No. 29 Brian Betty Executive Director of RNZCGP

[00:01:01.480]

Welcome, Brian. Thank you for your time, Brian. Appreciate it. Pleasure must be here first and foremost. Please introduce yourself, but also don’t know you. And that is about the college as well. Yeah, so look, I’m a specialist general practitioner. I’ve spent 1517 years working in Cannons Creek and East Parole, which is a high needs area with mainly Maori, Pacific and refugee populations. Prior to that, I was in Australia. I worked up in the outback in Australia, and for the last three years, over covert in particular, I’ve been medical director

 

[00:01:39.360]

of the Royal New Zealand College General Practitioners, which has been an interesting job over the last two or three years. So how do you find the pressure now that we are opening the borders? Yeah, so look, I mean, it’s interesting, isn’t it? So Covet has been the focus pretty well exclusively for the last two years, and suddenly that sort of starts to lose its focus and a whole lot of other things come to the forest. So it’s just as busy in many ways. Interesting times. We have an increasing number of autistic children knowing for me, being a parent now, aware of the growing numbers of autistic

 

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children, how is the college looking at in terms of, I don’t know, maybe a training to our GPS on how to have any plans or long term goals for that? Yeah, look, I think there’s two things there to work as a GP in New Zealand, most GPS now go through what’s called fellowship training. Okay? And that’s a three year program. So you do your basic medical degree for six years. You then do hospital rotations for two to four years. And that can be general medicine, surgery, psychiatry, whatever it is, emergency medicine. And then you go into a three year training program. So that training program is for what we

 

[00:03:04.320]

call generalism, which is for a wide range of conditions. Part of that program is around pediatrics children and part of the issues around there, obviously, that is part of the program and can be examined on in terms of examiners. We do ausk’s and things is about basic knowledge of various conditions and autism, obviously, and child neurodevelopmental issues would be part of that. So, yeah, look, it is part of what is part of the program, which we’re just revamping at this point. We’ve gone through that process in terms of education. Our expectation on GPS,

 

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once they qualify as they take part in continuing medical education over a three year cycle, so they’re expected to do continuing training. What we tend to find is GPS who may have an interest in pediatrics or may have patients who present to them who have specific conditions such as autism. GPS tend to source training, which is widely and generally available through a number of different forums in that area, and start to up school themselves in that particular area. So there’s basic training and then what happens post fellowship that becomes really important in this area. Is the assessment going to go through the GP or the HP?

 

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The reason why I’m asking this is that every parent that I came across with, they have different paths. For me personally. We happen to GP that time. So we’re now under the Dhpk. Sure. Susie, who’s one of the amazing parents here as well, she was referred to camp for me. It looks like there’s a bit of disconnection. Sure. The problem that arises here is we’re in the system of DHB driven access to service.

 

[00:05:06.480]

Okay? So each area across New Zealand traditionally has had different pathways to access care, either through pediatric camps. A whole lot of different things occur. So there’s no national consistency in terms of where you access specialist care. Most kids where a problem is flagged about potential autism, I think the job of the GPS start to reflect back and listen to the parents. Obviously they’ve got concerns to look at the situation that’s going on the child and ask the question, yes, is specialist intervention required here, which obviously is with autism, and to access the pathway to get

 

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that specialist intervention across New Zealand. One of the comments I’d make about that, though, what we have seen and what’s become really apparent, there is a huge amount of pressure on those services to do those initial assessments and to look at intervention or support that’s required for a child with autism. So the GPS role in many cases is to acknowledge the parent any concerns that are there to do the initial assessment, then to advocate or push through to the pathway that is available to them within the local region. Given that, is it not potentially possible for GP to have an assessment about autism. And I understand that the HVACs are currently under the pump and very busy and there’s this huge waiting list.

 

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And for me as a parent, I feel like we’re missing the boat on getting the support. This gives me a require. My question is, is there a potential avenue that our GP can do an assessment about autism? And perhaps that can be considered by the order. HP yes, in an ideal world that would be the case. Okay. So, no, I don’t have any problem with what you’re saying about that. And then, look, there are some GPS who are very skilled with child developmental issues and they have an interest in that area, whether it be autism, ADHD, a whole lot of range of stuff.

 

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And there are GPS who do that in their special interest groups that do that. However, the system often demands for access to service that you go through secondary services for a formal assessment. That’s certainly the way the system operates. Is it the same across maybe other countries or is it New Zealand only? Well, it’s the way the New Zealand system works. Every country is different in terms of the services they have, the way their medical system works, way their primary, secondary or community hospital system works, special system. So every country has a different way of doing it. That’s one of the problems we run into. No system is perfect.

 

[00:08:00.960]

That’s a comment I would make, and we see that in New Zealand. And it’d be fair to say for, I think, something like autism or child developmental issues. I think a lot of parents have very variable journeys through the system. Different. In my experience with us. And I speak about my experience where difficulties arise with the system. My job as a GP is to advocate for the parent and the family within the system. I spend a lot of time doing that. I know a lot of my colleagues spend a lot of time doing that as well. And often we as GPS get quite frustrated

 

[00:08:42.000]

with the system and the way the system is geared. But there is no doubt there are real pressures across the system which makes for variable access. In an ideal world, what we want is the identification of a potential issue and either through the GP or the specialist service, the elucidation of the issue, which in this case we’re talking about autism in a really timely, effective manner and then the supports put into place in a very timely, effective manner. And that’s what’s really required. Right. And early intervention is still applied. Right. It’s still effective, in your opinion, early intervention?

 

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Well, I think the earlier you pick up on a problem I see, the better. Yeah. Regardless condition, the earlier you pick up on. There is an issue here that we need to think about and look at what supports required both for the family, the child and whatever educational process to go through or whatever is happening. The sooner that’s done, the better, as a general rule. Okay. Yeah. And then there’s this tool. Yesterday, I think, when I had a chance to speak to some of the experts from Victoria University, they were saying that there’s this as the tech that they wanted to test across Wellington.

 

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This will help perhaps, in my view as well, alleviate the pressure under the DHBs. I mean, this as detect is 80% accurate, around 88% accurate, and could potentially be used by the cheapest. Is it something that we can perhaps test 100%? I think all these interventions over time or what starts to happen here is a positive. And if there was a pilot to be put up where that was used and looked at, I think that’s absolutely a positive. Because you always look at these things in terms of pilots or where they used, all these things come up.

 

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And often what we see in the system as they are tested and if they are of value, they can then be rolled out in some sort of coherent national way, which is what you want to have happen. So we’ve seen that happen with depression scores and things like that. They’re very widely used in the system now. They weren’t there ten years ago. They then became intermittently used, they then became part of practice and they’re now easily accessible because one of the things we have with these scores, of these things that we can do is we have these practice management systems that are electronic. We get easy access to a lot of the things that become validated and used on things called patient dashboards.

 

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So anything that actually, I think, facilitates the assessment. The first step assessment of a potential issue that is identified by a family or a parent I think is an absolute positive and should be trialed. And then what’s the process? Can we just reach out to the college for that just in case they get the funding that they are asking? Well, if they get the funding for it, they didn’t go through a process of looking at the best way of doing it. So you either do that the college is one avenue of some say, could you do that? The other avenue is what’s called PH OS or primary healthcare organizations are often involved in this type of study. So you can take a particular area,

 

[00:11:57.400]

for instance, ACC is doing one at the moment in the concussion treatments. Right? And they’ve got two areas in Christchurch and Auckland where they’re running out standardized approach to concussion for children. Okay. And so they’re trying that over a year in these particular areas to see if it’s got national validity in terms of its use. Utility cannot be used and how effective is it and does it actually move the whole system forward in terms of the treatment of concussion across the country? That’s the type of thing that’s often done in these situations, yeah. Okay. And then you did mention about the practice or practices. And are we also preparing the practices in terms of the environment, for example?

 

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I know it’s not yet that huge in terms of the numbers of going to practices like Autistic, people who are not, for example, not acquaintable with noises and things like that. Is it something that we are looking at as well? Things. I would say we’ve got 1000 practices across New Zealand, right? We’ve got five and a half thousand GPS working within those practices. We’ve got about 10,000 nurses. It’s a very large sector. We have about 80,000 consults today. We have about 20.5 million consultations a year. It’s very large. What you tend to find is every practice starts to operate in a slightly different

 

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way, dependent on its practice population and dependent on its practice base. So what we do see in the system, and I’ll just make this comment, is we see certain practices start to attract certain patients because they operate in a certain way that meets the patient’s needs. Does that make sense? Yes. So what you tend to start to see in that situation is things done to ameliorate. So I’ll just use an example of our practice out of Cannons Creek. So, look, I’ve got a number of autistic children and actually teenagers and adults in my practice. We tend to work in a particular way. And I’m thinking of one in particular who’s now older teenager, where noise and distraction is an issue.

 

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So we just set up an individual plan that when he comes in with mum, we put him in a quiet room by himself or waiting room, rather than in the waiting room, which can be very busy and noisy and disruptive. So, look, that’s easy to set up. It’s what’s required for the individual becomes the issue here. And I think it’s recognizing that and saying those type of things happen all the time. And look, I’m not so proud suggesting it happens perfectly because it doesn’t. But a lot of cases, that’s the type of thing that’s put into place. And look, one of the things I would say, if you’re a parent with a child where that is a potential issue, talk to your GP or talk to your nurse about look,

 

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if my child comes in with me, we’ve got this issue, how do we deal with that? And look, no one’s going to say, let’s not have that conversation. It’s actually bringing it up. And I think one of the things I’d say, if you are a parent and you’re concerned about that, look, bring it up and talk about it. I’m not going to say if a parent brings it up with me, I’m not going to say stop there. We can’t talk about that. We talk about it. We need to resolve it because it’s about the outcome for the child, the adolescent, the adult, whoever, in terms of what’s going on, that’s what’s really important. Let’s move into the prescriptions.

 

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So in terms of prescribing medications like people with autism and then plus key in or less coupled with, let’s say ADHD as an example, is the GP the one supposed to do it? The prescription or is it going to. Be it depends on the situation. Okay. So often what we find in this situation well, look, we talk about ADHD. What we find in these situations is the specialist initiates the prescription and that’s share requirement under what we call the Special Authority. Okay? So it has to come from a psychiatrist or a pediatrician with an interest or child development pediatrician. However, once that’s done, it’s usually the GP to monitor

 

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and do it every two years is meant to be some sort of review. That might be a telephone review, it might be a letter. We often do a letter exchange to say, look, things are stable, things are going okay and the prescription is continued. GPS will often adjust the doses. I do that all the time during that time, and if there’s a problem, refer back to the specialist. Often we have a phone conversation, I’ll just get on the phone and say, look, this is the issue. Do you need to see them again? Or can we sort it out just through a conversation and look, after I find 70% of the time you canceled out on the phone.

 

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Right. That’s allowed. Yeah. Because once a prescribing is set up for a medication, like an ADHD medication, the GP is prescribed and the GP is responsible for that prescribing at that point. The thing about general practice is it’s knowing your limitation, your skill base, and where you actually need to ask for help. So often ask to help be a phone call or a conversation, and it may be saying, look, I need the psychiatrist, we need to see this person now, this child now, let’s book them back in for a reassessment. So that’s the type of thing that goes on. Yeah. Okay. And then they will just send you the prescriptions or the parent with the new prescription, and now they can do a repeat?

 

[00:17:33.960]

No, they set up what’s called the Special Authority, the GP prescribes from that point onwards. So it’s actually getting this thing called the Special Authority number. Now, these are the ADHD medications. So you need what’s called a Special Authority number to be prescribed. Once you’ve got that, the GP can prescribe it. Okay. So you don’t have to go back to the specialist at that point. And that needs to be reviewed in some way every two years. But it doesn’t necessarily have to be a face to face review. Right. And then the specials will need to do the review, not the GP, right? Well, no, with the review,

 

[00:18:08.040]

it may just be a conversation or maybe an email between this GP and the specialist. So the specialist doesn’t necessarily need to see the patient face to face at the GM. I’m just curious, do we know the numbers of autistic children across out there? Sorry, you’ve got me on that. There are probably those numbers there, but I sorry I didn’t look it up. There’d be a number out there somewhere. Probably the Ministry of Health would be right. The place to go. I’m not sure where in the ministry. It’s probably the mental health going back to that prescription. In terms of side effects, I’m pretty aware that all medicines have side effects, regardless if it’s a supplement or something else. Sure. In terms of informing, advising, is it something that we train the GPS

 

[00:18:54.840]

from the cash that we need to inform the parents? 100%. I mean, so that’s basic any prescription writing. There’s very strict medical counsel guidelines about that. So in reality, there should be a conversation about the pros and cons of the medication. Because all medications have side effects, medication has benefit and your benefit needs to outweigh your side effect. That’s the issue. Right. Every medication is the same. So we prescribe across a range of therapeutic areas. But there’s a thing about informed consent that it’s important that a parent understands the pros and cons of a medication.

 

[00:19:32.320]

There should be a discussion around that. Okay. And that’s part of prescribing. So if something goes wrong with that and the parent wasn’t informed, then it will come back to the prescriber. That’s where the HTC gets involved. So, yeah, with all prescribing, that’s what happens. And it’s called informed consent. Do we usually regularly check, I mean, not personally the practice, but perhaps just the nurse checking on the parents, how was the medicine or medication? Yeah, look, with medications like this, where there is potential side effects or

 

[00:20:03.720]

problems, if I was starting a medication like that, or they just started, I generally try and see the patient or the family sort of reasonably regularly to know we get it kickstarted and there’s no problems. If there are no problems, it goes back to every three or six months or whatever it happens to be, and you check in and make sure. And one of the things you do with that is just checking there are no problems or apparent problems that have risen with medication. And also things like ADHD, going back to ADHD medication with children growing and that you need to do that regularly because obviously the dose adjustment becomes really important. That becomes really important part of what goes on. Yeah.

 

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If the parent would say no for that side effect, I mean, let’s say I heard a side effect that she doesn’t want, can they say no? Is there a recommendation? No. No one can force you to take the medication. Look what happens in conversations around this and my experience with this, often with medication, you sort of get a feel as the doctor that there will be benefit if you go on that medication. Okay, right. So my job as a GP in those situations is to be very clear about the benefit, but also with side effects and things not to overdo side effects. I can sit here and list the 101 side

 

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effects it may be on what we call a data sheet. Okay. That really doesn’t help because in many cases, A, they won’t occur and they’re very minor and it just raises anxiety. Okay. So I often talk about the major issues that could rise. I also tend to put it in perspective that this issue would rise in one and 100 children. So we need to be clear on that. And if it does, contact me, we’ll have a chat about it or see me and we’ll see about it because we often find that side effects settled down after a period of time. And also I leave it open that if there’s anything else they noticed that they are concerned about to talk to me about it. So I can discuss and see whether it’s related to the medication or not. I’ll be very honest about that. But you’ve got to weigh that up with the benefits of doing medication. The only reason for doing medication is if there’s going to be a benefit. Right. Otherwise don’t do it. There’s no point just like taking something. That would hurt someone. Well, exactly right. There’s no point in doing that. Yeah, I mean, takivatana is a Maori term for autism and this is the term that I’ve been using ever since. And I’ve heard about Terrell Habit, which is using it’s a glossary term used for mental health, disability and addiction. And these are Maori terms, change terms to Maori terminology. Is it something that we can perhaps not too much to ask, but is it something that we can perhaps start using? Okay, look, that’s a really good question. Look, I think there’s two ways I’d answer this and it’s actually really important. Number one, just going back to the college and training for GPS. Right. Mari approach, cultural appropriateness is a big part of training now across the whole spectrum. So it’s a very important component of training and to treat your obligations and what actually happens. So that has become a major part of the training for GPS. Coming through the training scheme over the last few years, it’s really increased in importance, as it should. Okay. I think treatment of any patients in the context of their cultural belief and where they come from is actually incredibly important. Okay. Because you fail miserably if you don’t. Okay, so, yeah, the answer to your question is yes. And it is actually appropriate. And the second part of the question is we need to be very cognizant of and culturally aware of maori in particular, but also Pacific refugee, just a whole range in what’s culturally appropriate because you go a lot further when you start to acknowledge and engage in a cultural behavior, appropriate behavior within a consultation. Right. In relation to that question as well, what’s equity? I mean, when I got into the college, it’s the first time that I heard about equity. So what’s equity in your point of view? It’s a good question, isn’t it? Equitable access to things or equity is about outcome. That across different ethnic groups. And we know we have a huge problem with disparity in this country, especially with Mary and Pacific,

 

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that actually equity is about whatever we do. We need to have equivalent outcomes and that often needs differential resource. That’s where it gets tricky. And I look at its thing, but it is what’s required. So if you’ve got a gap in terms of outcome and what actually occurs, you often need to pump more in down there to bring it up to there and then the whole system up. And so we’ve started to move into that space in New Zealand, our Toyota in New Zealand, and we need to move into that space because we need Equitable outcome. Yeah.

 

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And then are we looking at timeline for that? How long is a piece of string? I mean, the problem we’ve had in New Zealand is this has been a problem that’s been apparent for 100 years now, longer. And it is getting started to get the attention that’s due. I mean, I still see Rheumatic fever in Cannons Creek. We should never see rheumatic fever. It is a total sign of an equitable outcome in this country. So that requires a social determinist for health approach, which is housing, education, a whole lot of things. Access to medical care, access to quality medical care, which is something the college is really sort of strong on and access to quality, culturally appropriate care.

 

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Okay. Those things need to start to line up and that requires resourcing both at a government level to follow or Health New Zealand and at the practice level as well. And then you mention about government. The college is just working currently with MCNZ, right. Not directly to the Ministry of Health, New Zealand. Now, the college has a lot of contact with Health New Zealand. Huge amount. Not just one. No. So we spend a lot of time in meetings and talking to Health New Zealand about issues. However, the issues with health New Zealand are large. I’m hoping that it takes a whole system forward. And also the Maori Health Authority, which again, the Maori Health Authority has been set up under the treaty obligations, but also as a vehicle for looking at and specifically looking at disparity with Maori versus Europeans, especially in New Zealand.

 

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And what can be done in that. Space, what is in the ice of prime? It is a condition that is absolutely real, poorly understood. Very poorly understood. A lot more research needs to be done into it and focus to make sure that kids who may be on the autistic spectrum, because there is a spectrum obviously are picked up early and the support both for the child and the family is put in place appropriate in the context of a system that cares. Right. Okay. And then last two questions. The second to the last is what do you think in your view, parents like me can do to help the college or the general practice or maybe the wider ministry to support.

 

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Okay, look, there’s national organizations, obviously, that trying and influence the ministry and integrate the politicians and all the rest of it. And that happens at an individual basis, if you want my opinion on that. It’s what we said before when we talked about what a child may need coming into a surgery, maybe in terms of a quiet room, be honest. Okay? There’s two things. Be honest with your practitioner, your general practitioner or your nurse. Just be honest. If you got issues, don’t be afraid to raise them and be very truthful about them. Secondly, and probably this is my biggest thing, and I do have a bit of a beef about this look, try and land on a general practitioner that you are comfortable with and you build a relationship with.

 

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Okay? We know from all the international research, regardless of the system, regardless of what goes on, regardless of how bad or poor secretary services are, if you have a continuous relationship with a single general practitioner, you get much better outcomes down the track. And talking as a practitioner myself, the reason for that is I start to understand the child, start to understand the family and the dynamics, and start to work out where I can actually add some value in terms of advocating or working the system. Because often you have to work the system, right? Yeah. That would be my biggest piece of advice. Be honest,

 

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but find a practitioner that you relate to and you can have continuity with. I think with long term conditions such as autism, ADHD, anything else I’d range. Continuity becomes a critical factor because if you think about it from practice, if I only ever see you once with the complexity of what you’re dealing with, I can never understand that. Right. I start to build up a picture over four to ten times, because it’s over time I get a really clear picture of what’s going on. And you can actually start to find the pressure points that you need to do things. And you talk to all general practitioners have been around for a while. They talk about that aspect of things, and I don’t think we talk about that enough in the system.

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