Unsettling times in our communities and across the world
It is an unsettling time.
We know young people, their parents and teachers have been preoccupied with school closures for several weeks. We are aware that families in our community are facing new challenges, juggling the responsibilities of caring for family members – young and old. Thousands of people are adjusting to new working arrangements, while others, in casual employment or small business are fearful about future incomes.
And then there are the health professionals.
The GPs and their teams.
The medical and nursing professionals working at hospitals.
The Nurses working in aged care.
The Aboriginal Health Workers reaching out to support communities.
These professionals have been working for weeks to respond to, and prepare for, the spread of COVID 19.
We knew COVID 19 was coming and its impact was to going to be significant. Australia’s leading medical professionals and GPs having been working around the clock to prepare Australia, the health system and GP practices. Thankfully, our politicians have been listening to the medical experts and responding to their advice. But more needs to be done.
As at 3:00pm on 25 March 2020, there have been 2,423 confirmed cases of COVID-19 in Australia. This figure is rising I am still hopeful it will flatten in response to the recent restrictions . GPs are on the frontline. Every day, we see patients who need testing or who are displaying symptoms that are causing them to be concerned. As GPs we balance keeping our staff and ourselves safe, whilst also attempting to achieve continuity of care.
There is a long road ahead for each of us and our communities. Our patients look to us as the calm providers of advice. They seek out our guidance and look to us to reassure them. We have the skills and expertise to be at the frontline of the campaign to keep all of us healthy and safe. However, to do this role well, we need open lines of communication with decision makers, access to evidence, timely testing and plenty of PPE.
Australia has more than 26,000 specialist GPs[i]. We are working in communities all across Australia. We want to help our patients and their families through this time. To do this we are going to need our support networks, our leaders and our resilience. I am confident that Australia’s GPs are up to the challenge. Our communities are depending on it.
[i] Medical Board of Australia. Registrant Data – December 2019. Accessed 22 March 2020 https://www.medicalboard.gov.au/News/Statistics.aspx
A collaborative approach is what we need for rural GP training
I recently had the opportunity to host a Rural GP Summit in Alice Springs. The summit brought together the key people and organisations that contribute towards ensuring there is quality general practice in rural Australia.
At the summit, we analysed what is working well to support GPs to train in rural Australia. We also acknowledged the need for improvements. Including harnessing innovative contemporary learning models, which are flexible, and offer new opportunities. For more details about the announcements the RACGP made at the Rural GP Summit and the opportunities this will create for registrars, see link here.
For me, the greatest outcome from the Rural GP Summit was seeing the willingness of delegates to come together to talk about, and debate, the future of rural general practice education and training. There was such generosity in the sharing of ideas and solutions. There was also courage to discuss what is not working well.
We all know about the challenges associated with supporting general practitioners to train and work in rural Australia.
We know about the struggles to enlist experienced supervisors, and the barriers that prevent registrars from feeling confident to undertake their training in a rural community.
We have lived through the historical division between GP organisations and have witnessed the arm wrestling that occurs between Commonwealth and State Government agencies. All of which creates confusion and duplication and further prevents GPs from addressing community need.
However, we also know that working in rural Australia, as a GP, is one of the best jobs there is.
Where else do you get to use all of your training (sometimes before lunchtime) to provide continuity of care for your community. Rural general practice is about teamwork. Working in teams to address community need in a rural community, is immensely satisfying.
Listening to the discussion and ideas at the Rural GP Summit has given me hope. It has confirmed to me that we need to build collaboration into the design and delivery of future rural general practice training.
We need to ensure junior doctors and registrars are at the table when the education and training frameworks are created. We need to invite medical educators and supervisors to be part of the discussion about how we deliver general practice training in rural Australia. We need to regularly invite feedback from our partner agencies and rural stakeholders. We also need to work with our stakeholders to monitor trends and to mobilise our collective energies and resources, when there are obstacles that are hindering high quality general practice training in rural Australia.
If we can work in collaboration, I am confident we can reform our current approaches to rural general practice training. I am hopeful we can create new flexible models that reflect the aspirations and expectations of our current and future registrars. If we can harness the energy and insights of our registrars, educators and rural stakeholders we can achieve great things.
Our rural communities will be the big winners if we can get this right.
Comprehensive community general practice, coupled with emergency management is the heart that will keep rural generalism alive
Comprehensive community general practice, coupled with emergency management, is the heart that will keep rural generalism alive
I recently had the opportunity to spend a few days in Western Australia meeting with GPs, government officials and experts in rural and remote health.
It is apparent that comprehensive community general practice, coupled with emergency management is the heart that will keep rural generalism alive. This was evident during my visit. The leadership of GPs such as Dr Michael Mears in Esperance and Dr Michael Livingston in Ravensthorpe demonstrated how rural generalism is thriving.
I met Dr Mears and 11 of his colleagues, early one morning. This group of 12 GPs, representing a number of local GP clinics, provide comprehensive primary care, as well as emergency medicine, anaesthetic, obstetrics and surgical services. They shared with me their collaborative model for addressing patient need within their community. They are outstanding educators and are committed to supporting the next generation of rural GPs. I enjoyed the opportunity to discuss the RACGP’s vision for general practice and to hear their ideas for the future of rural generalism.
I was also privileged to meet with Dr Michael Livingston at his practice in Ravensthorpe. His practice supports a community of 2000 people and he is a passionate rural generalist. His approach to comprehensive patient care is leading to outstanding health outcomes. It was also great to meet with his wife and family. The commitment and sacrifice they offer to the community of Ravensthorpe is remarkable. Michael shared with me his concerns about the viability of general practice in rural WA communities and the impact on patient care from a lack of integration between Commonwealth and State governments. Michael has many ideas for enhancing the sustainability of general practice in rural and remote Australia.
When I am next in Canberra, I intend to speak to the issues and ideas shared with me in Esperance and Ravensthorpe. I am keen to ensure that MPs and government officials hear and act upon the voice of grassroots GPs.
The visit to WA gave me the opportunity to meet with leaders and rural health experts at a number of relevant agencies including WAGPET, WA Department of Health, WACHS, Rural Health West, the AMA, Rural Clinical School of WA and the WA Primary Health Alliance. I was briefed on the challenges of recruiting health professionals to work in rural WA and how communities thrive when there is continuity of care from a GP.
It was good to receive an update on the efforts of many to provide medical students, junior doctors and registrars with fantastic education and training experiences. Rural and remote WA is a wonderful place to learn how to become a great GP.
I have returned from my trip, energised about rural general practice and inspired by my colleagues in WA.
I extend my appreciation to Adj Professor Janice Bell and her team at WAGPET for arranging the visit. I also wish to acknowledge the following individuals who meet with me and shared their expert knowledge on rural health care in Western Australia.
Photo 1: Dr Michael Livingston and family in Ravensthorpe, Western Australia
Photo 2: Dr Mears and colleagues in Esperance, Western Australia
Dr Ayman Shenouda
When we stand together, great change is possible
I love being a GP. I love being part of the general practice profession. Our community of GPs is vibrant and diverse. We are passionate about the profession of general practice and compelled to improve the health of our patients and families.
As I think about how to make general practice even better, I think about creating new opportunities for GPs to come together. I believe it is through working together that we can make change happen.
In my experience, collaboration to bring about change is never clear cut, quick or easy. It is messy, fragmented, divisive, confusing and draining. However, collaboration when it works can bring about change that was never thought possible.
Throughout my career I have joined committees and working groups in a hope my voice and actions will contribute to bringing about change. Sometimes these roles have led to positive outcomes, other times I have become frustrated at the barriers put in the way of positive progress.
One of my most positive experiences, in collaborating for change, has been as Chair of RACGP Rural. It has been in this role that I have seen how change can happen. One such change, achieved through the collaboration of many GPs across Australia, relates to rural generalist medicine.
The focus of the rural generalist reforms have been about obtaining recognition and subsequent remuneration for the advanced skills of rural general practitioners. Debates have centred on how to enable general practitioners to work in both primary care and hospital settings in rural communities. It has also been about supporting the next generation of rural general practitioners to acquire and maintain skills in advanced areas of general practice.
I am optimistic that the rural generalist reforms, championed by so many GPs, will be positive for the profession and for rural communities.
Bringing about fundamental change to general practice is hard. I have seen general practitioners spend their whole careers championing rural general practice and rural generalist medicine. I have seen them represent their profession on committees and working groups where change has not seen possible. But I have seen how change can happen, when there is alignment on vision, sustained leadership, a willingness to try something new and a commitment to collaboration. Hard working general practitioners know how to get things done. When these same GPs find commonality and a way to work together change becomes possible.
I am hopeful as a profession we can create other opportunities to come together to make general practice the profession of choice for young doctors.
I am keen to hear your ideas. How can we work together to make change happen in general practice? Send me your thoughts or give me a call.
Dr Ayman Shenouda
Bushfires continue and the essential role of GPs in supporting their communities
This week, it has been heartening to learn about the contribution of general practitioners during the Australian bushfire crisis. A number of GPs have contacted me to share their experiences. The recent RACGP article on the role of GPs in Merimbula is a great example of GPs coordinating the health care needs of their fire affected community. https://www1.racgp.org.au/newsgp/professional/paper-cups-for-spacers-oxygen-from-dive-shops-how
I have also heard first-hand about the challenges GPs have experienced in providing essential primary care in partnership with state and federal agencies. It is evident there are lessons to be learnt. Conversations and planning is needed now to ensure, state and federal agencies immediately collaborate with general practitioners.
Along with my colleagues, I am advocating for greater recognition of the role of GPs during an emergency crisis. General practitioners have the required expertise and need to be part of future disaster planning at a state and commonwealth level.
For bushfire affected communities, GPs are central to community rebuilding. General practitioners will be there to support individuals and families as they assess their situation and begin the task of rebuilding their homes, lives and incomes. Patients in these communities will want timely access to GPs. They will expect continuity of care and coordinated support from their GP as they engage with multiple agencies to rebuild their lives. General practitioners are ready for this work.
The two new Bushfire Recovery Agencies, one at a Commonwealth level to be led by Mr Andrew Colvin, and one in Victoria to be chaired by Mr Ken Lay have important work to do. Their work will benefit from engaging now with rural general practitioners working on the ground with fire affected communities. I recommend these agencies appoint a general practitioner to work alongside the leadership. The role of the GP would be to inform appropriate consultation, ensure genuine community responses and smart investments that benefit the long term health needs of communities impacted by bushfires.
As the threats from Australian bushfires continue, I extend my thanks to GPs in these communities for their work and I hope they continue to be safe.
As we continue to watch the bushfire crisis unfold, I am in awe at the impressive, selfless community effort of people across Australia. Every hour we learn more about the role of communities, firefighters, emergency service personnel, our defence force and public officials who are working around the clock to respond to these fires. I am thinking of all of you at this difficult time.
In many areas, fires have been impacting communities for several months. In other towns, the threat of fires is new. The community spirit of support, volunteerism and teamwork is evident to everyone. At this time, there is a sense of solidarity, of looking after each other and of not leaving anyone behind.
There are many general practitioners who live in communities that have been affected by fires. I have been thinking of these GPs, their teams and their families. I have heard stories of GPs providing quality health care during the crisis. I know these GPs will continue to support their communities, after the crisis has passed. However, I have also heard from GPs of their admiration for the role of community members in looking out for each other and in coordinating a community response. At this time, general practitioners are just one of many, working together, to support communities who are faced with unimaginable devastation or the ongoing threat of fire.
My thoughts and prayers are for all involved. Take care and be safe and always reach out for support if you need it.
On the health of our profession: Are we our own worst enemies?
Dr Ayman Shenouda
On career choice
High quality placements in general practice is key to combating current trend which sees medical students turning away from our speciality.
But this too will fail if all they see is the effects of low job satisfaction whether it be remuneration, recognition or hours of work.
This only reinforces the already impaired image internalised by both medical school culture and attitudes from role models – dominated by hospital doctors where our training system direct them.
And workplace culture really is everything. Unconscious bias is the hidden obstacle we really need to deal with if we are going to turn this around.
We need to ensure that what they see dispels some of these myths and allows them to make a more informed choice.
On career choice - we are currently sitting at 15% of final-year medical students (2018 cohort) stating general practice as their preference.
Educational reform to help shift mindsets and ensuring exposure more realistically aligns towards workforce need would go a long way toward shifting these results.
But there’s so much more to this stat and we have more power than we think – pay differential aside.
On our role
So, what more can we do to ensure they resist the pull of the hospital-based specialisms?
Firstly, as a discipline we are not helping by talking down our profession.
I find discussions with some of my fellow colleagues frustrating when we ourselves are not pushing the value of general practice.
We focus on a lack of quality, on those providing sub-optimal care an of 5-minute medicine. The business of making money as rebates drop in value every minute after the six-minute mark.
Members feel they are not adequately remunerated for the job they do but still contribute to this vibe of a lack of quality.
Positive role modelling
We know positive role modelling is key. This is really the only pull factor that remains in our control. And it starts with the power of talk.
Clearly it is more difficult to control badmouthing between disciplines.
This obviously affects students’ career choices. And there is more we should be doing collectively – across the medical colleges - to stop this.
Do we know what they want?
But first, do we know what do Gen Y doctors really want from a medical career?
One survey showed that if they were interested in a career in general practice, it tended to be because it fit well with a desire for work and lifestyle balance. Is that still something we have on our side with our recent survey showing more GPs reporting they have an excessive workload?
Doctors do differ by generation and if you were a recruiter you would say there’s a good fit here.
Gen Y graduates want to constantly learn new skills, be challenged intellectually and both professionally and continually achieve. Dealing with uncertainty and undifferentiated nature of symptoms encountered most certainly sets you on a course for continuous learning.
Achievement is an important one and this is where we come in.
Talk about our achievements
We need to convince medical students that general practice is exciting and real medicine happens here. We need to find a better way to tell our discipline’s story.
We need to celebrate the achievements of general practice - state what is positive about our profession.
It’s true that preventive medicine takes time to be seen. But we have plenty to be proud of here.
On our public health achievements alone – on immunisation and disease illumination, cervical screening, and reduced smoking rates.
Our immunisation achievements are world–leading. We’re set to become the first country in the world to eliminate cervical cancer. And, we’re a pioneer in tobacco control with fewer people dying due to smoking.
It is in these achievements that we should be most proud as without the dedication of GPs this would not have happened.
And with multimorbidity on the rise, our work in managing chronic disease also needs to be highlighted.
General practice provides the majority of care to patients with chronic illness. Most GPs manage patients with multiple health concerns.
Our work in mental health with most now occurring in general practice.
Mental health remains the most common issue managed by GPs and is showing an upward trend (from 61% in 2017 to 65% in 2019).
Talk more on our achievements
Clearly, we’ve achieved a lot. General practice is no longer a gatekeeper – it is the cornerstone of our health system.
We’ve done this despite having to find workarounds within a suboptimal health system designed to combat acute care of single conditions.
On the health of our profession we seem to be our own worst enemies. It’s time to turn this around and focus on the areas where we still have influence.
We have so much to be proud of and I think we should start focusing on the key role we play in keeping Australians healthy.
Unpacking the stats
This is clearly not a new issue here but the continued underinvestment shows in the stats predicting a very grim future of health unless we can turn this around.
No doubt this will continue to decline unless we see real action through more investment in general practice.
When you place the career choice stat alongside the other standouts for general practice it’s easy to see why there is such disinterest.
In terms of total health expenditure – general practice is at 7.4% of total health expenditure. This is despite general practice being the most accessed part of the health system.
But then there’s the pay differential. Remuneration as it stands is certainly not going to get them there either.
Average GP’s annual earnings amount to slightly more than half that of other medical specialists – and this gap has widened in recent years.
Then alongside stats that give an all too real glimpse of the workload we face. It is clear continued underinvestment is starting to bite hard and most visible through increasing workloads.
We saw this when tested in a recent survey that showed 29% of GPs either disagreeing or strongly disagreeing that their work–life balance has improved over the past five years.
 AusDoc.Plus. Medical students shun general practice Published 4th October 2019.
 Ipsos Healthcare Survey. published in August 2012.
 RACGP. Report. Health of the Nation 2019. Available at: https://www.racgp.org.au/general-practice-health-of-the-nation
 GRB UK. Understanding Gen Y as a recruiter. Available at: https://www.grb.uk.com/recruiter-research/generation-y
 PHAA, Top 10 public health successes over the last 20 years, PHAA Monograph Series No. 2, Canberra: Public Health Association of Australia, 2018Great
 The Royal Australian College of General Practitioners. General Practice: Health of the Nation 2019. East Melbourne, Vic: RACGP, 2019.
 University of Melbourne, Monash University. Medicine in Australia: Balancing Employment and Life (MABEL). MABEL Wave 10 survey. Melbourne: MABEL, 2019.
 EY Sweeney. RACGP GP Survey, May 2019. Melbourne: EY Sweeney, 2019
Dr Ayman Shenouda
General practice is the foundation of Australia’s healthcare system. Our profession is vital to the health of our nation, yet it remains the most devalued profession. We are underpaid, underprioritised and overstretched by rising demand. This is despite the strong trust patients place in their GP’s - being the most accessed healthcare service with more than two million appointments made every week. Here I discuss some key areas in tackling the funding crisis in general practice.
General practice in crisis
General practice in Australia is now at crisis point.
Many general practices remain on the edge of viability. Practice closures are on the increase as GPs are simply struggling to maintain quality services. There are more and more timebomb towns emerging where GP to patient ratios stretch to breaking point.
Despite the rhetoric, bulk billing rates have dropped by -0.1% to -0.5% throughout rural Australia, while out-of-pocket cost has risen by over a dollar to $38.05. These are all factors deterring our doctors in training from pursuing a career in general practice.
This all leads to a worsening workforce crisis, particularly in rural Australia. Rural registrar placements have already declined by 40% in some areas and unless we start making careers in general practice attractive, including remuneration in line with hospital specialities, there will be serious consequences.
And with a declining general practice workforce, the true cost will be seen in future years in the declining health of the nation. Urgent trust and investment in general practice is now needed.
The shift needed
Our healthcare system is already the envy of many countries around the world. But how healthy is it when less than 9% of annual funding goes to general practice?
The hospital system and other tertiary services continue to be prioritised. Despite the evidence, policy makers seem intent on preserving a reactive and acute care focused system. Yet we know the impact of chronic disease will only intensify and this requires a strong preventive focus.
Australia faces a rising chronic disease burden, an ageing population and a significant rise in mental health problems and palliative care need. According to the latest National Health Survey almost half of all Australians (47.3%) are now living with a chronic disease. We know that a third of chronic disease is preventable yet there is an allocated health spend of only 1.3% of our health total budget.
We know that without strong and effective primary health care countries will struggle to maintain their health services. It is by far the most efficient and cost-effective part of the healthcare system yet it remains so grossly underfunded.
There is clear global evidence that health systems with strong primary care will secure long term efficiencies. Benefits from prioritised investment include achieving lower rates of hospitalisation, fewer health inequities and better health outcomes including lower mortality.
A solid foundation
Chronic disease is complex and difficult to manage. The only way to curb the impacts of the rise in chronic diseases is through prevention.
We have the key components already in place to underpin strong population health outcomes.
The unsustainable rise in healthcare funding needs structures towards prevention and management and we already have a solid foundation to work from.
General practice provides the foundation for what can be the best and most effective, high-quality and sustainable health system. An equitable system that supports optimal outcomes which see patients actively managing their healthcare needs to stay as healthy as possible.
The Government is clearly not capitalising on this opportunity. Why do we find it so hard to direct funding to where it is most needed?
Despite having had the best policy intentions the funding committed towards primary care unfortunately has not been spent in the right places. Lots of investment in different organisations has had a destabilising effect – contestable funding and competitive service markets are just not commensurate with addressing significant unmet health need.
This approach is having a negative impact on the delivery of vital health services. It stifles innovation making it very difficult to be creative to deliver quality care for patients. Direct investment in the most effective part of our health system – general practice - in driving patient centred outcomes is what’s needed.
In my journey in general practice I have met a lot of amazing GPs. My colleagues continually inspire me with their passion and tenacity to overcome these challenges and their enduring commitment to serving their communities. The reality is that the majority of GPs are doing exactly that.
Governments are using this passion and commitment to their advantage. A lack of appropriate government investment in general practice has put our health system at risk. General practice services in Australia are close to breaking point. A strong investment in general practice is what is needed to secure a healthier future for all Australians.
The health of our nation is an enormous responsibility and more funding is needed so that we can continue to provide optimal care. Strong united leadership with a united approach to this major crisis is now urgently needed.
Dr Ayman Shenouda
Despite having had the best policy intentions, we still have too many specialists, and too few general practitioners. The policy response has led to an unprecedented supply of junior doctors feeding a training crisis that will take many years to resolve. Here I’d like to share some ideas around how we can deliver a training model that prioritises need.
Making general practice more attractive
Ensuing graduates meet the needs of the community requires a new training model and approach.
It’s time for a rethink. If we are going to address general practice recruitment, we first need to deal with our image problem. We need to stop general practice from being a second choice. To do this we need to work through the problems in recruitment and this means doing thing very differently.
In making general practice a specialty of choice – we need to impart an early positive image which can then be backed by positive experience. Key to making this work is having more control as a specialty in ensuring exposure during those prevocational years.
Lost in the prevocational space
In increasing its attractiveness as a career choice for junior doctors we need to increase the status of generalism at all stages of medical education and training. It’s clear we are losing them in the prevocational space. It comes down to sufficiency of exposure to general practice and the need for specialty control at that point.
In getting them this exposure – which is currently intermittent – postgraduate medical curriculums need more focus on general practice and rural health. While there are now new programs to direct our efforts – the Hubs, RJDTIF and more recently through MDRAP - it is the uncoordinated decision making that will continue to limited our success.
The prevocational years remain problematic due to differing state arrangements dominated by hospital need and an underlying lack of ownership. The only consistency through the layers of complexity is the trainee. The funding needs to follow the trainee but we need to build in incentives to retain them on a specific pathway.
A collaborative approach led by the colleges of general practice and all organizations involved in those programs is urgently needed
There is also a need to formalise a supportive structure through funding the relationship between the trainee and the GP Colleges. This would support a key shift in establishing the relationship earlier, focusing on early identification and continuous support. It provides for the much-needed connection to general practice throughout prevocational and into vocational general practice training.
Remuneration is also important
GPs are overworked, undervalued and underpaid. We know that expected future earnings influence specialty choice with many choosing general practice following rejection of another specialty. In attracting more to general practice, we need to be able to compete with the higher earing specialties. The way we are paying registrars also needs to be reviewed. GP job satisfaction is also falling which further impacts on GP recruitment and retention.[i] The solution lies in the need to reform the funding model to prioritise primary care and generalism.
Funding for general practice
The current system devalues primary care. The government needs to be thinking seriously about funding for general practice. Income growth is impacted by decisions around incentives, the prolonged impact of stagnant Medicare reimbursement rates and a continued narrow focus on bulk billing. Significant new investment is required to enable longer consultations particularly in addressing chronic disease and factoring the real costs of delivering this care.
Flexible supportive pathway
The delivery of quality training through a flexible supportive pathway design needs continuity of funding. We need a long-term commitment that can continue to channel doctors into rural areas. We also need to change this perception that going rural means you have to stay rural forever. Enabling real flexibility of choice comes from building general practice training capacity in rural and remote areas to support the development of high-quality training.
Prevocational and postgraduate medical training also has to be aligned with the needs of the health care system. This means the incentives have to be aligned towards general practice and this needs to be led by the GP Colleges.
[i] Scott A. 2017. ANZ – Melbourne Institute Health Sector Report. General practice trends. Melbourne Institute of Applied Economic and Social Research, The University of Melbourne.
Policy responses to increasing workforce supply: IMGs, policy failure and continued reliance
Dr Ayman Shenouda
Over the coming weeks I’d like to start a discussion to support planning around a future Australian medical training model. The first starts here with IMGs and our continued reliance on them and what’s next in the context of national self-sufficiency planning.
A rural workforce reality: IMGs remain a key part of the rural medical workforce despite increasing graduate supply.
Whether described as policy failure or policy still in motion, it is clear we are yet to harness our increased domestic supply as intended. Our planned approach for less reliance on IMGs towards self-sufficiency has clearly not met its objective.
We’ve seen an increase in domestic supply of 2.7 per cent per year and above population growth. The raw numbers show an overall increase of 5.3 per cent per year, from 59,359 in 2005 to just under 94,000 in 2017.[i] But, despite these results, we just haven’t effectively utilised gains from increased supply to improve distribution.
It is a lack of a coordinated national planning approach which has seen a strong policy response in increasing local medical workforce supply fail at both the prevocational and vocational training points. This has made workforce supplementation through migration less of a temporary fix and more of a permanent policy fixture.
Despite slow gains in workforce planning we’re starting to see some key shifts coinciding with changes to the visa system and a broader commitment towards a national workforce strategy.
Policy announced earlier this year through the Commonwealth’s Visas for GPs initiative sees a reduction in IMG intake over the next four years. This remains a short-term measure. The wider medical workforce maldistribution problem in rural Australia needs a stronger national medical workforce plan and approach as discussed in newsGP when the policy was announced.
This strategy brings rural workforce planning into alignment with the broader skilled migration policy changes with the introduction of the Temporary Skill Shortage visa (subclass 482) replacing the former 457 visa. In facilitating targeted use of overseas workers to address temporary skill shortages – it provides stronger policy controls to direct these doctors to where they are needed the most.
Getting this policy lever to work for us and towards national workforce planning objectives is an important step in the right direction. This should always have been the aim and is more policy realignment than reform but represents an important first step.
Workforce distribution through migration can lead to unintended policy consequences in the absence of a national medical workforce plan.
Workforce supplementation through migration is a divisive issue: many will say the most obvious solution is forced distribution of our domestic supply. But we know forced policies just don’t work. We already have one, in the form of the 10-year moratorium, and this has seen most IMGs return to urban settings once they’ve satisfied the regulatory requirements.
Broader than policy, and putting cultural isolation issues aside, there are still plenty of negatives for the IMG. Often described as a two-tiered system, we place limits on their professional development and career opportunities while placing them in an unsupported and clinically complex environment.
Our failure to nurture rural retention just makes it so much harder for those wanting to stay. This makes this forced distribution scheme just flawed policy working against retention aims. It has led to a constant stream of IMGs leaving rural areas once they obtain their unrestricted licenses.
So, despite considerable policy efforts, the issue we started with nearly two decades ago remains. We still don’t have enough doctors in the areas where we need them the most. In fact, forced measures like these have just make rural practice less viable and appealing.
More broadly though, it is a lack of coordinated national medical workforce planning has led us here. The recent COAG Health Ministers commitment towards a national medical workforce planning strategy will enable a much stronger needs-based approach providing a way forward towards self-sufficiency.
Important to self-sufficiency planning, a recent review on the reliance of our IMG workforce highlights our obligation to consider global maldistribution and not just our own in workforce planning.[ii]
The review led by O’Sullivan et al. 2019 states that our ability to minimise our reliance on IMGs is important for equitable global workforce distribution. It highlights a key role in workforce planning, specifically in developing national workforce data capacity to help inform sustainable medical health workforce planning.
For Australia, in achieving the right balance of locally trained doctors, this review states policy to reduce our reliance on IMGs has to be mindful of the flow on effects to developing countries. This is an important point that often gets lost in the urgency to fill local positions. And, while I think more recent shifts to our visa controls brings us closer to meeting our moral obligations here, we still need to fully utilise the significant data and associate studies to support a national plan.
In working through this aim, this review skilfully demonstrates how the available data, in this case from the MABEL study findings can be used to consolidate the best available national evidence to inform self-sufficiency planning.
New stratified analyses of MABEL data have been captured to identify IMG work location patterns. Results show the proportion of IMGs among rural GPs and other specialists increases for each cohort of doctors entering medicine since 1970 peaking for entrants in 2005-2009. In our efforts to build a locally trained workforce for rural Australia, the review also confirms recent domestic graduates are less likely to work either as GPs or in rural communities.
This study helps to identify the key drivers to successfully growing a local rural medical workforce - what we’ve done well and where we now need to focus our efforts. These are the broader reforms with many initiatives already in train.
These key policy enablers, important to recruitment and retention, will be the focus of my next blog in this series. They include the required focus on generalism in ensuring the right balance of skills in moving closer to the National Rural Generalist Pathway. In addition, the more recent work towards an Integrated Rural Training Pipeline to support high quality rural medical training and as a key component of reform to ensure growth in graduates flows through to gains for rural Australia.
A more supportive approach
Distribution policies which can allow for self-sufficiency remain our key objective but benefits from increasing domestic supply will take time. However, it is clear that IMGs continue to address critical shortages in rural and remote areas and we need to continue to support them.
The focus should include a mix of retention strategies and education supports toward Fellowship which encourage a permanent place in the community they’ve served. The recently announced More Doctors for Rural Australia Program (MDRAP) will provide targeted support for non-VR doctors providing GP services towards attaining Fellowship.
A further positive shift in the new RACGP Practice Experience Program (PEP) Specialist Stream, replacing the current Specialist Recognition Program (SRP) from September, will allow doctors to access the highest Medicare benefits while working towards Fellowship. The PEP Stream encompasses educational modules as well as a workplace-based assessment with a core aim is to support professional development providing feedback on individual progress towards Fellowship. newsGP
Importantly, the O’Sullivan led study[iii] also highlights the need for continued support. The authors conclude that IMGs are a key part of ongoing rural medical workforce planning and while we need to monitor our reliance, we also need to continue to support them.
The positive is that we are now starting to see recognised our continued reliance on IMGs and the fact that they remain a key part of rural medical workforce. Importantly, we are seeing a strengthening of the data-policy link in national medical workforce planning leading to greater support. My message has always been: If you don’t need them – don’t get them. But if you need them then you must support them. It’s clear we need them and they must be continued to be supported in policy.
[i] Scott A.(2019) Health Sector Report The future of the medical workforce. ANZ Melbourne Institute: Applied Economic & Social Research, The University of Melbourne.
[ii] O'Sullivan, Belinda, Russell, Deborah J., McGrail, Matthew R. and Scott, Anthony (2019) Reviewing reliance on overseas-trained doctors in rural Australia and planning for self-sufficiency: applying 10 years' MABEL evidence. Human Resources for Health, 17 1: 8. doi:10.1186/s12960-018-0339-z
Future GP workforce: The strategies needed to get ahead of the crisis curve
Dr Ayman Shenouda
A recent GP workforce discussion in the Herald Sun has warned supply is set to worsen over the next decade due to recruitment failures and broader impacts brought about by casualisation.
There are some key issues impacting here and at this point in the election cycle, it is a good time to highlight precisely what has led us to these recruitment failures and how to fix them.
We know what the path to a sustainable health system looks like and it involves a solid commitment to properly fund general practice and primary care.
If we want to design a system around patient needs then it is in primary care where we must focus our health reforms.
We have strong evidence to support this. We know that general practitioner supply is significantly associated with better population health.
Countless studies have confirmed this – the most notable being those from Starfield and Shi – yet successive governments have failed to put in place an action plan to realise these benefits.
Getting ahead of the crisis curve
In order to get ourselves ahead of the GP workforce crisis curve, a cohesive national strategy is now required.
It will certainly require a much stronger national policy focus to both recruitment and retention planning than we’ve seen in the past in order to build the GP workforce of the future.
A longer-term vision is what is required: half promises set within short-term electoral cycles will not build the health system our patients deserve.
At the heart of the issue is valuing general practice as a specialist discipline. The fact is that there is a lot of devaluing happening.
Professional negativism exposure during training, which seems firmly entrenched within the hospital-based specialties, is very much part of the problem.
We have to find a way to ensure general practice is high on the list in junior doctor’s specialisation choices.
To do this, we need to work on the perception of primary as distinct from, and of lower status than, secondary care.
When to direct our efforts
Medical career decision making is complex and much of that occurs during the early postgraduate years.
This is one or two years after graduation and for most their influences or role models will be from within the hospital system.
This is the time that doctors are making important career decisions and where positive exposure to general practice needs to occur.
Understanding the career choice determinants is important and there is an abundance of literature around this.
I would like to see a strategy that prioritises general practice and primary care with targeted attraction policies that trigger at those key decision points for junior doctors.
We need to work with other specialties to address professional negativism and find ways to provide more GP role models at these critical points in career decision making.
Other factors at play
Beyond recognition, it is important to highlight that there are other factors impacting significantly on our profession.
These not only limit our ability to attract doctors to our specialty but are adding to professional dissatisfaction among the current GP workforce.
Whether it is in its financing, remuneration or barriers to integration with the broader health system these are key capacity issues which persistently impact on our specialty.
We can already see that the Medicare Review Taskforce’s proposed revamp of GP items is set to place a whole new set of restrictions.
This combined with the impacts from the Medicare freeze and a persistent lack of investment in primary care is what makes our specialty a less attractive choice.
These all contribute to the pressures of working in the current health system and places restrictions on the value of care we can provide as specialists.
GP workforce action plan
It is clear that GP workforce reform would need to see more funding to strengthen primary care.
It would need less bureaucracy and significantly more funding to support patients with complex care needs for a system aligned with the multimorbidity in the community.
It would require a sustained effort to lift the profile and prioritise supports to encourage junior doctors towards careers in general practice.
We’re doing more to ensure the training occurs in primary care but that effort is diminished if all they see is a system in crisis.
There is a need to include a targeted strategy which financially incentivises GPs into training and practices where they are most needed.
But overall, we need to strengthen the role of generalist within the health system.
A high-performing health system built on integrated models of care must prioritise primary care and GP leadership.
We need to see a comprehensive GP workforce action plan prioritised by the major parties at the 2019 federal election.
Rural maternity services: It takes a team to make it work
Dr Ayman Shenouda
Timing is everything - this is particularly true in healthcare - and in birthing services right now, it’s actually getting quite critical for GP obstetrics.
For the rural GP obstetrician, the discussion is no longer about a rebirth of rural obstetric services for rural areas but in has moved rapidly to the preservation of this critical role.
Two key discussions are occurring in obstetric care in Australia at the moment both lacking one vital component and that is valuing the key role of the GP obstetrician in providing this care.
The first, occurring at the national level, in setting national directions for maternity services prioritises access yet omits GPs almost entirely despite their reliance in rural and remote areas.
The other discussion involves a state-led shift in WA towards a new model of care which seems to locks GP obstetricians out completely.
We are seeing spot fires right around the country including in northern NSW but on a slightly different front in resistance of midwifery units to GP involvement.
Combined these are worrying developments and it is clear that major change looms unless we can work to reframe the discussion.
We have the solution
The vital role of the GP obstetrician has to now dominate the national discussion and the National Rural Generalist Pathway is the connecting policy thread here.
We are now at a critical point in building a future rural workforce which offers a single solution by factoring together all the required enablers in one.
The vital work done over the last twenty years has shown us solutions which brought together in one pathway will offer a sustainable way to address rural health needs.
It’s a model that will work – one that prioritises the skills needed – which are reflective of local health needs with the required training supports embedded.
This is a model that brings flexible models of care bridging the primary care and hospital care continuum – it’s based on community need.
And it provides a way to keep it sustainable by enabling a highly skilled GP workforce integrating primary, secondary and tertiary care skills.
But it is reliant on enabling infrastructure too and in keeping it sustainable and so much is connected to a town’s capacity to preserve procedural services like birthing.
State of play
Here’s a brief outline of the current state of play.
Round 2 of the National Strategic Approach to Maternity Services Consultation has just closed (20 November).
The Australian Health Ministers’ Advisory Council’s consultation draft Strategic Directions for Australian Maternity Services is structured around four values — respect, access, choice, and safety. Enabling access to services for rural and remote women is emphasised.
Our College has advocated strongly for the federal government to acknowledge the role of GPs when this strategy is finally released next year having previously outlined concerns about the marginalisation of general practitioners out of obstetric care.
Meanwhile, in Western Australia, the debate continues to heat up on hospital led changes to the obstetric care model in that State which is seeing GP obstetricians increasingly locked out.
The WA shifts
In WA we are hearing that this shift has been occurring gradually over a five-year period.
The move to a hospital system with very little GP involvement and reliant on the fly in fly out specialist with onsite junior staff is becoming more prevalent.
Local reports state that GP obstetricians are being excluded from being involved in intrapartum care with the new model using a salaried medical workforce and shift to midwifery-led care.
This model has resulted in a significant disconnect between the hospital staff and the local primary care workforce.
This being at odds with what the federal government is trying to achieve nationally through the NRGP in building a resilient rural GP workforce.
Choice for women
But perhaps the most important point is that with a new maternity model which favours salaried medical staff over GP obstetricians it is the patient that loses most of all.
With GP obstetricians unable to care for public obstetric patients’ the choice for women is now much limited as a result.
In these towns, the continuity of care role sits with GP obstetricians and carving this off piece by piece to a fly in fly out service model will come at a significant cost.
In other towns we are seeing services close - women and their families have to travel significant distances to access care for pregnancy and birth.
We know the risks that come with increased distance as well as the associated financial burden on already struggling rural families.
Delivering care close to the patient is what works. Rural communities depend on their GP obstetrician with more babies delivered by GP-obstetricians than specialists in rural areas.
A collaborative model
What is missing in these discussions is a real understanding of team care and what it takes to address patient need in small rural towns.
That is, what it actually takes to sustain a rural maternity service and those interconnective factors for why it matters so much for other services.
We know that it takes a collaborative approach and advanced clinical skills encompassing medicine, midwifery, nursing, Aboriginal health and allied health.
What’s important is understanding the role of the team and scope of practice enabling all to work together without comprising quality.
It takes the whole team to make this work. A sustainable model involves a coordinated team involving the obstetrician, GP obstetrician and midwives and a roster divided among all of them.
This is how the service is maintained and we only have to look at the success of places like Albury Wodonga to see how this model sustains their service – sharing on call and the prenatal and antenatal.
We also know the other sustaining factor here – that the maternity service often opens up ways for other procedural services to develop.
A vital skill set
GP obstetricians skilled in childbirth require support, not barriers, in retaining such a vital skill set.
At a national level, procedural training grants ensure they can maintain their skills yet on a state-level, at least in parts, this is not sustainable when access is denied.
These latest developments not only risk the provision of obstetric services in rural areas becoming even more of a rarity but there will be some very real flow-on effects for our discipline.
The attraction and retention of GPs to the region is closely tied to the GPO model and it is a skill set we need to nurture to preserve through the National Rural Generalist Framework.
It is about getting the right skilled workforce in place, supporting a collaborative team structure to secure and sustain birthing services across rural Australia.
The rural generalist model offers a way forward which will make a difference for rural patients - ensuring safe, affordable and accessible healthcare.
MHR – It’s time for a policy reset
Dr Ayman Shenouda
It’s a particularly hectic Monday morning and first up I have a 70-year-old male patient who has just been discharged from hospital.
It will be no surprise that there is no information from the hospital. He’s had some blood tests though and his potassium is very high. This is why he was admitted - that along with some kidney problems.
He’s accompanied by his son who is not aware of any previous conditions and not forthcoming about much at all.
There’s some patchy interpretation offered of what was conveyed to them in hospital – but too cryptic to work through and the confusion was just making this patient more anxious.
But what we do have is all his medication in a bag – a complication mix of current and old meds to sift through – so with that, the usual diagnostic challenge begins.
Looking through I find Spironolactone – a potassium-sparing diuretic – and an obvious issue for a patient admitted with high potassium if he continue on this meds it can be life-threatening. He also had a very severe itch and swollen legs and few other chronic disease including renal failure
This mixed bag of medications alongside some troubling symptoms makes for a very complicated patient.
It took half a day to sort this patient out. More blood tests, phone calls and inquiry in order to reassure that all issues were adequately covered.
It is when you have to deal with this spaghetti of information around a patient that access to their record in real time would have been helpful.
Particularly when combined with the lack of discharge summary and the fact that both patient and son had little to no health literacy.
It is those times when patients are moving between doctors, during emergencies and for post-acute episode follow-up that having this information to hand really counts.
This is where My Health Record (MHR) would support better healthcare decisions and enable GPs to find information quickly.
The crisis of progress – in terms of resistance and technology – is something we’ve come to expect when introducing significant change.
People resist change and with technology, this is intensified commensurate with risk, perceived or otherwise, which is precisely what we’ve just seen with MHR implementation.
Expecting resistance to change and planning for it is something good policy planners do.
But with this one, the MHR, really from its outset, there have been problems really from the early policy development to now in attempting implementation.
There were problems on a number of fronts in working through the opt-in then opt-out rather than compulsion. But these are just your usual pain points in working through complex policy implementation.
There were issues during the design phase and a seeming reluctance to take technical advice at critical points.
With the focus now of course predominantly on the risks: the risks to privacy, cybersecurity and hacking with minimal success in lessening privacy concerns.
From the very first day of the opt-out period, those opposed were stating that it is an ‘uncontrolled’ data dump.[i]
Right up to the penultimate day as the deadline to opt-out loomed yesterday the movement in the Senate called for a delay for a further 12 months.
This last-hour intervention was made while Australians were rushing to opt-out causing system overload with both website and phone line were being reported as down.
I’m pleased to see Minister Hunt has decided to extend the opt-out period to 31 January 2019 which should enable some time to work through the many issues and hopefully reassure the public.
Where to next?
Our entire lives, it seems, are already in a databank of sorts and this lack of control is precisely why consumers needed that reassurance around privacy in this rollout.
A centralised database with widespread access is of course problematic. It required precision in design and diligence around patient privacy concerns and effective responsive communication to implement.
This needed a framework of trust and any attempt to implement without it was always going to lead to this point.
From the lack of informed consent, privacy and security challenges and limited protections around these - some have suggested the MHR is the health sector’s NBN and there are certain similarities here.
The risks are high and the right to privacy in the digital age relies on good laws and the lack of privacy and security provisions made it not ready in my view. These are complex technical and privacy concerns and this is where the problem lies.
These risks are poorly understood and the fact that we’ve only just reached some consensus around some new protections through recent RACGP-led negotiations this makes for a good time for a policy reset.
The extension to the end of January provides some time to work through the Senate Standing Committee on Community Affairs Report (which doesn’t recommend the abandonment of the system).
The benefits of the MHR or any redesign can only be realised through regular use so that it becomes a routine part of healthcare and only then will its full benefits be realised.
Broader take up can only eventuate once trust has been restored and there’s still quite a journey ahead before we get even close to this level given the policy implementation failures to date.
[i] Zhou N. Media Article: My Health Record: privacy, cybersecurity and the hacking risk. 16 Jul 2018. Available at: https://amp.theguardian.com/australia-news/2018/jul/16/my-health-record-privacy-cybersecurity-and-the-hacking-risk
New models of care: making integrated out-of-hospital care a reality
Dr Ayman Shenouda
As the cost and need for care rise – with an ageing population and increasing disease burden - we will need new models of care to meet the healthcare needs of our communities.
Improving the ability of healthcare systems to respond to the demands of patients in acute care and particularly for older patients presents a significant system and funding challenge.
We need to define and fund new ways of working to better support our patients through a preventive strategy to reduce hospital admissions.
We also need to ensure those receiving acute care actually require hospitalisation and for those who don’t we need new ways to transition from hospital to less costly, more appropriate settings.
For our system to be sustainable we need to ensure our patients receive care in the most appropriate, least expensive setting.
But an admission avoidance – hospital avoidance strategy requires integration of acute care with preventive and primary care something our funders resist despite the obvious efficiencies. It requires better integration of acute care within local and nationally funded health systems.
This represents a paradigm shift that provides an acute service but that can be referred to across primary, secondary and tertiary care.
It is about bringing teams together consolidating different points of access to care and providing that care in the home.
This is already being by providing short home-based acute care to public hospital patients through a Hospital in the Home (HITH) model. A model tested and proven to be a viable alternative to hospital admission providing same or better patient outcomes and service delivery.
Hospital in the Home
Recently I met a doctor who is working hard to realise this vision for his community in Townsville.
Dr Michael Young is a rural GP with advanced skills in ED and currently working as a Senior Medical Officer with the Hospital in the Home Service (HIHS) in the Townsville Hospital.
For the last 4.5 years, he has been developing a team to run the acute HITH service in Townsville.
Funded by the Queensland Government since 2014, Dr Young says it is an exceptionally efficient service which has equal or better length of stay and readmission criteria than that of an inpatient stay across a number of different diagnosis-related groups.
These models are often state-led and funded and have been around for some time. An early investment in Victoria more than 25 years ago means we now have good evidence validating the model.
Recent studies have shown significant benefits from an active HITH program affiliated with an acute tertiary hospital.
What makes the model work?
Firstly, the Townsville HITH Service runs as an acute facilitation service with a state-based tertiary hospital. The nature of the services places it as an extension to an acute care setting.
Clearly, the model can be adapted to function from other funded tiers - including primary care and residential aged care – and applying to these models is expanded on later in the discussion.
Secondly, team structure and success in part is reliant on having a doctor-facilitated referral service. This helps to build the required trust between referrers.
It is also well recognised that having a medical officer improves the scope of what you can reasonably treat in the home.
The Townsville experience sees 80 percent of patients come directly from ED while the other 20 percent are step down referred by surgeons, physicians, oncologist.
These patients are usually referred to the HITH service for ongoing care for three or four days to complete their course of antibiotics or other treatment.
The Townsville model operates leveraging three disciplines –infectious diseases physicians; general physicians and gerontologists; and general practitioners.
The GPs involved are usually rural generalists with skills in acute inpatient management and some hospitalist skills.
This brings a solid skillset to the team with GPs having familiarity with community medicine, acute medicine and with good knowledge on what can reasonably be treated in the community setting.
Thirdly, for the model to work, it needs to focus on select conditions and an agreed patient cohort that are HITH amendable services.
Hospital in the Nursing Home (HINH)
I believe a step-up approach within nursing homes is another way to apply this model.
The HITH model is currently predominantly step downs taking patients straight out of the ED and off the ward and back to the RACF to complete their treatment course or for additional care.
However, the model can flex and pilots should be encouraged particularly for HINH and in primary care as an expanded healthcare home model.
We need to focus on different models of nursing home care that can support general practitioner decisions. A step-up approach to support interventions and reduce acute hospitalisations from nursing homes.
Reducing unplanned admissions means we have to start dealing with those issues in the nursing home setting and with that requires appropriately funded infrastructure including adequate nurse support.
It would also work as a model to deliver end-of-life care. This could direct state investment in better quality end of life care facilitated by the GP out-of-hospital.
It would certainly save the $2000 on average per night for a stay in ICU for what is often considered futile treatments.
Tech platforms and monitoring through biometric devices also offer hope particularly in monitoring chronic disease in the home.
Placing the technology into healthcare homes model would help to recognise acute deterioration early. GP can step in early to prevent deterioration and avoid hospital admission.
But technology is only an enabler and we need to focus on investing in the model that underpins that technology.
In summary some key enablers for getting the model to work.
Firstly, the communication framework is really important and a lack of engagement with the referring doctor is where these models have tended to fail in the past.
Whether referral is directly from private rooms or RACF the primary GP has been involved in the diagnosis and finding ways for those lines of communication to stay open is key.
It is important when transferring that care back that a thorough yet succinct discharge summary is transmitted to the GP (and provided to the patient). A shared medical platform would be the ideal to ensure GPs have that window into the acute treatment base.
Another key point, expanding on the discussion earlier, is getting the patient selection correct. That is to clearly design the scope of what you do - clinical or disease pathways – and how you do it based on need.
Finally, in bringing together the required team – doctors, nurses and allied health professionals - to enable treatment to be administered safely and effectively in the home or RACF.
The current funding model is a key barrier in shifting resources to the community - primary care which is federally funded against state-funded tertiary care model makes this difficult.
This is the lingering elephant in the room which sees a state-funded system that cannot always see the value of investing in primary care. This is then often set against a federal funder hesitant to top up what it already sees as a large investment in tertiary care.
It’s a discussion we’ve had before and it comes down to valuing primary care and preventative work. But this investment is surely better than building larger hospitals and funding costly stays for patients that just don’t need to be there.
Whole care continuum
The ideal model is one that supports the whole care continuum so that a patient can achieve acute care whether referred from hospital or GP.
Facilitating direct admissions from the GP is where the funding discussion now needs to occur as an extension of this model. But also looking beyond acute care to enable us to broaden the services we offer such as treating chemotherapy in the home.
As we’ve discussed throughout, this model needs the right clinical and corporate governance framework around it. The right service parameters –patient selection and disease selection. It also needs volume to realise cost benefits and feeding that data back.
We already have enough evidence around the HITH model but we need to do more measuring to ensure our funders start to tangibly realise those benefits. This is the only way we can make integrated out-of-hospital care a reality.
Raising the Care Factor: Royal Commission into Aged Care
Dr Ayman Shenouda
There is hope that ensuring dignified support for people in aged care will be one step further with the announcement of a Royal Commission into Aged Care.
I certainly welcome this royal commission and see it as a key step forward in ensuring our patients get the right care, support, and dignity they deserve.
This not only provides hope for patients and their families but hope for those working in the sector and committed to providing consistent, quality care to their residents.
What have we learnt?
Most working in the sector would welcome the opportunity for real reform through a comprehensive consultation and review of this kind.
The issue certainly qualifies for such a focus but it’s not like there haven’t been any policy questions posed in this space in recent years.
The royal commission is just the latest in a very long line of inquiries in aged care. We’ve had years of review and countless recommendations with most now, it seems, awaiting web archive.
It has been reported in recent days that there have been 20 federal inquiries by the Senate and others into aged care since 2009.
Even the Aged Care Minister admitted to that only a few weeks out from this latest policy shift:
"…after two years and maybe $200 million being spent on it, it will come back with the same set or a very similar set of recommendations, the governments will respond and put into place similar bodies".
Let’s not forget the states who have also had a strong focus over many years and there’s plenty of positive state-driven change and too many to list here.
The point is that we know there are systemic national challenges in aged care and through significant review, we now have the policy answers.
Ensuring quality care
This Royal Commission certainly places a stronger lens on the issues but the areas of reform are already clear and this might just keep us in a constant policy cycle of inaction.
Having worked in aged care over many years it is as clear to me what needs to occur as it would be for most in the sector.
I should add that some of these facilities provide excellent care and this should not be lost in what will likely be a very intense and confronting royal commission.
One glaring omission from a more recent review - the Government’s Review of National Aged Care Quality Regulatory Processes – was a required focus on enabling a more collaborative patient-centred care model.
This model is reliant on adequate remuneration and unless this is prioritised residents in aged care will have their medical care compromised.
Ensuring a key role of general practice in aged care service provision is integral to the solution.
The review failed to acknowledge the critical role of GPs in improving the quality of care in these facilities and I wrote about it at that time.
It is these obvious service issues, central to ensuring quality, that continue to be ignored or held over for the next review.
What are the priorities?
A focus on quality has to look at ways to make improvements including through stronger staffing and appropriate skill mix levels.
We need to focus on different models of nursing home care that can support general practitioner decisions. It’s a step-up approach to support interventions to reduce acute hospitalisations from nursing homes.
Reducing unplanned admissions means we have to start dealing with those issues in the nursing home setting and with that requires appropriately funded infrastructure including adequate nurse support.
It is clear we need very different models of care than those currently funded in order to provide the complex support for those vulnerable to acute and deteriorating illness.
Currently, the role of the GP is clearly limited due to low rates of reimbursement through the MBS.
Optimal models of care cannot work in an underfunded service environment. Integrated pharmacy is another clear requirement.
Ensuring the holistic needs of patients with dementia requires much more focus and there has been good research around this.
More broadly, the emphasis needs to be placed on individualised care in supporting those with complex care needs including negotiating priorities for those with multimorbidity.
In meeting the complexities in medications, in rehabilitation and functionality combined with broader family decision-making requirements it really requires a good team.
These teams should be supported by a financial model which can allocate time for multidisciplinary case conferences.
Training and roles
Training is a big part of it to ensure care workers are better equipped to cope with the demands of providing this very complex care.
In a largely for-profit sector, to ensure patient-centred quality care, there is really no choice but to mandate staff ratios.
The other related aspect to this and it’s good to see it coming through in the discussion early is around valuing roles.
Starting with care workers or care assistants - we need to make this a career worth having to ensure we attract the right people and skill sets.
They must be properly paid and qualified for what is a role which carries with it a lot of responsibility.
Registered nurses and so integral to ensuring quality of care and also key to preventing adverse events among residents.
But RNs who work for nursing homes also tend to earn less than those working for other major employers.
In welcoming the Royal Commission, the RDAA called for better incentives to recruit more registered nurses into aged care facilities along with improving infrastructure.
Future policy must ensure registered nurses are in place to lead the team and this requirement should extend to prioritising RN coverage at night.
This structure is optimal and can then accommodate different levels of nurses and staffing and ensure quality patient care.
New models of nursing-home care
It really comes down to the value we place on our older Australians and I think there are some key lessons for us from other countries with strong policy in place.
There are also excellent models of care within Australia but we need a funding system to prioritise support of their development.
We also need to ensure we balance this discussion by highlighting the good work some nursing homes are already doing.
These are my thoughts to the key requirements to reform and I would welcome your contributions to keep this discussion going.
Dr Ayman Shenouda
There remains a deep undercurrent of racism in this country but it is not mainstream Australian opinion driving it.
The problem is that the public debate in and around migration is persistently led by a far-right minority.
And actively challenging such intolerance is vital otherwise I think these low debates will come at a high price for us all.
I really think all doctors must unite against racist attacks on IMGs. This is doing considerable damage and we need to challenge these views.
Where’s the evidence?
If you were looking for more evidence that the media is complicit in fueling racism it could be clearly seen on the front page of The Weekend Australian last weekend.
Beneath a headline that read ‘Foreign doctors blow out Medicare’ sprawled the most unbalanced, uninformed piece which firmly targets International Medical Graduates (IMGs) as exploiters of Medicare.
This article, whether deliberate or not, purely through a sole focus on IMGs infers that they alone are responsible for driving some very complex problems facing our health system.
Issues around over servicing and professional standards are not confined to IMGs and we have effective non-discriminatory processes in place through various codes, guidelines, and policies to address these.
Let’s unpack the bias
Starting with over-servicing and alleged Medicare fraud we’re told about “a rampant increase in IMG Medicare billing”.
The article, of course, fails to balance this with required comparators for Gross Billings for Australian Trained Doctors (ATDs).
There is also policy in place which addresses such issues – the Professional Services Review - and this is not confined to IMGs.
Some much-needed context around what might be driving such increases other than the inferred fraud would have helped balance it.
Issues such as long hours and caseload, acuity and complexity of patient need, and broader need for the specific population and working to align resources to need all factor strongly.
The predictable narrow migration narrative
The article then forewarns a policy shakeup which will see the number of IMGs or ‘imported GPs’ slashed in coming years and then states a budget return for policy justification.
This just adds to a growing trend which sees skilled migration used as political fodder.
Skills lists really are a decision for government and if we don’t need them then don’t get them.
I actually don’t disagree that we should place strict parameters around skilled migration policy to ensure we are targeting the skills most in need.
But if we do need them then we need to support them and that is the key issue here. More on that later!
Recent policy through the new Temporary Skill Shortage (TSS) visa now works through short and medium-term skill requirement.
This is a good policy reform which also works to limit the pathway to permanent residency.
Where’s the detail behind the analysis?
The article alludes to some analysis that claims average billing of IMGs — across Medicare, the Pharmaceutical Benefits Scheme, and referrals — has tripled in three years.
Let’s be clear here defining total cost as MBS + PBS + referrals in no way reflects a GPs actual income.
We’re then told that removing IMGs would result in a forecast saving of $415.5 million. This, of course, assumes that most if not all the services provided by the IMG equated to over-servicing.
The article claims this is based on a policy assumption that other doctors would not cover the equivalent Medicare services or subsidised drugs and only half as many referrals.
This is a very big assumption and one that is impossible to verify against such diverse need.
Now to provide a much-needed defense for IMGs.
A reality check on the doctor shortage
Statistics might show there is no doctor shortage in Australia but there certainly remains a maldistribution issue.
Maldistribution persists in rural Australia and with increasing remoteness you can expect to see both workforce shortages and a higher burden of disease.
This is despite efforts to increase supply through policy measures which see increasing numbers of Australian Trained Doctors (ATDs) and broader workforce supplementation measures through skilled migration.
Some policy insights
Benefits from increasing domestic supply will of course take time and we’ve made great progress with more students training in rural areas through the Rural Clinical Schools.
What is not seen beneath the supply stats are the policy complexities in regard to addressing population need, ensuring the right workforce mix, health infrastructure deficits, and distance and geographic location.
There are still too many one doctor towns in rural Australia in need of an urgent injection of basic medical facilities.
Keeping services viable in these contexts is the story not told. And it is for all these reasons IMGs remain an integral part of our workforce.
Rural Generalist Training
Excessive specialisation means there are not enough generalists particularly in rural Australia.
We’ve been working hard to address this through the National Rural Generalist Framework.
This is key to ensuring a supportive pathway providing rural exposure in order to prepare trainees for work in a rural and remote setting.
There is significant policy work currently being undertaken in this area led by the National Rural Health Commissioner.
We need to facilitate some key shifts which turns a structure which currently sees most of the training being undertaken in the bigger tertiary hospital in the cities.
We need to turn that on its head to provide more training in regional locations to encourage more domestic graduates to take up and retain postings in rural and remote areas.
Currently, they are seconded for six months to a rural area but it’s just not going to be enough to give them the exposure they need to entice them to return.
They spend most of their time training in cities and naturally build a life around that. We need to provide more opportunity for them to work in rural areas and experience the rewards.
It is just about facilitating the training to connect these doctors to the communities that need them the most. It’s really quite simple and we’re now on the right path to make this happen.
IMGs and their contribution
IMGs are the lifeblood of rural towns. They are the backbone of our healthcare services in rural areas. You see without them many rural communities would be without a doctor.
It is estimated that IMGs comprise approximately 40% of the medical workforce in Australia and 46% of general practitioners in rural and remote locations.
IMGs saved this country from a disaster over the past 10-15 years and this type of reporting is just unhelpful.
Let’s not forget that they are often recruited to work in some of the most difficult environments, with little support.
IMG is also a broad definition
If we are going to persist with a debate that sets IMGs up against ATDs then lets first clarify the definition. I don’t think it is well understood just how broad this term is. And it’s a term that sticks.
IMG simply means that you have been trained overseas and while we’re on that point it also means that you’ve not cost the country a cent in your training.
Many IMGs have been through the system, working in rural areas for many years and achieved Fellowship. These doctors are serving their communities delivering a very high standard of care.
Legacy of forced distribution
The legacy of a forced distribution policy – the 10-year Moratorium – is that the gains for our rural communities are only short term, as doctors seek to return to more populated areas.
The policy may only provide intermittent gains, and ultimately fail to provide a stable workforce for the rural and remote areas in need.
For it to work, it is reliant on a longer-term commitment from IMGs – a key consideration which currently lacks policy focus.
For some practical policy solutions, here’s a link to a conference paper from the 14th National Rural Health Conference last year: Keeping them there: shifting our focus toward IMG retention, beyond moratorium obligations
Now one final word on the debate we ought to be having. The discussion we need to be having is keeping doctors where we need them.
For rural and remote communities, we need to shift the focus toward IMG retention, beyond moratorium obligations.
But we also need to focus most on a policy which prioritises and secures domestic graduates for regional, rural and remote Australia.
A strong investment in the National Rural Generalist Pathway will support this outcome.
The reality is that we will also need to continue to rely on those IMGs currently working in regional, rural and remote Australia to help train our domestic workforce coming through.
IMGs are vital in securing the next generation of rural GPs and this is a really important point that just gets lost in these divisive debates.
The health effects of drought and our role in planning
Dr Ayman Shenouda
Last week’s blog on GP-led strategies to reach out to drought-affected farmers has started some good discussion around the role of GPs and our broader public health role.
What we are seeing is a significant drought particularly in the worst-affected parts of NSW where the current dry conditions have spread to most inland parts of the state.
The recent media focus is a good thing to keep some philanthropic and government dollars flowing, but we really need a better preventative strategy to protect our farmers and our food resources from these extremes.
What we are seeing is reactive policy which only demonstrates the ineffectiveness of our national drought management policies.
While short-term drought-related health shocks can be more obvious, it is those longer term, more indirect health implications that are harder to measure and monitor.
In helping our communities prepare for drought, GPs should have a leading public health role in developing drought-related public health vulnerability assessments.
This involves working with the community and key partners to ensure coordinated preparedness and response efforts. Staying engaged through non-drought periods is essential.
Here are some key steps that we could consider in undertaking drought planning and vulnerability assessments in our own communities.
Identify vulnerable populations
It is clear that drought severity and the vulnerability of particular populations requires a more targeted and planned response.
While the health effects of drought can be severe, the health disparities in diverse rural communities can make public health planning a challenge.
This is why GPs need to have an active role in identifying those priority groups within our community.
Most rural practices sustain themselves by being attentive to key changes within their communities and know how to work within constrained resources.
We need to allocate a greater proportion of total health resources to drought impact mitigation and prevention.
A key part of this is enabling planning and establishing a leadership role for GPs in decisions to develop appropriate models of health care for these at-risk groups.
It is important to note that there is also a doctor drought in some regions too.
The distribution of GPs to underserved areas requires similar planning together with ensuring the adequacy of health infrastructure for longer-term service viability.
Make disease projections
We need more data around this but generally, populations face an increased risk of illness in the year they are exposed to drought.
A formal role for GPs in addressing the data gaps to build more evidence around the causal links between health and the environment is needed to inform future policy nationally.
More research dollars and faster research into what works at the local level to help us better understand the risks and health status of populations.
This requires a sustained research effort and is part of a broader investment strategy and structured support towards disease prevention.
Planning for specific health effects
Droughts have many consequences for health. Social impacts are quite obvious as drought contributes to debt burden and the psychological impacts run deep.
Generally, we will see more air and water-borne diseases and infections, with effects on air quality including related respiratory illness.
The worsening of chronic illnesses and mental health conditions through social impacts and compromised food and nutrition.
The more immediate impacts of heat include increased risk of dehydration and heat stress.
A community capacity-building program for drought response should be prioritised to both assess drought impacts and explore actions in response from a health perspective.
We have a good understanding of what the health vulnerabilities are for our own communities in times of drought. Allocation of funds towards drought mitigation in relation to health is needed.
Establish intervention strategies
Inadequate social impact indicators make this task harder but we need to think about building resilience to drought.
In building resilience, implementing critical programs to protect the most vulnerable health populations in specific locations is important.
Building the evidence base for population-level interventions will also help close the gap between research and practice.
A national program to support communities to undertake drought-related public health vulnerability assessments is a good way to make this happen.
GPs should have a leading role in supporting proactive mitigation and health planning measures in managing drought risk and health impacts for their communities.
Healing in times of drought: GP-led strategies to reach out to drought-affected farmers
Dr Ayman Shenouda
Those living in rural Australia don’t need to see a politician donning an Akubra to confirm just how bad this drought is.
Rural communities know only too well what this almost constant climate of suffering looks like. How this hardship can impact on community morale and health and particularly for mental health.
This is clearly seen at the practice level in our patients with notable increases in the rates of depression and anxiety and with more and more patients disclosing suicidal thoughts.
The most devastating reality of drought is of course suicide which is in part a system failure and a shift in placing prevention at its heart will require a very different model to the one we have.
Only this week a patient came to me and described just how close he had come to suicide:
‘I came very close this time. Opening my shed looking at the rifle - it was very tempting to finish it all.’
This was a farmer reaching out for support and with this key step, the healing journey can begin.
The depression begins with a downturn in cash flow and in a multi-year drought, there is often no clear way forward for them.
A key hurdle for us is in reaching out to those more adept at hiding the problem. Trust is a big part of it.
In rural people, particularly men, this is sometimes very well hidden. They often try and hide the problem and all too often we find it is too late to help.
We are missing a lot of patients – those who won’t come forward – and this is where our funding dollars are most needed right now.
It is often the case that even when mental health services do exist within a community, farmers are unlikely to utilise these services.
A solution is for the GP to get out to the community and this is precisely what we’ve been doing in Wagga and The Rock Communities
It involves taking your practice to the patient and there’s currently no real funding tied to this. This effort relies on the goodwill of the GPs, nurses, other clinicians and allied health professionals.
These are ground-up initiatives to help communities manage their health and mental health. And these are the strategies that we know work in rural communities.
I’d like to share a couple of practical strategies we’ve undertaken to reach out to those harder to reach farming patients.
The Pub Patient information nights
The pub is a good place to start. We often do talks in the pub which will have a formal health topic for the evening inviting the community to join us in the discussion.
We see two groups form here. The ones actively involved in the discussion and those sitting at the bar (but listening). It is the latter that is often the most critical to reach.
But it can start the conversation and importantly their involvement in their own health and wellbeing as well as new strategies to cope.
Field day pitstop
The field day pitstop check-up clinic places us right in the thick of the action. This is where farmers gather to exchange ideas, trade their goods and importantly just get together.
We usually set up a tent clinic with a couple of doctors and practice nurses providing health and lifestyle assessments.
We cover emotional wellbeing and general health checks looking at BMI, blood pressure, respiratory testing, blood glucose and covering other risk factors including cholesterol screening.
These tests are vital and will often get them into your clinic and under your care longer term.
Sparking that vital conversation around mental health is a key objective here and we aim to provide links to rural helplines and connect through to outreach initiatives.
Dr Ayman Shenouda
Patient loyalty and trust
It’s hard to pinpoint precisely what inspires long-term patient loyalty.
Quality of care and trust must come into it. The ability to listen, having a caring presence and reliability would also factor highly.
From my own experience, I think patient loyalty is mostly about trust. And it is timely and effective communication that builds that trust.
Of course, for doctors, communication also involves giving the patient bad news. Listening actively and providing comfort being core communication skills.
There are very few studies that have explored those factors seen to build and maintain a patient’s loyalty towards their GP or a practice.
Some recent research in France provides some specific insights while a more recent study closer to home provides a new novel way to measure both GP and practice loyalty.
The loyalty equation
First, let’s look at a possible loyalty equation. A 2016 French study tested aspects of patient loyalty in the general practice context.
This study found that loyalty was more complex than commonly assumed and is reliant on a few factors. It involves dimensions of trust, listening, quality of care, availability, and familiarity.
So, the loyalty equation from this study looks like this:
Trust + Listening + Quality of Care + Availability + Familiarly = Patient Loyalty
This is interesting enough but I think what makes this study really interesting is that the loyalty factor was seen as important enough to formalise it in policy.
The efficiency factor to loyalty
In France, the Caisse d’Assurance Maladie (public health insurance fund) recognises a coherence in maintaining the doctor-patient relationship in terms of efficiency and healthcare costs.
This has been formalised in law since 2004 and was part of broader reforms to health insurance which requires a ‘preferred doctor declaration’.
The policy requires adult patients who want optimal coverage of their care by national health insurance to choose a preferred doctor - typically a general practitioner. 
What we see in France is the use of a single lever-regulation through what it calls its ‘gatekeeping’ reform.
The carrot and stick approach of this effectively means that every adult must first choose a primary doctor, or médecin traitant, or risk higher healthcare fees and being reimbursed at a lower rate.
The policy aim is to control both the demand and supply side of health care provision to improve care coordination and reduce utilisation of specialists’ services.
The policy operates by encouraging patients to choose one GP and imposes financial sanctions if they don’t. This gives value to the relationship and makes the patient’s loyalty official.
One evaluation of this reform explored effect and found that specialist visits fell slightly while self-referred visits and the number of different GPs seen also declined.
In other words – policy success – but does a forced scheme generate patient loyalty?
What can we learn from the French experiment?
Forced schemes like this are never good policy. But while this scheme is perhaps set out to control access to specialists the positives will be seen over time through continuity of care.
The French patient loyalty study actually found this to be true. That, by inciting patients to always consult the same doctor, the reform of the preferred doctor scheme reinforced that bond.
Patient loyalty in the Australian policy context has resulted through a stronger policy framework which enables choice. So, where are we at in terms of policy success against the loyalty factor?
The Australian context
The richness and potential of de-identified Medicare data were shown through a recent Australian study led by the Centre for Big Data Research in Health, UNSW, and published this month in the MJA. 
This study is said to open up a new toolbox for exploring how patients use healthcare services. It’s the innovative approach using network analysis that makes this a standout.
It uses network analysis of big data analysing millions of Medicare claims to gain insights into the organisation and characteristics of Australian general practice over a 20-year period.
New ways to measure loyalty
Providing a novel way to measure change in Australian general practice over two decades, the study shows that while there has been a move towards bigger GP practices, patient loyalty remains high.
These results were found by looking at the claims to see when patients were visiting different doctors for their GP services.
By applying a network analysis approach, it showed where doctors had many patients in common that they were likely to be sharing the care for these patients in the same practice.
These were grouped as a provider-practice community or PPC which also provided new insights into patient loyalty.
The results showed that patients’ loyalty to their usual GP and usual GP practice is high and has been stable over the last 20 years.
The loyalty result is exciting combined with the innovative approach used in this study to find that the density of patient sharing within a PPC correlated with patient loyalty.
The fact that patients see multiple GPs within a practice is also significant in terms of practice design and enabling more team-based GP care models.
The further link made in this study in terms of supporting future program design in terms of where to target incentives for encouraging quality primary care is also good news for our practices.
For good policy reach, program success relies in part on the patients’ choice of practice and this fact is now more keenly linked to that loyalty factor as a result of this study.
Australian success story
These results provide a really positive outlook on Australian general practice and our approach to healthcare policy in enabling equity in access.
In contrast to the French policy experience whereby a forced scheme has formalised patient loyalty in a way, the Australian experience shows that patient loyalty and choice of practice comes through less forced means.
It will be interesting to see what more can be explored through big data analytics and the network analysis approach used in this study to better understand our health system.
 Gérard L, François M, de Chefdebien M, Saint-Lary O, Jami A. The patient, the doctor, and the patient’s loyalty: A qualitative study in French general practice. Br J Gen Pract 10 October 2016; bjgpnov-2016-66-652-gerard-fl-p. DOI: https://doi.org/10.3399/bjgp16X687541 Available at http://bjgp.org/content/early/2016/10/10/bjgp16X687541#ref-9
 Law No. 2004-810 of 13 August 2004 concerning health insurance. Article 7. Published in JORF n°190 2004–08–17: 14598. [In French]. Legifrance Paris, 2015.
 Le Fur P, Yilmaz E. (2008) Referral to specialist consultations in France in 2006 and changes since the 2004 Health Insurance reform. 2004 and 2006 Health, Health Care and Insurance surveys. Questions d’Économie de la Santé 134:http://www.irdes.fr/EspaceAnglais/Publications/IrdesPublications/QES134.pdf
 Gerard 2016 Op. cit.
 Dumontet M, Buchmueller T, Dourgnon P, Jusot F, Wittwer J. Original research article. Gatekeeping and the utilization of physician services in France: Evidence on the Médecin traitant reform. ScienceDirect Health Policy Volume121,Issue6,June2017,Pages675-682.Availableat: https://www.sciencedirect.com/science/article/pii/S016885101730115X
 Gerard 2016 Op. cit.
 Tran B, Straka P, O Falster M, Douglas KA, Britz T, Jorm LR. Research. Overcoming the data drought: exploring general practice in Australia by network analysis of big data. MJA 209 (2) j 16 July 2018. Pages 68-73. Available at:
GPDU18 – Proving we’re better together!
Dr Ayman Shenouda
GPs Down Under
There was plenty of discussion about collaboration at the recent GPDU18 inaugural conference on the Gold Coast. This was collegiality at its best and perhaps not surprising given we know that flat hierarchies are where innovation and collaboration will thrive the most.
GPDU offers healthy debate which is open and inclusive with all members encouraged to moderate. There is very little censorship here provided you remain on topic – GP learning, peer support, and advocacy.
Enabling an inclusive dialogue is why this Facebook community of over 5000 members exists and thrives. It provides the opportunity for real-time online discussion in a forum for GPs - one that is free from corporate vetting offering a rare open communication channel.
If there was one clear connect from this conference it was that we need better collaboration.
Collaboration creates value in communities. It is about sharing vulnerabilities and being open and being brave enough to distribute your power to many.
For GPDU18, day one great debate certainly focused on a rather divisive topic: ‘The Three, Two, One Debate (how many colleges is too many?) which saw an overwhelming yes (79%) for a single united college.
Panelists’ Drs Cameron Loy, Fiona McKinnon, and Liza Lack in this session provided either the for or against – one, two or three (college) - noting they didn’t get to choose which side they were on. They each worked through issues including what a college should be doing for their members and more broadly about their values.
There was also a discussion during conference on tribalism and the stages of tribal culture led by Dr Edwin Kruys. Based on the work by Logan, King, and Wright in their bestseller Tribal Leadership which takes you through the five kinds of tribes that humans naturally form and the benefit of establishing triadic relationships.
It was a timely and interesting reflection allowing us to turn our attention towards building the culture we want. You could sum up both sessions in three words - we’re better together!
Building the culture, we want
In building the culture we want, it is important to understand why tribes exist. This is really important as an understanding of tribalism is a key strategy for improving collaboration.
And, certainly on both topics – one college and that of tribalism - I really don’t think these issues are necessarily separate. Collaboration begins with organisational culture and we are all seeking a more collaborative approach and there were plenty of lessons to take home here.
While I doubt the vision for a single college will ever be realised, I think what we certainly do need is more coalition building. This is what GPDU does really well and why it works. It forms coalitions with those holding similar values, interests, and goals to combine expertise and resources for a common purpose.
Primary care and collaboration
In a past blog about the possibilities of having a united front in primary care and the need to find some common ground, we established that for collaboration to work then this relies on respect and trust. A lack of trust only stifles collaboration. We need to create a shared vision of the future and move towards it together. Have an agreed common goal and sign up for it.
In a more recent blog, we discussed ways to position ourselves as leaders of primary care into the future and the idea of a College for Primary Care. Getting back to our value proposition to achieve integration as well as satisfy funders positioning ourselves together in the health system will be important. This is key to ensuring we make the shifts towards a health care system based on wellness rather than the treatment of illness.
Collaborative healthcare leadership
We need a focus on positioning ourselves together to advance primary care reform and to help orchestrate a collaborative culture. Formalising this structure more would create a work culture that values collaboration. It would help us to put in place the adaptive collaborative learning systems required for the future.
For me, GPDU18 just proved that we’re better together and certainly the key themes that emerged particularly around collaboration reinforced a need for a stronger focus around this.
Building trust and blurring traditional boundaries will help end tribalism and silos – it would help bring the ‘we’ (as in the primary care team) instead of ‘me’ (the GP) back into focus.
Our sector needs to find a place for more inclusive reform and opportunities for collaboration through communities like GPDU. Working together towards a common agenda is the only way we will see the sector-wide change required. Improving health value in the healthcare system starts with us and it’s time to reconnect.
Dr Ayman Shenouda
When each of us experience hardship, it changes us - yet not all of us experience lasting harm as a result. Stress affects people differently with many factors influencing the strength of our stress response.
Resilience is our capacity to overcome adversity and our resilience is shaped by our experiences – both good and bad. And it’s really only when you’re faced with extreme stress that your level of resilience can be determined.
‘You only know what you are made of when you are broken.’
This was the moving statement from a father who lost his unborn baby during the recent Grenfell Tower inquiry.
It is said that we can all overcome adversity and choose to be resilient. But how can we increase emotional resilience and cultivate more resilience for ourselves and for others?
Neuroplasticity and resilience
Can neuroplasticity help us to understand resilience?
Mindfulness sites are full of the promise of rewiring your brain through neurally inspired therapies to increase emotional resilience.
Brain researchers reassure us that the brain can change and that brain reorganisation is not limited by age. That it is the brain’s plasticity that can help us to overcome adversity.
Neuroplasticity is the brain’s ability to grow and change in response to experience. It is supported by chemical, by structural and by functional changes across the whole brain and together they support learning.
What is it that limits and facilitates neuroplasticity?
Dr Lara Boyd Neuroscientist and Physical Therapist at the University of British Columbia explains this well in her work which looks at what can be done to help patients recover from stroke.
In looking at how we learn she states that the best driver of neuroplastic change in your brain is your behaviour. But that it needs practice and you have to do the work with increased difficulty leading to more learning and greater structural change.
Our uniqueness holds the key
Dr Boyd’s research has looked to therapies that prime or prepare the brain to learn – brain stimulation, exercise, and robotics. But she also states that a major limitation is that patterns of neuroplasticity are highly variable from person to person.
It is this variability in studying the brain after stroke that she believes provides some valuable transferable lessons. Learnt neuroplasticity after stroke applies to everyone. It is these individual patterns and variabilities in change that allow us to develop new and effective interventions.
It is partly personalised medicine with each individual requiring their own intervention. However, this concept is then broadened through embracing our uniqueness with personalised learning being key.
This research shows that biomarkers are helpful to match specific therapies with individual patients. More specifically it is a combination of biomarkers that best predicts neuroplastic change and patterns of recovery after stroke.
Applying this learning
Dr Boyd’s advice is to study how and what you learn best. Repeat those behaviours that are healthy for your brain and break those that are not.
In applying this learning, it is clear that resilience can be taught. But it requires supportive relationships and opportunities for personalised learning.
Bringing this back to our own workplace, how can we harness the brain’s innate capacity to change? Not only in our patients and ourselves but applying this knowledge in equipping our trainees with strategies to cope in dealing with stress.
Resilience in the workplace
I think it is important to look at how can we inspire resilience in others. Working through what strategies work for the individual is important but so is providing a workplace free from harm, neglect, and disrespect.
More emphasis on building positive work environments, coping strategies and the importance of self-care is needed. Training in neuroplasticity and how to exploit it should be part of our armoury.
For our trainees, we need to think more about building their stress fitness and coaching and mentoring are helpful in developing this resilience. Trainees would benefit from a buddy and a mentor to improve resilience and this needs to be formalised in our training system.
Funding for formalised training programs to improve resilience in our trainees should also be prioritised. Webinars in workplace wellbeing, resilience, mindfulness, cognitive reappraisal training should all be pursued.
Resilient people are able to see things from others perspectives. They also tend to value others.
Simply conversing in a compassionate way changes the brain.
Coming back to neuroplasticity, if we repeat certain throughs or behaviours often enough the neural pathway can be created. Forming new connections and weakening those patterns that are not working for you being key.
In mastering resilience, we know that much of it has to come down to the individual and effort. Fixing a self-critical neural network is doable but takes practice and training to chart new pathways.
In untapping resilience by harnessing the brain’s innate capacity to change we must prioritise the tools proven to bring about these shifts. This is particularly important in supporting our trainees so that together we can inspire and create a more resilient workforce.
Federal Budget 2018
Dr Ayman Shenouda
Expectations around this year’s Federal Budget were high. The Government certainly worked hard in its lead up trying to lower expectations promising an economically responsible and fair budget.
We knew we would see an election budget here and with that, we expected a strong focus on some key areas important to the majority of Australians.
Voters wanted to see a focus on cost of living pressures and improving the health system and these two items came out on top in earlier polling.
A budget for a healthier Australia?
So, what is the verdict - is this a budget for a healthier Australia?
There were certainly strong gains in rural health, aged care, mental health and medical research.
There are some really positive initiatives in this budget but at a time of record inequality, more wellness measures through formalising a preventative health strategy would have made this a great budget.
This is required to help drive a strategy forward to really address some of those causes of ill health.
Spending measures in countering the high numbers of our population who are overweight or obese, for example, are needed and it would have been good to see some strategy around this.
We all know to get to the bottom of the causes of health disparities then the focus needs to be on those social determinants of health.
The investment is beyond health and an overall policy approach to protect those factors which stretch a range of personal, social, economic and environmental factors.
Primary prevention focus
A strong and broad primary prevention focus is needed to counter those health risks factors and improve health outcomes for all Australians.
This budget does pick up a number of these issues, including for women’s health and wellbeing and more broadly through its More Choices for a Longer Life Package.
Mental Health funding of $338 million and priority on suicide prevention clearly goes a long way towards addressing the system gap around crisis support.
The allocation for older Australians which includes $83 million for more services within the RACF, again addressing a significant gap, is a really positive step forward.
While short on detail, the new primary care funding model for the Indigenous Australians’ Health Program is another key area which required focus.
The increases for PBS and new funding for medical research, development of diagnostic tools and medical technologies, and clinical trials of new drugs all represent a significant health investment.
The standout here in terms of addressing disparities and ensuring a primary prevention focus is the rural investment and the Government has certainly delivered here.
Equity for rural Australians
The key rural health workforce measures are provided through the $83.3 million new Stronger Rural Health Strategy which includes some solid measures to secure more GPs for rural Australia.
This is a 10-year plan and a $550 million commitment which promises 3000 more doctors, 3000 nurses and hundreds of allied health professionals to our regions.
The plan provides an unprecedented level of funding and commitment for rural Australia and its packed with measures that show the Government has listened on addressing rural health need.
The workforce component will see integration through the entire training continuum as well as measures to support the existing rural workforce with an important focus on retention.
Stronger targeting of rural bulk billing incentives and key focus on accessing rural services particularly for older Australians with $40 million towards rural aged care infrastructure another positive shift.
For Aboriginal and Torres Strait Islander communities, there is a $105 million boost towards access to services which are culturally appropriate and closer to home.
There is a new MBS item to deliver dialysis services to remote areas representing a $35 million investment.
We have some great leadership here at the moment in our Rural Health Minister, Senator the Hon Bridget McKenzie and Commissioner Professor Paul Worley and it shows in the budget.
Rural pathway package
The rural workforce package is certainly comprehensive and a significant step forward in securing a stable rural workforce with a number of the key components to this strategy covered in earlier blogs.
There is a priority placed on establishing a homegrown rural medical workforce with an important emphasis on skills.
Many of the placement gaps that make it harder to remain in a rural area have been addressed.
More intern placements in general practice and an additional 100 vocational training places are committed. The latter committed from 2021 as part of the National Rural Generalist Pathway.
New training facilities to help rural students aspiring to become rural doctors study closer to home is also welcomed.
The $95.4 million new Murray-Darling Medical Schools Network will help universities work together to support medical teaching in our regions.
It’s also great to see that the new Workforce Incentive Program will extend to supporting general practices to employ more allied health workers.
Strong IMG focus
It’s great to see strong action to ensure we retain the rural workforce in this package of measures which extends to providing incentives for IMGs to progress towards Fellowship.
Those working in rural areas know the huge contribution IMGs make and it is great to see the shift here towards IMG retention. These doctors play a vital role in rural and remote communities and they deserve some support.
The rural strategy outlined in this budget invests in the next generation through domestic recruitment to rural areas but shows a commitment to the existing workforce through investment in skills and retention with an important focus on IMG retention.
In Aged Care, reduced waiting lists and incentives to stay in the home longer sees another important policy shift.
Measures which keep older patients in their homes longer is welcomed policy with this initiative providing $1.6 billion for 14,000 new places for home-care recipients.
This is a good start but not nearly enough with more than 100,000 people on the waiting list. However, the policy is certainly headed in the right direction towards an integrated care at home program.
Some of these measures will restore some of the cuts to the aged care sector of recent years. But it is unclear if they will provide for the targeted supports needed to deliver the complex care required which needs more focus on enabling more GP-led care.
A healthier future
There are some major challenges in funding and delivery of healthcare in securing a healthier future and for this budget, we’re seeing shifts in the right direction.
Health is so integral to our nation’s prosperity and the Government through its investment particularly in rural Australia shows that it understands the value of general practice and primary care.
This budget will certainly improve the lives of the seven million people living in rural and remote Australia.
The rural health measures will help to address disparities and important gains will be realised through this investment and this is a clear win for the sector.
The mental health and aged care gains are also significant and it is great to see those more vulnerable Australians being prioritised.
Dr Ayman Shenouda
Proving our value
Recent coverage around the failed Health Care Homes roll-out saw some unsettling truths coming through in the comments by the reform architect Dr Steve Hambleton.
This is in the context of the continuing trend for value-based care models, Dr Hambleton’s comments highlight a need in general practice to strengthen our data capture capability to prove our value.
What was said really cuts to the truth in terms of where our focus needs to be and how we ought to align or perhaps realign ourselves to better capture outcomes measurement.
For those who missed it, here’s the quote:
“What I will say to GPs is that unless we have the [patient outcome] data to take to the government that proves the value of the healthcare we are providing, they are going to keep investing in the bits of the health system where they do have the data, which is hospitals.” Dr Steve Hambleton
The case for Primary Care
In delivering more effective, equitable, and efficient health services, it is clear that strong investment in primary care would see fewer disparities across populations.
The value and need of strong primary health care systems are already well established. There is robust evidence to show that good primary care is associated with better health outcomes. 
Primary care improves quality and reduces costs. But primary care integration and care management are made harder by a system that has at its core a prime focus on episodic acute care.
The shift to value-based care is inevitable. However, creating savings in the healthcare system is as much about structures as it is about payment reform or data capture in driving that reform.
In measuring value, the current system and structure makes this very challenging. In many ways, the Health Care Homes model provided that answer in terms of how to provide and organise care in the future while enabling measurement and the policy is still worth pursuing.
The key requirement in embedding value-based care as a business model into general practice will require a shift in terms of enabling more team-based care to occur in order to remain viable.
Value in healthcare
Value in healthcare is measured around patient populations requiring different bundles care, these are defined patient groups with similar needs determined by combined efforts over the full cycle of care. 
This confirms the focus needs to be on primary care or new models of primary care but we need a stronger team-based focus and more support structures to make this work.
We need to leverage as much as we can from the current payment system to provide integration across settings. Much of this already falls to the general practice but enabling integration is hard and often non-remunerable work.
Our value proposition
The lack of networked or organisational architecture to support the level of data capture required to measure the quality of care and outcomes achieved through preventive primary care lets us down.
If we are going to achieve the level of integration required, satisfy funders with data capture demonstrating value then I think part of the solution also lies in how we position ourselves in the health system.
We already have the right strategy to fix healthcare and that solution lies in more investment in primary and preventive care through a Health Care Homes model.
In establishing our value proposition, if we must face off as Dr Hambleton suggests against advanced data-capture systems like those used in hospitals to capture detail right down to the bandages, then clearly, we need to get organised.
Capturing quality measures and measuring performance on a continuous basis will be complex and creating reliable structures will be key to our success.
Part of that challenge is around data capture and standardising that process and in particular who’s holding the data.
The strength of our primary care system is associated with improved population health outcomes and we know that enabling service integration is key in terms of realising these aims.
The other challenge will be our capacity to leverage technology, integrate more and build up those required team structures.
It’s clear there is still much to work through here. But what often gets missed is the need to enhance professional experience and I think it is here where we have some real opportunities.
Time for a rethink?
Right now, we should be thinking about what we can do to be more proactive in terms of redesigning what we can for ourselves.
We’ve been a College of GPs for some time now and certainly, that structure has been integral to the world-class health system we have today through supporting Australian GPs to provide the best possible care.
We need to ensure we have in place the adaptive collaborative learning systems required for the future. Is it now time to think about primary care as the future and not only GPs as the centre of that model?
College for Primary Care
The new models of primary care required in response to the healthcare system shifts towards value-based care will rely more and more on team-based care.
In demonstrating value, we need to think about those finite costs capturing those bandages too but this also needs to be about developing the primary care team. There is a real opportunity to support all the individuals working in general practice and train the whole team to enable more integration.
Collaborative healthcare leadership will be needed in shaping the future workforce to support new models of care. The existing College structure can help provide this leadership model to bring about the transformative change required.
Taking a more proactive approach to designing the health system means less focus on payment reform and more interest in investing in the primary care team.
 News Article. Health Care Homes roll out 'went wrong somewhere' says reform architect March 27, 2018. Australian Doctor. Available at: https://www.australiandoctor.com.au/news/health-care-homes-roll-out-went-wrong-somewhere-says-reform-architect
 Starfield B. The future of primary care: refocusing the system. N Engl J Med 2008;359:2087-91.
 Porter ME. Perspective. What Is Value in Health Care? December 23, 2010. N Engl J Med 2010; 363:2477-2481
DOI: 10.1056/NEJMp1011024 Available at: http://www.nejm.org/doi/full/10.1056/NEJMp1011024
Let’s fix the health deficit through a more equitable distribution
Dr Ayman Shenouda
The alarming population growth in our major cities is not surprising and highlights a lack of a national population planning approach for sustainable development.
This issue has been in the news recently and these conversations for me always highlight inequity and missed opportunities. There is usually fallout in distributional terms for rural Australia which continue to be left behind. This is despite the fact that rural areas don’t even get a mention in the discussion.
The lack of rural focus is the underlying problem here with no attention to the broader spatial dimensions which result in increasing inequities. This is a much bigger issue than the inconvenience of the long city commute to work. It’s about the fair distribution of impacts to bring about more equitable outcomes.
In prioritising health, we know a community’s economic health is closely tied to health outcomes. There are persistent inequities in Australia and particularly in our remote Aboriginal communities.
Returning from the Solomon Island’s recently and talking to a colleague about the plight of the people in the Pacific, I was reminded that some remote communities in Australia are worse than Third World.
To get to the bottom of the causes of health disparities you need to look to the social determinants of health. Invest in policies which protect those factors which stretch a range of personal, social, economic and environmental factors and you will get results.
Rural health disparities
The converse is, of course, true and this is why we have such marked health disparities in rural areas.
There is an estimated health deficit of $2.1 billion in rural and remote Australia.
The impact in health terms is that rural Australians are living shorter lives and they have poorer health outcomes and higher rates of disease. The more remote you go, the worse it is.
It is the compounding effect that impacts here - where we see high levels of socio-economic vulnerability combined with lack of access to services.
In addressing these issues, health workforce distribution is of course key to enabling access but so is getting to the bottom of what’s driving the disadvantage.
We need to focus on the value of working across sectors to address those causal factors.
It is those causal or upstream factors – social disadvantage, risk exposure and social inequities – that present the real opportunities for improving health and reducing health disparities.
These powerful determinants of health inequality are why we need to put the spatial dimension back into population planning. More collaborative planning is needed to address the unique needs of these communities.
Rural health investments
Part of the planning discussion needs to focus on the role that rural health investments have creating healthy and sustainable communities. There is a failure to recognise the comprehensive impact of health care funding as a driver for local economic development. 
I know from my own experience that just bringing a health service to an area will help to sustain it. When I established my practice at The Rock the medical facility was being run out of a rented room in the CWA building.
We worked hard to not only establish our practice but build the required broader health service around us. Through our sustained efforts the pharmacy soon followed, then a pathology service and now finally an aged care facility.
The economics of poor health
We know all too well the economic effects of poor health.
An investment in rural health boosts these local economies. A fairer health budget spend would realise strong returns and a healthier future for 30 percent of our population.
But, it is not just a rural issue as there are pockets of disadvantage elsewhere including in our cities and on the fringes and of course in regional centres as well.
Whether in urban or rural areas, pockets of entrenched disadvantage will remain unless we start to align health and causal factors in national planning.
Fixing the health deficit
We need to fix the health deficit through a more equitable distribution.
In planning for a healthier Australia, a much broader focus is required which targets and acts on those upstream determinants.
It’s not just medical care alone that influences health with social factors known powerful determinants of health. This is the formula for a healthy Australia.
 NRHA Fact Sheet. The extent of the rural health deficit. National Rural Health Alliance. 2016. http://ruralhealth.org.au/sites/default/files/publications/fact-sheet-27-election2016-13-may-2016.pdf
 Bharmal N, Pitkin Derose K, Felician M, Weden MM. Working Paper. Understanding the Upstream Social Determinants of Health. RAND Health. May 2015. https://www.rand.org/content/dam/rand/pubs/working_papers/WR1000/WR1096/RAND_WR1096.pdf
 Russell L. The economics of delivering primary health care in rural and underserved areas—what works? Menzies Centre for Health Policy. University of Sydney. 14th National Rural Health Conference. http://www.ruralhealth.org.au/14nrhc/sites/default/files/Russell%2C%20Kesley%2C%20KN.pdf
 Braveman P, Gottlieb L. The Social Determinants of Health: It’s Time to Consider the Causes of the Causes. Public Health Reports. 2014;129(Suppl 2):19-31. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3863696/
Nowhere to go: tackling homelessness for older women
Dr Ayman Shenouda
A measure of our society
It was Ghandi who said ‘a nation's greatness is measured by how it treats its weakest members’. I’m not sure where that places us as a society particularly with the rise of homelessness in Australia. I strongly believe that governments are there for those who need them the most. Better still, if we had their focussed investment on preventive strategies it is certain that our country would be much better off.
On the issue of homelessness, we’ve seen very slow progress. This is despite a strong focus by state and territory governments. But this issue cut across departments and really requires a national focus in my view particularly to direct funds to improve healthcare management in primary care.
Housing and employment are two significant social determinants of health. We know homelessness can significantly impact on health outcomes. While social and economic factors lead to increased risk exposures. The patient-centred medical home can help meet the healthcare needs of the homeless population but this is reliant on a targeted program of funding.
Rising rates of homeless older women
One in three older women are living in income poverty in Australia.[i] Older single women are particularly at risk of becoming homeless with significant numbers experiencing rental stress. This is a public health crisis and requires careful policy planning overtime which is difficult to do in our short-term electoral cycles. Health status must remain a priority across government and not just health to provide for integrated services and supports.
Social workers have warned that Australia is facing a generational “tsunami” of this older demographic in coming years. This policy catastrophe is really not all that surprising when you consider the soft policy responses to those known drivers of poverty.
Women have less super due to disparity in earnings with years of lost income due to time out for family. There are cost impacts which include high-priced housing or losing a job as well as broader factors such as the rising divorce rate or death of a spouse. There is also less capacity to earn with the casualisation of the workforce which is also marred by ageist stereotypes.
Combating ageism in our society is something this country really needs to work on.
How is it even plausible that in the modern workplace you are considered old at 45 or 50? This seems to be the case yet Australia’s future prosperity is reliant on older workers. Perhaps this factor alone will make our policymakers more focussed on solutions in future.
Older women are locked out of the jobs market. Losing a job is said to be one of the most common triggers that can plunge older women into poverty.[ii] Ageism has very real mental and physical health consequences. There is less discussion on the impact that ageism has on health and we need to be louder here. These are two clear areas which require more policy development.
My older female patients often describe feeling invisible and that’s always heartbreaking to hear. But it seems this invisibility may have also crept into the policy space. Like so many things, we know policy inaction will be more costly over time.
The UK in prioritising a Minister for Loneliness is perhaps a step in the right direction. Addressing issues of isolation will help build stronger, healthier older Australians and we really need that national policy setting.
We’ve been treating the symptoms and not the know causes for too long.
Securing long-term tenancy options for this vulnerable cohort has to be prioritised. The fact is that we have had enough warnings in order to evacuate safely from the impending tsunami. We need to address wealth inequality, and particularly gender and income disparity in later life. Addressing ageism and particularly employment-based age discrimination too.
It is about helping women before they reach crisis point. More integration across the health and homelessness support systems would help to identify earlier those at risk. Also, understanding those pathways to homelessness among older adults and ensuring prevention and service interventions are adapted to meet different needs is another key piece to this policy puzzle. [iii]
[i] O’Keefe, D. One in three older women living in income poverty in Australia: study. Australian Ageing Agenda. March 9, 2016. Available at: https://www.australianageingagenda.com.au/2016/03/09/one-in-three-older-women-living-in-income-poverty-in-australia-study/
[iii] Brown RT, Goodman L, Guzman D, Tieu L, Ponath C, Kushel MB (2016) Pathways to Homelessness among Older Homeless Adults: Results from the HOPE HOME Study. PLoS ONE 11(5): e0155065. https://doi.org/10.1371/journal.pone.0155065