New Zealand’s healthcare system is funded by government garnered taxes and offers a comprehensive set of free core health services to all New Zealanders as well as those who live in New Zealand and hold a residency or work visa. Although the specialty of gastroenterology encompasses a multitude of disorders, comparable to other western societies, a few diseases account for a significant part of the health burden. New Zealand has among the highest rates of colorectal cancer (CRC) worldwide^1,2 and CRC is the second leading cause of death from cancer in New Zealand,³ with approximately 3,000 new diagnoses and 1,200 deaths each year.^3,4 Although the age-adjusted risk of CRC has been declining in New Zealand over recent years,^2,5 an ageing population has resulted in a yearly increase in the incidence of CRC.⁵ Screening for CRC was trialled by the Waitemata District Health Board (DHB) between 2012 and 2017,⁶ and the rollout of the National Bowel Screening Programme (NBSP) to the remainder of New Zealand’s 20 DHBs is scheduled to be complete by June 2021.⁷ This rollout has been shown to increase demand for colonoscopy provision for screening, but additionally there has been a nationwide increase of up to 25% in patients referred for symptomatic indications, likely related to heightened awareness of CRC among patients and general practitioners.

In addition to CRC, New Zealand also has one of the highest rates of inflammatory bowel disease (IBD) in the world, which is predicted to increase.^8,9 Due to its chronic nature and relatively early onset in life, IBD results in a substantial health burden and direct and indirect healthcare costs to society,^10,11 as well as exerting a significant adverse effect on general wellbeing and a considerable impact on productivity among those affected. Additionally, over the last 30 years, data on liver transplant patients has revealed a steady increase in preventable liver disease due to Hepatitis C (HCV), alcohol-related liver disease (ALD) and non-alcohol-related fatty liver disease (NAFLD).¹² Finally, there is a looming burden of HCV infection, with many cases estimated to be undiagnosed and if untreated, will result in significant liver damage including progressive fibrosis, cirrhosis, liver failure and hepatocellular carcinoma.^13,14 Due to historic, geographic and cultural reasons, substantial health inequities prevail in New Zealand.^15,16 Ethnicity and socioeconomic factors have been recognised as important determinants of all-cause mortality and health outcomes.¹⁷ Māori have a lower incidence, but worse survival rates for CRC, than European New Zealanders, and a higher incidence in many other cancers including gastric cancer.^18–20 Healthcare access has been reported as a possible associated factor.^19,21 Recognising this, Māori, Pacific and those living in deprived areas have been listed as a priority groups for the NBSP. Additionally, Māori have a higher prevalence of hepatitis B and a higher prevalence of hepatocellular carcinoma.²² Socioeconomic determinants have also been reported to result in a higher incidence of HCV in Australia,²³ which may be comparable to New Zealand.

In 2011, a Health Workforce New Zealand (HWNZ) review of the gastroenterology workforce²⁴ recommended that current vacancies for gastroenterologists, in particular in smaller DHBs, be filled, and an increase in the number of gastroenterologists to bring New Zealand in line with gastroenterologist numbers per head of population with similar countries, including Australia and the UK, should be achieved. Additionally, several recommendations were made to increase gastroenterology training capacity, integrate nurse specialists, and training of non-specialist endoscopists.²⁴ These recommendations were targeted towards the year 2020. Due to the predicted increase in health burden, a critical assessment of the current and future specialist workforce in gastroenterology is required. Understanding health specialists’ distribution across the country is important to target inequities and optimise nation-wide healthcare provision.

This study reports on the findings of a recent gastroenterology workforce survey by the New Zealand Society of Gastroenterology of specialist gastroenterologists, in order to determine the capacity of New Zealand’s gastroenterology workforce to implement the NBSP, address the overall growing burden of gastroenterological diseases and inform strategies to decrease healthcare provision inequities across DHBs.

Method

The New Zealand Society of Gastroenterology conducted a workforce survey from 2016 to 2017. Data on the number of gastroenterologists and number of endoscopy lists was obtained through personal visits to DHBs and communication with the head endoscopy nurse for each DHB by MA and TC. Specialist gastroenterologists were asked to complete a questionnaire with questions about their age, their estimated number of years until retirement, their DHB place of employment, the institution/country where their primary medical degree and specialist qualification were obtained, FTE spent in public and private employment system, the number of endoscopy sessions per week, and the number of colonoscopies per year for the last 12 months in public and private healthcare. The questionnaire was e-mailed to members of the New Zealand Society of Gastroenterology as well as handed out to members attending conference. Non-specialists, including fellows and physicians with an interest were not included. Similarly, to the data collected for specialist gastroenterologists, data from general surgeons was collected on the number of colonoscopies per year for the last 12 months in public and private healthcare; however, only 22 general surgeons provided data via questionnaire. We excluded data from general surgeons due to the low sample numbers.

The resulting data was augmented by MA and TC. MA visited individual DHBs during a sabbatical and as part of his role with the National Endoscopy Quality Improvement Programme (NEQIP) and TC contacted individual people and DHBs for further information. Data on new diagnoses of colorectal cancer for each DHB for the years 2016–17 were obtained from a cancer registry using the ICD-10 codes for colorectal cancer C18-C20. Population estimates by DHB for the years 2016–17 were obtained from Stats NZ. Stata 15.1 was used to perform simple linear regression to determine the relationship between the crude incidence of colorectal cancer for each DHB and the ratio of gastroenterologists working in public healthcare per 100,000 head of population.

Results

At the time of completion of the survey in November 2017, there were 93 gastroenterology specialists providing clinical service in New Zealand, with nine working exclusively in private practice. This translated to a headcount of 1.96 specialists/100,000 people, and 1.77/100,000 people excluding those working only in private practice. Out of 93 gastroenterology specialists, 50 (55%) returned the workforce survey.

Table 1 shows the workforce characteristics of the gastroenterology specialists. Just over half of the respondents were aged over 50 years and approximately 42% aimed to retire within the next 10 years. Approximately 40% received their primary degree or their specialist qualification overseas. The mean number of FTEs spent working in public gastroenterology was 0.75. One quarter of gastroenterologists spent time working in general internal medicine in public hospitals, and 70% spent some of their time working in private gastroenterology. The median (25th–75th percentile) number of colonoscopies performed by gastroenterologists was 233 (128–423) per year in the public healthcare system and 120 (0–250) per year in the private healthcare system (data not shown).

Table 1: Workforce characteristics of specialist gastroenterologists.

The distribution of gastroenterologists (excluding those working exclusively in private practice) by DHB is listed in Table 2 alongside the number of gastroenterologists per 100,000 people for each DHB. Four of the 20 DHBs had no gastroenterologist. DHBs with higher rates of colorectal cancer tended to have a lower ratio of gastroenterologists (simple linear regression P=0.087) (Figure 1).

Table 2: Distribution of GE specialists and CRC rates by DHB.

Figure 1: Incidence of colorectal cancer by number of gastroenterologist specialists in public healthcare for each district health board. The results of the simple linear regression (P=0.087) and 95% confidence intervals are also shown. CRC, colorectal cancer.

Discussion

In the current survey there were 93 gastroenterologist specialists working in New Zealand in 2017. While this is an improvement from the 2008 estimate of 73 GE specialists,²⁴ the ratio of GE specialists per head of population of 1.96 per 100,000 is low compared with similar countries internationally. Furthermore, the distribution of specialists among the DHBs was inequitable. The findings of this recent gastroenterology workforce survey by the New Zealand Society of Gastroenterology demonstrate several shortcomings in the current healthcare workforce. Notably, an older workforce, with 42% of gastroenterologists intending to retire in the next 10 years, and several DHBs without a specialist gastroenterologist and low numbers of specialists per head of population compared with international standards. These findings imply that by 2021 when the NBSP is fully implemented and with the continued increase in disease burden, the GE workforce is highly unlikely to be able to keep up with the demand for GE services.

Data on diagnostic waiting times for colonoscopy in New Zealand show that services are already stretched. In the month of June 2019, while 93.5% of patients requiring an urgent colonoscopy received one within two weeks of being accepted for the procedure achieving the national target of 90%. However, only 54.1% of patients requiring a non-urgent colonoscopy received one within six weeks and only 54.9% requiring a surveillance colonoscopy received one within 12 weeks, both falling short of the national targets of 70%.²⁵ These data indicate that the capacity for increased colonoscopy services nationally may already be stretched and insufficient to keep up with demand unless improvements are made to the availability of gastroenterologist specialists and other healthcare specialists capable of performing colonoscopy.

New Zealand has among the highest rates of CRC cancer worldwide and this is predicted to rise along with most other common gastrointestinal cancers due to an aging population.^1,2 This is in addition to a high IBD prevalence that is predicted to continue to increase,^9,26 with a prevalence of one in every 227 people most recently reported in 2016.²⁶ IBD is a chronic, life-long disease, and hence early diagnosis and appropriate timely management improves overall health outcomes and decrease in associated healthcare costs²⁷ and impact on lifestyle and productivity. Additionally, in a 2014 study, Gane et al used statistical modelling to estimate approximately 50,000 people in New Zealand had HCV and of these more than half were estimated to be undiagnosed and requiring treatment to prevent cirrhosis, liver failure, and liver cancer.¹⁴ These complications and worse health outcomes are expected to be more pronounced in patients from more socioeconomically deprived areas and marginalised populations.²³ In addition to liver disease caused by HCV, the burden of liver disease due to ALD and NAFLD has also increased over the last 30 years.¹² Epidemiologic data on many other common diseases in gastroenterology in New Zealand are lacking, however, high rates of overweight and obesity and an ageing population in New Zealand are likely to result in increased demand for gastroenterology services over time.²⁸ The distribution of gastroenterologists in New Zealand has potential for widening health inequalities. Of the DHBs with less than one gastroenterologist per 100,000 people, Northland, Tairawhiti, Wairarapa and Whanganui have a disproportionately higher proportion of people with higher deprivation and a higher percentage of Māori compared with the national average, while Taranaki and the West Coast DHBs have a higher proportion of people in the middle quintiles of deprivation.²⁹ Furthermore, the incidence of CRC was well above the national average of 63.9/100,000 in these DHBs, with the exception of Tairawhiti. Regardless, data from the Health Quality and Safety Commission from 2009–13 showed that Tairawhiti DHB had among the highest rates of distant extent diagnoses of CRC, indicating a later stage of diagnosis, and Māori had a disproportionately higher rate of CRC diagnosed following emergency presentation compared with other DHBs.³⁰ Tairawhiti is a DHB representing just under 50,000 people, with almost half of their population in the most deprived quintile and just over half of Māori ethnicity.²⁹ In addition to an inequitable distribution of gastroenterologists, New Zealand has a lower number of gastroenterologists than comparable western countries, including the UK (2.3/100,000), Canada (2.3/100,000), Australia (3.0/100,1000) and the US (4.5/100,000).^31–34 In order to reach a comparable standard with the UK, New Zealand would need to employ 16 more specialist gastroenterologists, while to reach the recommended standard from the 2011 workforce report of 3/100,000 gastroenterologists, New Zealand would require 52 more specialist gastroenterologists to be employed. This would bring New Zealand into parity with Australia.

There is evidence to support the theory that a ratio of 3.3/100,000 gastroenterologists per head of population can result in a lower incidence of late-stage CRC.³⁵ In our dataset, we also found a tendency toward significance, whereby DHBs with lower gastroenterologists per head of population had a higher prevalence of CRC within our dataset. Albeit the findings of our study do not support a causal relationship between the number of gastroenterologists and prevention of late-stage CRC. There are likely to be many explanations for this, including differences in socioeconomic status, and this may indicate that a greater number of gastroenterologists is necessary, particularly where there is a low ratio of gastroenterologists, as screening and treatment requirements for CRC are likely to be higher in those areas. Increasing the number of specialist gastroenterologists in New Zealand, and in particular in DHBs with no or a low ratio of specialists per capita will be critical in attempting to reduce gastroenterological health inequities in New Zealand.

Although there is a need for improvement in the number of trained gastroenterologists in New Zealand, a particular concern highlighted by this study is the need for replacement of gastroenterologists who have already reached or will soon reach retirement age. In this study, 42% of gastroenterologists intended on retiring within the next 10 years. This can be extrapolated to the need to replace approximately four gastroenterologists per year. This is in contrast to an anticipated 33.8% of gastroenterologists retiring in Australia³¹ and only 16% gastroenterologists being above 55 years old in the UK.³⁶ Data from 2000 to 2009 show that on average four gastroenterologists completed training every year, with a quarter leaving New Zealand, and in some years as many as half leaving.²⁴ The current trend in numbers of trainees in gastroenterology is insufficient to keep up with the rate of retirement of the GE workforce and international recruitment of GE specialists is necessary to supplement the workforce. Due to the time and resources required to train gastroenterology specialists, timely action is needed to meet the future burden. As a short-term measure and in order to improve the working environment, specialist nurses in areas such as Hepatology and IBD should be employed to improve service provision and patient care.

This survey has some limitations in that only 55% of gastroenterologists returned the survey questionnaire and that the scope of the questionnaire was limited. It would have been interesting to determine the diversity of the current gastroenterologist workforce, including their gender and ethnicity in order to inform future recruitment of GE specialists. It has been suggested that the Medical Council of New Zealand in future collect and distribute more detailed data on our workforce. The data collected by MA in his visits to DHB endoscopy units throughout New Zealand (all but two units were visited in person, and data on those units not visited was acquired via personal communication with the endoscopy team in situ) was from the chief endoscopy nursing staff and this information is thought to be reliable.

In conclusion, we found that the New Zealand gastroenterology workforce is insufficient to meet the current and future needs of the growing gastroenterology disease burden in the country. Importantly the current distribution of the gastroenterologists is uneven throughout the country with lower specialist access in more deprived areas that have worse health outcomes.