Today marks exactly one year since we arrived in our new home town, and I am in a reflective mood. There are many differences between medicine in the UK and New Zealand, but those between primary care and geriatrics in the two are perhaps most striking. The semi-private nature of General Practice is something that on the surface seems abhorrent, as we Poms still hold dear to the ideals of a healthcare system free at the point of use.
However, there are many ways in which patients in New Zealand can be supported to pay consultation and prescription fees, and the latter are generally capped at $5 (≈£2.50) per item. Secondary care (including access to the Emergency Department) is free to all New Zealanders and most visitors. It is rare to hear of elderly patients missing out on vital reviews for reasons of cost. Most of the older patients I come across have excellent relationships with, and real respect for, their GPs and other doctors that comes as a pleasant surprise to those used to dealing with readers of the tabloid press.
There is also a notable stoicism amongst the average Kiwi, whether naturally born or immigrant. The jokey image of a 75 year old Kiwi farmer hopping into the Emergency Department with half a leg torn off is surprisingly close to the truth at times, though the worried well do appear to be of increasing number amongst middle aged patients. An example might be the 79 year old lady who was seen in ED with a broken collarbone, having fallen trimming an avocado tree during near-gale force winds, who then attended again the next week having broken the other side putting her washing out; or the 100 year old admitted with pneumonia doing laps of the ward to prove he was well enough to get back to his orchards (there are more trees than sheep in the Bay of Plenty).
Most of the time, patient stoicism is a boon to the busy medical doctor, as patients can be pretty clear regarding their goals for treatment, and also relaxed about discussions regarding life and death issues. Many will want to know whether or not they have cancer, but mainly so they can plan their funeral, re-write their will or sell the aforementioned orchard. This can mean conversations are reversed, and we often work hard to persuade people that chemotherapy or radiotherapy might be helpful to their symptoms. Not a week goes by where I don’t have to explain to a patient that it’s OK to take painkillers regularly if they are in severe or ongoing pain.
One side effect of this stoicism is the late presentation of many acute and chronic disorders, noticeably heart failure, dementia and Parkinsonism. There are good assessment, management and support services for patients with chronic diseases from the public and voluntary sector, but work is ongoing to improve early diagnosis. The proportion of undiagnosed dementia sufferers is similar between the UK and NZ (up to 60%), but that of Parkinsonism is unknown, but has been estimated as high as 2/3 compared to 25% in the UK. Certainly it is common to come across community dwellers with obvious and severe Parkinsonism who are not known to their GP or hospital specialists. This is a challenge, and one the new breed of Geriatricians is looking to address.
Images by mdid & Gordon Haws, via flickr