AS general practice undergoes yet another major policy shift, with whisperings of government plans to renege on a transition to college-led training, it is timely to explore what’s behind all the policy iteration and what intended or unintended consequences it could have for the Australian health system and, therefore, the Australian public.
Since the 1990s, the government has played a strong hand in shaping general practice and rural practice through extensive policies. While many government strategies are important, their intersecting nature means that even small changes can have major ripple effects. Change can produce widespread uncertainty, particularly if done without adequate policy consultation. This is also because changes threaten GP ideals for practice autonomy and high quality patient care. The sense of threat is exacerbated if policy interventions are not positioned as part of an integrated “whole of workforce” plan.
The release of a National Medical Workforce Strategy (NMWS) is imminent. It is expected to signpost how Australia can achieve a balance of generalist to specialist-trained and distributed doctors, when and where we need them. But to successfully future-proof the primary care workforce and enough generalists, the NMWS must be brave enough to embrace the prevocational, hospital and non-GP specialties and metropolitan centres, where the surplus of doctors is growing (here and here). Rather than passing off this excess as the product of other organisations, if the government has a commitment to generalist and rural workforce goals, then it must mobilise these pockets of oversupply. This will require nationally led coordinated action, using all the available levers (national, state and local), across the entire medical workforce, of the right volume and direction.
If training is a major lever to address the distribution of a generalist skilled medical workforce, then early career planning and training pathway coordination roles across disciplines may be a valuable investment. But currently in medicine, career pathways and their coordination are strongly divided on specialist and generalist lines and locations.
Although the $62.2 million cash injection over 4 years to the National Rural Generalist Pathway (NRGP) in 2019 has been a plus for state-led regional training coordination units for career planning for rural generalist doctors, it is limited to selected rural doctors. A further $200 million annually is spent on the Rural Health Multidisciplinary Training program (RHMT), part of which supports 26 regional training hubs brokering specialist and/or generalist training pathways and support for junior doctors in rural areas. Regional training organisations are national but exist solely for general practice not other specialists. And Rural Workforce Agencies coordinate rural pathways for overseas trained doctors, both specialist and generalist.
Yet, given the number of providers involved in training pathways, evidence clearly points to strengthening holistic coordination of place-based training-career pathways, particularly to achieve community goals rather than play into stakeholder interests. Dislocated pathways may particularly deter (the now majority of) female doctors and doctors wanting portfolio careers of mixed rural and urban practice, across a broad scope.
Despite having fewer levers in the non-GP specialist arena (typically the domain of state governments, hospitals and colleges), the federal government has a very clear role to play. Critically, it can rebalance Medicare Benefits Schedule-related payment systems offered to some specialist groups, and cease taking items away from GPs. To foster the financial attractiveness and professional rewards of being a GP compared with another type of specialist, digital health items for GPs could be developed in screening/prevention and clinical education/advice as an excellent way to expand the upstream holistic health care and prevent hospital overuse. Such items could also drive community service access through nurse-led rural and remote clinical posts and medical homes, servicing the community outside of traditional bricks-and-mortar business hours.
Achieving a generalist workforce balance also urgently requires the government to lead revision of the Australian Medical Council (AMC) standards about selection and training to which colleges must comply for their own accreditation. Such standards could specifically promote the selection of doctors with pre-vocational generalist experiences (non-specialist roles in rural hospitals and the community) as well as selecting entrants with rural background and interest. Further, AMC standards could require longer rural immersive terms during specialist training, aligning with the GP training framework of general and rural pathways options. This would allow rural-focused specialists to stay and train rurally for a significant period, critical to develop specialists with a wider range of skills (generalist and subspecialist). Regional training pathways in GP and non-GP specialties have been mapped out by regional training hubs, but they require investment at all levels to become a reality. AMC standards for regional training may be the catalyst for this.
While specialists have long gained from salaried positions in hospitals, it is timely to implement the option of salaried general practice, as part of both GP training and ongoing practice. Even if lower paid, salaried roles provide attractive job conditions, including set hours, part-time employment and leave entitlements, helping to attract young doctors to underserved areas and fields of lower prestige (here and here). Single employer models (salary and entitlements) for GP registrars were endorsed ministerially in 2019, as Recommendation 9 of building the National Rural Generalist Pathway:
“A mechanism for ensuring preservation of employment benefits and continuity of mentorship, for example, a ‘duration of training contract’ by a single employer, is included in the business case for the Pathway”
This employment model is being tested in a number of rural trial sites announced in 2020. As the current federal Budget includes $3.3 million to explore sustainable rural general practice models, it is also important to consider the options of salaried or fee-for-service GP practice models country-wide.
Finally, attracting to doctors to rural medicine, whether that be as hospitalists, GPs, or other specialists, can be supported through routine access to regionally-based academic medicine opportunities. The government could achieve this by funding a higher proportion of rural specialist training positions and investing in a national (rural-based) institute to lead rural clinical research and conduct longitudinal studies that inform rural training pathways. This could articulate with the current distributed network of researchers already supported by the Rural Health Multidisciplinary Training program, although any national vision for rural research seems to have been overlooked in the recent RHMT evaluation (here and here). Further, other mechanisms may include investing in geographically targeted Medical Research Future Fund calls to grow rural academic medicine and rural health system quality improvement. Similar targeted calls should also be hosted at the National Health and Medical Research Council, where rural health research attracts 1.1% of the current research funding largely because few grants are structured to fit it.
In conclusion, incremental policy shifts in general practice have the potential to be highly disruptive and work against the agenda for a generalist and distributed generalist workforce because they ignore the wider players and dynamics in the field. There are significant levers beyond general practice that the government needs to mobilise to promote the success of the National Medical Workforce Strategy. Action is desperately needed in the specialist, hospital and metropolitan domains, as well as truly rewarding training and careers in both primary care and rural settings. By integrating existing policies and actions around a community vision and supporting and valuing those involved in implementation, then it is possible to imagine a health system in which it is possible for all people to see a doctor and one doctor can do most of things you need done.
Belinda O’Sullivan is a Senior Research Fellow in the University of Queensland Rural Clinical School. Her passion and interest is in generalist medicine and rural workforce distribution. She was formerly a member of the MABEL research team and Director of Research and Evidence in the Office of the Rural Health Commissioner.
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.