Tim’s MD thesis charted his 20-year journey in health services research both in the UK and in Aotearoa New Zealand.
“People have diseases, its not about diseases, but the people who have the diseases.”
Tim Stokes is the Elaine Gurr Professor of General Practice at the Department of Primary Care, Otago School of Medicine, based at the Dunedin campus, New Zealand.
Tim is an academic general practitioner with a particular interest in health care delivery and implementation research, using a range of quantitative and qualitative methodologies. His particular interests are in rural health services and health systems, evaluating complex health system interventions, and new ways of delivering health services for acute and chronic clinical conditions in primary care and across the primary/community – secondary care interface He was a member of NZ’s Pharmaceutical Management Agency (PHARMAC) Pharmacology and Therapeutics Advisory Group (PTAC) from 2016 to 2022. He is Co-Editor-in-Chief, Journal of Primary Health Care, and Past President, Australasian Association for Academic Primary Care (AAAPC)
He was previously Senior Clinical Lecturer in Primary Care, University of Birmingham 2013–2014; Consultant Clinical Adviser, National Institute for Health and Care Excellence (NICE), a Visiting Professor at the Universities of Leicester and Leeds 2006–2013, and Lecturer / Senior Lecturer in General Practice, University of Leicester, UK 1997–2006.
Emilie Couchman is a salaried GP with the Sarum Health Group in Wiltshire. She considers her clinical remit to be generalism and is a firm advocate of continuity in clinical practice. Emilie is an NIHR Clinical Lecturer in General Practice with the Division of Primary Care Palliative Care and Public Health at Leeds University. For the past 16 years, her academic field of interest has been palliative and end of life care. She is married to a resplendent man and they have two young children and a middle-aged Hungarian Vizsla.
Emilie Couchman: Kia Ora Tim, Welcome. I like to start these conversations by thinking about where your inspiration to become a clinician might have come from. I understand you’ve always had bilateral sensorineural hearing loss, which has significantly worsened over recent years, do you think this might have played a part in your career choice? And, do you think it might have shaped how you practice as a doctor?
Tim Stokes: I was diagnosed with bilateral sensorineural hearing loss, which at that point was of moderate severity when I was about 5 or 6 years old, by my local GP, Doctor Hall, working on Lancashire coast in the late ‘60s. He did an ear, nose, and throat, attachment at the local hospital so he looked after me. He did recommend that I wear some hearing aids, which I did for a short time at primary school but I hated wearing them because they were stigmatizing. I will come back to that later. I then got hearing aids in my last year of medical school and have worn them ever since. Doctor Hall was always a supporter of me and, when he heard I wanted to go to medical school, I remember him coming round to my house with a cassette tape, which is in the box somewhere, of heart sounds, and he said ‘you might find this helpful, particularly with your hearing loss’. So I suppose that just touches on perhaps how doctors saw hearing loss, particularly when I was at medical school in the 1980s. I do think it was seen primarily a technical matter that could be fixed either by sitting near the front of a lecture theatre or by getting an amplified stethoscope. I don’t remember anybody ever discussing with me the challenges that I would face during a surgical or anaesthetic attachment with mask wearing and the effect that would have on your ability to hear.
That just emphasizes how hearing loss can be stigmatizing condition but I think it gets less as you get older, I think.
I’m a great fan of Erving Goffman’s work on stigma who says that people with stigma always want to pass as normal because you live in an enabled world. You can’t keep asking people to repeat themselves indefinitelyso you have to pass as normal. I’ve done that because my hearing has got worse, but it’s always been a loss. I’ve never been able to hear everything anyone ever says to me- sometimes a lot, sometimes nothing, but sometimes in between.
I have to say, I think my medical career choice was driven by other factors, it wasn’t driven by my hearing loss. I think it was driven by great exposure to both general practice in Edinburgh from John Howie, and his work on diagnosis is a great read. And also, I have to say, the psychiatry teaching from Professor Robert Kendall was fantastic as well. So those were my two early passions, and I think they were driven by a positive medical school experience and also the hidden curriculum around about being treated humanely and respectfully, and listened to, and your opinion valued on attachments such as general practice and psychiatry.
TS: You asked about my career choice. Would you like to know how it affected my work as a doctor?
EC: I think you’ve indirectly started to answer that question.
TS: You can see disability is a deficit, but I think it’s important to see disability is also a strength because, for people who are disabled, if they succeed, they will have developed strategies to succeed. Strategies to succeed in my case included from active listening to reading the room and lip reading.
And, thinking about it in the consultation, I guess, it’s that I’ve been sensitive to patients’ non-verbal cues, reading how they react, and making sure I lip read, obviously being open to people about being deaf. I still do wonder how many ‘by the way’ comments have got missed if they weren’t standing in my visual field because I probably wouldn’t have heard it. But I can’t do anything about that.
I think being a doctor is more than just individual one to one consultations, its about working in teams and, particularly, as I work through the university, it’s about chairing meetings, leadership work. And I do believe that finely tuning skills around lip reading and, in particular, reading the room have made me a good chair and I’ve had feedback for that. I do believe it actually helps how you work with people, because I think you’re much more switched on in terms of reading what’s happening in the meeting, having a sense when people may not agree with something, asking those questions. I think there are strengths that I’ve developed through having a deficit.
As the first President of the Australasian Association for Academic Primary Care (AAAPC) from Aotearoa New Zealand I’ve been reflecting on the Māori whakatauki (proverb) “Ka Mua Ka muri” which translates as “walking backwards into the future.” AAAPC has experienced a number of challenges over the last 10 years, notably the defunding of PHCRIS and COVID-19, and I’d like to acknowledge the hard work of all past Presidents, including my predecessor Phyllis Lau, that has enabled us to take the Association forward to where it is today. I’ll be continuing on Executive as Immediate Past President and look forward to hashtagAAAPC26!
Stokes, T., Tarrant, C., Mainous, A., Schers, H., Freeman, G., Baker, R.(2005) Continuity of care – is the personal doctor still important? An international survey of general practitioners and family physicians in England & Wales, Netherlands and United States (2005). Annals of Family Medicine, 3:353-369
International survey showing general practitioners from 3 differing health care systems all place high value on being able to provide personal continuity of care to patients. Personal continuity of care remains a core value of general practice/family medicine and should be taken account of by policy makers when redesigning health care systems.
EC: You’ve mentioned a little about the values that you hold with respect to general practice already, but can we go to your perspective on generalism and what that means in clinical practice- and I’m particularly interested in your thoughts on whether generalism adds more value in the rural health setting compared to other contexts.
TS: Just thinking about generalism, I guess generalism has a number of dimensions.
I think the first dimension is that generalism is about breadth and specialism is about depth. But I do believe generalism is also about developing long term relationships with people over time.
I have to be careful here because there are specialists who develop important long term relations with their patients over time,and I think of psychiatrists and people who review chronic medical condition management. But I think, in general, specialism is about single disease based episodic care. And I also want to bring in something from Aotearoa, as we live in a multicultural country and if I could quote a Maori proverb, which is “He tāngata, he tāngata, he tāngata”
.Which is; its the people, its the people, its the people. So that to me, in the context of generalism, is emphasizing that generalism, should value connection to community and relationships.
There are other things you can add to that; managing complexity and managing undifferentiated disease. But I think those are the core things, it’s really about developing relationships with people. People have diseases, its not about diseases, but the people who have the diseases. So you ask me about it being more perhaps important in rural areas, that’s an interesting question. I think it’s certainly true that generalism is about the connection, community, and relationships. And, if you work as a rural practitioner, and I worked personally as a rural practitioner in the UK, I worked in the Pennines for a number of years, and I also worked in the fens of East Anglia.
Reflecting on that, and I can also talk to my colleagues in New Zealand because I do a lot of work with rural generalists, and with rural GPs in terms of research, is the emphasis around looking after a defined population of people over time, living in the community, perhaps being in a goldfish bowl, developing the strengths of being with people from cradle to grave, satisfaction of caring form people over time.
Also, developing strategies to manage your own needs at times and to not to be quite so immersed in that community, and the ways you do that in a positive way.
And thinking about other practice as well, because I don’t think urban is homogenous. I’ve worked as an urban GP and I’ve worked in suburbia, I’ve worked in areas of high deprivation, and now in very high deprivation. And I think it applies in other contexts such as urban deprived practice, where often you are the person they’ve met for the first time that is prepared to treat them as a person, who wants to listen to their story, when they feel they are just a number in the benefits office, and I think that’s really quite important as well.
So my reflection is that generalism is really important when you’re dealing with patient groups who need you, need your practice team, to provide them with personal continuing primary care.
New Zealand’s oldest university – the Victorian clocktower complex in spring & autumn
Tan, T., Little, P., Stokes, T. on behalf of guideline development group. (2008). NICE Guideline (CG69): Antibiotic prescribing for self limiting respiratory tract infections in primary care.
British Medical Journal, 337:232-233.
An example of one of a number of national clinical guidelines our team developed for NICE. It was adapted for use in New Zealand general practice in 2014.
Penno, E., Atmore, C., Maclennan, B., Richard, L., Wyeth, E., Richards, R., Doolan-Noble, F., Gray, A.R., Sullivan, T., Gauld, R., Stokes, T. (2023)
How did New Zealand’s regional District Health Board groupings work to improve service integration and health outcomes: a realist evaluation
Moving on from trust in the clinical consultation to trust in organisations, this realist evaluation found that the complexity of DHB regional working meant that success hinged on building relationships, leadership and trust, alongside robust planning and process mechanisms. As NZ reorients its health system towards a more centralised model underpinned by collaborations between local providers, our findings point to a need to align policy expectations and foster environments that support connection and collegiality across the health system.
EC: Bringing the geography into it, how has your life been shaped by your own geographical journey. You spent your childhood in northern England…
TS: I’ve probably had a pretty standard middle class existence, growing up on the Lancashire coast, being a bright grammar school boy, and going to Oxford University in 1982, which was an entry into a different world, and then finishing my medical degree at Edinburgh in 1989. I certainly didn’t have a particularly ambitious geographical life as a student, but it’s interesting how I came to work in New Zealand. At one level it was actually serendipity. At the time, I’d recently moved to a job at the University of Birmingham, and I was approached out of the blue back in 2013 to apply for the Elaine Gurr professorship of general practice at the University of Otago. At that point it really ticked a number of boxes. My kids, who must have been aged about7 or 8 or, 9 or 10 at that time, had the opportunity to experience a new country, to live somewhere else. I’d also got pretty fed up with commuting. I did a lot of extreme commuting to jobs at that point in my career, as well as working a day a week in a local practice, and I was quite keen to change to live somewhere like Dunedin, where I could easily live and work in the same place.
However, I’d spent a bit of time there in 2005 at the University of Otago in the department of general practice and that was actually a trigger for my PhD research, which I’d done at the University of Leicester in the late 90s, on ending the doctor patient relationship.
That was a time when there was a qualitative research renaissance. Maybe renaissance isn’t the right word. One of my good colleagues, Chrys Jaye, at that point a senior lecturer in medical anthropology in my department, wrote a very nice paper in Family Practice exploring the value of a qualitative research for GP researchers. From working with her, I got to know a GP called Hamish Wilson in Dunedin who had been doing something similar in New Zealand. And Hamish used the guidance from my thesis in dealing with difficult patients with the New Zealand Medical Council. I don’t think I’d have moved had I not already had an existing relationship, and had known people through my contacts. I took the role I have now on the 1st of July 2014. That’s nearly 12 years ago.
EC: And are there any stark differences that you think are important to highlight between the UK and the New Zealand, in terms of the health care services and the system?
TS: Let me just start by emphasizing the similarities as I think that’s important. First of all, there is universal access to healthcare both in primary and secondary care and there’s a strong primary care GP gatekeeper role, and good use of team working within general practice and across the sector. And, certainly, in terms of consulting with Pakeha, that is New Zealand European patients, I found it very straightforward and I didn’t have any particular problems culturally working with Pakeha patients coming to New Zealand. This conversation is not around the cultural nature of practice, but it’s important to emphasize it is very important to learn new ways of working with, and being culturally safe, with people who are Maori and Pacific.
The major difference is in primary health care, because the public health system at secondary level is very like the NHS in that its free at the point of use. You have to pay to see a GP except in various exceptional circumstances, usually through charitable organizations, so there is a fee.
New Zealand actually developed a socialized health system ten years before the UK in the late 1930s and at that point, the doctors would have nothing to do with socialised care. There seems to be a view, certainly in those days and maybe even now in some areas, that people don’t value anything unless you pay for it. So, GP’s are private providers. It’s a 50 -50 system, it’s got 50% capitation payments and that came in about 20 years ago. There is capitation payment that covers all the responsibilities of providing population level care. But 50% of your income comes from fee for service. So you could conceptualize, as I might do, as someone who is working in the public sector and providing public service, but receives a private co-pay. Or, I might conceptualise my work as being essentially a private business person or private practitioner, but drawing in some public work funding with a need to provide services. It does mean that financial issues are a barrier to access for people that can be mitigated as there are very low cost access clinics available, but it’s usual to pay at least something when you see a GP.
There are advantages to using a private model, I think that’s entrepreneurism. The system has been very innovative over the years and has been able to develop innovative ways of using technology using bottom up approaches so there was very early computerization of systems, very early patient portals, really good secondary- primary integration of referrals and also notes transfer. They are actually much further ahead than secondary care in New Zealand.
So actually there have been strengths in the early adoption of technology. The other area of difference, and I think this probably goes beyond the health system, is to remember that it is a small connected country with two degrees of separation, so relationships are really important.
And it does mean that even when the system is under great strain, like the UK, and I would argue that we have a government that is destabilizing the public health system in this country at the moment and is favouring more private provision but, because it’s small, the system is porous. If you ring up, someone will try to help and someone will get you through to the right person.
Without going into medical details, I have been hugely impressed as a recent patient with the intrinsic motivation of our public radiology staff, for example, who were quite prepared to say that although I’d only attended for one scan, I was due another in a different body area and they said they’d do them together as it was much more efficient and they had the capacity. Thinking about the NHS, I just can’t see the NHS responding in that way. And the other thing I would say as well is that because the system is not fully public, there’s a lot of good use of the not for profit organizations to provide care as well. The cochlear implant that I will get is actually going to be provided by a charity that partners with the private hospital provider to deliver the services, but with public funding, just emphasizing the need for some flexibility in the system.
And that brings me to the third thing, that while New Zealand has an NHS type secondary care, private primary care, it also has the social insurance model for accidents. We have something called the Accident Compensation Corporation whereby, if you injure yourself you get a subsidy for care.
Stepping down as Head of Department of Primary Health Care (formerly General Practice & Rural Health) in the Faculty of Medicine – Dunedin University of Otago – in 2025.
Presented with this fine ceramic lalaga (woven) bowl by the Rural Health team to recognise this contribution: Nāku te rourou, nāu te rourou, ka ora ai te iwi. A Māori whakataukī (proverb) which in this context can be translated as “with your knowledge basket and our knowledge basket we will thrive.” Thank you to the team – (from left to right) Kati Blattner, Rory Miller, Lynne Clay and Gary Nixon.
Tarrant, C., Dixon-Woods, M., Colman, A.M., Stokes, T. (2010). Continuity and trust in primary care: A qualitative study informed by game theory.
Annals of Family Medicine, 8:440-446.
Carolyn Tarrant was my first PhD student and this work makes an important theoretical contribution as to how secure trust between GPs and patients can develop. The findings highlight that patients do not see GPs as interchangeable and that the move toward organizing services around single encounters may disrupt the development of secure trust.
EC: Expanding a little on thinking about that interface across, primary, secondary, or tertiary care, do you think as we become increasingly more multidisciplinary, that continuity, coordination, navigation of the system is becoming really difficult or do the positives outweigh the negatives?
TS: I think it is becoming more complicated. There are many people involved. But I guess we do have to have to recognize the strengths of primary health care as opposed to being a GP. There are strengths of using different people with different skills in the team and how through that, you can provide more than what one person or one discipline can provide, which is really important. Just thinking about Jeannie Haggerty’s work on defining continuity of care in the BMJ. (https://www.bmj.com/content/327/7425/1219) this idea of having three definitions; informational continuity, management continuity and, relationship continuity. We talk quite a lot about relationship continuity because that’s something I certainly really value. But informational continuity is critical. And, as I mentioned, having a shared record system, transfer of notes from primary to secondary care will help inform that, and management continuity as well. So I think that we need to work hard to fix that.
From a New Zealand perspective, again, we can draw on the small connectedness of the country to say that we would bring people in from secondary care, if that’s our provider, to talk to us, to build a working relationship with those people. And we would try to work as best we can with people in those roles. I know that can be difficult [in the UK] because you can have a high turnover of staff and that makes things difficult. New Zealand is a smaller country and its different to the way the UK works. The UK is larger. And, you’ve got particular problems in the city environment. It might be easier in the rural area if you know who the people are because somehow, you’ve got to get the people involved as it can’t just be around using information and management continuity. You do have to somehow get the people involved with care so you can build a working relationship. I also think it’s critical for the people working in that system that you nurture and grow high levels of intrinsic motivation, which basically means that they feel empowered to do the best thing they can for the patient, which is what I was alluding to with the scan scenario earlier.
EC: As a health services researcher and a GP, is there ever any tension across those two roles or do you find it very straightforward to balance them?
TS: I have to say that, while we look after individuals and we have to respond, I do believe we are there to serve a defined population of people in the practice that is usually geographically defined or should be defined if possible. And, through that, we are there to focus on prevention; early intervention and community based care to improve population health. For me, I don’t see that as a tension because that’s how I would define my role as the GP, but given that definition, would I want to work, for example, as an independent GP, perhaps providing services to a particular disease group that’s not within primary care generalist arena? That wouldn’t be of interest for me. My passion would be the delivery of primary care based preventive health as well providing relationally based generalist care.
“A favourite pastime is just to get up to the Otago peninsula and walk – its nearest beach is a 5 minute drive, nothing is more than a 40 minute drive away, and great to climb harbour cone and other hills; I also cycle up the peninsula on the harbour path to MacAndrew Bay on my Brompton. ”
Stokes, T., Shaw, E.J. Camosso-Stefinovic, J., Imamura, M., Kanguru, L., Hussein, J. (2016) Barriers and enablers to guideline implementation strategies to improve obstetric care practice in low- and middle-income countries: a systematic review of qualitative evidence.
Implementation Science 11: 144.
This systematic review synthesises qualitative evidence on guideline implementation strategies to improve obstetric care practice in LMIC in order to identify barriers and enablers to their successful implementation. A key finding of the framework synthesis was that “high” and “low” intrinsic health care professional motivation are overall enablers and barriers, respectively, of successful guideline implementation.
Stokes, T., Tumilty, E., Doolan-Noble, F., Gauld, R. (2017) Multimorbidity, clinical decision making and health care delivery in New Zealand Primary care: a qualitative study.
My first NZ research paper. Primary care professionals encountered challenges in providing care to patients with multimorbidity with respect to both clinical decision making and health care delivery. We highlight specific NZ barriers to the delivery of primary care to patients living with multimorbidity.
EC: Clearly I phrased the question in a fairly negative way and then you flipped it on its head, which is great. And, that brings me to my last question, and I suspect the answer will be a resounding yes, do you feel able to be the type of GP that you want to be in the context within which you work?
TS: Yes, I do. And, as I think back over my career moving from, as most academic GPs did, spending the majority of their time working in the practice, sometimes as a partner, sometimes a salaried GP, to a position where I now do a much more limited amount of clinical work because of other activities, I do feel I’d like to acknowledge all the practices with whom I’ve worked.
Obviously in your career there are negatives, and I ‘ve had a partnership split early on in my career, but I don’t want to talk about that today. The main thing is around the positives and, at each point both working in the UK and in New Zealand, I’ve been able to find a practice to work in, and to work with fantastic colleagues, and to work in great functional small teams which a good general practice does.
And in New Zealand as well, I’ve also had the opportunity, and you could say it’s a negative that the charitable third sector has to provide care for the most vulnerable in society in New Zealand, to homeless people for example, but that provision allows me to work in a charitable third sector clinic to provide pro-bono care to homeless people and also people with very high levels of physical and psychological co-morbidity. And, you know, that is a real pleasure, in a very small practice, with all the advantages of having a small list. It works for people in that they’re built to work relationally well or with the team, the nurses and other members of the primary health care team, and indeed with the relevant referral agencies. And, I feel that I’ve been able to dovetail that with my academic work in terms of being able to do both.
So, I have no regrets. It’s over 40 years now since I got my first degree in 1985 and I’ve had a really good innings, to be honest.
EC: Tim, thank you so much for your time today and for sharing your experiences.
Nga mihi. Thank you.
“We live just a 5 minute walk up the road from St Clair beach. Two pleasures- Coffee and the Brompton. Beans and a flat white from the oldest coffee shop in town – Mazagran – on Moray Place. It has blackboard art which changes monthly. My GP practice is just a round the corner.”
