25 August 2017 Dr Ayman Shenouda
RECRUIT, TRAIN AND RETAIN
Getting the policy settings right
I don’t think there’s ever been a better time to secure the next generation of rural GPs. Now more than ever before we have the right policy settings in place. We need to seize this opportunity to ensure we select the right doctors for rural Australia.
Once we’ve overcome that first hurdle in getting them there, we need to then ensure those registrars who choose rural practice, that once secured, they remain there. But not only remain there that they continue to thrive. To do this we need to ensure the right supports are in place.
The policy momentum has been building for some time with the help of thousands of rural GP champions – possibly most now reading this blog – who have advocated for change over many years.
We now have the right set of policy conditions: an overall increase in medical school intake with quarantined placements for rural; a rural emphasis and exposure with a focus on generalism as a priority in the training; and, of course, the regional training hubs which will soon be in place to help link the various stages of training.
We finally have the makings of an integrated rural medical training pathway. This includes a priority on rural community internships – a clear gap which needed fixing – and soon with the regional hubs, training can be structured in a more coordinated facilitated way.
The hubs, in particular, will strengthen the efforts of the Rural Clinical Schools’ and help build the facilities and infrastructure and teaching capacity needed to make this work. For the trainee, it will help to provide the navigational supports that have been so lacking in the past from medical school to rural practice. Importantly, we have a focus on non-coercive strategies in securing the next generation of rural GPs.
Why enter, why stay, why leave?
We know that many factors influence rural intention and that it is getting those supports right and across the full training continuum that counts.
Ruralising the curriculum is a key one. Embedding more primary care early into the medical curriculum is essential and this has certainly been said often enough. But other simple things like placing a rural scenario in the exam would also help to formalise assessment to enforce primary care and emphasise the important role of the generalist.
Getting them in early and interact as often as possible is another key requirement. Nurturing your registrars once there requires a whole of community effort.
I think it is instilling that sense of belonging that is vital at this point so the emphasis then needs to be multifactorial. Positive exposure offering a mix of rural experiences including clinical and nonclinical competencies and of the latter leadership being a key one here, the ability to lead and work in teams cannot be emphasised enough.
Trainees want broad exposure and the opportunity for multiple levels of clinical learning through blended placements. Trainees need to be empowered to make informed career decisions and to obtain the skills they need in the local setting. A community with the right structures and partnerships in place can facilitate this well.
Next is community connection and engagement and getting that right. This really gets to the heart of the issue – this is why they stay – that sense of place and identity. Ensuring a strong rural connection is hard work in training terms but worth the effort in the long run.
This is all part of developing a professional identity and mentoring plays a key role here. Longer-term placements in and around the same community also help to build those lasting relationships.
While I think an intrinsic characteristic of most GPs is their altruism there are also limits. We need to formalise that mentoring point – and at every learning stage – so that rural GPs and broader teaching staff are able to commit their focus towards mentoring.
More funding for mentoring has to be part of the suite of incentives in support of rural intention. Formalising succession planning in this way would help to ease the pressure on those nearing retirement too. That’s the ‘gracious exit’ part that often gets forgotten but just as vital as ‘easy entry’ for rural.
A rural pipeline functioning well can support these broader retention outcomes in terms of supplementing supply over time through a constant stream of new entrants. This would help make rural practice even more attractive as it provides an exit strategy for rural GPs without having to make that lifetime commitment. Rural GPs could stay for a shorter period, up to five years, without causing the workforce disruption that currently occurs upon exiting. Rural practice could become a standard part of the GP journey with supportive policy offering more flexibility and opportunity to spend at least part of your career within a rural community.
Now finally, getting to the hardest bit. Once you have them, then the focus then shifts to keeping them there. And getting to the bottom of that is a whole new set of questions which tend to include broader impacts including those on family.
Factors including an adequate income, appropriate workload, locum provision, access to specialists’ advice and continuing education, spouse career opportunities and children education all come in to play. Again, it takes a whole community to help make this work.
Bringing it all together
Piecing it all together there are a lot of factors that need to come together to get rural recruitment, training and retention right. Ensuring we have the right set of incentives in place for those making the commitment is key to policy success including rewarding advanced skills, procedural and non-procedural.
In understanding intentions to practice rurally, we know that rural origin plus a rural clinical school placement is a significant predictor. But there are many ways to get there and we should keep an open mind as many get there by accident. I think I fit that last category having only come to rural practice at the age of 35 after commencing in a completely different specialty to being with.
In securing strong rural outcomes, it comes down to nurturing those with an interest and being able to bundle those known influences. We’ve certainly come a long way in securing the right supports and focus to realise a fully integrated rural training pathway. It’s a multitude of factors including supportive policy and a strong local commitment from each and every one of us, but not least the trainee to secure the next generation of rural GPs.
 RACGP. New approaches to integrated rural training for medical practitioners. Royal Australian College of General Practitioners. 2014. Available at: http://www.racgp.org.au/download/Documents/Rural/nrffinalreport.pdf
 Parlier AB, Galvin SL, Thach S, Kruidenier D, Fagan EB. The Road to Rural Primary Care: A Narrative Review of Factors That Help Develop, Recruit, and Retain Rural Primary Care Physicians. Acad Med. 2017 Aug 1. doi: 10.1097/ACM.0000000000001839. [Epub ahead of print]Availablat: http://journals.lww.com/academicmedicine/Abstract/publishahead/The_Road_to_Rural_Primary_Care___A_Narrative.98154.aspx
 RACGP 2014, op. cit. p.65.
 Humphreys J, Jones J, Jones M, et al. A critical review of rural medical workforce retention in Australia. Aust Health Rev 2001;24:91-102. [PubMed]
 Walker JH, DeWitt DE, Pallant JF, Cunningham CE. Rural origin plus a rural clinical school placement is a significant predictor of medical students’ intentions to practice rurally: a multi-university study. Rural Remote Health. 2012;12:1908.PubMed
18 August 2017
Dr Ayman Shenouda
Most will agree that high quality care in general practice relies on effective teamwork. There are some good studies providing insights into the key features of effective primary health care teams confirming a strong correlation between a good team climate within the practice and a range of aspects of high quality care. [i] A stronger focus on research within general practice, in my view, would provide more quantitative studies detailing the effects of integrated multidisciplinary teams from within the practice setting for differing health populations and geographic regions.
From a broader health system perspective, there is currently strong interest on the efficiencies of multidisciplinary teams and their effectiveness in improving health outcomes and lowering costs. The role of the team in supporting integration between services and in enabling a shift from episodic to continuous care at a whole of system level. Driving this interest is also the need to develop new models of care in addressing increased demands associated with an ageing population and as the disease burden increases.
The multidisciplinary team is best defined by Cohen and Bailey (1997) as ‘a collection of individuals who are independent in their tasks, who share responsibility for outcomes, who see themselves and who are seen by others as an intact social entity embedded in one or more larger social systems and who manage their relationships across organisational boundaries’.[ii] Therefore, ‘teamwork’, in this context, is the product of interactions between healthcare professionals in a team.[iii]
Teamwork starts at the practice level
My focus here is in establishing structures to support effective team interactions within your own practice first, providing ways to evaluate or measure success, which can then build toward broader integration aims.
In measuring practice-level performance, teamwork in the primary care setting is often determined through a focus on a specific disease area such as effectiveness in terms of management of chronic diseases. Organisational capacity within general practice can also be tested through quality improvement measures such as through clinical audit.[iv] In my experience, clinical audit provides an effective way to measure the effectiveness of multidisciplinary teams in a value driven hole practice approach that aims to deliver quality patient care with clear achievable outcomes. Its participatory structure also allows you to ensure involvement from the full team in finding practical solutions.
We know a much broader funding focus is required in terms of driving more effective ways to manage the increased complexities and costs associated with the new patient norm of multiple comorbidities and chronic diseases. Structural and system supports are required to enable coordination and collaboration across boundaries – primary, secondary and tertiary care. In order to truly tackle and address fragmentation and achieve a more seamless service for patients throughout their disease trajectory much more focus is required on ensuring the required supports at the practice level.
Effective team characteristics
Collaborative teamwork provides a link between efficient organisational practice and high-quality patient care.[v] A large cross-sectional study of Australian general practices undertaken in 2007 showed that team climate was important for patient and staff satisfaction. Interestingly, this study also found that in terms of large general practices, that separate sub-cultures may exist between administrative and clinical staff, which has implications for designing effective team interventions.[vi]
But how much do we know around the qualitative aspects of what makes for a well-functioning multidisciplinary team in the practice setting?
One key study identified 10 characteristics underpinning effective interdisciplinary team work which is useful in terms of guiding a practice redesign. [vii]
The 10 underlying characteristics of an effective team.
I agree that all these aspects are important to a well-designed and high functioning team. From my own practice perspective, I would attribute the most reliant performance factors around good practice governance and business management systems including clinical information systems in supporting integration. But a great deal of focus for us also lies in providing a supportive team environment and in strengthening the capacity of the team.
Role utilisation and supports
A practice can make a significant difference for its patient population by using the team to their full capacity. Greater use of the primary care practice nurse through nurse-led clinics has provided significant benefits in my own practices. Our nurse-led diabetes clinic is proving very effective in delivering this care. As are our COPD and other chronic disease nurse-led clinics through offering enhanced patient management of chronic and complex conditions by helping patients in managing their conditions.
Nurse-led clinics not only lead to improved health care but can lead to patient empowerment as well as nurse empowerment. These models do not impact on continuity of care and instead provide a sustainable practice model enabling constant monitoring and management. Time intensive tasks such as data extraction, data management and patient recall systems in coordinating aspects of care are just a few examples which can be shared across the team.
Exposure to the full workings of the multidisciplinary team can enhance the training experience for the medical student, prevocational doctor or registrar in the general practice environment. A culture of teamwork needs to be instilled early and can only enhance the learning experience for the trainee. They need to be immersed in this structure and fully exposed to the workings of the multidisciplinary team. It helps to improve their understanding of others’ roles and builds respect and understanding.
Broader benefits for the entire patient population are achieved through stronger utilisation of the full practice team. Time efficiencies and cost benefits can be realised through increased throughput of patients. Patient booking can be made for both doctor and nurse, each with their own specific caseload and role but with a shared focus on enhanced patient care. The GP can then be better utilised in their specialist capacity to focus their expertise on more complex areas of care.
Primary care service delivery models that optimise the performance of the full multidisciplinary team should underpin future funding decisions. This is a key requirement to shifting care to the more cost-effective sector of primary care and out of hospitals. Increased costs in addressing demand must be met through flexible funding solutions to help meet the additional cost burden for private practices. The effective use of skills to optimise the full practice team is key to providing patient centred collaborative care but the funding must now follow.
[i] Campbell S M, Hann M, Hacker J, Burns C, Oliver D, Thapar A et al. Identifying predictors of high quality care in English general practice: observational study BMJ 2001; 323 :784
[ii] Cohen, SG and Bailey, DR (1997). What makes teams work: group effectiveness research from the shop floor to the executive suite. Journal of Management 23: 238–90, DOI: https://doi.org/10.1177/014920639702300303
[iii] Van Dijk-de Vries AN, Duimel-Peeters IGP, Muris JW, Wesseling GJ, Beusmans GHMI, Vrijhoef HJ. Effectiveness of Teamwork in an Integrated Care Setting for Patients with COPD: Development and Testing of a Self-Evaluation Instrument for Interprofessional Teams. International Journal of Integrated Care. 2016;16(1):9. DOI: http://doi.org/10.5334/ijic.2454
[iv] Amoroso C, Proudfoot J, Bubner T, Swan E, Espinel P, Barton C et al. Quality improvement activities associated with organisational capacity in general practice. Australian Family Physician Vol. 36, No. 1/2, January/February 2007 8-84.
[v] Mickan S, Rodger S. The organisational context for teamwork: comparing health care and business literature. Aust Health Rev 2000;23:179–92.
[vi] Proudfoot J, Jayasinghe UW, Holton C, Grimm J, Bubner T, Amoroso C, Beilby J, Harris MF. Team climate for innovation: what difference does it make in general practice? International Journal for Quality Health Care. 2007 Jun;19(3):164-9. Epub 2007 Mar 2.
[vii] Nancarrow SA, Booth A, Ariss S, Smith T, Enderby P, Roots A. Ten principles of good interdisciplinary team work. Human Resources for Health. 2013;11:19. doi:10.1186/1478-4491-11-19.
[viii] Nancarrow SA, Booth A, Ariss S, Smith T, Enderby P, Roots A. Ten principles of good interdisciplinary team work. Human Resources for Health. 2013;11:19. doi:10.1186/1478-4491-11-19.
11 August 2017
Dr Ayman Shenouda
Developing a skill set around your community’s needs.
Just like lifelong learning, community needs assessment is a continual process that helps us to ensure our community has the best possible service mix. Health needs assessment is developmental and has to be added to or adjusted over time as the community’s needs change. It is alongside that process that we commit to continual learning, to adjust our skills over time to ensure these needs are met.
For a rural community, where resources and infrastructure are scarce, needs assessment is a critical process. It helps you to prioritise where you can make the biggest impact, to plan and deliver the most effective care against those areas of critical need. It enables you to work collaboratively with the local community to develop the infrastructure required. Most of all it becomes a partnership as people centred health relies on community participation and through this process, you find yourself fully immersed in community life.
When I arrived in Wagga Wagga 17 years ago, I was armed with some advanced surgical skills acquired while working as a surgical registrar in Egypt, then further honed in Tasmania during my initial few years in Australia. Naturally, my fellow GPs in the practice referred to me patients with surgical skin conditions. This was great as it allowed me to utilise my skills, on the other hand, though patient expectations increased as they were under the impression that I was a Dermatologist!
In all honesty, my dermatology skills weren’t all that flash and it was clear the local service gap in Dermatology needed fixing. I subsequently completed a Diploma of Dermatology in 2003 through the University of Wales in Cardiff. I became very popular and started to have referrals from other practices in town, as without a local area specialist that role continued to fall to me. It was out of unmet need that this became a necessity of course but it really was the community driving that decision to upskill.
Now the Wagga community has access to dermatology services I am adjusting again but to a new requirement in palliative care. This is demonstrative of lifelong learning in practice – The good GP never stops learning – in providing lifelong care there relies a commitment to lifelong learning to adapting your skills to meet changing needs.
For those looking for more inspiration, there were some great rural stories produced some years ago. During 2012, the RACGP rural faculty celebrated its 20th anniversary and as part of our commemorating that milestone we produced a series of inspiring stories “Getting to know our rural GPs”. These stories were truly demonstrative of just how diverse the profession is and the depth of skills needed in supporting the often-complex needs of rural communities, while also highlighting the unique nature and rewards of living and working in rural general practice.
Applying a lifelong learning framework
In applying a lifelong learning framework, we already have the key structures to facilitate this. The Fellowship of the Royal Australian College of General Practitioners (FRACGP) signifies that a GP has been assessed as competent across the core skills of general practice enabling him or her to practice safely, unsupervised, anywhere in Australia.
The FARGP is a qualification awarded by the RACGP in addition to the vocational Fellowship (FRACGP). Providing a dedicated pathway for both general practice registrars and experienced practising GPs, the FARGP aims to develop advanced rural skills and broaden options for safe, accessible and comprehensive care for Australia’s rural, remote and very remote communities.
The FARGP is unique here in terms of using a population health approach to plan and execute health service needs for a community. The community-focussed project is undertaken over a six-month period and enables you to get to know your community and engage with them to improve health. This important requirement equips the candidate with essential planning tools and establishes leadership in a community.
Skill development in policy
For trainees, key to ensuring broad skill exposure is the need to map the training process to ensure a wide variety of experiences can be provided. Needs analysis is again critical here and this level of planning is something we should be doing more of at both the state and national levels. This level of planning provides a comprehensive training program and a way to ensure skills learned are transferrable to their practice after the completion of training posts in building a resilient workforce.
After all, it is these trainees that will provide vital services in the future. Ensuring broad exposure and allocating placements according to specific learning needs and against community need at this early stage makes perfect sense in planning a future generalist workforce. The new regional training hubs should help to support this needs assessment to tailor a training package which provides for the level of flexibility required to truly immerse in the community as well as ensure relevant clinical exposure.
Just as vital is the requirement for a skill-acquisition pathway for practising rural GPs acknowledging the lifelong learning requirement and addressing unmet need. A stronger focus is required at both the state and national levels in terms of providing that structure or mechanism in the current arrangements to facilitate training for those who wish to go back and retrain to meet a skill need in their community.
The Commonwealth’s Rural Procedural Grants Program is vital in supporting skill maintenance in some key hospital-based skill areas. Applying a population health needs assessment in terms of skill acquisition requirements should guide decisions at the policy level. This process would see an expansion of the procedural grants program to include essential non-procedural advanced skills. Policy planning needs to factor and be responsive to current and future need just as the GP does in responding to the changing health needs of their community over a lifetime.
5 August 2017
Dr Ayman Shenouda
Often a really good policy solution will in turn place more pressure on a part of the health system it relies. This isn’t necessarily a bad thing and is usually indicative of good policy spend. It is sometimes an outcome of optimal policy coverage as is the case for disease screening measures. The National Bowel Cancer Screening program, introduced in 2006, is an example of a policy working well.
We know that one in 12 Australians will develop bowel cancer by the age of 85 which makes it the second most common cause of cancer-related death in Australia after lung cancer. But, if detected and treated early the cure rate is around 90% which makes policy intervention through prevention and in this case, through screening measures, so vitally important. [i]
The is a great policy intervention which we’ve seen expanded under successive governments with broad coverage now currently available to Australians aged 50, 55, 60,64, 70, 72 and 74. Once fully implemented by 2020, all Australians aged 50 to 74 will be able to be screened every two years.[ii]
But as a result of this policy, we’ve seen demand increase for lower gastrointestinal endoscopies. This growth in demand means there is a need for the endoscopic workforce in Australia to be well planned in order to cope with future demand associated with expanded cancer screening, particularly with an ageing population. Service solutions to address current demand including nurse endoscopists are now being rolled out in Queensland and Victoria. But is this the right workforce response for Australia or is it more of a temporary fix to a growing system issue?
Here’s the policy background to the issue. The policy response to limited endoscopy capacity a few years ago saw the now defunct Health Workforce Australia (HWA) invest in a project to train nurses to perform endoscopic procedures. Expanding the scope of practice of health professionals was a typical policy response being keenly pursued at that time by HWA. This particular decision though saw unprecedented action with a policy preference to train non-medical endoscopists and build capacity from within nursing.
At the time, the medical press reported that doctors were calling for a moratorium on nurse endoscopy.[iii] From a resource perspective, it is important to also note that this was a decision undertaken within the broader context of increased medical graduates coming through and claims of impending oversupply.
The Advanced Practice in Endoscopy Nursing (APEN) program was modelled on approaches elsewhere including in the UK where the nurse endoscopist was well established. Although nurse endoscopy training and delivery of endoscopic services is not a new policy response: the first report of nurse endoscopy in the US was more than 35 years ago for flexible sigmoidoscopy.[iv] But I think it is important to work through policy alternatives for Australia particularly if one solution has limitations both in terms of efficacy and coverage.
The University of Wollongong evaluation of the HWA-funded APEN sub-project in 2014 highlighted some key points in terms of the validity of a nurse-led model as a workforce solution.
Firstly, it stated that one of the main drivers for the program was the need to respond to growing demand for lower gastrointestinal endoscopies arising from bowel screening. However, it also stated that only about a quarter of same-day colonoscopies are performed in public hospitals. A key detail that severely limits the ability of nurse endoscopists to meet this growing demand. The evaluation also stated that given full implementation was not achieved, that relative advantage in terms of effectiveness and cost effectiveness of the model could not be evaluated and could only be measured after trainees were qualified and working at full capacity. [v]
The Australian Medical Association of Queensland (AMAQ) in commenting on the Queensland roll out of nurse model to Cairns and Townsville, stated that medical endoscopists were more cost effective than nurses as surgery could be performed at the time of procedure.[vi]
Cost-effectiveness of the nurse-led model as a workforce solution has also been challenged in a study published in the World Journal of Gastroenterology in 2015. The study examined the available evidence on safety, competency and cost-effectiveness of nursing staff providing gastrointestinal (GI) endoscopy services. The study concluded that the empirical evidence that supports non-physician endoscopists is limited to strictly supervised roles in larger metropolitan settings and mainly flexible sigmoidoscopy and upper endoscopy for asymptomatic or low complexity patients. [vii]
This same study also stated that contrary to general beliefs, endoscopic services provided by nurse endoscopists are not more cost effective compared to standard service models due largely to the increased need for subsequent endoscopies, specialist follow-up and primary care consultations. It stated that studies measuring cognitive competency were limited and providing endoscopic services is more than mastering the technical skills required to safely advance the scope. Further, that making clinical decisions in the context of the patient’s full clinical picture is critical to delivering efficient and meaningful services.[viii]
In finding an effective solution, the most obvious question for me in terms of utilising the available workforce is around why we are not looking to general practice to address excess demand? Some of the pressure placed on endoscopy units in managing this increased demand can certainly be addressed by general practitioners.
General practice offers a particularly viable solution for rural communities in endoscopy. Keeping trained procedural GPs in rural areas should be made a priority and this is a good example of where support is needed to sustain local solutions where rural GPs fill a service gap like this. Access to diagnostic endoscopy is limited in rural and remote areas and service expansion by GPs provides significant patient benefits in terms of time and costs.
While savings including around reduced costly patient transfers are obvious to most, the investment in GP procedural practice where it offers a sustainable service model should be sufficient for policy makers. It would help to reduce the demand placed on regional tertiary services and could help make GP procedural practice more viable in the smaller towns. We know that rural GP proceduralists must be supported to consolidate their skills in the communities they serve and this is one service solution which can help realise this aim. It is a workforce solution that needs to be considered.
[i] Cancer Council Australia. Position Statement. Bowel Cancer. Available from: http://www.cancer.org.au/policy-and-advocacy/position-statements/bowel-cancer.html
[iii] Australian Doctor. Doctors call for moratorium on nurse endoscopy. 30 January, 2015. Available from: https://www.australiandoctor.com.au/news/latest-news/nurses-expand-scope-into-endoscopy
[iv] Spencer RJ, Ready RL. Utilization of nurse endoscopists for sigmoidoscopic examinations. Dis Colon Rectum. 1977;20:94–96. Available from: https://www.ncbi.nlm.nih.gov/pubmed/844404
[v] Thompson C, Williams K, Morris D, Lago L, Quinsey K, Kobel C, Andersen P, Eckermann S, Gordon R and Masso (2014) HWA Expanded Scopes of Practice Program Evaluation: Advanced Practice in Endoscopy Nursing Sub-Project Final Report. Centre for Health Service Development, Australian Health Services Research Institute, University of Wollongong. Available from: http://ro.uow.edu.au/cgi/viewcontent.cgi?article=1384&context=ahsri
[vi] ABC News. More gastroenterologists needed rather than using nurse endoscopists in hsopitals, AMAQ says. 18 Apr 2016. Available from: http://www.abc.net.au/news/2016-04-18/amaq-more-gastroenterologists-rather-than-nurse-endoscopists-qld/7336202
[vii] Stephens M, Hourigan LF, Appleyard M, et al. Non-physician endoscopists: A systematic review. World Journal of Gastroenterology : WJG. 2015;21(16):5056-5071. doi:10.3748/wjg.v21.i16.5056. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4408481/
Dr Ayman Shenouda