28 January 2022

GP training off the rails, Part II: Saving the train

ACRRM PHNs RACGP Reform Training

Given what the DoH is asking for in its tenders, the best thing would be for the colleges to go rogue.


When we left off last week, Denzel was wondering how to stop a runaway train from plunging into a ravine with his daughter and thousands of other GP registrars on board, along with a supporting cast of college, departmental PHN and RTO management.

We looked at the RTOs’ swiftly approaching deadline for non-existence, the potential redeclaring of the college wars and the GP Synergy deal, and started to look at the DoH tenders. Now let’s look at those tenders and into a bit more detail, where we may find a devil or two.

‘College-led’ or ‘college-delivered’ training?  

The title of the main tender, which includes the words “college-led” general practice training, is disingenuous: this contract is led entirely by the DoH. 

The KPIs are all about inputs specified by the DoH, measured by a bevy of performance KPIs. 

There are no outcomes to be seen in the measurement of success.  

You want to worry when you see that because that’s process taking over the potential for progress (which you might get if you use outcomes as your measure). 

If this whole thing was college led, why would the RACGP have to put in a tender? 

What we really have is “college-delivered” training, “led” by an increasingly controlling DoH, stipulating fairly specifically what it wants to do and how it should be done. 

That does not leave much room for what colleges, or much more crucially, what their members, want to do and how they want to do it. 

Why are there two tenders now and who is delivering the new part? 

If you blinked, you may have missed that in September last year, the DoH changed its mind (yet again) and split the tender to manage the transition of training from RTOs into two parts.  

The main tender, for “college-led” training, is largely what I’ve been talking about above and only the two colleges can apply.  

The second (new) tender is about working with the DoH to determine the needs of a local region (as defined by Primary Health Network boundaries) and provide strategy for how to make sure those needs can be met. Prior to the creating of this split-out, this function was rolled into what the colleges were to do. 

Literally anyone can apply for this second part of the tender and – surprise, surprise – it’s tailor made for PHNs to apply.  

In fact, the work dovetails nicely with what they already do. 

The DoH has a lot more control over the PHNs than it does of the colleges. 

If you were a paranoid person (I am), you might think, if you were in the colleges, that this split-out was created by the DoH deliberately to open the door to PHNs to get a foothold in GP training.  

A really paranoid person (me again) might think that the DoH is clever enough to think, if the colleges stuff this all up, and if PHNs have enough of an “in”, they can take over training instead one day.

If you think about the GP Synergy debacle and what that signals about the colleges’ intent to go to war again, this isn’t such a dumb idea on the part of the DoH. 

A big problem with this idea, however, is that, just like the RACGP and ACRRM, the PHNs have no clue how to run regional placement and training of GPs.  

If this scenario ever comes to pass, the RTOs will by that time be like mythological creatures of the past, featured in bedtime stories told by old war horse GP trainers and mentors to new registrars.  

Their magic – and they do have some magic in their knowledge and IP of regional GP training – will have been lost to the past and now be the stuff of mythology. 

Apparently, some RTO staff are being contracted to help write up PHN applications, so my guess is a lot of PHNs will win, without actually having a clue of how to run things (unless they subsequently employ that RTO person, which they might do, of course). 

Oh, cool. Now we have ACRRM, the RACGP and the PHNs fighting over the soon-to-be carcasses of the RTOs. 

That’s efficient. 

Perhaps, though, the RACGP and ACRRM will think hard about the possibility of PHNs moving in on what they’ve both coveted for so long, and decide that some form of detente is actually a good way for them to go. 

Timing: what could possibly go wrong? 

Submissions for both tenders are due to the DoH by January 21, assessment is set at four weeks, and the earliest start date being mooted by the DoH is April 1, 2022 for the winners. 

Spoiler alert:  the main tender, which can be applied for only by the RACGP and ACRRM, is going to be awarded to the RACGP and ACRRM. 

April 1 (did they pick April Fool’s Day deliberately?) is a very unlikely start date, though.  

It’s super-wishful thinking given covid, the possibility of each college putting in non-compliant tenders, and that every other important date of this whole program has been missed.  

Missing the start date will be a good thing, though. 

The DoH tender is an impossible contract 

If you’re wondering how directive- and input-based the DoH tender is, there are 37 KPIs in it (starting page 6). Browse them, then quickly posit a guess on how many of those KPIs you think the colleges might actually be able to realistically hit in year one. 

There’s a nasty sting in the tail of some of the KPIs that isn’t immediately obvious either. 

Let’s take one of the most interesting ones – No 16 – and dive a bit deeper and see what lies beneath.   

The operative words here are “training places by GP catchment …”.  

There are about 300 catchments, so think town or postcode specificity. 

In the old RTO world, placement wasn’t nearly so specific. If they didn’t place a trainee in one place, they had a fair bit of leeway to put them somewhere else nearby or with the potential for a similar outcome.

Not any more. If you don’t place in a specified catchment, you lose your funding for that placement.

It’s a hard money signal which is very directive. There are few if any repercussions for those running a trainee if they should place a trainee somewhere they aren’t suited to be. The colleges will tell you that they’d never do that. It would be counterproductive (which it would be). But they did it in the old system on occasion for various reasons (often of commercial conflict of a local practice). And now the specificity of the new system adds a whole new dimension of stress in the system to go this way.

Such signals classically result in behind-the-scenes bad behaviour on the part of persons in the chain of command where conflict exists.  

We know from the past that a lot of conflict can exist in trainee placement. 

Performance management of the colleges in the new regime 

What happens if (probably more like when) the colleges miss a few or a lot of these KPIs?  

What does the DoH do then?  

They can hardly sack the winning tenderers and claim breach of tender contract.  

Who else could pick up the work?  

Remember, we’ve entirely dismantled the old RTO network by this point and we’ve given PHNs only a sniff of this game so far. They aren’t ready to take over.  

This is a one-way trip. 

ACRRM and RACGP have no management bandwidth to run these tenders  

ACRRM and the RACGP, especially the RACGP, have stuffed up quite a few things in the past few years in terms of their existing mandate to provide CPD and run exams for registrars.  

The RACGP is loaded with money as a result of the monopoly it has had on CPD and registrar exams, but still it has stuffed things up quite badly, especially in respect to exams. 

What makes everyone think it is going to get a lot better quickly at managing complex things? 

Because if it is going to run training at this scale and with specificity in the regions, it will need to be a lot better quickly. 

How, from a standing start, can these organisations suddenly manage what nine RTOs took decades to learn and master, and then didn’t even master well, according to the DoH? 

A virtual takeover of GP Synergy might help the RACGP start to understand things in NSW.  

But what about the rest of Australia, and what about ACRRM in NSW sans any GP Synergy IP or local networks?  

Is the RACGP going to take over every RTO before February 2023 and learn all their secret recipes in time to run the 2023 trainee batch properly? 

Even if it did, imagine the management challenge of doing all that in less than one year.  

One positive for the RACGP is its new CEO, who has at least seen action on the sort of bloody battlefield he is about to lead his troops onto after February 2023.  

He’s run an organisation that had to wrangle all of Australia’s universities into some form of alignment, which is a near-impossible feat if you consider just how political and complex such a task would have been.  

He’s also had on-the-ground experience with the largest professional member organisation in Australia, and a highly influential one in Canberra: the CPAs. 

How long before the train goes off the bridge into the deep ravine? 

If the various parties do nothing to change their current plans and set-up, you’ll see a lot of  smoke in the first year, covered up by the usual, “Oh, there were always going to be teething problems”, naked flames in the second year (and some screams), as the fire starts to burn out of control, covered up by something like “we just need to push through this thing now” (thanks Scomo), and something disturbingly catastrophic around the end of year three, which might stimulate some sort of giant revamp project. 

But by then, it will be too late for three generations of trainees. 

Unfortunately, this sort of change will not blow up on day one and have to be addressed immediately for its very obvious flaws.  

Scene: Super-slow motion of train going off the rails and diving into the deep ravine (lots of wonderment on the faces of passengers looking out the window looking around as it does). But because communications are out (the blizzard is high in the mountains, remember) and the accident is remote, the horror of the accident will be invisible to most, initially.  

Nothing will or can be done for some time. Survivors of the initial accident will freeze to death at the bottom of the ravine. 

When big trains go off the rails in this way, there is a lot of resistance to admitting you lost the whole train and all its passengers, and it’s now in a smoking mess at the bottom of a ravine with a lot of distressed relatives to placate, and lots of clean-up costs and legal cases.  

You generally have to roll through a whole generational change in a government department before people will be empowered enough to call out this sort of train crash.   

If you’re looking for an example of such a crash in recent health administration, look no further than My Health Record, which started as a thought bubble by a not-so-bright Labor health minister in 2009, got some initial momentum for its populist hooks, then somehow morphed into an unstoppable $2 billion slow train wreck over the next 12 years.  

A lot of government people still will not admit that this project, in retrospect, has been disastrous for Australian healthcare because it has starved the digital health sector of funds and detoured the whole system way off the path of proper health interoperability.   

If you add opportunity cost to the loss in this project, you’re going to get up to about $5 billion wasted. 

Who admits they wasted $5 billion and they never saw it in the 12 years they were running it?  

It’s just very hard for anyone to do that. But that’s how government can roll sometimes. 

To give you some sense of the scale of damage that blowing up GP training could do to our entire healthcare system: it would probably make the My Health Record project look trifling. 

GPs are at ground zero for the country being able to effectively control costs, and navigate the transition of our system, in the future, to effective management of chronic health between aged care, hospitals and the community.  

If we stuff up our supply of GP workforce at this point of time, the damage could easily be catastrophic. 

Any chance we can slow this runaway train? 

Back to Denzel and his beloved train.   

Denzel has to get to the train, out there in the Rockies in a blizzard, heading for the ravine, and somehow slow it right down.  

You probably don’t want to stop it entirely, because if you do, all the passengers might starve or freeze to death in the blizzard (translation: the time of RTOs is over now so we do need something to replace them or the mess will still be huge). 

Tricky. 

Who might a Denzel be in the real-life version of this story? 

Paul Wappett, the CEO of the RACGP, might be able to slow this train down. 

The DoH at a stretch could get around ACRRM playing up, but not the RACGP. It’s too big.

Wappett would have to convince his board to make a very brave decision: either simply not have the RACGP submit a tender application (unlikely), or submit a tender that meets the needs of the RACGP members first and foremost. Such a submission would almost certainly be non compliant, because meeting the DoH tender specifications as it currently stands would not be good for college members.

What could the DoH do?

Like everyone else in this game of trains, it is out of time, and options. 

Wappett, as a relative outsider and newcomer to ACRRM-RACGP hostilities, might be in a good position to mediate. That would probably mean the RACGP giving ground to ACRRM in negotiation. But better the colleges sort out their problems on funding than the DoH dictate the process through its tender.

The RTOs are over, but they can probably still be mustered in some way under the management of the colleges.  

The dynamic that the DoH has rekindled in its main training tender is one of FOMO between the colleges. That fear is stoking mistrust between the two organisations and this isn’t helping. Maybe Wappett could broker some middle ground where the colleges each give a little in order to be united enough so they are no longer beholden to what the DoH is foisting on them and their members.

Between covid, the hard line DoH position on RTOs and the colleges refusal to give ground on funding positions, everyone has got themselves into a big hole. 

All parties could do with a circuit breaker.  

It’s not like the process hasn’t been stalled and delayed in the past, and what better excuse for stalling one more time than covid and omicron. Seems like the go to excuse everyone can get away with these days.

So, the colleges work out an agreeable split themselves (hint: it won’t be 70/30 or 90/10), and then quickly go to the RTOs and get them to novate all their contracts to the two colleges as soon as is practical. 

If the colleges handle this process gently, and tactfully, they should be able to manage the proper transition of the skills, knowledge and management that the RTOs have, over time.

A neat side effect of such a set of deals would be the positive energy it would generate across all vested parties, something the sector is in dire need of. 

The colleges avoid their train of registrars plunging into a deep ravine, with all the future problems that would cause, and many of the staff at RTOs would get a chance to stay connected to the game to which so many of them have become committed over time. 

It would need to be done quickly, before all the good RTO staff start getting new jobs, and dissipating, as they must because none of them have jobs come February 2023.  

The only possible hiccup? 

A stubborn and proud DoH. 

People in the DoH have always meant well, but they don’t like taking a step backwards, they never admit they are wrong, and (lol, ironic but true) they don’t trust doctors to do anything well. 

What might get the DoH over the line? 

If Wappett decided to reposition the RACGP in the process by submitting a non-compliant tender, that would at least get the DoH to the line, from where everyone can try to renegotiate. 

If the colleges could then agree between themselves on the funding split and some sensible rules of engagement, then the DoH, and its highly directive tender process, would lose its power in the whole process. The DoH can’t transition training without the colleges and if the colleges stop fighting, they will have the whip hand in the process rather than ceding it to the DoH through a fairly strange tender process.

Wappett could do it more easily than ACRRM, as nothing is getting done without the RACGP given how much of the training they are slated to eventually take over.

From a DoH perspective, maybe the idea that whoever is seen to be the architect of all of this might one day be party to one of the biggest class actions against an Australian government department in history, will be enough to get them back to the table.

Or, maybe someone in the DoH will work out that whoever ends up playing Denzel in this movie will end up a star one day, and it’s not too late to take the role.

That would be a neat and welcome twist to the plot.

One thing is certain, without someone playing Denzel, this train is going off that bridge.