30 October 2020

Exam fails, IMG distress, training confusion and more

COVID-19 General Practice RACGP Telehealth

It’s hard to imagine a period in the history of general practice when so much change, so much stress and so many challenges were afoot at the same time.

It’s also hard to imagine a more difficult time to be the CEO or incoming president of the RACGP. But it might turn out for each, and for RACGP members, to be the best time, too.

Change is in the air. Already the new CEO is showing a willingness to get out in front of issues publicly, standing side by side with the vice president (the president-elect isn’t technically enabled until the AGM in November), and working hard at the many issues hitting at the same time in a transparent manner. That’s a big change from the past and might endear a tired and cynical membership just a little more to the opportunity of new leadership.

The crisis immediately at hand is the failure of the AKT and KFP exams and the follow up for a severely distressed group of students, most of all international medical graduates. Given the nature of the failure and the immediate confusion and distress in communication immediately after, the response of the executive of the college has been to get things sorted as rapidly and practically as possible. Any solution wasn’t ever going to be pretty, but at least students now have a date in the near future, and a format (pen and paper), and are getting their queries answered at relative speed. Despite some concern over being able to use a pen and write legibly, it looks like the short-term issues for students worrying will largely be sorted before Christmas.

There are lots of questions.

For example, does the college make a profit off student exams?

The answer is no: while the exams (KFP, AKT and what was the OSCE) generated $15.7 million in revenue in 2019-20, they cost $16.9 million, so the RACGP realised a $1.2 million loss on exams.

Then there’s this: how can the exams cost the same if you are doing them online when you used to have to hire halls and swathes of computers all over the country to get them done?

CEO Dr Miles answered this one personally:

“Around one-third of all RACGP employees directly or indirectly support the development and delivery of exams and assessments.

“Holding the Fellowship exams remotely did cut down on some costs such as travel and accommodation. However, the majority of our fixed costs of exam development and delivery remain. This includes costs such as curriculum development, question development and review, censors, employee salaries and marking and coordination.

“Conducting the exams and assessments remotely has also involved new costs such as technology support for exam staff and candidates. At this point in time, the fees accurately reflect the cost of delivering equitable, effective exams that determine competency to begin unsupervised general practice in Australia.”

The main thing here is that you have the CEO of the college, with the vice president, out there engaging with the members. If it turns out that the numbers aren’t quite right, the executive has put some numbers to the members, and the members have something to work with. In the past, it’s doubtful that any of this information would have been released.

As tends to happen with a crisis like this one, it’s sometimes the sleeping background issues that are exposed which end up being a bigger issue in the end.

One issue that is far more apparent than it was prior to the crisis is just how much stress IMGs are experiencing, over and above locals, in the whole VR process.

This week one of our journos had to ask stressed IMGs to email her rather than call as her phone was starting to ring off the hook. Many had financial issues, many others, visa issues.

I got a call personally from an IMG fellow, whose husband was sitting the exam for the 7th time after a series of near misses, was facing having no income moving forward because of the requirement now to be vocationally registered, and who was simply lost for what to do. She was crying on the phone and asked if we could do anything to help because she had written to the college a couple of times and in the two weeks since the exam failure and when she wrote, she had not received any correspondence back from the college.

Her distress was palpable. She needed someone to chat to her and listen.

If there are large numbers of IMGs in similar distress, you can imagine that engaging meaningfully with all of them in a short amount of time might represent a massive logistical challenge for the college. But it’s probably one they need to think carefully about. Clearly, IMGs are not playing on the same field as students who have been raised, educated and trained within Australia, who understand the culture, and who will usually have on average better communication ability.

In the light of the federal government’s position of encouraging more IMGs to come to Australia to help fill a growing void of skilled GPs especially in regional Australia, the question becomes, how much special provision and resource should be given to IMGs in order to level the playing field for them?

This is not to say make standards or exams easier, or lower the bar of professionalism that the college feels is necessary. It is simply to look into the special problems that many of them have in a system that was never designed for them.

It’s probably an important impending test for the new leadership at the college.

A related and compounding issue is, who is going to train registrars and how as we move forward?

A few weeks back the Department of Health surprised everyone, including both colleges, by announcing it would be exploring different operational models for general practice training than what was in train. Proposed changes would remove GP training from the general practice workforce and could include trainees and their supervisors being remunerated by the government, instead of under the current practice model.

Caught by surprise, the RACGP was quick to say that it felt the review was a good idea and that it still would be leading training in the new model.

This didn’t completely gel with what the DoH was saying. But the DoH wasn’t saying much. There has been a lot of confusion.

This week the RACGP and ACRRM came out with a joint positioning statement on training, which for many commentators and interested parties, transformed something confusing to something nearly incomprehensible.

The joint statement is HERE.

You should read the full document and try to interpret what is being said against the backdrop of the DoH’s announcement a few weeks back that it was stopping the current trajectory of training being handed over the colleges, and reviewing everything, including the possibility of having a single employer (the DoH) for trainees and supervisors. Quite a few people are struggling to understand what is actually being said.

What we think the RACGP and ACRRM are saying is that they really feel and hope that in the end the DoH will see fit to allow them to control the whole training show from go to woe – hence the first bit about it being “led” by the colleges, rather than “delivered” which seemed to be the tone of the original DoH announcement. But of course there needs to be a lot of discussion and thinking in between.

What it comes across as is “nothing to see here, just another review we’re doing with the DoH, all good, we’ll be back soon with a few adjustments, it’s all under control, don’t anyone worry about a thing”.

In other words, their tendency to keep repeating that the government wants them to lead training and give them full control, and that they will be, starts to get into the realm of if we keep saying it enough, it will come true.

Part of the Statement reads: “We are jointly considering the best approaches to deliver workforce planning and distribution support for the colleges, practices and other settings involved in training GPs, and to the communities which benefit from health services delivered during training and beyond. The government is committed to preserving all funding under AGPT so that it not only continues to support, but enhances the GP training experience.

“Once we have a common approach, the department and colleges will resume consultations with broader GP training stakeholders about potential reforms and timing of implementation of reforms through the transition.”

We asked several in-the-know individuals for their translation of the statement and no one was able to offer a clear assessment of what it means, it was that oblique.

Our best translation after talking to as many interested parties as we could is that the DoH, listening for years to the colleges about all sorts of issues with training, and regional workforce issues, intervened as soon as a few new senior people felt they could to stop everything before things went too far with a basic handover of the RTO model to the colleges.

Now everyone is going to sit down and try to work out what might actually serve the future of general practice, and regional healthcare, much better than that old system, being run and controlled by the colleges.

Of course, a new system might have the colleges leading everything and controlling things. But it’s not likely to be controlling everything, especially if the DoH is going to be holding the purse strings on salaries for trainees and supervisors centrally. That setup is going to look quite a bit different. And quite rightly the DoH has put a moratorium on everything and is keep stumm for now. It is going to conduct a thorough review with the colleges and other interested parties and that is going to take some time. Hence, a stay of execution for the RTOs – an announcement that the current RTO setup with be extended until at least the beginning of 2023 for now.

There is talk that RTOs are finished as we knew them. But that’s just talk, and it’s hard to see how you could just finish RTOs without causing quite a bit of havoc, given how close they have always been to the coalface of training, and given how much long-term corporate memory sits within their staffing. More likely is some managed transition eventually.

That colleges put out a statement like this is a sign that they are pretty worried about what might actually happen, and would like their members on their side should the DoH do something which sees them delivering training, not so much leading it.

Other than how initially freaked out the colleges are acting, the decision to stop and review is seen by most as a good idea. Slow things down a bit, look at how you should really structure training, incentivise it and fund it in order to better meet the needs of the future of the system, and especially the need for a good regional workforce.

And take your time if you like. There is a lot at stake.

As if to reinforce that it was fully in control the RACGP announced yesterday with a bit of fanfare that it had a new “position statement  [that] outlines general practice’s ‘indisputable’ position at the forefront of Australia’s health system”.

Phew. I thought it was slipping to third place for a minute there.

The statement reads pretty much the same as the last position statement and when I read the revised vision of 2015, I couldn’t immediately discern any differences from the last version.

Which is all fine and I’m being narky for sure, but with all the changes that COVID and telehealth have brought about, and are likely to continuing bringing, it just felt like the author had written most of it prior to these two significant events, and given how disruptive they are likely to be, was reluctant to add anything just yet addressing them.

COVID caused telehealth. Telehealth changes everything bigtime.

If you think about a business model for GPs which hasn’t effectively changed much for decades, which is centred around seeing all patients face to face, and what telehealth will eventually do to that business model over a relatively short period of time, then you are talking about something that should be at the centre of the universe of thinking of both colleges, more than both probably are at present.

No matter which way you look at telehealth, it’s game changing for the whole health system. And if you follow the RACGP statement that GPs are at the forefront of Australia’s health system, then they are going to need to get their skates on re: telehealth because they aren’t at the forefront of that at all. Not that anyone is blaming them. At the beginning of the year, telehealth was never happening, so of course GPs aren’t prepared, and haven’t invested in it.

The problem is, it’s here to stay, and the government is going to spend the next six to 12 months working out how that is going to work. It is committing $19m to working out how it will look and has apparently agreed already to extend the March deadline for the current set up to June to give itself more time.

The problem feels like with so much going on with GPs, COVID, and changes at the college, for some reason, the enormity of this change for general practice isn’t being fully recognised yet. It’s possibly because in all the COVID mayhem, most practices have settled into a very pragmatic pattern of using the phone to triage and getting patients to come in when things get just a bit too hairy. But that is not going to play out too much longer. Soon smart and innovative practices are going to recognise the competitive advantage in video. And almost certainly the government will introduce differential pricing between video and phone in order to incentivise the better video consult a lot more. Some practices are doing a third of their consults on the phone now. What happens when that money is halved unless they are set up properly for video and continuity? Is the college getting in front of this inevitability on behalf of members?

You don’t have to think too hard to imagine how disruptive the change should eventually be. Here’s a few ideas:

  • Smart and innovative practices, and likely the corporates, will develop video consulting that is effective and provides a lot more continuity for certain classes of patients. Unprepared practices will lose business and the shape of practices and patient management will change substantively.
  • If you develop a good telehealth practice, your old practice with all those car parks, big waiting rooms, and lots of on call doctors at work, won’t be fit for purpose any more. GPs will need to plan strategically for the change. That isn’t going to be easy because forecasting the speed, the competition and patient behaviour is almost impossible.
  • The government isn’t going to sit back and just pay more for general practice because telehealth is going to cost it more, and it is not going to drop telehealth. It is going to force other changes to rein cost back in. It might require some of those changes to telehealth itself, and that will likely impact a practice as well.

There’s a lot more to be said here. With training and exam issues, COVID-19, and new leadership across the colleges, a lot of GPs are looking the other way at the moment. Not deliberately. It’s circumstantial. The colleges need to get in front of telehealth more than some of their other currently slated priorities in their visions.

Which brings us to the op ed by RACGP president-elect Dr Karen Price last week in the email newsletter Medical Observer (just one of a few that Australian Doctor puts out).

Dr Price, obviously frustrated with the “elect” status where she is reasonably powerless to do anything (she needs to be confirmed at the upcoming RACGP AGM in November before she is official), chose to say what was on her mind in an opinion piece in the media.

What we got was a lot of promises, which is OK because she’s not really authorised to do much else while she is president-elect.

What might not be OK is that the promises feel a bit out of date, other than a pretty big one to make “healing exam trauma a pivotal part of her next presidency”. The other big promises, were from her presidential campaign: “rebranding, rebuilding and rewarding general practice”.

Is rebranding GPs a practical project at the moment given everything else that is going on?

Rebranding by the way, has the largest failure rate of just about any project that major corporates ever take on. It’s an extraordinarily complex area to get into, something the RACGP should be painfully aware of after they rebranded their major print journal to members from Australian Family Physician, to the Australian Journal of General Practice, and in doing so lost an almost certain lead in medical publishing readership, dropping from about 72% in one year to 56%, and losing the college millions in advertising as a result. Ironically, Dr Price thinks that the family physician tag is a good brand.

Rebuilding might be a little insulting to a lot of people. Sure, things have been grim for a long time, including pay and recognition, so no one is really saying, don’t do better. Rebuilding, though, is a big word, encompassing a lot of things which aren’t that well defined.

Reward?

Well, the secret to reward may just lie in how the college manages to work with the government on what eventually telehealth looks like. While the government is probably never going to get away with pay freeze again, it’s equally unlikely in a post-COVID budget world to be giving GPs big catch-up payments either. The college is going to need to be very innovative here. And you suspect the innovation is going to start with how the profession pivots itself around its new business model of telehealth.

It even feels likely that some pivot around telehealth and structure might be an opportunity for more shift away from fee for service, as telehealth provides a much better basis for continuity of care and connected care for chronic health management.

With all this said, with all the issues, all the change and all complexity facing GPs, I’m a little envious of the leadership groups of both colleges.

They’ve not got an easy job, sure. But there has never been a time when change for the better was more possible given the government’s position on general practice and the huge changes that both COVID-19 and telehealth are ushering into the system.

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