COVID-19 is the type of disruptive event we don’t often see in health. New Zealanders recently learnt that the first COVID-19 patient death occurred in Greymouth Hospital. What has been most revealing for local clinicians is the effect on our workforce. Simultaneously 21 staff members have been put into self-isolation.

While this is across professions, for senior medical officers (SMOs), this combined with permanent staff changing their work patterns and an almost universal cessation of locums coming to the coast, on which there has traditionally been a high reliance, means a substantial decrease to our available medical workforce. Moreover, dependence on international medical graduates (IMGs) to fill permanent positions has been exposed. Many have returned home and, with borders shut, the traditional avenues for recruitment have dried up.

The coast has looked at innovative ways of tackling workforce issues for some time. From 2010 the focus has been on a collaborative regional solution with Christchurch. This has been named the ‘Transalpine approach’. Linked to this has been capability advancement in telehealth.¹

However, increasingly there has been a need for a robust local workforce solution. New Zealand has had positive outcomes from the introduction of a post-graduate medical training programme focused on the service needs in rural areas.² The coast has been able to utilise rural hospital medicine specialists in roles that includes support for emergency, paediatric, and orthopaedic services.³ In addition, the West Coast District Health Board (WCDHB) is unique in that it owns most of the primary care practices on the West Coast, thus responsible for employing a substantive number of staff involved in delivering primary care services.

Despite this, current service frameworks are very traditional with GP care delivered by those ‘employed as GPs’ and neglected relative to hospital-based services delivered by ‘specialists’. Running hand in hand with workforce issues is recognition this is not meeting the patient need in a rural setting like the West Coast.

Therefore senior managers and clinicians agreed in November 2018  that the full spectrum of care delivered by rural generalists, encompassed in the Cairns Consensus statement,⁴ is needed for the WCDHB to have a stable SMO workforce.

Specifically, this means the ability to work across the spectrum of primary care, emergency and hospital services (targeting areas like internal medicine, obstetrics and anaesthetics). It also encompasses a population health approach and the ability to do this as part of a multi-professional and multi-disciplinary team of colleagues within a system of care.

The current COVID-19 pandemic only strengthens the need to move to a more flexible workforce rurally, where clinicians can flex across services, maximising skill sets and ensuring the workforce is utilised effectively. This is something specialty workforces cannot do effectively, as they lack the training to deliver care in other areas. When the elective work is removed, as is happening within this COVID-19 environment, a ‘specialist’ workforce is often unable to respond to  urgent service needs. These thoughts are mirrored by Australia’s Commissioner for Rural Health, Professor Worley.⁵

While the anticipated change has been slow coming in Greymouth Hospital, rural generalists have immediately proved their worth as COVID-19 responses ramped up. They were able to flex into primary care as the need demanded and rapidly back into hospital inpatient work as locums cancelled and staff were asked to self-isolate. Likewise, obstetrics which is a key component of such a model, was well prepared. WCDHB had already begun collaborating with Christchurch on ways to ensure rural generalists had the ability to manage intra-partum care, perform caesarean sections and assisted deliveries, providing certainty in a key service.  Such an approach was advocated in a piece in the NZMJ as far back as 2006 by Don Simmers.⁶

GPs across the country have switched their ways of working immediately. However, unlike many who are concerned about the viability of their practices,⁷ the WCDHB GPs are salaried employees. This provides certainty, which is crucial in rural settings and was a model explored in a recent editorial in this journal.⁸

Finally, utilising an equally flexible allied health, midwifery and nursing workforce, there has been reliability of service delivery by the WCDHB in its more remote clinics. The WCDHB approaches were recognised in the 2019 Health and Disability System Review Interim Report, which discussed enabling the health workforce to apply generalist skills and call on specialist skills as needed, while also using the health and disability workforce differently.⁹

The opportunity a crisis has provided to do better for patients cannot be squandered. This would see the coast develop a more resilient SMO workforce, while delivering care at a responsible price. In the long term, this would see a combination of local and Christchurch-based specialists working collaboratively with a team of rural generalists to provide the right care for patients into the future.

COVID-19 is the type of disruptive event we don’t often see in health. New Zealanders recently learnt that the first COVID-19 patient death occurred in Greymouth Hospital. What has been most revealing for local clinicians is the effect on our workforce. Simultaneously 21 staff members have been put into self-isolation.

While this is across professions, for senior medical officers (SMOs), this combined with permanent staff changing their work patterns and an almost universal cessation of locums coming to the coast, on which there has traditionally been a high reliance, means a substantial decrease to our available medical workforce. Moreover, dependence on international medical graduates (IMGs) to fill permanent positions has been exposed. Many have returned home and, with borders shut, the traditional avenues for recruitment have dried up.

The coast has looked at innovative ways of tackling workforce issues for some time. From 2010 the focus has been on a collaborative regional solution with Christchurch. This has been named the ‘Transalpine approach’. Linked to this has been capability advancement in telehealth.¹

However, increasingly there has been a need for a robust local workforce solution. New Zealand has had positive outcomes from the introduction of a post-graduate medical training programme focused on the service needs in rural areas.² The coast has been able to utilise rural hospital medicine specialists in roles that includes support for emergency, paediatric, and orthopaedic services.³ In addition, the West Coast District Health Board (WCDHB) is unique in that it owns most of the primary care practices on the West Coast, thus responsible for employing a substantive number of staff involved in delivering primary care services.

Despite this, current service frameworks are very traditional with GP care delivered by those ‘employed as GPs’ and neglected relative to hospital-based services delivered by ‘specialists’. Running hand in hand with workforce issues is recognition this is not meeting the patient need in a rural setting like the West Coast.

Therefore senior managers and clinicians agreed in November 2018  that the full spectrum of care delivered by rural generalists, encompassed in the Cairns Consensus statement,⁴ is needed for the WCDHB to have a stable SMO workforce.

Specifically, this means the ability to work across the spectrum of primary care, emergency and hospital services (targeting areas like internal medicine, obstetrics and anaesthetics). It also encompasses a population health approach and the ability to do this as part of a multi-professional and multi-disciplinary team of colleagues within a system of care.

The current COVID-19 pandemic only strengthens the need to move to a more flexible workforce rurally, where clinicians can flex across services, maximising skill sets and ensuring the workforce is utilised effectively. This is something specialty workforces cannot do effectively, as they lack the training to deliver care in other areas. When the elective work is removed, as is happening within this COVID-19 environment, a ‘specialist’ workforce is often unable to respond to  urgent service needs. These thoughts are mirrored by Australia’s Commissioner for Rural Health, Professor Worley.⁵

While the anticipated change has been slow coming in Greymouth Hospital, rural generalists have immediately proved their worth as COVID-19 responses ramped up. They were able to flex into primary care as the need demanded and rapidly back into hospital inpatient work as locums cancelled and staff were asked to self-isolate. Likewise, obstetrics which is a key component of such a model, was well prepared. WCDHB had already begun collaborating with Christchurch on ways to ensure rural generalists had the ability to manage intra-partum care, perform caesarean sections and assisted deliveries, providing certainty in a key service.  Such an approach was advocated in a piece in the NZMJ as far back as 2006 by Don Simmers.⁶

GPs across the country have switched their ways of working immediately. However, unlike many who are concerned about the viability of their practices,⁷ the WCDHB GPs are salaried employees. This provides certainty, which is crucial in rural settings and was a model explored in a recent editorial in this journal.⁸

Finally, utilising an equally flexible allied health, midwifery and nursing workforce, there has been reliability of service delivery by the WCDHB in its more remote clinics. The WCDHB approaches were recognised in the 2019 Health and Disability System Review Interim Report, which discussed enabling the health workforce to apply generalist skills and call on specialist skills as needed, while also using the health and disability workforce differently.⁹

The opportunity a crisis has provided to do better for patients cannot be squandered. This would see the coast develop a more resilient SMO workforce, while delivering care at a responsible price. In the long term, this would see a combination of local and Christchurch-based specialists working collaboratively with a team of rural generalists to provide the right care for patients into the future.