The Devil is Always in the Detail…

GPSA welcomes the return of training to the colleges. Supervisors are the experts in knowing how to mentor and nurture our learners into the profession. GP’s are the experts in knowing what is best for their profession and their patients. What we need now is detail, certainty and a time frame from the colleges and the department, to inspire confidence in the future of the profession.

The Australian GP Training Program made an important first step towards articulating itself to stakeholders last week, but the lack of detail has many stakeholders feeling nervous.

Why? Because the Devil is always in the detail.

Last month GPSA published the findings of its member survey in which 83% of respondents identified that they did not feel adequately consulted which is extraordinary given the dramatic changes afoot in the AGPT program.

Supervisors ensure our patients and registrars are safe. Governments, ministers, departmental staff, Regional Training Organisations and registrars all come and go, but Supervisors are always there. We are the constant in GP training.

Supervisors and training practices are the foundation of general practice training. Supervisors, training practices and supervision related issues feature explicitly in the RACGP model and there is an absolute commitment to the apprenticeship model. We acknowledge the RACGP for recognising the importance of the relationship between supervisor and registrar.

GPSA met with RACGP following the release of its much anticipated training model. What is reassuring is that the College are indeed listening. Supervisors and training practices now want to see the detail and to understand what a regionalised delivery model will mean to them. There is a great deal of uncertainty within the sector as many training practices remember how difficult the transition was in 2015.

GPSA’s feedback and discussions have really focussed on what we can see so far, which is not a lot.

Progressive assessment

The act of supervision is unfunded. We have fed back that progressive assessment throughout a registrars journey is likely to work well, but the college will need to think about who is expected to complete the assessment and what level of time impost it will require. If this is another thing supervisors are expected to do unfunded, then they need to be aware supervisor time and resource is finite not infinite.

Who will hold and distribute the supervisor funds?

The question over who will hold the funds for supervisors and how the said funds will be distributed remains up in the air. It is a BIG deal.  This very question is something GPSA has been grappling with for months in its review of payments across programs.

The challenge is really that the GP training system from a supervision perspective is woefully underfunded, and as we see across programs, no one agency has come up with a reasonable rationale for how and why supervisors are funded (or not).  Our industry bodies do not appreciate, nor understand the complexities of supervision across the whole of what we do.

• AGPT –  funds supervisor education activities but not supervision – All AGPT registrars require level one supervision at the start of their first term which means we need to see all of their patients to ensure that the patients and registrar are safe. Supervisors are only funded to deliver 1.5 – 3hrs of in practice teaching only for GPT1/2 but not for the rest of the week that they are supervising a learner.
• MDRAP funds supervision but a workforce agency administrator determines who “needs” what, in a less than transparent or nationally consistent way. Most of the doctors engaged in this program require level 1 supervision.
• RJTIF, once the travel, accommodation and junior doctor salary is removed, is a subsidy in its funding of supervision – these doctors require level 1 supervision.
• PEP and IP DO NOT fund supervision at all. That’s not to say that these doctors don’t need supervising – it is just that a bureaucrat thought that they weren’t worthy of the same experience as Australian trained GP’s in training. We have the most vulnerable of doctors working without supervision.
• Medical student placements – these students require level 1 supervision.

Why is this significant?

When supervisors are doing a good job – nobody sees what we do. We are the safety net of the training system. We keep our patients safe. We protect our registrars.

We (not supervisors, but ‘the system’) seem to forget the time it takes to effectively supervise a level one learner.

It is costly to the person providing that service. One that requires a supervisor to:

• check every single patient before they leave the practice,
• enquire or read about the history,
• assess the diagnosis and treatment plan presented
• use the event as a learning opportunity to explain what and why an alternate course may be more appropriate, 
• ask any qualifying questions that may have been missed by the learner
• check that results have been interpreted correctly and acted on appropriately

Supervisors are an invisible service to Government and to patients, and seemingly even our industry colleagues, at times when they design programs without funded supervision.  Supervisors underpin the safety of the primary care system.

Supervision is seamless and safe for the patient and the learner. So seamless the patient often isn’t aware they are being treated by a learner. The learner will never forget those moments a supervisor saved them and their patient from a really unfortunate outcome.

Open market accreditation

It is also apparent that the RACGP intends, seemingly at the behest of the department, to follow an open market practice and supervisor accreditation scheme. Allowing anyone who wants to be accredited to be accredited. While we understand the fair competition argument, we have fed back that having too many training practices where they are not needed just makes GP training unsustainable for everyone. Constantly accrediting practices who may not get a registrar is not a cheap endeavour and in fact, having an uncertain supply of registrars is also problematic for practices who build up their patient lists to accommodate an extra practitioner only to have no registrar in the subsequent term and finding themselves oversubscribed. The constant flux in patients is unsustainable.

Given the cost of accrediting, monitoring and maintaining more and more practices, the risk of this strategy leading to practices having to pay for accreditation is high. The question is how many barriers and costs to practices and supervisors can be put in place before practices can no longer afford to take on learners? And… is it an accreditation system that actually leads to quality outcomes? This all remains to be seen.

The mission now for the RACGP is to build out their model with more detail and to check in with the sector to see that they have it right at local state and national levels. They can only be certain they aren’t simply marketing to themselves if they actively engage with the sector. The signs are promising and we will keep you posted as further detail comes to hand.

So where is ACRRM?

At this stage we have not seen a training model nor the detail that sits behind it from ACRRM. We encourage them to be open about their intentions and to be checking with the sector to ensure they too haven’t convinced themselves their model is a good idea without bringing training practices and supervisors on the journey with them. The 83% of supervisors who stated they had not been adequately consulted was not college specific. Meaning both colleges need to do better in communicating their models.

How will the colleges work together?

GPSA have also asked the colleges to articulate how practices will be accredited. RTOs have commonly streamlined the accreditation process by accrediting practices and supervisors for both colleges at the same time. RTOs have reduced the burden in this way on practices. With the replacement of RTO’s at the coal face, and despite the colleges indicating they have a great relationship, we have not seen whether that extends to being great and mindful of training practices and supervisors, who are often the same regardless of the college a registrar has chosen.

We are 18 months away from a new model of training and the sector are none the wiser in understanding how and why they will be impacted by each college’s version of professional led training on the ground. We encourage both colleges to get their skates on.

COVID Vaccination roll-out

As a supervisor and practice owner who has been engaged in the respiratory clinic initiative and now the COVID vaccination initiative, I appreciate how challenging this time has been for all of our members. GPSA has fed into the Primary Health Care COVID weekly. We will continue to do this and if you have anything you would like us to share with the department, we would be happy to do so on behalf of GP supervisors at the coal face.

National Council of Primary Care Doctors (formally UGPA)
The band is back together with a new name to better represent who we are and what we do! GPSA welcomes the collaboration between GPSA, RACGP, ACRRM, AMA, GPRA, RDAA and AIDA. We are meeting regularly to discuss key areas relating to general practice such as training, accreditation, reducing red tape, wound care and telehealth.

Yours in training,

Dr Nicole Higgins
Chair GPSA