GP supervision model risks patient safety, say experts

PATIENTS will be at risk until the current Australian general practice supervision model is funded properly, say experts.

GP Supervisors Australia CEO Glen Wallace told InSight+ he has been telling the government for years that the current supervision models are not fit for purpose.

“The expansion of our programs has not kept the funding available for supervisors and training practices consistent, which means that you’ve got different learners and vulnerable learners receiving less support than what they need, which ultimately puts consumers at risk,” he said.

A Perspective published in the MJA recently sounded a similar warning.

Dr Gerard Ingham and Dr Caroline Johnson outlined a complicated GP supervision landscape riddled with inconsistencies and confusion.

“Despite the commonalities of the work undertaken by GP supervisors across all programs, there are differences in clinical oversight standards, prerequisite qualifications, professional development requirements, payment for supervision, and support from medical educators,” the authors wrote.

When Dr Ingham read through all the policy documents of all the training programs, their goals were the same.

“In all training and workforce programs, a supervisor has to ensure that the patient – the supervised doctor’s patient – is safe. And in all of the programs, the supervisor is expected to help the supervised doctor to learn and develop,” he told InSight+.

“They’ve got the same job in all these training and workforce programs, but in some, they’re given a payment for it. And in others they’re not. In some, they’re required to have a Fellowship. And in some they’re not. We also have doctors who should be supervised and don’t have a supervisor.

“Imagine a surgeon in a rural town saying, ‘Look, I’m not a fellow of the College of Surgeons but because it’s a rural area of workforce need and I’ve done a little bit of surgical training in the past and I’ve got full registration, I’ll operate out here without a supervisor’. That would never happen … yet we allow that to happen in general practice,” Dr Ingham said.

The current system means a person could fail their GP Fellowship exam but still work in an area of need as a GP with no supervision.

“The policy is moving towards closing that loophole. And that will end, but the fact that it still exists currently is fairly stunning,” Dr Ingham said.

The way GP supervision programs are measured is also of concern.

The Royal Australian College of GPs (RACGP) and the Australian College of Rural and Remote Medicine (ACRRM) have outcome-based standards – supervision matched to the registrar’s competence or needs.

“However, the standards do not specify how this outcome is achieved, and there are no proposed means of measuring it. Having an oversight structure that lacks specificity or measurement has raised concerns about whether appropriate clinical supervision is occurring in general practice training in Australia,” Ingham and Johnson wrote in the MJA.

Alternatively, the Medical Board of Australia standards required for international medical graduates is input-based, which is more measurable, but raises other concerns such as GP payment.

“Given that supervisors aren’t paid for doing it, isn’t this a disincentive for them to continue at higher levels of supervision?” Dr Ingham asked.

It’s not just payment for the supervising GP’s time that is a concern. According to Mr Wallace, many practices experience financial loss when they employ a doctor that needs supervision.

“Those practices supervising junior doctors on level one supervision means that they have to go into every single patient before the patient leaves the practice and check the junior doctor’s work. Which means that’s preventing them from seeing their own patient,” he told InSight+.

“Not only that, but the provider number that the junior doctors have available to them allows them to order tests and prescribe, but it does not allow the practice to bill the patients, not even bulk bill. Which means that the practice generates absolutely no income,” he said.

For most GP supervisors, it’s not about the money. For some, it’s about giving back to the profession.

“Many people find it satisfying. People enjoy becoming a mentor and having a long term relationship with a junior colleague. It’s one of the most satisfying things in my personal career,” Dr Ingham said.

Hiring a junior doctor can also help with workforce needs.

“Often there’s a motivation to recruit someone who will end up replacing them. There’s a motivation to deal with workforce needs within the practice,” Dr Ingham suggested.

However, sometimes these workforce needs are so pressing that if the doctor doesn’t bring on a junior to help, they risk burnout themselves.

“GPs are presented with an impossible choice. Either they take on [international medical graduates] and junior doctors that require a greater level of supervision, which then reduces the amount of patients that they can get through themselves. Or you choose to have nobody to help you with the load of patients in your rural and remote community. Neither of those options are attractive, but there’s literally no other alternative being presented,” Mr Wallace said.

As Ingham and Johnson wrote in the MJA: “The goodwill of GP supervisors to continue to labour under current conditions is not limitless”. They argue that it’s now time to overhaul the system.

“(We need to be) designing it from the point of view of how are we going to make the best supervision system, as opposed to designing it from the point of view of how are we going to distribute doctors,” Dr Ingham advised.

Mr Wallace believes that improving the GP supervision system will ultimately help those workforce distribution challenges.

“There’s an absolute focus within government on workforce distribution and getting this piece right is the biggest impediment to achieving that,” he said.