The Future of General Practice Training – An Overview Simon Willcock

1.The Future of General Practice? 2.Do we need Postgraduate Training for General Practice? 3.Learning from the Past – Lessons from GP Training In Australia 1975 to Current Issues for General Practice Training 5.? Solutions

 Evidence of the health-promoting influence of primary care has been accumulating… and shows that primary care helps prevent illness and death (more so than specialist care) and is associated with a more equitable distribution of health in populations BARBARA STARFIELD, LEIYU SHI, and JAMES MACINKO

 About 75 percent of visits to a pulmonary specialty clinic were just for “checkups,” even though the patients’ primary care physicians, once they had access to the specialists’ reports, could just as easily perform this function and report the findings to the specialists. (From Hewlet et al)

Summary: From economic, equity and outcome perspectives we need a robust primary health care system in Australia… … that articulates with an appropriately accessed specialist consultant system

 …or are you just a GP?  The perception of General(ist) practitioners has varied from a “cornerstone of the health system” (Osler) …

… to a redundant/default option (? Precipitated by the Flexnerian organ systems based approach to medical education along with exponential increases in knowledge)…

… and back to “cornerstone” status in recognition of the unique set of skills needed by the generalist (Patient centred care and the “digital revolution” have facilitated this)

 Pre 1975 – no prescribed formal training, (but a wide scope of potential experience prior to independent practice).  1975 – 2000 – Family Medicine Program, and RACGP TP – characterised by progressively less flexibility in training and a progressively more dense and prescribed curriculum  ~2000 “crisis” with RACGP losing control of the TP and establishment of GPET and RTPs.

 2002 – 2014 – GPET/RTP model (External administration while RACGP and ACCRM maintain control of “standards” and assessment  2015 – announcement of a new Training Region Model – details still unclear (Can we see the wood for the trees?)

Figure 1: Applicants and training places by intake year

Figure 2: Applicants to AGPT by graduate status and intake year

Figure 3: Proportion of recent AMG (post-graduate year 1 to 5) applying for AGPT

Figure 7: Relative contribution of AGPT to GP workforce by RA

Figure 13: Registrars and accredited facilities and trainers by training year

1.Seeing the wood for the trees!! The previous systems have been of a high standard, but… - expensive in terms of the total cost per trainee - administratively cumbersome ? reasons for this - overly prescriptive and lacking in flexibility (both Colleges have contributed)

2.Inconsistency in the training pipeline - variable (and overall poor) support and funding for community based training at an undergraduate level - the bizarre and illogical decision to discontinue funding for prevocational terms in general practice (? a casualty of federal/state bickering) - insufficient increase in local medical graduate numbers in GP training

Australia’s Health Workforce 2025 – HWA, 2012

3.Failure to support a sustainable General Practice sector by the Commonwealth, leading to… - trainee recruitment problems - supervisor engagement problems

1. Back to Basics in terms of training principles (Patient centred care and continuity of care) 2. Consistent messages and support from the Commonwealth (consistency is more important than quantum) 3. More equitable relationships between the Primary Care sector and State and Territory health departments

 Supporting trainees (to become mature independent practitioners)  Flexible curriculum (focussing on general practice skills rather than discrete knowledge)  Flexible training environments  Minimal administrative bureaucracy  Supporting supervisors

Note: 35-50% are associated with NO concerns Hickson GB, et al. So Med J. 2007;100:791-6; Hickson GB, et al. JAMA Jun 12;287(22):

 It is Bismarck who reputedly observed that those who love sausages or laws or both should not watch them being made.  He could have said much the same about health policy, certainly the health policy on the table at this election Professor Stephen Leeder (Director of the Menzies centre for health Policy) - SMH - August 19,

Yes we can! Thank you… Have fun… Make a difference !