Tue May 16

New Zealand's reliance on foreign doctors to plug gaps highlights the need for another medical school

Written by Ross Lawrenson, Professor of Population Health, University of Waikato

The New Zealand health system is currently in the throes of its biggest reorganisation ^[1] in more than 20 years. The aim is to provide more efficiency and equity.

But while it is acknowledged New Zealand has under-invested in health infrastructure, more damaging has been the under-investment in people.

This lack of planning for the future health workforce is directly responsible for the staffing shortages now being experienced. These shortages are being patched up with short-term solutions such as attracting overseas-trained health workers with promises of quick pathways to citizenship.

So as well as structural reform of the health services, the vision for those services and subsequent workforce demands needs to be articulated. Ideally this would include a budget that invests in training more – and more diverse – New Zealand doctors.

Relentless demand

We know the demand for more doctors is relentless – fuelled by a growing and ageing population. At the same time, we have an ageing medical workforce, with many doctors planning to retire in the next decade.

There has been a 40% increase in the number of doctors registered with the Medical Council over the past decade, from 13,880 in 2012 to 19,623 in 2023 – a year-on-year increase of 3%.

To sustain this modest growth each year, we will need to increase the total medical workforce by 590 annually. We will also need an additional 300 doctors a year to replace those who are retiring or leaving to work in Australia and elsewhere.

Yet we currently only have two medical schools training 550 doctors a year between them. So we continue to rely on importing doctors from other countries.

Out of the OECD, New Zealand has the highest dependency ^[3] on overseas-trained doctors, with 42% of the workforce being international medical graduates (IMGs).

The regions with the lowest percentages of IMGs are Auckland (31%), Capital & Coast (34%), and Canterbury (36%). But this can climb to 60% in many rural regions. Last year, 1,232 IMGs were registered to practice here, reflecting the high demand for doctors not being met through local training and retention.

Paradoxically, one of Health New Zealand’s goals is to increase the number of Māori and Pacific doctors, which is hard to do when we rely on importing twice as many doctors as we train.

Our missing GPs

Doctor shortages are not evenly spread. There are particular problems in the less wealthy regions, and in particular specialities such as general practice. GPs are the backbone of the health system, with 90% of health consultations occurring in primary care.

Yet while we have increased the number of doctors by 5,000 over the past ten years, the number of GPs has only increased by 260. This means we have GP shortages, resulting in increasing demand on hospitals, increasing waiting times in the emergency departments, and a growing problem of late diagnosis and poorer health outcomes.

The Royal New Zealand College of General Practitioners has called for these shortages to be urgently addressed ^[4] by increasing the number of junior doctors training in general practice to 300 per year. This is hardly possible with only two existing medical schools – it would mean more than half their total output of graduates going into the GP training programme.

Currently, just 25% of the 550 medical school graduates (130-140 doctors a year) choose to go into general practice. To achieve a goal of 300 we would need to double the number of doctors training or take a substantial number of junior doctors out of the other speciality training schemes.

There are geographical differences in where doctors are working, too. New Zealand graduates tend to choose to practice in the major centres where they have trained, while high needs communities and regional centres have to rely even more heavily on attracting IMGs.

Thus the Te Manawa Taki region – serving a predominantly rural population of over a million people across the central North Island, including 25% Maori – has 7% fewer doctors than the other regions (or 265 fewer doctors than would be expected).

Investing in training

The United Kingdom recently opened five new medical schools ^[6], while Canada is set to open three ^[7]. In both countries, research showed doctors tended to stay and work in the area where they trained. The new medical schools are located in regions with high needs and recruitment difficulties.

There is no doubt New Zealand should be following suit.

The New Zealand Resident Doctors’ Association is calling for another 200 medical students a year to be trained. This should be just the start, with ongoing commitments to increase student numbers in line with the growing medical workforce.

But simply increasing the number of students going to Auckland and Otago medical schools will not work. We cannot expect different health workforce outcomes by doing the same thing again and again.

We need more doctors in training, we need to attract students from a wider range of backgrounds, we need to place these students in the regions they are needed, and we need a new curriculum that will prepare for a workforce consistent with the future demands of the New Zealand health system.

That can only be achieved with a new and more socially accountable medical school, and significant investment. It is said the best time to plant a tree is 20 years ago. The next best time is now.