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.
6 October 2017
Dr Ayman Shenouda
A focus on palliative care
There was some great discussion generated from my recent blog on frailty and ICU outcomes. The importance of patient empowerment and preference towards care in the community resonated with many. Palliative care is an important extension to that discussion. This is an area, which we know is expanding with demand which is set to rise alongside disease rates and an ageing population. Despite a stronger national focus on palliative care, the patient’s preference for community care is not translating into policy.
Palliative care should improve the quality of life of patients with an active, progressive disease that has little or no prospect of a cure. More and more we’re seeing patients’ preference for palliative care in the home. We know that 70 percent of Australians would rather die at home than in hospital. Whatever the choice, the model of care must enable access to all patients facing a life-limiting illness. We know that those who would get the most benefit from palliative care often accessed it too late. There is still so much in this area that we need to fix. I think a good place to start is ensuring our patients’ preferences around dying at home.
Access and choice
In finding a way through the system to facilitate choice for more community-level care we are still a long way from enabling equitable access. Early access to palliative care services is an internationally recognised policy goal. However, it is clear that our shared policy goal is not being met in Australia when it comes to access and choice.
This highlights our first policy failure, which is around equity in access which of course stretches beyond just palliative care and can be persistent throughout life for some most in need.
Where you live and your socioeconomic status has some bearing on choice in terms of preference of setting in palliative care. AIHW 2014-15 data released early in the year showed that there is a higher proportion of palliative care-related hospitalisations (22.4%) in the lowest socioeconomic status areas. The rate of palliative care-related public hospitalisations was also highest for those living in these areas (30.9 per 10,000 population). Conversely, the rate of public palliative care-related hospitalisations was lowest for those living in the highest socioeconomic status areas (14.5 per 10,000).
Funding and policy context
Funding and policy context really matters here. This is because funding models clearly influence service provision and the development of palliative care services. Funding for palliative care involves a mixed system of public, private and charitable players. A mismatch between policy goals and palliative care funding mechanisms can compromise our shared aim in addressing need. 
This leads to the next policy failure which is around service planning and problematic due to care being split across levels of government.
Service planning relies on quality data and this is a key gap in palliative care. The sole Physician MBS item numbers map only a very small sample of service provision which really limits service planning, particularly in enabling patient choice to die at home.
This palliative medicine focus, while important, is limiting. It means that what is actually occurring at the community level in terms of GP-led palliative care is less likely to inform policy decisions. The undefined role of the general practitioner in palliative care across a range of settings is a contributing factor. While we are seeing more and more GPs with special clinical interests in palliative care meeting these needs in primary rather than secondary care, the system just doesn’t see them.
In the absence of item numbers, how can GP-led palliative care ever be fully measured? GPs play a critical role here. Chronic disease management and home visit item numbers are not sufficient in terms of planning for future demand or in capturing the complexity and non-clinical time involved in providing this care. The only available BEACH data shows that about 1 in 1,000 GP encounters in 2014-15 were palliative care-related, which equates to around 5 encounters per 1,000 population. This is most certainly an underestimate of the actual numbers given services delivered by GPs cannot be established from Medicare data.
Another key issue is that palliative care services have many individual providers both public and private. It is clear we need to get better at ensuring a more seamless service transition for the patient and family. Service integration prioritising multidisciplinary care at the local level relies on flexibility to facilitate the integration of funding streams. In rural areas, this can be particularly challenging even when there is a strong commitment by local service providers.
Service integration at the primary care level remains a key policy failing and much more effort is required to provide the necessary supports to enable a more integrated system.
General practice is the gateway for patients to the broader health system. We need new expanded funding measures specifically designed to enable service integration for palliative care in the community. Efficiencies can be found in community-based care, yet there is a reluctance to put the system supports in place to make it happen.
The recent $8.3 million announced in the Federal Budget will help boost the role that the PHNs have in coordinating end-of-life care. It is understood that the funding will support the provision of a facilitator which may help take the pressure off GP practices who are fulfilling much of this role already for their patients. But much more needs to be done in the area of facilitating greater access to GP-led palliative care services. Building local capacity to address increasing and future demand will require a significantly larger investment than we’ve seen to date.
Capturing broader perspectives
We know that demand for palliative care in Australia will grow. This, in turn, requires an expansion of home and community care in meeting patient preference. An important policy perspective needs to be captured from those receiving care and their caregivers. This will help us work through further how we can improve services to support dying at home.
A final additional focus therefore needs to be on the patient and caregiver if we are going to get this policy right.
A qualitative study of patient and family caregiver experiences of Hospice at Home care provides insights. It states that we need to focus on additional supports for older people and those living alone, recognised as high risk of being unable to receive this type of support. More targeted supports for older caregivers who are at a higher risk of caregiver burden are also required. The policy goal here has to be around promoting their quality of life with an emphasis on training for the full care team in the ethos of palliative care to ensure holistic care.
Where to now?
We know that GP-led community palliative care needs to be prioritised in policy. Yet there remains plenty of barriers limiting service expansion to facilitate this care from within the community and across settings.
Ensuring our system is more responsive to patient choice is of course what needs to drive all policy decisions. We know in this case that it is often a preference for care outside of the hospital setting. But when our system automatically preferences to tertiary care, it makes it harder to facilitate that care. This is unless of course you have well established and integrated service links and a significant local community commitment to make it work.
There’s a pattern emerging here and it’s about prioritising patient-centred healthcare in primary care. Access enabling choice, service planning and data capture, integration prioritising GP-led care and encompassing the patient and caregiver perspectives would bring us closer to a more responsive palliative care service system.
 AIHW. Web Report. Palliative care services in Australia. Last updated 24 May 2017. Available at: https://www.aihw.gov.au/reports/palliative-care-services/palliative-care-services-in-australia/contents/palliative-care-in-general-practice
 Palliative Care Australia. National health statistics highlight inequitable access to palliative care. 24 May 2017. Available at: http://palliativecare.org.au/palliative-matters/national-health-statistics/
 Parliament of Victoria. Legislative Council Legal and Social Issues Committee. Inquiry into end of life choices Final Report. June 2016 PP No 174, Session 2014-16 (Document 1 of 2) ISBN 978 1 925458 38 1 (print version) 978 1 925458 39 8 (PDF version). Available at: https://www.parliament.vic.gov.au/lsic/article/2611
 Connor SR and Bermedo MCS. Global atlas of palliative care at the end of life (Worldwide palliative care alliance, World Health Organization), 2014, http://www.who.int/ nmh/Global_Atlas_of_Palliative_Care.pdf
 AIHW, op.cit. Profile of palliative care related hospitalisations.
 Groeneveld EI, Cassel JB, Bausewein C, et al. Funding models in palliative care: Lessons from international experience. McCaffrey N, Cassel JB, Coast J, eds. Palliative Medicine. 2017;31(4):296-305. doi:10.1177/0269216316689015.
 Australian Institute of Health and Welfare 2014. Palliative care services in Australia 2014. Cat. no. HWI 128. Canberra: AIHW.
 Palliative Care Australia. Budget offers new support to coordinate end-of-life care. 10 May 2017. Available at: http://palliativecare.org.au/palliative-matters/budget-phns/
 Jack B.A., Mitchell T.K., Cope L.C. & O'Brien M.R. (2016) Supporting older people with cancer and life-limiting conditions dying at home: a qualitative study of patient and family caregiver experiences of Hospice at Home care. Journal of Advanced Nursing 72(9), 2162–2172. doi: 10.1111/jan.12983
25 August 2017 Dr Ayman Shenouda
RECRUIT, TRAIN AND RETAIN
Getting the policy settings right
I don’t think there’s ever been a better time to secure the next generation of rural GPs. Now more than ever before we have the right policy settings in place. We need to seize this opportunity to ensure we select the right doctors for rural Australia.
Once we’ve overcome that first hurdle in getting them there, we need to then ensure those registrars who choose rural practice, that once secured, they remain there. But not only remain there that they continue to thrive. To do this we need to ensure the right supports are in place.
The policy momentum has been building for some time with the help of thousands of rural GP champions – possibly most now reading this blog – who have advocated for change over many years.
We now have the right set of policy conditions: an overall increase in medical school intake with quarantined placements for rural; a rural emphasis and exposure with a focus on generalism as a priority in the training; and, of course, the regional training hubs which will soon be in place to help link the various stages of training.
We finally have the makings of an integrated rural medical training pathway. This includes a priority on rural community internships – a clear gap which needed fixing – and soon with the regional hubs, training can be structured in a more coordinated facilitated way.
The hubs, in particular, will strengthen the efforts of the Rural Clinical Schools’ and help build the facilities and infrastructure and teaching capacity needed to make this work. For the trainee, it will help to provide the navigational supports that have been so lacking in the past from medical school to rural practice. Importantly, we have a focus on non-coercive strategies in securing the next generation of rural GPs.
Why enter, why stay, why leave?
We know that many factors influence rural intention and that it is getting those supports right and across the full training continuum that counts.
Ruralising the curriculum is a key one. Embedding more primary care early into the medical curriculum is essential and this has certainly been said often enough. But other simple things like placing a rural scenario in the exam would also help to formalise assessment to enforce primary care and emphasise the important role of the generalist.
Getting them in early and interact as often as possible is another key requirement. Nurturing your registrars once there requires a whole of community effort.
I think it is instilling that sense of belonging that is vital at this point so the emphasis then needs to be multifactorial. Positive exposure offering a mix of rural experiences including clinical and nonclinical competencies and of the latter leadership being a key one here, the ability to lead and work in teams cannot be emphasised enough.
Trainees want broad exposure and the opportunity for multiple levels of clinical learning through blended placements. Trainees need to be empowered to make informed career decisions and to obtain the skills they need in the local setting. A community with the right structures and partnerships in place can facilitate this well.
Next is community connection and engagement and getting that right. This really gets to the heart of the issue – this is why they stay – that sense of place and identity. Ensuring a strong rural connection is hard work in training terms but worth the effort in the long run.
This is all part of developing a professional identity and mentoring plays a key role here. Longer-term placements in and around the same community also help to build those lasting relationships.
While I think an intrinsic characteristic of most GPs is their altruism there are also limits. We need to formalise that mentoring point – and at every learning stage – so that rural GPs and broader teaching staff are able to commit their focus towards mentoring.
More funding for mentoring has to be part of the suite of incentives in support of rural intention. Formalising succession planning in this way would help to ease the pressure on those nearing retirement too. That’s the ‘gracious exit’ part that often gets forgotten but just as vital as ‘easy entry’ for rural.
A rural pipeline functioning well can support these broader retention outcomes in terms of supplementing supply over time through a constant stream of new entrants. This would help make rural practice even more attractive as it provides an exit strategy for rural GPs without having to make that lifetime commitment. Rural GPs could stay for a shorter period, up to five years, without causing the workforce disruption that currently occurs upon exiting. Rural practice could become a standard part of the GP journey with supportive policy offering more flexibility and opportunity to spend at least part of your career within a rural community.
Now finally, getting to the hardest bit. Once you have them, then the focus then shifts to keeping them there. And getting to the bottom of that is a whole new set of questions which tend to include broader impacts including those on family.
Factors including an adequate income, appropriate workload, locum provision, access to specialists’ advice and continuing education, spouse career opportunities and children education all come in to play. Again, it takes a whole community to help make this work.
Bringing it all together
Piecing it all together there are a lot of factors that need to come together to get rural recruitment, training and retention right. Ensuring we have the right set of incentives in place for those making the commitment is key to policy success including rewarding advanced skills, procedural and non-procedural.
In understanding intentions to practice rurally, we know that rural origin plus a rural clinical school placement is a significant predictor. But there are many ways to get there and we should keep an open mind as many get there by accident. I think I fit that last category having only come to rural practice at the age of 35 after commencing in a completely different specialty to being with.
In securing strong rural outcomes, it comes down to nurturing those with an interest and being able to bundle those known influences. We’ve certainly come a long way in securing the right supports and focus to realise a fully integrated rural training pathway. It’s a multitude of factors including supportive policy and a strong local commitment from each and every one of us, but not least the trainee to secure the next generation of rural GPs.
 RACGP. New approaches to integrated rural training for medical practitioners. Royal Australian College of General Practitioners. 2014. Available at: http://www.racgp.org.au/download/Documents/Rural/nrffinalreport.pdf
 Parlier AB, Galvin SL, Thach S, Kruidenier D, Fagan EB. The Road to Rural Primary Care: A Narrative Review of Factors That Help Develop, Recruit, and Retain Rural Primary Care Physicians. Acad Med. 2017 Aug 1. doi: 10.1097/ACM.0000000000001839. [Epub ahead of print]Availablat: http://journals.lww.com/academicmedicine/Abstract/publishahead/The_Road_to_Rural_Primary_Care___A_Narrative.98154.aspx
 RACGP 2014, op. cit. p.65.
 Humphreys J, Jones J, Jones M, et al. A critical review of rural medical workforce retention in Australia. Aust Health Rev 2001;24:91-102. [PubMed]
 Walker JH, DeWitt DE, Pallant JF, Cunningham CE. Rural origin plus a rural clinical school placement is a significant predictor of medical students’ intentions to practice rurally: a multi-university study. Rural Remote Health. 2012;12:1908.PubMed
11 August 2017
Dr Ayman Shenouda
Developing a skill set around your community’s needs.
Just like lifelong learning, community needs assessment is a continual process that helps us to ensure our community has the best possible service mix. Health needs assessment is developmental and has to be added to or adjusted over time as the community’s needs change. It is alongside that process that we commit to continual learning, to adjust our skills over time to ensure these needs are met.
For a rural community, where resources and infrastructure are scarce, needs assessment is a critical process. It helps you to prioritise where you can make the biggest impact, to plan and deliver the most effective care against those areas of critical need. It enables you to work collaboratively with the local community to develop the infrastructure required. Most of all it becomes a partnership as people centred health relies on community participation and through this process, you find yourself fully immersed in community life.
When I arrived in Wagga Wagga 17 years ago, I was armed with some advanced surgical skills acquired while working as a surgical registrar in Egypt, then further honed in Tasmania during my initial few years in Australia. Naturally, my fellow GPs in the practice referred to me patients with surgical skin conditions. This was great as it allowed me to utilise my skills, on the other hand, though patient expectations increased as they were under the impression that I was a Dermatologist!
In all honesty, my dermatology skills weren’t all that flash and it was clear the local service gap in Dermatology needed fixing. I subsequently completed a Diploma of Dermatology in 2003 through the University of Wales in Cardiff. I became very popular and started to have referrals from other practices in town, as without a local area specialist that role continued to fall to me. It was out of unmet need that this became a necessity of course but it really was the community driving that decision to upskill.
Now the Wagga community has access to dermatology services I am adjusting again but to a new requirement in palliative care. This is demonstrative of lifelong learning in practice – The good GP never stops learning – in providing lifelong care there relies a commitment to lifelong learning to adapting your skills to meet changing needs.
For those looking for more inspiration, there were some great rural stories produced some years ago. During 2012, the RACGP rural faculty celebrated its 20th anniversary and as part of our commemorating that milestone we produced a series of inspiring stories “Getting to know our rural GPs”. These stories were truly demonstrative of just how diverse the profession is and the depth of skills needed in supporting the often-complex needs of rural communities, while also highlighting the unique nature and rewards of living and working in rural general practice.
Applying a lifelong learning framework
In applying a lifelong learning framework, we already have the key structures to facilitate this. The Fellowship of the Royal Australian College of General Practitioners (FRACGP) signifies that a GP has been assessed as competent across the core skills of general practice enabling him or her to practice safely, unsupervised, anywhere in Australia.
The FARGP is a qualification awarded by the RACGP in addition to the vocational Fellowship (FRACGP). Providing a dedicated pathway for both general practice registrars and experienced practising GPs, the FARGP aims to develop advanced rural skills and broaden options for safe, accessible and comprehensive care for Australia’s rural, remote and very remote communities.
The FARGP is unique here in terms of using a population health approach to plan and execute health service needs for a community. The community-focussed project is undertaken over a six-month period and enables you to get to know your community and engage with them to improve health. This important requirement equips the candidate with essential planning tools and establishes leadership in a community.
Skill development in policy
For trainees, key to ensuring broad skill exposure is the need to map the training process to ensure a wide variety of experiences can be provided. Needs analysis is again critical here and this level of planning is something we should be doing more of at both the state and national levels. This level of planning provides a comprehensive training program and a way to ensure skills learned are transferrable to their practice after the completion of training posts in building a resilient workforce.
After all, it is these trainees that will provide vital services in the future. Ensuring broad exposure and allocating placements according to specific learning needs and against community need at this early stage makes perfect sense in planning a future generalist workforce. The new regional training hubs should help to support this needs assessment to tailor a training package which provides for the level of flexibility required to truly immerse in the community as well as ensure relevant clinical exposure.
Just as vital is the requirement for a skill-acquisition pathway for practising rural GPs acknowledging the lifelong learning requirement and addressing unmet need. A stronger focus is required at both the state and national levels in terms of providing that structure or mechanism in the current arrangements to facilitate training for those who wish to go back and retrain to meet a skill need in their community.
The Commonwealth’s Rural Procedural Grants Program is vital in supporting skill maintenance in some key hospital-based skill areas. Applying a population health needs assessment in terms of skill acquisition requirements should guide decisions at the policy level. This process would see an expansion of the procedural grants program to include essential non-procedural advanced skills. Policy planning needs to factor and be responsive to current and future need just as the GP does in responding to the changing health needs of their community over a lifetime.
5 August 2017
Dr Ayman Shenouda
Often a really good policy solution will in turn place more pressure on a part of the health system it relies. This isn’t necessarily a bad thing and is usually indicative of good policy spend. It is sometimes an outcome of optimal policy coverage as is the case for disease screening measures. The National Bowel Cancer Screening program, introduced in 2006, is an example of a policy working well.
We know that one in 12 Australians will develop bowel cancer by the age of 85 which makes it the second most common cause of cancer-related death in Australia after lung cancer. But, if detected and treated early the cure rate is around 90% which makes policy intervention through prevention and in this case, through screening measures, so vitally important. [i]
The is a great policy intervention which we’ve seen expanded under successive governments with broad coverage now currently available to Australians aged 50, 55, 60,64, 70, 72 and 74. Once fully implemented by 2020, all Australians aged 50 to 74 will be able to be screened every two years.[ii]
But as a result of this policy, we’ve seen demand increase for lower gastrointestinal endoscopies. This growth in demand means there is a need for the endoscopic workforce in Australia to be well planned in order to cope with future demand associated with expanded cancer screening, particularly with an ageing population. Service solutions to address current demand including nurse endoscopists are now being rolled out in Queensland and Victoria. But is this the right workforce response for Australia or is it more of a temporary fix to a growing system issue?
Here’s the policy background to the issue. The policy response to limited endoscopy capacity a few years ago saw the now defunct Health Workforce Australia (HWA) invest in a project to train nurses to perform endoscopic procedures. Expanding the scope of practice of health professionals was a typical policy response being keenly pursued at that time by HWA. This particular decision though saw unprecedented action with a policy preference to train non-medical endoscopists and build capacity from within nursing.
At the time, the medical press reported that doctors were calling for a moratorium on nurse endoscopy.[iii] From a resource perspective, it is important to also note that this was a decision undertaken within the broader context of increased medical graduates coming through and claims of impending oversupply.
The Advanced Practice in Endoscopy Nursing (APEN) program was modelled on approaches elsewhere including in the UK where the nurse endoscopist was well established. Although nurse endoscopy training and delivery of endoscopic services is not a new policy response: the first report of nurse endoscopy in the US was more than 35 years ago for flexible sigmoidoscopy.[iv] But I think it is important to work through policy alternatives for Australia particularly if one solution has limitations both in terms of efficacy and coverage.
The University of Wollongong evaluation of the HWA-funded APEN sub-project in 2014 highlighted some key points in terms of the validity of a nurse-led model as a workforce solution.
Firstly, it stated that one of the main drivers for the program was the need to respond to growing demand for lower gastrointestinal endoscopies arising from bowel screening. However, it also stated that only about a quarter of same-day colonoscopies are performed in public hospitals. A key detail that severely limits the ability of nurse endoscopists to meet this growing demand. The evaluation also stated that given full implementation was not achieved, that relative advantage in terms of effectiveness and cost effectiveness of the model could not be evaluated and could only be measured after trainees were qualified and working at full capacity. [v]
The Australian Medical Association of Queensland (AMAQ) in commenting on the Queensland roll out of nurse model to Cairns and Townsville, stated that medical endoscopists were more cost effective than nurses as surgery could be performed at the time of procedure.[vi]
Cost-effectiveness of the nurse-led model as a workforce solution has also been challenged in a study published in the World Journal of Gastroenterology in 2015. The study examined the available evidence on safety, competency and cost-effectiveness of nursing staff providing gastrointestinal (GI) endoscopy services. The study concluded that the empirical evidence that supports non-physician endoscopists is limited to strictly supervised roles in larger metropolitan settings and mainly flexible sigmoidoscopy and upper endoscopy for asymptomatic or low complexity patients. [vii]
This same study also stated that contrary to general beliefs, endoscopic services provided by nurse endoscopists are not more cost effective compared to standard service models due largely to the increased need for subsequent endoscopies, specialist follow-up and primary care consultations. It stated that studies measuring cognitive competency were limited and providing endoscopic services is more than mastering the technical skills required to safely advance the scope. Further, that making clinical decisions in the context of the patient’s full clinical picture is critical to delivering efficient and meaningful services.[viii]
In finding an effective solution, the most obvious question for me in terms of utilising the available workforce is around why we are not looking to general practice to address excess demand? Some of the pressure placed on endoscopy units in managing this increased demand can certainly be addressed by general practitioners.
General practice offers a particularly viable solution for rural communities in endoscopy. Keeping trained procedural GPs in rural areas should be made a priority and this is a good example of where support is needed to sustain local solutions where rural GPs fill a service gap like this. Access to diagnostic endoscopy is limited in rural and remote areas and service expansion by GPs provides significant patient benefits in terms of time and costs.
While savings including around reduced costly patient transfers are obvious to most, the investment in GP procedural practice where it offers a sustainable service model should be sufficient for policy makers. It would help to reduce the demand placed on regional tertiary services and could help make GP procedural practice more viable in the smaller towns. We know that rural GP proceduralists must be supported to consolidate their skills in the communities they serve and this is one service solution which can help realise this aim. It is a workforce solution that needs to be considered.
[i] Cancer Council Australia. Position Statement. Bowel Cancer. Available from: http://www.cancer.org.au/policy-and-advocacy/position-statements/bowel-cancer.html
[iii] Australian Doctor. Doctors call for moratorium on nurse endoscopy. 30 January, 2015. Available from: https://www.australiandoctor.com.au/news/latest-news/nurses-expand-scope-into-endoscopy
[iv] Spencer RJ, Ready RL. Utilization of nurse endoscopists for sigmoidoscopic examinations. Dis Colon Rectum. 1977;20:94–96. Available from: https://www.ncbi.nlm.nih.gov/pubmed/844404
[v] Thompson C, Williams K, Morris D, Lago L, Quinsey K, Kobel C, Andersen P, Eckermann S, Gordon R and Masso (2014) HWA Expanded Scopes of Practice Program Evaluation: Advanced Practice in Endoscopy Nursing Sub-Project Final Report. Centre for Health Service Development, Australian Health Services Research Institute, University of Wollongong. Available from: http://ro.uow.edu.au/cgi/viewcontent.cgi?article=1384&context=ahsri
[vi] ABC News. More gastroenterologists needed rather than using nurse endoscopists in hsopitals, AMAQ says. 18 Apr 2016. Available from: http://www.abc.net.au/news/2016-04-18/amaq-more-gastroenterologists-rather-than-nurse-endoscopists-qld/7336202
[vii] Stephens M, Hourigan LF, Appleyard M, et al. Non-physician endoscopists: A systematic review. World Journal of Gastroenterology : WJG. 2015;21(16):5056-5071. doi:10.3748/wjg.v21.i16.5056. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4408481/
Broad skill depth is what makes general practice unique and so central to addressing patient need. An essential part of that skill mix and key to addressing an aging population with more complex health care needs are non-procedural advanced skills.
The development of specialist clinical interests by GPs has always been a key feature of general practice. These are often the skills needed to meet identified patient need and provide an effective way to address access constraints, particularly for rural areas.
It makes sense then that in order to provide training to match demand that we don’t over emphasise or value certain skills over others. It’s also important to value the workforce you have as well as prioritise policy to support the next generation of GPs. This is the case for both urban and rural GPs we need to provide more opportunities in those extended skills or advanced skill areas identified and prioritised by the profession.
This is particularly important for practising rural GPs who need flexible training options so that they can acquire new skills to address unmet service need. And in meeting this need this requires an equal focus on both non-procedural and procedural skill acquisition.
We need an equal focus on both recruitment and retention strategies which in turn means factoring into the policy design both learning stage and time in career. To achieve this, we need targeted strategies to support both the existing workforce and those at an earlier learning and career stage.
Funding not only needs to be prioritised for skill acquisition but also for maintenance. Skill certainty is also crucial so that the GP can utilise the skills they’ve acquired to support their community. The return on investment is substantial and means that patients get the services they need and deserve.
Research led by RACGP Rural in 2013 helped to clarify the extent of advanced skills used and needed by GPs in rural and remote Australia. Not surprisingly the number of advanced skills acquired and used across most areas increased with rurality.
Mental health came out in front as the most commonly practised advanced skill in the study, followed closely by emergency medicine and chronic disease management. Of those skills GPs would seek to acquire to meet a community need, emergency medicine was the most prevalent, but this was followed by palliative care, paediatrics, and mental health.
Skills in emergency medicine were expectedly prominent with approximately 60% of respondents indicating that emergency medicine was relevant in rural general practice. However, only 38.7% had acquired it and 33.6% were currently using it. More broadly though, of those who had acquired an advanced skill, most were continuing to use that skill which was most reassuring.
The most important policy points from the study had to be the high prevalence of non-procedural advance skills as well as the continued reliance on emergency medicine in addressing need. There would be no surprises here particularly for those rural GPs currently overstretched to keep providing emergency and in-patient services. But also to those struggling to meet an increasing need in palliative care, paediatrics and mental health which extend to psycho-geriatric skillsets.
The policy requirement extends beyond providing training opportunity with a need to address system constraints which act as deterrents to working outside of the practice setting. Increased training opportunities need to be delivered in a supportive framework which enables skill utilisation facilitating service continuity otherwise it’s like doing half the job.
Capturing service complexity and rewarding GPs working across settings or in targeted areas of need offers a service solution in these areas. Investment in these skill-specific solutions based on need with a focus on GP-led models of care offer real solutions for health service viability.
We need to focus on enhancing health system interfaces where those non-procedural advanced skills factor strongly. In managing demand at the interface between primary and acute health care settings or various stages of illness – in palliative care or those with multiple chronic conditions for example – requires much more focus and across the full multidisciplinary team.
We need clear referral pathways which promote continuity of care for patients moving in and out of primary and tertiary care. The type of coordinated care planning made possible by that initial skill investment to enable an expanded role, but which is then further invested in terms of ensuring continued skill use across settings to provide for the required continuity of care.
15 July 2017 Dr Ayman Shenouda
The Federal Government’s $54.4 million investment to create 26 regional training hub sites nationally sees yet another significant rural health reform realised. Providing a more seamless transition from undergraduate training into rural practice, I believe the hubs measure is one of the most important reforms since the establishment of the Rural Clinical Schools nationally in 2000.
Having this policy realised is also a proud moment for me knowing that RACGP Rural was at the forefront of this reform having developed rural medical training pathway options for the Commonwealth through a major study undertaken in 2013.
What we now have with this policy is the level of integration we called for with the hubs being our highest ask. It’s also clear that other aspects of the full pipeline investment were informed by this study, which was one of the largest member-led rural consultations ever undertaken. Collectively these initiatives represent a significant rural training investment and it’s a great achievement for the sector.
It’s a substantial package, the three-part integrated rural pipeline package provides just short of $94 million over four years with the regional training hubs forming a key policy component. It also includes a rural junior doctor innovation fund and further investment to expand the rural specialist training program. Three new University Departments of Rural Health have also been committed for strategic sites across WA, NSW, and Queensland.
We’re also seeing some policy shifts here which are significant. Particularly in those key areas where we’ve been calling for change in order to address the policy gaps which impede integration. These are those junctions which occur from student to intern and intern to registrar which offer real opportunity in terms of being critical rural commitment points.
Firstly, in this policy, we see a clear focus on embedding more primary care earlier into the training. A new strategy to provide more internships that include rotations in general practice addresses a really significant problem where the lack of exposure to rural practice at this critical time impacts our recruitment goals. Factoring rural primary care rotations for rurally based first-year interns ensures this exposure across multiple settings. It doesn’t minimise the required hospital exposure but ensures essential exposure to community-based rural general practice.
While the early linkage of intern positions with specialist training positions is also evident through providing up to 100 new rural training places. We need to ensure our next generation of rural doctors are nurtured and supported once captured. This investment will go a long way towards supporting that aim by ensuring there is the capacity to provide high-quality rural placements.
We know there is a link between where a student ends up and where they completed their post-graduate studies. But even with the strongest rural interest and the best intentions, not everyone is suited and it takes a substantial personal commitment to make it work and stay.
We now have more capacity through this pipeline initiative to get those supportive elements right in order to provide a stable learning environment to equip trainees with the skillset they will need. Even more importantly it helps to ensure support can be sustained long enough to provide trainees with the skills and confidence required which makes staying much more likely.
The hubs provide for the right set of supports that will help us capture for rural the increasing domestic graduates coming through. It enables the university-hospital-community partnerships we need to set the right conditions to encourage more doctors to practise in rural areas.
This model facilitates a level of integration that will allow adequate clinical exposure in a rural area across all training stages. Most of all it provides a way to maintain a link to a specific rural community and to facilitate longer terms in rural areas.
What also needs to be emphasised here is a program of complete immersion. The step beyond rural exposure and a commitment towards longer placements. Community connectedness can only be achieved through longer placements in the same community throughout the full training continuum.
More cohesive and tailored training options will result. A more varied training experience will be able to occur, one which is appropriate to the learning stage but also flexible enough to be in line with community health needs.
Longer placements with multiple levels of learning are more effective allowing for the required immersion. It connects the trainee to the key players in the community, developing a network and connection to community through mentorship. Importantly they learn the value of rural general practice on their way through.
Policy success will, of course, be determined by improvements in the rural retention rate over time but I have no doubt the pipeline investment will work to build the right supports to make rural training a much more viable option.
These measures provide for the supportive and coordination factors as well as some much-needed infrastructure to make rural training work. It helps to formalise the networks needed to provide a pathway continuum for medical education and training from medical school to rural practice. All this combined provides a comprehensive policy solution which will translate into rural recruitment success and workforce retention over time.
Further reading: RACGP Rural developed a Position Statement to support policy implementation of the Regional Training Hubs.
General Practice has faced many challenges over recent years –Medicare rebate freeze, new PHNs structure and recent changes in training delivery. All of these are impacting on the future of our profession. I believe General practice continues to evolve to meet the current and future challenges facing the Australian health system. However the College of GP’s has a pivotal role to support general practice to deliver an effective and sustainable healthcare for the communities they serve. This article is an attempt to explore and answer the question. How can the RACGP Add Value to General Practice?
As general practice expands to meet the new environment and future challenges it is imperative to have a systemic approach backed by a solid business model that underpins quality care. There is also a need to support the creation of new models of care delivery as many of the RACGP members are either seeking the opportunity to open new practices or refine existing practices. I believe that the College can play an important role in supporting the business of general practice this will in turn support a sustainable and viable small business models regardless of whether you work in, or own it.
The Australian health system ranks as one of the bests in the world I believe the strength of our health system lies in its reliance on general practice and the pivotal role of the general practitioner. I believe that it is essential that the solution for current and future challenges needs to come from within the profession by utilising the wealth of knowledge and expertise that exists within the College and its membership. This can position the RACGP as a leading voice in writing health policies and creating solutions alongside government.
We also need to continue to actively promote and celebrate the role of GPs as highly trained medical specialists that offer solutions to address future complex health issues. We need to continue lobbying government and advocating for change to the funding models to close the gap between specialist and GP rebates.
The strength of the College can only be realised by strong representation and engagement of its members. We need to create communication channels, which allow members to input ideas and concerns on key issues and provide a forum for expression of new ideas. Similarly, communication between the faculties and council needs to be enhanced. The College is privileged to have developed 9 faculties, each of which contributes important information and feedback on specialised aspects of general practice. Links between the colleges and sharing of information and practices can only serve to strengthen the workings of the College.
To cope with the increasing complexity of issues and constantly changing primary care environment there is an urgent need to build leadership, which harnesses the individual and collective talents of primary health, teams. This requires proper engagement with college members by recognising potential leaders and fostering their talents through specific training pathways and mentorship.
Research is the cornerstone of an academic college and the key to shaping our future practice. The general practitioner is in an ideal position to engage in research in primary care and help in the translation of new ideas and evaluation of interventions to the general public. There is a wealth of knowledge and research experience amongst our professorial members and Deans of General Practice, which can be utilised by the College. Our General Practices are a rich source for data collection, audit and real world experiences, which we need to encourage our College members as scientists to explore record and publish.
Imparting the art of general practice is part of our responsibility in passing the baton to the next generation and instilling in future doctors a passion for the profession of general practice. Promoting career pathways in general practice in both rural and metropolitan settings is a key role for the College. We need to support training, education and innovative thinking through a wide variety of programs to enhance skill development at all stages of training.
These are some of what I consider to be the key issues that the RACGP needs to engage with and I believe I have the experience in my past and present roles and the vision to lead the RACGP in the future to work alongside Council to add value to general practice.