Signed, sealed and (about to be) delivered? The return of GP training

It was August 26th in the stands of a rugby league match on a wintry Melbourne night that RACGP CEO Paul Wappett signed the biggest contract in the college’s history.

Amounting to several hundred million dollars, the contract carried a heavy symbolism.

It was the one that finally gave back control of training to the college some twenty years after it had suffered the humiliation of it being taken over by the Federal Government because it was not delivering rural workforce supply.

Even then it was six months overdue, with the delays fueling mass uncertainty among registrars, still unclear on what impact it would have on their future lives.

“We had been working towards it all week and we were expecting to sign it that morning,” Mr Wappett said.

“But there were some last minute changes that were required, some agreed amendments that hadn’t found their way into the final version.

“There is quite a bureaucracy associated with getting contracts signed by the Commonwealth … they got it back to me right in the second half of the Melbourne Storm game.”

Four weeks later he says attention has now turned to pulling off “one of the most complex mergers that will happen in Australia this year” when nine organisations, the current regional training providers (RTOs), will effectively become one.

The RACGP has already started recruitment to fill some 900 staff, including the training coordinators and medical educators who will make up local teams on the ground.

Regional teams will also be set up to oversee training co-ordination and ensure consistency.

Ever since the hand back of GP training was suddenly announced at the college’s AGM conference in 2017 by then federal Minister for Health Greg Hunt — an announcement that came out of the blue — there has been much disquiet about the futures of RTO staff.

Mr Wappett says the college wants to employ as many as possible to retain their local knowledge, expertise and relationships with practices and the community.

More than 1000 of them have apparently expressed an interest in taking up the roles being advertised.

While the exact agreement between the colleges and the federal Department of Health and Aged Care has not been made public, some of the new details have emerged.

One of the biggest surprises is that the RACGP and ACRRM have decided to contract James Cook University (JCU), which is currently in charge of one of Queensland’s two RTOs, to deliver training locally in the state’s north and west.

It is the only exception, with the college teams to run training in all other areas.

General Practice Registrars Australia president Dr Antony Bolton said the decision only added to the confusion and uncertainty that surrounded the soon-to-be launched GP training program.

“My personal opinion is this is a very good example of changing the goalposts.

“It contradicts the previous decision by the government to get rid of the RTOs because they were not fulfilling the need to get registrars into rural areas.

“I’m sure there are staff from other RTOs feeling frustrated and hard done by because their hard work serving those communities hasn’t been recognised.”

Mr Wappett stressed that while JCU would be employing the local staff to deliver the training program, it would be doing so as the agent of the college, not as an RTO, and would also report to the college’s regional and national structure.

When asked about the reason for the turnabout, he said: “That was a requirement of government, for us to enter into those arrangements.

“I think it’s fair to say the previous health minister and regional health minister were very keen to ensure that JCU has a continued footprint because of their end-to-end delivery, seeing students all the way through from medical school.

“That was the thing that made it distinctive from the other RTOs.”

The department has also announced who will form the so-called “GP Workforce Planning and Prioritisation organisations”.

It’s not the sexiest, most thrilling name, even for obscure bureaucracies.

But these agencies are important because they raise that uncomfortable question about the extent to which registrars will be used as fodder to fix the ever-growing workforce holes in rural Australia – the problem that led the college to lose the program in the first place.

These are the agencies which are being tasked with identifying the communities in most need and therefore where to prioritise GP registrar placements.

The cost of this bureaucracy is not minimal. They will get a slightly staggering $42 million in total over the next three-and-a-half years.

There will be six of them across Australia, mostly made up of primary health networks, with rural workforce agencies and a state health department also involved in some instances.

Their first job will be to provide a workforce needs report in November. This will be lodged with the federal health department. Then in the new year they will draw up a second report on the extent of GP training capacity.

The data collated will be used to inform the health department’s distribution targets, which the colleges will be bound by — a point of contention among many stakeholders who have raised fears of registrars being subjected to “involuntary placements”.

The source of these concerns emerged from departmental guidelines published last year which suggested the colleges would have to fill 100% of places to meet their contractual KPIs. If they failed then they risked having their funding cut.

But it appears the colleges have secured a compromise of sorts during the subsequent negotiations.

Mr Wappett said the RACGP would have a “fair bit of input” in the department’s targets.

“That’s critical — if we don’t get that right, no-one’s interest is going to be met.”

There was also an understanding that the department would consider circumstances outside of the colleges’ control when reviewing the KPIs.

Again, it is not too clear what this means in reality — or put another way, how hard the department will apply the stick to the college and through the college to registrars, if it is not happy with the workforce impact it is trying to buy for its dollars.

This relates to the question that burns brightest for GP registrars: What is happening to the selection and placement processes after semester one, which is currently being handled by the RTOs.

Mr Wappett said there would be no major re-engineering, for now.

Junior doctors wanting to become GP registrars will still sit the Candidate Assessment and Applied Knowledge Test entrance exam — the entrance exam introduced in 2017 with a $725 fee attached.

They will also be asked for their location preferences, and if they pass, then be selected for interview.

This then gets fed into the college’s matching process.

There will be multiple rounds for placements, with the preferences of GP supervisors and training sites and the healthcare needs of communities also considered.

So what about those unwanted locations? For those communities hardest to fill, where the demands on the registrars will be greatest, the college has promised intensive case management to “guide and support” registrars.

Mr Wappett said a “nationally consistent” program would make it easier for registrars to change locations because there would be the same approach to education, supervision and record keeping no matter where they ended up.

“We’ll have a look over the course of the next few years to see whether or not there are things that might need some improvement,” Mr Wappett said.

“But certainly in the short term, our intent is just to make this as seamless a transition as possible for the registrars, the supervisors and the practices.”

As for the reason for the contract’s delay, Mr Wappett said some terms and conditions had been “very difficult to negotiate on” with a lot of back and forth. It also took some time to determine the split of funds between ACRRM and the RACGP. Just to be clear, under the contract, the RACGP will train 1350 registrars, ACRRM 150.

The approval process also took longer than expected, Mr Wappett added.

As far as registrars are concerned, the delays are bad. At a time when general practice desperately needs to attract the brightest and best junior doctors, the uncertainty of what they would face if they did apply for GP training has not helped.

“It’s a real shame that we’ve had to go through an entire recruitment round without being able to say with any certainty what training will actually look like,” Dr Bolton said.

“We will have to wait and see whether that impacts on numbers, but we’ve had a lot of anecdotal stories from pre-vocational doctors who were just waiting to see how it was all going to come out in the wash before making a decision.

“The important thing now is we urgently get information out to everyone affected, about what’s going to happen, particularly those in the program at the moment.”

The college is more optimistic.

“[The contract] took longer than expected, longer than we would have liked and it has left us with a fairly short time frame until February,” Mr Wappett said.

“But we’re really delighted that it’s signed, and we’re raring to go.”