.org.nz

New Zealand Doctor


CMPMedica (NZ) Ltd
P O Box 31-348
Auckland 1330
Tel: +64-9-488 4266

10
Fax: +64-9-488 4284
Email: editor@nzdoctor.co.nz
Website: www.nzdoctor.co.nz

Locum employment
New Zealand has two Government-funded rural locum schemes:

Northern Rural General Practice Consortium


(covers north of Warkworth)
P O Box 57
Kerikeri 0470
Tel: +64-9-407 3561
Fax: +64-9-407 3571
Email: ruralgps@xtra.co.nz
Website: www.ruraldocs.co.nz

NZ Rural GP Network
(covers Warkworth south)
P O Box 547
Wellington
Tel: +64-4-472 3901
Fax: +64-4-472 0904
Email: enquiries@rgpn.org.nz
Website: www.nzlocums.com.nz

There are a large number of non-government recruitment agencies;


a few of these are listed below:

Auckland Medical Bureau


P O Box 37-753
Parnell
Auckland

11
Tel: +64-9-377 5903
Fax: +64-9-377 5902
Email: doctors-amb.nz@xtra.co.nz
Website: www.doctorjobs.co.nz

Geneva Health International


Level 2
137 Quay Street
P O Box 106339
Auckland
Tel: +64-9-916 0200
Fax: +64-9-916 0201
Email: bridgetm@genevahealth.com
Website: www.genevahealth.com

Gold Standard Locums


P O Box 487
Cambridge
Tel: +64-7-823 4607
Fax: +64-7-823 4608
Email: info@locums.co.nz
Website: www.locums.co.nz

KIWIS Stat
Unit 1, 88 Hayton Road
Christchurch
Tel: +64-3-339 0335
Fax: +64-3-339 0598
Email: manager@kiwisstat.co.nz

12
The Canterbury Medical Locums Association
Medlab South
Christchurch
Tel: +64-3-363 0824
Fax: +64-3-363 0803

Locum List
Practice Manager, Dunedin Urgent Doctors and Accident Centre
Tel: +64-3-479 2900
Fax: +64-3-477 0194
Email: manager@urgentdocs.co.nz

Section 88
General practitioners working outside the Primary Health Organisa-
tions (see page 36) are required to hold a Section 88 notice to qualify
for subsidies. These are generally geographically restricted and new
section 88s are only allocated in areas where there is an undersupply
of doctors. The section 88s are being rapidly phased out however as
the overwhelming majority of patients will be treated in PHOs where
there is capitation paid quarterly for the patient population enrolled
with that PHO.

13
SECTION 2
General practice overview

What services do GPs provide?


In New Zealand general practitioners provide primary, community-
based, comprehensive and continuing patient-centred care to indi-
viduals, families or whanau and their community, hapu and iwi.

Functions of general practice include: first contact, diagnosis, man-


agement, continuity of care, health promotion, prevention and screen-
ing. GPs act as gatekeepers, as access to public secondary and ter-
tiary services requires referral by a GP. Many private specialists also
only see patients referred by a GP.

General practices are normally involved in the provision of 24-hour


cover for their population. Provision for after hours cover is provided
in a variety of ways. For example, some practices run their own after
hours care, while others are members of an after hours centre or
roster after hour care with other practices.

What is the work environment?


Many general practices run as private businesses but organisations
such as community trusts, accident and emergency services, or Maori
health providers employ GPs.

14
In New Zealand, general practices function as teams. Most general
practices employ practice nurses and reception staff and a growing
number employ practice managers. Practice nurses play an impor-
tant role, providing health advice and services such as immunisa-
tion, screening, diet, diabetes and asthma care. Other staff such as
psychologists, social workers, physiotherapists may work in, or be
associated with, practices.

Who pays for general practice visits?


Most practices are in Primary Health Organisations (PHOs, see page
36) and receive funding based on their enrolled population. Those
practices who provide care for populations with a high percentage of
Maori, Pacific and lower socio-economic groups receive increased fund-
ing and are able to provide consultations at a lower cost to all their
patients. This provision also applies to 65-year-olds and older, to
under six-year-olds, and is being extended to other age groups by
2007. Almost 95 per cent of the population were enrolled in 79
PHOs by 2005.

A few practices continue to be funded on a fee-for-service basis,


where patients are charged a fee for each consultation, reduced if
applicable by a subsidy from the government (see Appendix 1).

In addition, some patients carry health insurance, which may in-


clude a refund for GP visits, but the majority have cover only for
specialist or surgical services. Where the insurance covers GP visits,
the full fee is charged and the patient makes a claim to their insurer.

Self-employed GPs set their own fees for consultations and other serv-
ices, although under new funding arrangements there may be a cap
to the amount charged. Practitioners’ fees vary depending on the way

15
they are funded, their population, the cost of operating the practice
(rents etc.), factors relating to the consultation such as the time and
complexity of the consultation and the circumstances of the patient.

It is best to check with the practice where you will be working.

Referred services
Most laboratory tests and x-rays are free to the patient, but may be
associated with a budget held by the practice; check with your prac-
tice for details. Private radiology clinics charge for all tests under-
taken, unless they have been contracted to provide them by a local
District Health Board.

Medicines
Some medicines are subsidised in New Zealand. PHARMAC
(www.pharmac.co.nz), a government organisation, specifies which
medicines will be subsidised; these are listed in the pharmaceutical
schedule. Where there is more than one medicine with similar ef-
fects, the Government may subsidise only one brand (for more de-
tailed information see Appendix 1).

Computerisation
Almost all practices in New Zealand are computerised to some ex-
tent. Some have only reception activities such as an age/sex register,
daily log, and accounts on a computer, but increasingly practices
have fully integrated clinical notes, integrated lab results and clinic
letters, and email and internet access.

There are a number of patient management systems (PMS) in use for


example MedTech, Houston and Profile.

16
General practice workforce
As of March 2003, 2324 doctors reported their main work place as
general practice, this is 37 per cent of the medical workforce.2 A
considerable proportion of the New Zealand general practice
workforce was trained overseas; The Medical Council vocational
register at March 2003 showed that of a total of 13,094 medical
practitioners in all vocations 5270, or 40 per cent obtained their
primary medical qualification overseas.

New Zealand has an average of 1150 patients per doctor. However


there is considerable variation between rural (1488 per doctor) and
urban regions (1093 per doctor).2 As these figures suggest, New
Zealand has a shortage of GPs in rural areas and also in the more
deprived urban areas. The Medical Council workforce report can be
found on its website: www.mcnz.org.nz.

The Health Workforce Advisory committee provides information to


the Minister of Health on workforce issues. Its website provides some
informative reports: www.hwac.govt.nz.

Medico legal environment


The Accident Compensation Corporation (ACC) (www.acc.co.nz)
provides compensation for personal injuries to all people in New
Zealand and removes the right to sue for personal injury (other than
for exemplary damages); this includes treatment injury.

This system is reflected in the cost of medical indemnity premiums in


New Zealand, which are considerably lower than in other countries
such as Australia. Medical indemnity insurance, or malpractice in-
surance, is not compulsory for the self-employed, but it is strongly
recommended.

17
Medical indemnity insurance is provided by:
The Medical Protection Society
Website: www.mps.org.uk
Tel: 0800 225 5677

Despite this protection from being sued, there are still a number of
investigations to which a GP can be subject, such as from the Health
and Disability Commissioner, or a coroner.

For further information contact the RNZCGP or the Medical Protec-


tion Society on the 0800 number above.

18
Professional development

The legal framework for general practitioners is the Health Practition-


ers Competence Assurance Act, whose primary purpose is to ensure
that all medical practitioners are competent to practise medicine. The
Medical Council has set up a number of processes to implement this
provision. All doctors throughout their career must be involved in con-
tinuing education, quality improvement activities and audit.

See the Medical Council website (www.mcnz.org.nz) for more in-


formation on requirements.

Contact the College or your local independent practitioners’ asso-


ciation to find out about CME programmes and what is available in
your area.

The Royal New Zealand College of General Practitioners


The College (www.rnzcgp.org.nz) is a membership-based organi-
sation; its current membership is around 3500, covering about 95%
of New Zealand’s GPs. We provide advocacy and support for general
practice and practitioners, delivering postgraduate education, pro-
fessional development and quality tools – all aimed at supporting
and strengthening general practice.

The College provides educational programmes that focus on rural


general practice for undergraduates, and a two-stage General Prac-

19
tice Education Programme (GPEP). The Stage One programme in-
cludes both a 40-week course for registrars and a seminar programme,
each aimed at preparing candidates for the College’s Primary Mem-
bership Examination (Primex).

The exam has both written and practical components, and once
passed candidates have achieved Membership of the College.

The Stage Two Advanced Vocational Education (AVE) programme


leads to Fellowship of the College and enables the GP to apply to
the Medical Council for registration within the vocational scope of
general practice. This entitles doctors to practise in general practice
without supervision. Currently this pathway for general practice
registration is the only pathway recognised by the Medical Council.

The diagram below describes the preferred pathway to Fellowship.


A number of other options are also available.

Educational Pathway to Fellowship and Vocational Registration

Postgraduate years

Hospital General Practice Maintainance of


based Education Programme Professional
training (GPEP) Standards (MOPS)

Rural STAGE I STAGE II


general General Advanced
PRIMEX Examination

practice Practice Vocational


Assessment Visit

rotation Education Education 3 year


MRNZCGP

FRNZCGP

option Programme cycle


and
Seminar
Programme
Option
Registration within the Vocational
Scope of General Practice

20
Doctors who are registered within the vocational scope of general
practice are required by the Medical Council to undertake a
Maintenance of Professional Standards Programme (MOPS); the
College provides a MOPS programme for its members, currently the
only programme for GPs which is recognised by the Medical Council.

The College maintains a national network of continuing medical edu-


cation providers. These organisations have agreed to run GP fo-
cused education that meets the criteria for high quality.

Practice accreditation
The College has a practice accreditation programme, Cornerstone,
whereby practice teams assess themselves against general practice
standards set out in the College publication Aiming for Excellence.
Teams of trained independent assessors – GPs, nurses and practice
managers – check the assessment findings, aiming at achieving the
optimum patient care in every practice. GPs also earn MOPS credits
going through the process. Full details are available from the College.

Independent Practitioner Associations


Since 1993 the majority of general practitioners have organised them-
selves into groups called Independent Practitioner Associations (IPAs).
IPAs provide a range of management and support services for their
members such as continuing medical education, quality improvement
activities and information technology support. Some are also linked
to Primary Health Organisations.

New Zealand Guidelines Group (NZGG)


The New Zealand Guidelines Group provides training on develop-
ing guidelines and manages the production of many NZ clinical

21
guidelines. Clinical guidelines are produced to help doctors and
patients make decisions about health care in specific clinical circum-
stances. The NZGG also maintains a website containing its own and
other New Zealand guidelines, and provides links to overseas sites:
www.nzgg.org.nz

Medical Journals
The key publications for GPs in NZ are:

New Zealand Family Physician: journal of the Royal New Zealand


College of General Practitioners, tel: +64-4-496 5972.

GP Pulse: current affairs magazine of RNZCGP, tel: +64-4-496 5962

New Zealand Medical Journal: journal of the New Zealand Medi-


cal Association, tel: +64-4-472 4741.

New Zealand Doctor: fortnightly newspaper produced by


CMPMedica, tel: +64-9-488 4279.

22
Doctor/patient relationship

Patient-centred care
Good general practice in New Zealand is based on patient-centred
practice. In using patient-centred approaches the doctor moves be-
yond the pathophysiology of disease and explores the biological,
psychological and social components of their patients’ illnesses. Pa-
tient-centredness does not diminish the importance of biomedicine,
but assumes biomedical expertise and builds from it.

The patient-centred method consists of six interactive components:3

1. Exploring both the disease and the illness experience: this


involves the GP understanding two conceptualisations of ill
health: disease and illness.*
2. Understanding the whole person: over time accumulat-
ing an understanding of the whole person to enable the un-

* ‘Disease’ which relies on signs and symptoms to detect abnormalities of


structure or function and to make a diagnosis.
‘Illness’ which is the patient’s individual experience of ill health. It fo-
cuses on their feelings about being ill, ideas about what is wrong, the
effect of their problems on their function and their expectations of what
should be done.
Effective patient-centred care requires attending as much to the patient’s
personal experiences of illness as their disease.

23
derstanding of illness in terms of their life setting and stage
of development.
3. Finding common ground: requires working with the patient to
develop an effective management plan by reaching agreement
about the nature of the problem and priorities, the goals of
treatment and the roles of the patient and doctor.
4. Incorporating prevention and health promotion: working
together to identify areas of lifestyle etc. that need strengthen-
ing in the interests of long-term physical and mental health.
Also monitoring recognised problems and screening for unrec-
ognised disease.
5. Enhancing the patient-doctor relationship: building effec-
tive relationships which encourage working together and can
assist in healing.
6. Being realistic: learning to manage time and energy efficiently
for the maximum benefit of patients.

FIFE
The acronym FIFE4 provides a guide to undertaking a patient-cen-
tred assessment.

F: Feelings “Do you have any fears and concerns I should know about?”

I: Ideas “What do you think this pain means?”

F: Function “How does this illness affect your daily activities?”

E: Expectations “What is your expectation of this consultation?”

The New Zealand Medical Association Code of Ethics


These principles of ethical behaviour are applicable to all doctors,
including those who may not be engaged directly in clinical practice.

24
1. Consider the health and well-being of your patient to be your
first priority.
2. Respect the rights of the patient.
3. Respect the patient’s autonomy and freedom of choice.
4. Avoid exploiting the patient in any manner.
5. Protect the patient’s private information throughout his/her life-
time and following death, unless there are overriding public
interest considerations at stake, or a patient’s own safety re-
quires a breach of confidentiality.
6. Strive to improve your knowledge and skill so that the best pos-
sible advice and treatment can be afforded to your patient.
7. Adhere to the scientific basis for medical practice while acknowl-
edging the limits of current knowledge.
8. Honour your profession and its traditions in the ways that best
serve the interests of the patient.
9. Recognise your own limitations and the special skills of others in
the prevention and treatment of disease.
10. Accept a responsibility for assisting in the allocation of limited
resources to maximise medical benefit across the community.
11. Accept a responsibility for advocating for adequate resourcing of
medical services.

www.nzma.org.nz/about/ethics.html

Boundary issues
Boundary issues are very important in general practice, in particular
in rural communities where many patients will be your friends or
acquaintances. There is a need to set clear boundaries clarifying
what is acceptable to you and your profession. How you manage

25
boundaries will depend on the situation, the people involved and
your own style. Some ways of maintaining boundaries include:5

• Asking only relevant personal details when taking a medical


history.
• Explaining sensitive examinations or treatment before carrying
them out.
• Keeping discussions and records confidential.
• Providing privacy with screens for undressing, draping or dressing.
• Checking if the patient wants a chaperone or support person present.
• Avoiding words, actions or jokes that are sexual put downs or
are embarrassing.
• The doctor keeping own personal problems private.

The Medical Council provides clear guidance on sexual relation-


ships between a doctor and patient.

Medical Council statement on sexual abuse


in the doctor/patient relationship
Sexual behaviour in a professional context is abusive. Sexual behav-
iour comprises any words or actions designed or intended to arouse
or gratify sexual desires. The doctor must ensure that every interac-
tion with a patient is conducted in a sensitive and appropriate man-
ner, with full information and consent.

The Council condemns all forms of sexual abuse in the doctor/pa-


tient relationship for the following reasons:
• The ethical doctor/patient relationship depends upon the doc-
tor creating an environment of mutual respect and trust in which
the patient can have confidence and safety.

26
• The onus is on the doctor to behave in a professional manner.
Total integrity of doctors is the proper expectation of the com-
munity and of the profession.
• The community must be confident that personal boundaries will
be maintained and that as patients they will not be at risk. It is
not acceptable to blame the patient for the sexual misconduct.
• The doctor is in a privileged position, which requires physical
and emotional proximity to the patient. This may increase the
risk of boundaries being broken.
• Sexual misconduct by a doctor risks causing psychological dam-
age to the patient.
• The doctor/patient relationship is not equal. In seeking assistance,
guidance and treatment, the patient is vulnerable. Exploitation of
the patient is therefore an abuse of power and patient consent
cannot be a defence in disciplinary hearings of sexual abuse.
• Sexual involvement with a patient impairs clinical judgment in
the medical management of that patient. The Council will not
tolerate sexual activity with a current patient by a doctor.

See Medical Council website for further guidance:


www.mcnz.org.nz/standards/guidanceresources/#sexualabuse

27
SECTION 3
Health of New Zealanders

Cultural diversity
The main cultural groups in New Zealand are 80% European, 14.7%
Maori, 6.5% Pacific peoples, 2.9 % Chinese and 1.7% Indian. These
figures are from the 2001 census taken from the Statistics New Zea-
land website. Respondents may claim more than one ethnicity. Each
of these groups has a different place in the history of New Zealand.

Maori are the indigenous people of New Zealand arriving here from
around the 10th century A.D. Estimates of the size of the Maori popu-
lation at the time of European contact at the beginning of the nine-
teenth century range from 100 000 to 500 000.6 In the years follow-
ing contact with Europeans, numbers decreased dramatically to a
lowest point of 42 000 in 1896.6 From this time there has been a
recovery in Maori population.

European settlement in New Zealand started around 1840, predomi-


nantly with settlers from the British Isles but later also included peo-
ple from the Netherlands, Yugoslavia, Germany and other nations.

Since 1960 people from the Pacific Islands have added to the cul-
tural diversity of New Zealand. The population from Pacific Islands
ethnic groups has grown sharply from 100 000 in 1981 to 262 000
in 2001.

28
New Zealand has received refugees from different areas of the world
since the 1930s. These include Indo-China (largest group), Poland,
Chile, Russia, East Europe, Assyria, Ethiopia, Bosnia and Somalia.6

See the Statistics New Zealand website for further information:


www.stats.govt.nz

Health status
(MSD 2004 social report, MoH 2004 Pacific Health Chart book)
Overall mortality rates in New Zealand have declined dramatically
over the last 50 years. In the period 2000–2002, life expectancy at
birth is 81.1 years for women and 76.3 years for men. Since the mid
1980s, gains in longevity have been greater for males than for fe-
males. With the decline in the infant mortality rate (from 11.2 deaths
per 1000 live births in 1986 to 4.9 per 1000 in 2003), the impact of
infant death on life expectancy has fallen. The gains in life expect-
ancy since the mid 1980s can be attributed mainly to reduced mor-
tality in middle-aged and old age groups (45–84 years).

There are marked ethnic differences in life expectancy. In 2000–2002,


female life expectancy at birth was 81.9 for non-Maori, 76.7 for Pacific
people, and 73.2 years for Maori; male life expectancy at birth 77.2
for non-Maori, 71.5 for Pacific people and 69 years for Maori.

Common diagnoses
(Portrait of Health Key results of the 2002/3 NZ health survey)
One in five adults aged 15–44 years have been diagnosed with
asthma. There was no significant difference between women and
men aged 15–44 years. In both females and males the prevalence
of asthma was significantly higher (about four times) in Maori and
European/Other groups, then Pacific people and Asian ethnic groups.

29
One in 10 adults have been diagnosed with heart disease. There was
no significant difference between women and men nor in ethnic groups.

One in 20 adults have been diagnosed with cancer. Females are


significantly more likely than males to be diagnosed with cancer.

One in 23 adults have been diagnosed with diabeters and its preva-
lence was higher in Maori and Pacific people than in the European/
Other ethnic group.

Maori also have higher death rates from sudden infant death syndrome
(SIDS), youth suicide, violence and motor vehicle crashes. Maori infant
mortality is significantly higher, 11.6 per 1000 compared with 5.3 per
1000. Maori and non-Maori differences in health are present in almost
every disease category as well as admission rates to hospital.9

Pacific people
Pacific people also have poorer health outcomes than the nation as
a whole. Life expectancy for Pacific women is 76.2 years, and for
Pacific males 68.8 years, around six years less than European New
Zealanders.8

Pacific people have the highest rates of meningococcal disease, rheu-


matic heart disease and obesity of all people living in New Zealand.
There is an increasing rate of SIDS, low immunisation rates, high
hospitalisation rates in children, particularly for pneumonia, asthma
and middle ear infections and high rates of diabetes, tuberculosis
and liver cancer in adults.8

Reducing health inequalities


The government has made reducing health inequalities a key prior-
ity for all disadvantaged groups, particularly for Maori. This has in-
volved addressing issues of access to, and effectiveness of, health

30
services and also tackling the underlying social and economic con-
ditions that impact on people’s health.

Directions to improve health of Maori have involved:6


• Greater Maori participation at all levels of the health sector
• Development of Maori health organisations ‘by Maori for Maori’
• Resource allocations that take into account Maori health needs
and perspectives
• Development of culturally appropriate practices and procedures
by all health providers.

Maori health
To understand the reasons for Maori health disparities it is important
to understand the history of NZ and the current patterns and social
relationships.

The Treaty of Waitangi


The Treaty of Waitangi defines the relationship between Maori and
the Crown; it is recognised as the founding document of our nation.
The Treaty of Waitangi was signed in 1840 by Maori chiefs and by
Captain William Hobson on behalf of the Crown.

The Treaty was written in both the Maori and English languages but one
is not an exact translation of the other, so this has created different
expectations. Maori believed that greater recognition of Maori authority
was promised, whereas the government insisted that there had been a
full and complete transfer of sovereignty.6 In practice, power passed
very quickly from Maori to non-Maori. Grievances from the past continue
today around land, language, authority and self-determination.

Today the Treaty is used as the document that underpins the Govern-
ment’s relationship with Maori; it is reflected in all government strat-

31
egies. Some compromise has been reached around the differing
interpretations by defining principles inherent in the Treaty. The prin-
ciples most often applied to health are:6

• Partnership – working together with iwi, hapu, whanau and


Maori communities to develop strategies for improving the health
status of Maori.
• Participation – involving Maori at all levels of the sector in plan-
ning, development and delivery of health and disability services.
• Protection – ensuring Maori rates of illness are improved to at
least the same level as non-Maori, and safeguarding Maori cul-
tural concepts, values and practices.
More information on the Treaty can be found at www.govt.nz/
aboutnz/treaty.

A glossary of Maori words used in this document can be found on


page 71.

Maori view of health


Maori have an holistic view of health. The whare tapa wha (four-
sided house) model is one model used to describe the Maori health
perspective.6 The whare tapa wha model compares health to the
four walls of the house, all four being necessary to ensure strength
and symmetry, though each representing a different dimension: taha
wairua (the spiritual side), taha hinengaro (thoughts and feelings),
taha tinana (the physical side), taha whanau (family).

It is similar to the familiar ‘physical, psychological, social and spir-


itual’ dimensions of diagnosis promoted in British general practice
for many years.

32
The characteristics of whare tapa wha are:6
Focus Taha Taha Taha Taha
Wairua Hinengaro Tinana Whanau
(Spiritual) (Mental) (Physical) (Extended family)

Key aspects The capacity The capacity The capacity The capacity
for faith to commun- for physical to belong,
and wider icate, to growth and to care,
communion think, and development and to share
to feel
Themes Health is Mind and Good Individuals
related to body are physical are part of
unseen and inseparable health is wider social
unspoken necessary systems
energies for optimal
development

The Maori health website (www.maorihealth.govt.nz) provides


further information on Maori health.

33
Health care sector overview

Minister of Health
The Minister of Health has overall responsibility for the health sys-
tem. The Minister determines the health and disability strategies,
powers with respect to District Health Boards (DHBs), making ap-
pointments to ministerial committees and professional regulatory
boards, and agrees how much public money will be spent on the
public health system.

Ministry of Health
The Ministry of Health has a number of key functions including
providing policy advice to the Minister of Health on all aspects of
the health and disability sector, acting as the Minister’s agent and
providing a link between the Minister of Health and DHBs.

In addition, the Ministry of Health provides public health surveil-


lance and information services and implements and administers and
enforces relevant legislation and regulations. The Ministry of Health
has responsibility for funding some services such as public health
and disability support services. Over time the majority of funding for
health and disability support services is likely to be transferred to
District Health Boards.

District Health Boards


District Health Boards are responsible for the provision of health
care services in their area, including both primary care and hospital

34
services. There are currently 21 DHBs. The boards are made up of a
majority of members elected by the community and a minority ap-
pointed by the Minister of Health.

Central Government provides broad guidelines on what services the


DHBs must provide and national priorities have been identified in the
New Zealand Health Strategy. Services can be purchased from a range
of providers including general practitioners, public hospitals, non-profit
health agencies, iwi groups or private organisations. Funding is allo-
cated to DHBs using a weighted population-based funding formula.

The New Zealand Health Strategy


The New Zealand Health Strategy 2000 identifies seven fundamen-
tal principles for the health and disability sector:
1. Acknowledging the special relationship between Maori and the
Crown under the Treaty of Waitangi
2. Good health and well-being for all New Zealanders throughout
their lives
3. An improvement in health status of those currently disadvantaged
4. Collaborative health promotion and disease and injury preven-
tion by all sectors
5. Timely and equitable access for all New Zealanders to a com-
prehensive range of health and disability services, regardless of
ability to pay
6. A high-performing system in which people have confidence
7. Active involvement of consumers and communities at all levels.

It also highlights 13 population health objectives:


1. Reduce smoking
2. Improve nutrition
3. Reduce obesity

35
4. Increase the level of physical activity
5. Reduce the rate of suicides and suicide attempts
6. Minimise harm caused by alcohol and illicit and other drug use
to both individuals and the community
7. Reduce the incidence and impact of cancer
8. Reduce the incidence and impact of cardiovascular disease
9. Reduce the incidence and impact of diabetes
10. Improve oral health
11. Reduce violence in interpersonal relationships, families, schools,
and communities
12. Improve the health status of people with severe mental illness
13. Ensure access to appropriate child health care services includ-
ing well child and family health care and immunisation.

The Primary Health Care Strategy 2001


This strategy follows on from the New Zealand Health Strategy. It sets
a direction for primary care placing emphasis on population health
and the role of the community, health promotion and preventive care.

Primary Health Organisations (PHOs) have been set up to provide


essential primary health care services to a defined group of people
who are enrolled with them. People join a Primary Health Organisa-
tion by enrolling through a provider of primary health care services
such as a general practice. In March 2005 about 95% of the whole
population was enrolled in a Primary Health Organisation.

PHOs are not-for-profit bodies funded by District Health Boards. PHOs


are expected to involve their communities and all providers and prac-
titioners in their governing processes.

36
The new direction brings extra funding to primary health care, aiming
to provide lower cost primary health care to all New Zealanders. It is
being introduced gradually, originally over 10 years, but is now
scheduled to be complete in 2007, targeting those most in need; those
in low income groups, Maori and Pacific people, over 64s, and under
25s. All age groups will have full capitation by July 2007.

PHOs are taking different forms and have different funding arrange-
ments depending on the needs of their population. Some general
practice organisations (Independent Practitioner Associations) – see
page 21 – are joining or forming PHOs.

Further information on the health and disability sector can be ob-


tained from a number of websites including:

Ministry of Health: www.moh.govt.nz/publications


An overview of the Health and Disability Sector in New Zealand

European Observatory of Health Care Systems: www.observatory.dk


This site provides two reports describing the NZ health system: a
comprehensive profile of the New Zealand health care system, and
a comparison between health care systems in eight countries, one of
which is New Zealand.

37
Regulatory requirements

There is a range of regulatory requirements that GPs need to be aware


of in their numerous roles, as a medical practitioner, an employer, a
professional delivering services to ‘customers’ and a business person.

Described in brief below are some of the most important Acts and
Codes you need to know about as a medical practitioner. References
are also provided for important Medical Council statements that pro-
vide more specific guidance on the various aspects of medicine.

Health Practitioners Competence Assurance Act 2003


The principle purpose of this Act is to ensure that all registered health
practitioners are competent to practice. Risk to the public is a key con-
cept. The Act provides for registration authorities (the Medical Council
for medical practitioners) and also disciplinary providers and institutions.

Decisions on scopes of practice, vocational registration, maintenance


of competence and the effects of disciplinary processes are all taken
by the Medical Council.

Health and Disability Commissioner Act


This Act created the Office of the Health and Disability Commis-
sioner, the Code of Health and Disability Services Consumers’ Rights,
the Director of Advocacy and the Director of Proceedings.

The Office aims to promote and protect patient rights, resolve com-
plaints relating to those rights, and ongoing education of providers and
consumers. It is a key element in the new environment of consumer-
focused and consumer-accountable health and disability services.

38
For further information see www.hdc.org.nz.

The Code of Health and Disability Services Consumers’ Rights 1996

The Code of Consumers’ Rights (the Code) details the 10 rights of


consumers and the duties of providers:

1. The right to be treated with respect

2. The right to freedom from discrimination, coercion, harassment,


and exploitation

3. The right to dignity and independence

4. The right to services of an appropriate standard

5. The right to effective communication

6. The right to be fully informed

7. The right to make an informed choice and give informed consent

8. The right to support

9. Rights in respect of teaching or research

10. The right to complain.

Information and consent

Rights 5, 6 and 7 of the Code require doctors to obtain informed


consent. It is an interactive process between a doctor and patient
where the patient gains an understanding of what is involved in re-
ceiving a proposed procedure or treatment and, free from coercion,
gives agreement.

The Medical Council provides the following relevant statements on


informed consent:
• Information and consent
www.mcnz.org.nz/about/forms/ConsentApr02.PDF

39
• Legislative requirements about patient rights and consent (out-
lines the statutory provisions that allow a doctor to proceed with-
out obtaining informed consent).
www.mcnz.org.nz/about/forms/legislativereqpatientrights.PDF

Privacy Act 1993


The Act created the Office of the Privacy Commissioner and enabled
the Health Information Privacy Code to be issued. It applies to every
person or organisation in New Zealand in respect of personal infor-
mation held in any capacity other than for the purposes of their per-
sonal, family or household affairs.

The Act empowers the Privacy Commissioner to investigate com-


plaints of interferences with privacy, places some controls on the
administration of public registers and authorises some government
agencies to undertake information-matching programmes.

Health Information Privacy Code 1994

This Code deals with health information collected, used, held and
disclosed by ‘health agencies’ and is a substitute for the information
privacy principles in the Privacy Act.

It applies to health information relating to identifiable individuals;


the code does not apply to anonymous or aggregated statistical in-
formation where the individuals cannot be identified.

For further information see: www.privacy.org.nz

Guidelines for the maintenance and retention of patient records

The Medical Council provides specific information on this topic. They


cover: maintaining patient records, practice systems, fees and pa-

40
tient records, transferring patient records, retaining patient records,
storage requirements, destruction of patient records.

For further information see:


www.mcnz.org.nz/about/forms/recordsguide.PDF

Statement on confidentiality and public safety

The Medical Council provides guidance for doctors balancing the


need for confidentiality and disclosure of patient information in the
interests of public safety.

For further information see:


www.mcnz.org.nz/about/forms/confidentialityandpublic
safety.PDF

Medicines Act 1981 and the Misuse of Drugs Act 1975


These Acts and regulations govern legal and illegal use of all drugs
and prescribing. Medsafe (a business unit of the Ministry of Health)
administers them.

The Medicines Act and regulations control which products may le-
gally be distributed, the places where medicines may be manufac-
tured (through a licensing system), the importation and distribution
of medicines, as well as quality standards for medicines and for
packaging. It outlines the circumstances under which a person may
legally sell or distribute a new medicine. The general rule is that it is
an offence to distribute a medicine that has not received Ministerial
consent as notified in the New Zealand Gazette.

The Misuse of Drugs Act and regulations regulate controlled drugs


and outlines who may supply, possess and deal with them and how
they are to be stored.

41
Mental Health (Compulsory Assessment and Treatment)
Act 1992
This Act provides for the compulsory assessment and treatment of
people who are mentally disordered, as defined by the Act.

Mental disorder in relation to any person means an abnormal state


of mind (whether of a continuous or intermittent nature), character-
ised by delusions, or by disorders of mood perception or volition or
cognition, of such a degree that it:
• Poses a serious danger to the health or safety of others, or
• Seriously diminishes the capacity of that person to take care of
himself or herself, and ‘mentally disordered’ in relation to any
such person has a corresponding meaning.
A duly authorised officer should be contacted immediately for guid-
ance. The Act allows for medical practitioners to administer sedation
and/or call for police assistance in emergencies.

A doctor’s duty to help in an emergency


If a doctor is asked to attend a medical emergency as defined in this
statement, they must respond. It is both an ethical and legal obliga-
tion. Rarely will there be times when attending a medical emergency is
impossible or unsafe for the doctor or patient. If a doctor chooses not
to attend, he or she may be required to defend that decision in the
event of a charge of professional misconduct or criminal prosecution.

For a full copy of the statement see: www.mcnz.org.nz/about/


forms/obligation%20to%20render%20assistance.pdf

42
Guidelines on transmissible major viral infections
The Medical Council encourages the testing of health care workers
and patients exposed to Hepatitis B, C and HIV. It also provides guid-
ance to health care workers infected with these viruses.

For a full copy of the statement see: www.mcnz.org.nz/about/


forms/policy%20transmissible%20viral%20infection.pdf

43
Orientation to
general practice

This section provides practical information for getting started in New


Zealand general practice. It provides information on medical records,
prescribing, forms, making referrals and the recommended contents
of a doctor’s bag.

Content of medical records


The following are the recommendations for medical records in NZ:

Demographic data
• Name of patient
• NHI number
• Gender
• Address
• Date of birth
• Ethnicity
• Registration status
• Registered/casual
• Principal care giver/next of kin

44
• Significant relationships
• Contact phone number
• Community Services Card
• Occupation

Consultation records
• The entry is dated
• Person making entry is identifiable
• The entry is legible

Recent consultations recorded


• Reason for encounter
• History
• Examination findings
• Assessment
• Investigations ordered
• Management plan including medication change, additions, fol-
low up arrangements
• Medicines are clearly identifiable:
drug name/dose/frequency/time.

Medical records show


• Clinically important drug reactions and other allergies are eas-
ily identified
• Awareness alert for specific disability etc.
• Problem lists are easily identifiable
• Preventive care
• Current medicine list

45
• Risk factors are identified and markers used
– Family history
– Smoking
– Alcohol, drug
– Blood pressure
– Weight/height/BMI
• Immunisations
– Last tetanus booster recorded
– Childhood immunisations
– Flu shots if indicated
• Referrals and responses are easily accessible in clinical records
– Laboratory
– X-ray
– Other tests
– Other health information
• Screening
– Cervical smears
– Mammograms
– Other screening according to national or local policies.

Prescribing
The MIMS New Ethicals Catalogue (equivalent of the British MIMS)
is published twice a year and carries the details of all agents which
may be prescribed, in addition to lists of agents available ‘over the
counter’ (OTC), i.e. directly from pharmacists without a prescription,
and The Medical Practitioner Supply Order List (see below). There
are also a variety of tables at the back with information such as

46
height/weight charts, management of common poisonings, tropical
diseases, etc. Available in book form, on compact disk and through
some practice management computer systems.

The Pharmaceutical Schedule lists the prescription medicines and


related products that are subsidised by the government. PHARMAC
publishes the schedule three times a year and provides monthly up-
dates. It is distributed free to GPs and can also be accessed elec-
tronically via the PHARMAC website (www.pharmac.co.nz) or on
some patient management systems (PMS).

The medicines
The most commonly used agents tend to have one version, which is
fully funded. Either prescribe generically or choose Fully funded
agents marked with an S in the New Ethicals and a tick (✓) in the
Pharmaceutical Schedule.

If there is a part charge to the patient on an agent it is marked SP.

If the agent carries no subsidy (e.g. Viagra) it is marked NS.

Some expensive or sophisticated agents (e.g. cytotoxics) can only be


prescribed on the recommendation of an appropriate specialist.
These are marked ‘retail phcy, spec.’ or ‘hosp. phcy, spec.’ in
MIMS New Ethicals. When prescribing these, the script has to be
endorsed ‘Recommended by (insert the specialist’s name) and then
the date of recommendation’ e.g. ‘Recommended by Dr Grieg
20.02.2002’. The recommendation is valid for two years.

Some agents, usually expensive ones like ‘statins’, the newer antide-
pressants or long acting beta-agonists or recently released ones like
angiotensin II inhibitors, are only subsidised if certain patient criteria
are met. These require ‘Special Authority’ (marked SA in the book),
and require submission of an application form and approval.

47
Medical Practitioners Supply Orders (MPSO)
There is a list of agents in the front of MIMS New Ethicals, which can be
obtained by medical practitioners on a special order form for personal
administration to patients in emergencies or to initiate treatment. Rural
practitioners may select agents from the main body of the book but
beware that you will be liable for any part-charges relating to the agents
and will have to consider passing that charge on to the patient.

There is a special green form with which to put in your requests.

There is a separate MPSO form for controlled drugs. Ask another


GP in the practice.

Writing the prescription


There are a number of legal requirements, including:
• You will need a prescription pad with your name and Medical
Council number on it
• Always keep your prescription pad secure
• Prescription of controlled drugs is written on a special pad of
triplicate forms obtained from the Ministry of Health
• You have a responsibility to write prescriptions clearly and legibly
• All prescriptions must be dated.

For further information please refer to:


Medsafe www.medsafe.govt.nz

Ordering lab tests and x-rays


Most laboratory tests and x-rays are free. Private radiology clinics
charge for all tests undertaken, unless they have been contracted to
provide them by a local District Health Board.

Talk to the practice staff for information on where the closest services are.

48
Medical certification
As a GP you will be required to sign a range of medical certificates
such as sickness and death certificates.

The Medical Council provides guidelines on the requirements and


your obligations when completing these forms: Guidelines for
Medical Certification.
www.mcnz.org.nz/standards/guidanceresources/default.asp

Patient admission to hospital


or specialist referral
There are two systems available:
• Government-funded health care
• Private health care.

Government-funded health care


Secondary and tertiary care is provided entirely free through public
hospitals. They treat the majority of acute medical and surgical con-
ditions. A drawback is the waiting times for non-acute conditions.
However, there may be ways to expedite appointments for clinics or
surgery if a patient’s condition deteriorates. Phone contact with rel-
evant departments or specialists is usually necessary to make any
progress, and they will ask you to write another letter explaining the
need for greater urgency.

National and local guidelines on referral and assessment for pub-


licly funded secondary services are available from www.nzgg-
careplans.org.nz.

Chasing consultants at the hospital can be a variable experience.


Some respond within a minute of being paged, others don’t carry
pagers and can be difficult to contact. In general, when you want

49
advice, seek a consultant. To arrange admission, ask for the registrar
or house surgeon.

When seeking advice it is good to keep the patient beside you be-
cause inevitably you’ll be asked about something you haven’t thought
to check on. It also helps the patient to have the situation clarified for
them by listening to the call, though your technical conversation may
need translating afterwards for them.

Private health care


This is based on private specialist clinics and private hospitals. Pri-
vate care tends to be much quicker for non-emergencies; you choose
your consultant and the accommodation tends to be plusher.

There is a small General Specialist Subsidy but otherwise the patient


pays for everything. This includes specialist fees, surgical fees, theatre
fees, hospital accommodation, disposable supplies and materials.
Pharmaceuticals are funded in the same way as for primary care.

Insurance companies will pay variable amounts towards costs, typi-


cally 80% of an agreed schedule.

ACC will pay up to 100% of costs depending on circumstances for


accident-related conditions.

Access to specialists in their private practices is generally very good.


Talk to your practice about specialists available in your area.

Forms
This section includes a variety of the forms you will meet in your first
few days.

50
Practitioner Supply Order Form (F270)
This one is useful. You can use it to stock your medical bag from a
pharmacy. If you are a rural GP you are not restricted to the Practi-
tioner Supply Order in the front of MIMS New Ethicals but you need
to pay any charges.

ACC forms
ACC 45 – a form for registering the first consultation associated
with an accident. It can also be used at this time for referral for
investigations, therapy or specialist opinions. It is a quadruplicate
form with copies to:
1. ACC head office
2. the GP (keep in notes)
3. the patient (takes away), and
4. the one for referrals (give to patient or keep in notes if not im-
mediately needed).

ACC 18 – for subsequent consultations requiring time off work. Also


in quadruplicate, keep the second layer for the notes, the other three
go with the patient. (Re-visits for clinical reasons but not requiring
work certificates require no forms.)

ACC 41/ M 41 – for later referral for investigation etc. Triplicate form;
keep one for notes, give two to patient for the therapist to process.

ACC 2152 – for claims for injury caused by medical treatment.

Many practices now have these forms available on computer.

Sickness Benefits
The main form is called Community Wage – Medical Certificate. Put
out by the Ministry of Social Development.

51
Practices will have their own ‘sick notes’ for employers.

Disability Allowance Application


Also available from the Ministry of Social Development, these are
for people with a long-term disability (i.e. expected to last for at least
six months or during terminal illness) to cover such things as:
• Medical fees
• Prescription fees
• Transport to clinics
• Gardening
• Personal medical alarms
• Phone
• Heating
• Special foods
• Access to private counselling or physical treatments.
There is a section for GPs to fill in and they need to be renewed
regularly.

Pharmaceutical ‘Special Authority Application Form’


This form is for obtaining a waiver on patient part-charges for cer-
tain expensive but important items. A variety of forms exist such as
for lipid lowering agents (Statins), Long Acting Beta Agonists, Angi-
otensin II inhibitors and you will find these both as generic forms
from PHARMAC and pre-printed forms from the drug companies
promoting their products.

Medical Certificate for Driver Licence


The extent of the examination depends on the type of licence required
(e.g. commercial or driving heavy goods) and on the patient’s state of

52
health. See the booklet Medical Aspects of Fitness to Drive put out by
the Land Transport Safety Authority for further guidance.

Aviation medicals, racing drivers, jet-boat medicals, diving medicals


etc. all have their own forms (and in some cases designated medical
examiners – i.e. you can’t do them.)

Contents of a doctor’s bag


The content of a GP’s bag should enable the treatment of emergen-
cies, as well as other problems encountered on house calls. The
contents required will depend on the style and location of your prac-
tice, for example if you work in a rural area you may require more
emergency drugs.

The bag should be large enough to carry everything you need and be
well organised to enable items to be easily located. The bag should
always be kept in a secure location when not in your possession;
prescription pads should be kept to a minimum. Controlled drugs can
only be in the doctor’s bag if they are there for immediate use (with
the exception of diazepam). If controlled drugs are stored in the doctor’s
bag in case of an emergency use, there is a requirement for the bag
to be in a locked container bolted to the floor of the boot of the car.

The content of the bag needs to be reviewed regularly and a system


established to replace items when used or outdated.

The following are suggested minimum contents:11


• Airway
• Gloves
• Stethoscope
• Auriscope
• Opthalmoscope

53
• Sphygmomanometer
• Thermometer
• Tourniquet
• Lubricating jelly
• Spatula
• Alcohol wipes
• Range of needles and syringes
• Dressings
• Scissors
• Torch
• BM stix
• Protective device for mouth-to-mouth resuscitation
• Stationery:
– Prescription pads
– Letter writing paper
– Pen
– ACC forms
• Drugs for medical emergencies, minimum oral and injectable:
– Adrenalin 1/1000 or 1/10,000 inj.
– Aspirin tabs
– Atropine inj.
– Diazepam inj./rectal
– Ergometrine
– 50% Glucose/glucagon inj.
– Antihistamine inj.
– Local anaesthetic inj.

54
– Penicillin inj.
– Corticosteroid inj.
– Naloxone inj.
• Optional depending on the circumstances:
• Blood tubes:
– red top
– purple top
• Urine pots
• Laboratory swab
• Urine dipstix.

General practice systems


Providing good general practice care means working as part of a well
functioning team. Good quality care systems need to be in place, for
example, recall, managing patient test results and infection control.

The College, in collaboration with practice nurses, practice manag-


ers, consumers and many other organisations has developed a set
of indicators for general practice premises and systems in NZ. These
are described in Aiming for excellence: an assessment tool for gen-
eral practice.

It does not cover clinical competence, but covers:


• Factors affecting the patients
• Physical factors affecting the practice
• Practice systems
• Practice and patient information management
• Quality improvement and professional development.

55
Indicators are divided into those that are required by legislation,
those that are considered essential by the RNZCGP and those desir-
able to provide high quality care.

To obtain a copy contact the College.

56
Practice orientation

This template provides prompts for information considered impor-


tant for the orientation of new doctors to a practice; it may be altered
to suit the needs of your practice. It will take around 30 minutes to
complete initially but far less time to keep updated.

An electronic copy of this template can be downloaded from the


College website: www.rnzcgp.org.nz

Aim to have this information ready on the day you start work, or
ideally, a few days earlier.

Practice profile
The philosophy of our practice is…
Funding method (fund holding, capitation etc.)
The demographic mix of the practice’s patients is…
The socio-economic mix is…
Specific regional problems (e.g. freezing work accidents, leptospirosis)
The specialist areas of this practice are (e.g. acupuncture, maternity)…
The hours of consultation are…
Length of an average consultation is…
The number of patients we see a day is…

57
Practice staff
Practice partners
Practice manager
Practice nurse/s
Receptionist/s
Others who also work from the practice premises (e.g. physio)
The nurse’s duties include (smears, taking bloods)…
Where rosters are kept

Physical environment
A map of the area is found…
Layout of the practice and where to find dressings, emergency equip-
ment etc.
The layout of the room: smear equipment, forms etc.

Day-to-day routines
The patients are greeted…
The patients get from receptionist to doctor…
The patients information/fee is communicated to the receptionist…
The bloods/specimens are collected at…
Procedure for turning alarm on is…
Procedure for turning alarm off is…

Practice processes
Our protocol manual is kept…
The telephone consultation protocol for this practice is…
Prescription procedure is…

58
Repeat pharmaceutical prescribing policy is…
Patient test results protocol is…
Procedure for referring patients to hospital (i.e. outpatients)…
Procedure for admitting patients to hospital…
Protocol for dealing with non-registered patients i.e. visitors, tourists is…
Instructions for all electronic equipment is kept…
Privacy officer
Infectious control officer
Code of dress

Fees
(This is confidential information, please keep it in the confines of the
practice.)
Our fee schedule is…
Minimum fees
How much discretion does locum have with fees?

Emergencies
The emergency equipment is kept…
The emergency procedure is…
The panic button is found…
Police number
COOP protocol (in event of armed confrontation)
Fire control officer
Evacuation drill
The acute mental health services contact phone number is…

59
After hours arrangements
On call
Always ensure that someone knows where you are at all times
A second GP to cover you on call outs is…

House calls
House calls are/are not part of the service offered to the patients of
this practice
Any limitations e.g. only during the day
Time set aside for house calls
Patients we see on house calls
List of the special needs patients
Protocol for night visits (Some after hours clinics send their doctor in
a taxi – so they get there, and they have a chaperone if needed. They
also carry a cell phone which has a quick dial to the clinic, the am-
bulance and the hospital.)

Notes
Computerised practices
Patient management system used
Computer password
The information held on computer in this practice is…
The information you will be expected to put on computer is…
The key person to help you with accessing the computer information is…
Manuals are kept…

60
Manual practices
This is an example of how the patient notes are written (i.e. problem
list, progress notes)…
Recalls are written…
Follow-ups are written…
Results are written…
This is how the notes are organised…

Practice contacts
Name and phone number of :
Hospital
Physiotherapist
District nurse
Mental Health Services
Most frequently used specialists
Pharmacy
Investigations clinic (i.e. x-rays)
Laboratories used
Abuse contacts (e.g. women’s refuge, female solicitor, Children and
Young Persons Service, Doctors for Sexual Abuse Care, etc.)
Local self-help groups
Consumer advocate
Kaumatua
Iwi providers

61
Forms
Include forms most often used; examples of completed forms can be
useful.

Forms Refills When Delivery


kept processed pick-up
ACC
Death certificate
Specimens blood
Referral
Laboratory tests
GMS
MOT
Sickness
Other

Additional information for rural GPs


The local hospital is:
Hospital facilities (i.e. obstetrics, A&E, surgery)
The staff at the local hospital are…
The phone number is…
It is …kms from the practice
It takes …(time) to get to and from the practice

The base hospital is:


It is …kms from the practice
It takes …(time) to get to and from the practice

Ambulance
How to access ambulance
It takes …(time) to get an ambulance to the practice

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Ambulance officers – level of training
You will/will not be required to go to each ambulance call out
Other phone numbers you will need
The nearest GP support person is…
The emergency procedure is…

Emergency equipment
At practice:
• What is available
• Where kept
At home:
• What is available
• Where kept
At the local hospital:
• What is available
• Where kept

Essential information about the accommodation


The accommodation is…
The key and the spare is…
Water
Gas
Electricity
Rubbish
Milk
Other
Groceries

63
Leisure activities available
Local takeaways/restaurant

The duties that go with the accommodation are:


Pets
Garden
If you have any problems call…
Tradespeople/neighbours to call if you have problems with power,
water etc…
Insurance company
Please leave the house, car and the practice in a clean and tidy
condition.

64
APPENDICES
Appendix 1

Subsidies
General medical subsidy (GMS)
Entitlement to this patient subsidy depends on qualifying for a Com-
munity Services Card (CSC) – except for children under six years.
There is a scale of subsidies according to age and CSC status.
A3 (Adult, no CSC) Nil
A1 (Adult with CSC) $15
J3 (Juvenile six years and over, no CSC) $15
J1 (Juvenile six years and over, with CSC) $20
Y3 & Y1 (ALL children under six years) $35

High user health card (HUHC)


This may be obtained by those who are not entitled to a CSC but
have required 12 consultations over the preceding 12 month pe-
riod. The subsidies are the same as for CSCs.

See Health PAC for further information www.hbl.co.nz.

Medicines
From 1 July 2005 persons over 64, or under 25, or enrolled in an
Access PHO will pay at most $3 per prescription. Persons holding a
HUHC, CSC or Prescription Subsidy Card may get extra benefits.

65
Accident Compensation Corporation (ACC) payments
Treatment for accident-related injuries is subsidised by Accident Com-
pensation Corporation (ACC). For consultations relating to accidents
(defined as injury resulting from an external force or from occupa-
tional overuse – as well as sensitive claims relating to sexual abuse
and its consequences), GMS is not claimed. Most practices add a
patient surcharge to make up the usual fee. If a consultation in-
cludes both an accident-related and non-accident issue you may
claim both a GMS subsidy and an ACC payment. ACC makes fur-
ther payments for various procedures (e.g. suturing, splinting, aspi-
rating) according to a schedule.

Maternity benefits
All maternity consultations in primary care are free to the patient by
legislation and funded according to a schedule of fees. A Lead Ma-
ternity Carer (LMC), e.g. GP, midwife or specialist, holds fixed fund-
ing for each pregnancy. The involvement of anyone else in the shared
care of a pregnancy involves the billing of, and transfer of, funds
from the LMC who holds the budget.

Practice Nurse consultations


Each practice has its own philosophy on nurse-only consultations.
Legislation requires that a doctor must see a patient (and record this
with a clinical note) for GMS to be claimed. Some practices charge
patients for nurse consultations.

Immunisation subsidies
There is an immunisation subsidy available for immunisations.

66
Capitation subsidies
Most practices are subsidised on the basis of a profile of their patients
as defined by an ‘Age/Sex Register’ which is analysed quarterly by the
Ministry of Health. These practices receive a monthly income based
on a capitation formula which may take into account not only the age
and sex of the patient, but also their community service and high user
health card status, deprivation index and ethnicity.

Rural bonus
There are a variety of additional funds that rural practices may re-
ceive depending upon their isolation. The Rural Ranking Scale de-
fines the degree of isolation of the practice, taking into account is-
sues such as distance to nearest base hospital, ambulance support
services, on call poster etc. Bonuses usually take the form of an an-
nual or quarterly payment to the practice.

Various other sources of income include


Payments from insurance companies for medical examinations, so-
cial welfare payments (social welfare is administered by the Ministry
of Social Development and other private arrangements.

67
Appendix 2

Glossary of frequently used abbreviations


ACC Accident Compensation Commission

AVE Advanced Vocational Education

AMPA Accident and Medical Practitioners’ Association

CAC Complaints Assessment Committees

CMC Council of Medical Colleges

CME Continuing Medical Education

CRC Competence Review Committee

CTA Clinical Training Agency

DHB District Health Boards

FRNZCGP Fellow of the Royal New Zealand College of


General Practitioners

H&DC Health and Disability Commission

HUHC High User Health Card

HWAC Health Workforce Advisory Committee

68
GMS General Medical Services

ICTP Intensive Clinical Training Programme

IPA Independent Practitioners’ Association

IPAC Independent Practitioners’ Association Council

MCNZ Medical Council of New Zealand

MOH Ministry of Health

MOPS Maintenance of Professional Standards

MPDT Medical Practitioners’ Disciplinary Tribunal

MRNZCGP Member of the Royal New Zealand College of


General Practitioners

MSD Ministry of Social Development

NZFP New Zealand Family Physician – College journal


that focuses on general practice academic papers

NZMA New Zealand Medical Association

NZMJ New Zealand Medical Journal

NZNO New Zealand Nurses’ Organisation

Pharmac Pharmaceutical Management Agency

PHC Primary Health Care

PHO Primary Health Organisation

Primex Primary Membership Examination (of the College)

CQI Continuous Quality Improvement

Registrar Years 7,8,9 of the hospital run

69
RNZCGP Royal New Zealand College of General Practi-
tioners

WONCA World Organisation of Family Doctors

1/10th... % of weekly hours e.g. 2/10th =1 day

Maori words used in this document


Whanau Family

Hapu Section of a tribe

Iwi Tribe

Kaumatua Male tribal elder

Whare tapa wha Maori model of health

Taha wairua Spiritual health

Taha hinegaro Mental health

Taha tinana Physical health

Taha whanau Extended family

70
References

1. The Royal New Zealand of General Practitioners. Aiming for excellence:


The RNZCGP practice standards validation field trial final report.
Wellington: RNZCGP; 2001.

2. Medical Council of New Zealand. The New Zealand medical workforce


in 2000. Wellington: Medical Council of New Zealand; 2000.

3. Stewart M, Brown J, Weston W, McWhinney I, Mc William C and


Freeman T. Patient-centered medicne: Transforming the clinical
method. Thousand Oaks, CA: Sage Publications; 1995.

4. Gray R and Gray D Teaching. Patient-centered care family medicine


2002; 34(9): 644–645.

5. Corkill, C. The doctor-patient relationship. In Coles Medical practice


in New Zealand Medical Council; 1999.

6. Durie, M. Whaiora: Maori health development. Auckland: Oxford


University Press, Second edition; 1998.

7. Statistics New Zealand. Age, sex and ethnic diversity-family.


www.stats.govt.nz/domain accessed 20.08.02.

8. Health Funding Authority. Striking a better balance: A health funding


response to reducing inequalities in health. Dunedin: Health Funding
Authority; 2000.

9. Ministry of Health. The health and independence report: Director


Generals Annual Report on the state of public health. Wellington:
71
Ministry of Health; 2001.
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