​
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.

[ends]

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. 


Ayman Shenouda