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.
Dr Ayman Shenouda