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