Primary care prevents health problems from becoming more expensive – why doesn’t NZ fund it properly?

To most of us, a visit to the local pharmacy feels like a simple transaction: we hand over a prescription slip and collect a box of pills.

What we don’t see is all the clinical judgement that precedes it: a pharmacist spotting a potentially dangerous drug interaction, or a GP untangling multiple conditions before deciding what or whether to prescribe.

This invisible work is precisely what prevents disasters and keeps patients out of hospital. Yet New Zealand’s primary care funding model barely recognises it.

Instead, the system relies on a “hidden subsidy” buried within dispensing fees and retail margins that actively penalises the deepest, most necessary clinical work.

It’s here where New Zealand’s primary care model begins to fail: not in the quality of its clinicians, but in how it pays for their time. Fixing that structural flaw couldn’t be more urgent.

When prevention goes unpaid

Just as pharmacists prevent harm through meticulous medication review, GPs prevent deterioration through time-intensive consultations with complex patients.

Spending 30 minutes with a family doctor can sometimes be the difference between stability and a hospital admission. When it works, there is no adverse drug reaction and no trip to the emergency department.

Research consistently links primary care continuity to fewer hospitalisations. But our funding structures simply don’t reward the absence of harm.

New Zealand’s primary care sector runs on a model where complex, time-intensive care for the sickest patients is financially propped up by high-volume, transactional care for healthy ones.

Nobody explicitly pays for the time a pharmacist spends phoning a prescriber to challenge a risky dosage. That life-saving intervention is covered by the margin on dispensing 50 routine scripts, or by the markup on vitamins and sunscreen sold at the front of the shop.

The profits from simple transactions quietly bankroll the complex care. Far from being an accident, it is a structural feature of the Community Pharmacy Services Agreement.

For GPs, capitation funding models often fail to account for the extreme variation in patient complexity.

A practice in a deprived community serving patients with diabetes, chronic lung disease or depression often receives much the same base funding as one providing mostly routine check-ups in a wealthy neighbourhood.

The clinics doing the hardest work are financially penalised for it. Underpaying for clinical time burns out doctors, nurses and pharmacists. It also leaves the highest-need communities with less care than they require.

Read more: We studied primary care in 6 rich countries – it’s under unprecedented strain everywhere

Why price caps don’t work

When budgets are tight, governments trim fees and margins. Illness remains. The pressure moves from primary care to somewhere more expensive.

If a pharmacy is forced to increase dispensing volume just to stay solvent, pharmacists have less time for important safety checks. If a GP clinic is financially squeezed, consultation times shrink and doctors are forced to close their books. Complex needs go entirely unaddressed.

Often, this unmet need simply accumulates: economists call it latent demand.

The patient who missed out on a comprehensive medication review eventually turns up at an emergency department with a severe adverse reaction or an acute flare of a chronic condition.

By then, they’re far sicker, and the cost to the taxpayer is many times higher than the primary care intervention would have been. Underpaying for time in primary care is a catastrophic false economy.

Fixing the flaws

Addressing the hidden subsidy requires a definitive shift from volume-based transactions to complexity-based funding.

A pharmacist conducting a comprehensive medication reconciliation for an elderly patient on ten drugs should be compensated for that thinking, regardless of whether a physical product is dispensed. That clinical judgement has value in its own right.

The same applies in general practice. A consultation that prevents a hospital admission requires far more time and skill than a routine script renewal.

Funding models must recognise that variation and properly support practices serving high-need populations, so clinicians are enabled to spend more time with complex patients, not less.

When a primary care professional catches a prescribing error or intervenes to stop a chain of avoidable harm, that action saves the hospital system thousands of dollars. It should be explicitly recognised and paid for.

New Zealand cannot keep relying on retail margins and the goodwill of overworked clinicians to prop up its primary care sector. If it does, the safety net will continue to fray – and preventable harm will eventually follow.

Dylan A Mordaunt does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.