Amongst all the media chatter that followed the National Party’s promise to open a New Medical School at Waikato University, and add more medical training places at the Auckland and Dunedin medical schools, Harriet Wild’s comment that more medical students could lead to an imbalance in the doctor training pipeline was one of the more insightful. Here we outline the argument for why we need more doctors, map out the medical training pipeline, and explain why a new medical school is only part of the solution.

For quite a number of years, the number of doctors practicing in New Zealand has been growing faster than the population. In 2006, there were 297 doctors per 100,000 population. In 2022, the number had risen to 367. Despite this growth, Te Whatu Ora Health New Zealand have recently published a Health Workforce Plan 2023/24 which says that there is a shortage of 1,700 doctors in New Zealand. A key reason for the shortage is that the population is aging and older people require way more care than younger people. So, the number of doctors has been growing, but not fast enough.

New Zealand has tended to rely on overseas doctors to grow its medical workforce. Migrant doctors, or International Medical Graduates (IMGs), made up 41% of all doctors in 2022. IMGs tend to fill gaps in the workforce that locally trained doctors are unwilling or unable to fill. There’s no getting away from the fact that some medical jobs are more attractive than others. More on that later.

National’s promise to create 120 more places at a new Waikato medical school and add 50 extra spots at the Auckland and Dunedin schools, on top of the additional 50 funded by the current government in Budget 2023, should see the number of medical school places rise from 589 currently to 759 by the end of the decade. Attrition at New Zealand’s medical schools is very low (an average of 1.6%) so the number of medical graduates should rise almost as much as places.

Harriet Wild is the policy and research director at the Association of Salaried Medical Specialists. Her point that more medical students could lead to an imbalance in the medical training pipeline is a good one. Graduating from medical school is necessary for becoming a doctor in New Zealand. But it is by no means the end of the journey. Graduates become medical interns for a couple of years, then they practice as registrars for a year or two, after which most specialise in a specific medical field by taking up a vocational training post or train to become General Practitioners. There are only so many intern, registrar and vocational training places available. Junior doctors, especially interns, need a high degree of supervision so placements tend to be constrained by the number of senior doctors able and willing to provide supervision as well as funding.

According to the Medical Council, around 10% of the 18,780 doctors practicing in New Zealand in 2022 were interns. That’s about 1,878. Adding roughly 170 intern placements to cater for the additional medical graduates that National is proposing is no small thing. Those additional graduates will also need registrar places and vocational training placements.

More doctors won’t necessarily alleviate all shortages. Doctors tend to prefer to practice in large urban areas where they get exposure to a broad range of patient cases, and where the patient load is large enough for them to specialise if that is what they want to do. We lose doctors overseas to places like Australia and the UK with bigger population centres. Some doctors simply put down roots in the area where they attended medical school. Or they return to the place where they grew up. Consequently, some rural areas in New Zealand find it hard to attract medical staff.

Some medical specialties are more popular than others. Doctors choose their specialty for a range of reasons, including their personal interests. Working hours and the ability to work in private practice are also considerations. Not wanting to give emergency medicine a bad name – we’ve all been at the Emergency Department at some time or another - but a doctor specialising in emergency medicine is signing up to work in hospital EDs where the working hours are unsociable (because EDs are open 24/7). There is also little chance of opening a private practice in emergency medicine because there is no demand. Compare this with, say, psychiatry in which the working hours tend to be more sociable and there is the potential to work in both the public and private sectors.

A voluntary bonding scheme is currently in place to encourage doctors and other health professionals to work in hard-to-staff communities and specialties. Aimed at recent graduates, participants get payments in the first three-to-five years of their career to help repay their student loans or top up their incomes. Graduate doctors get $30,000 after three years and $10,000 in their fourth and fifth years. Medical degrees cost on average $77,000 in fees and first year doctors earn $65,949pa. So, a $50,000 top up is no small beer. However, places on this programme are limited by available funding.

National’s plan is for the new medical school to deliver more doctors to rural areas by having clinical training alliances with other universities and medical facilities in regional New Zealand.

There are broader shifts underway to help alleviate the shortage of doctors. But change is challenging. Health systems across the globe are under stress from rising costs, increasing demand for services from an aging population, an aging health workforce and an increasingly mobile health workforce that is migrating to countries where working conditions are better than in their home country.

Broadly speaking, policy makers are addressing these challenges, particularly that of rising costs, by shifting where care takes place away from hospitals (where care is expensive) to community settings (where it is less expensive). There are also moves to change who delivers the care. Some tasks that were traditionally performed by doctors, such as physical examinations and prescriptions for certain medications, are now performed by nurse practitioners. Nursing salaries are lower than doctors’ salaries so shifting care in this way is another way to cut costs. It can also lower the demand for doctors and potentially alleviate shortages.

However, change in the health sector is challenging and often slow. Patient care is at the forefront of every health professional’s mind. And rightly so. Any changes in the way care is delivered mustn’t compromise on the quality of care. That’s why it’s easier for policy makers to simply funnel more money into training more practitioners. And, if I am being cynical, which politician doesn’t want to cut the tape on a new medical school? But workforce policy needs to consider the whole workforce pipeline, not just grand gestures.