7 May 2021
GP training: Who’s flying this thing?
If the Department of Health can’t stage-manage a smoother transition of GP training than what it has mapped out, the whole system could be in a lot of trouble.
The most scared I’ve ever been flying was during my European gap year, when I booked a discount-airline flight from Gatwick Airport, south of London, to Madrid.
Halfway down the runway at speed, just prior to getting airborne, there was a clank at the back of the plane and the captain slammed on the brakes. Everyone looked nervously at one another, shocked but relieved when we eventually came to a stop safely and nothing was on fire.
The captain announced to us, with an eerie calm, that there had been a “slight hiccup”, which they were going to check. He taxied us back to the start of the runway, where we waited for a bit.
It was one of those situations where you know things are deteriorating but you’re not sure exactly when you should put your hand up and point out a few obvious things going on that you aren’t that happy with.
The front door of the plane was opened and in walked a man in blue greasy overalls and big black work-boots carrying a red toolbox (true story).
Anyone who had become calmer went back to a state of high anxiety.
The toolbox man proceeded to the back of the plane, did some hitting of something, and after few minutes walked the length of the aisle back past all the passengers to the front door, and the steward closed the door behind him.
At that point everyone including me was white with horror.
Are they really going to take off now?
I’d assumed someone was going to stand up and scream “stop this plane now”, but I guess everyone else thought that too. Most of the passengers were English and the English are weirdly too polite.
We all thought we were going to die, until the plane came to full stop safely on the runway in Madrid, a little under an hour later.
I realised I had supressed this awful memory until I listened this week to a senior leadership figure at our existing GP RTO training network summarise where he felt the current state of the GP training transformation process was at, given the relatively short time frame until an assumed handover of all the currently independent GP Regional Training Organisations (RTOs) to a single management regime run, in most part, by the RACGP.
“It’s a bit like we are all aboard a plane taxiing to the start of the runway for take-off, and we still have a whole lot of engineers on board building some significant parts of the plane,” he told me.
He wouldn’t provide me with any detail to support his metaphor.
He explained that there were lot of moving parts still and that there were a lot of people’s livelihoods hanging on those parts being pieced together properly so a lot of care needed to be taken.
He said that while he was obviously anxious at the state of affairs, given the timeframe and the amount of work to do, he remained optimistic that the various parties – the DoH, the colleges, the GPRA and the GPSA, and some others – would sort out the significant issues currently facing the transition plan in time.
This individual was like most of the people on the inside of the negotiations going on in the GP training changes that you try to talk too: anxious, careful, hopeful, trying to do the right thing, but also struggling to pick the right time and place, and the right people to talk to, in order to steer things the right way.
It all feels a little like me on that plane on the runway in Gatwick.
Not many people on the inside of the negotiations on the future of GP training will talk to you, even off the record. The stakes are that high. No one wants to be seen to be manipulating anything from the outside or to perturb anything, but they are all worried about take-off.
You get the feeling nearly all are in some fear that the captain of the plane – the DoH – might just turn around and kick them off the plane, and as much as they’re worried, they all want to stay on board and get to the next destination.
There are a lot of stakeholders with a lot hanging on the changes afoot.
If you’re the RACGP, would the DoH reverse its current setting and decide not to take such a huge leap of faith in your ability to pull off the mammoth management transformation that is currently in the plan? That wouldn’t be good.
If you’re an RTO, for which things are looking most unclear at present, you want to go through the process to the other side and somehow keep intact much of the work you’ve done for your community of the past 20 years. But how do you manage that?
The staff at RTOs don’t just want to retain a job going forward in some manner, they want to keep doing what they’ve been passionate about doing for much of their working lives, which is serving their local communities with a good supply of well-trained GPs and helping manage the training process among local practices.
What happens in a worst-case scenario?
The plane takes off on schedule and crashes soon after take-off, something that looks like it could happen, given the current settings (we will get into why it might crash below).
First and foremost, up the front of the plane are upwards of 1,000 RTO staff and contractors from 11 separate regions of the country (there are nine RTOs), many of whom with skills, corporate memory, deep community networks and a commitment to their work that is clearly irreplaceable in the larger scheme of the system, moving forward. Collectively these nine organisations are funded to the tune of nearly $200 million each year. It’s a big set-up.
This isn’t to say that the RTOs as they are currently constituted work perfectly well, are doing a great job and nothing should change. It is simply saying that whatever happens, most of the expertise, skill and community networks that make GP training run today, no matter how well or badly it runs, is captured in this community of professional trainers, supervisors and educators.
Next on board would be the up to 6,000 GP supervisors that currently service the system across the county, many of whom also have built up an important knowledge base and local networks with educational institutions, and who are the crucial link between the RTOs and the practices.
And getting towards the back of the plane, but still very important, there’d be quite a few important passengers from the RACGP and ACRRM, who have also built up systems and knowledge working with all those at the front of the plane to make sure that GP recruitment branding is happening, and that governance and standards are constantly updated and in synch for each year’s new crop of trainees.
Although the colleges haven’t formally been in charge of training for years, for obvious reasons they’ve been deeply involved in helping manage and guide the processes over the years.
And if the plane did go down, you’d probably have to take into the account casualties from the current batch of registrar trainees, which would be at least over 3,000 GPs in training today and could end up representing the first giant hole in future supply if things went really wrong.
Put simply, if that plane went down hard, it would immediately make the current problems of filling rural GP places, and the declining overall intake of GPs starting to threaten the future viability of the general practice network across the country, look like a picnic.
If we do stuff up the transition in a big way, which currently seems feasible, the future supply of GPs would be entirely compromised for a long period, the general practice network would start to break down, chronic care management would go south fast, the hospital system would have to take the load, and everything would start breaking down in a big way.
The states would be burdened significantly more, as they would need more funding, they’d start fighting even more with the federal government, and so on.
The whole healthcare system would enter a long period of chaos.
Of course, no one wants that and there are a lot of people working very hard to avoid it.
But from the outside looking in – most people won’t talk about the difficulty of the proposed changes for fear of upsetting very delicate negotiations – the current DoH roadmap for transition feels very much like the plane that is being built while taxiing for take-off.
A hard stop for the RTOs
Probably the biggest issue is that the DoH has decided that RTOs as we’ve known them will have a hard stop in early 2023. In essence, the system of nine independently run RTOs will cease to exist by that time, and somehow the whole show will be reconstituted under the management of the colleges, mainly the RACGP.
There is still just a little bit of grey in how hard a stop the DoH really has in mind.
We asked the DoH and a spokesperson explained it to us this way:
“It is not intended that the role of the RTOs, as set out in current AGPT grant agreements, will continue beyond February 2023, nor that the agreements will be novated to the colleges.”
That feels like a pretty hard stop. But no one is exactly clear, including some of the RTOs. One manager we talked to said to us that the DoH wording left room for RTOs to exist, but “in a different format”. That’s how unsure and confused some parties are.
No matter what format they moved to, at present there will be no funding for RTOs, and the RACGP won’t be allowed to subcontract them or novate any of their contracts. That doesn’t leave much room for simply a change of format.
No one seems to want this “hard stop” other than the DoH.
When the initial plan to transition training to the RACGP was announced in 2017, the DoH didn’t even originally envisage dismantling the RTOs entirely. It was thought then, as it is by most now, that dismantling such a complex, and probably eclectic, network of organisations and professionals simply wouldn’t be practical, at least in the short term.
Everyone seems to agree that there is good logic in centralising training within the colleges, as hard as this would still be, but dismantling the RTOs entirely and trying to put them all back together in some way in less than nine months or so?
Nine months is the timeframe we are putting on having to get the changes done because although it is not until early 2023 that this all has to be done, remember that early 2022 is the actual deadline if you want to have your 2023 intake of trainees.
So, there isn’t really 18 months to go, there are only nine months. Either that or you are going to need to parallel run your old RTO system with the new RACGP-run system somehow, and it’s hard to see how that might work for the trainees. One thing is for sure: if anyone thinking of becoming a GP in the next year or so got wind of the possible set-up, they might think twice about going in the intake in that year.
The RTO network is essentially nine separate companies, built up over 20 years or so each, each servicing their local community by developing localised networks and community-based programs to suit their region’s individual needs.
Apart from that likely causing huge differences in how each RTO is s set up and operate, they each have had almost completely independent management and culture paths to where they have built themselves. Even where they likely should be the same in the way they operate for common operational needs, they very likely aren’t.
Dismantling every one of them and trying to put it all back together again in the space of nine or even 18 months is a business management transformation project that would be beyond a dream team of the world’s greatest business managers of all time.
You do not have to cast any aspersions on the management capability of the RACGP at all to understand that it is in no way equipped, management wise, to pull off such a miracle of business management genius. Our best and brightest business leaders couldn’t do it.
But to cast just a little needed aspersion, the RACGP has in the past year failed quite spectacularly in trying to manage putting its registrar exams online, which in relative terms is a very simple project.
Not that the RACGP probably thinks that it’s a great idea to try to take on this task as they stand.
What we’ve heard is that they always thought they’d have the opportunity to at least sub-contract most of the RTOs at the start and work things out from there. And now they’re very nervous.
It is understood at this stage that the RACGP has contracted one of the big consulting firms for help: EY.
Not surprisingly, the DoH is calling in the consultant troops on the problem as well. It’s already probably getting expensive. We asked the DoH what it was doing to ensure that the colleges had the right management capability for such a task and it is obviously thinking hard on the potential problem.
“The department will be engaging a consultant to perform independent readiness assessments with each of the RACGP, and the ACRRM, in preparation of GP Training formally transitioning in February 2023” a spokesperson told us.
“The readiness assessments will be undertaken from an organisational perspective to assess the Colleges’ operational capabilities, governance, scope of work and the management of financial frameworks for the appropriation of public funds in the delivery of training.”
OK, great, they know there could be a problem and at least they are thinking around it.
But the scope of this problem is so obviously monstrous and the timeframe to take off so short.
And, of course, the colleges, especially the RACGP, will need help.
But given the current state of RACGP management experience and capability, no amount of consulting firm contracts and assistance is likely to result in any magical solution to what is, on paper so far at least, an impossible business problem.
For starters, the RACGP at this time probably isn’t equipped to even brief its consultant in the right way. And if the DoH hasn’t got its consultant on board yet, it is already behind on any reasonable timetable.
None of this is to say that the college hasn’t got a lot of deep IP and experience among its leadership doctors around how the training works and how it could work a lot better. The college has much to offer the whole process.
Many RACGP leaders have been and are part of the RTO ecosystem. Some senior leaders, such as Dr Bruce Willett and Dr Harry Nespolon, have held senior leadership roles within RTOs in the past. Off the record, some of the RTOs are very complimentary about the RACGP’s knowledge base and help in managing the training process currently. They even acknowledge that moving the system under the colleges is probably a good thing in the long run.
But the college executive and board aren’t structured like a professional education and training company would be. It is structured as a medical college, which isn’t the right structure to run such a complex training entity.
IP held by the college doctors in the processes of training and supervision isn’t synchronised necessarily with any of the skillsets and experience of its executive management team. Its management team hasn’t been built up over time with the running such an extraordinarily complex venture in mind and its board structure and governance aren’t designed to handle something so inordinately complex.
So the very basics of getting an appropriate brief to EY to get this job done is going to be fraught with difficulty. And if the RACGP in any way thinks it can actually take on this task and briefs EY to give it a grand plan to do that, well, that’s the wrong brief anyway.
If the college does manage to provide EY with all the gory issues at hand, you’d think EY has only two options to recommend:
- Go back to the DoH and explain to it that such a transition – total disbandment and then reconstitution of the RTOs under a new entity in one big bang in such a short period of time – is impossible from any logistics or management perspective. So all parties need revisit the manner of the transition.
Maybe there is some middle ground between Big Bang and simply subcontracting the RTOs to start with, but you don’t have to be a management consultant to realise that if you are going to try to take over nine separate companies in one go, spill all staff, procedures and processes and networks, and try to put them together into one entity, it just won’t work.
The most obvious thing to do at the start is sub-contract them, under one management regime, work with them and work out over time how you could do it.
But take your time. Understand the nuances of each group, the politics, the ways of working. Use your consultants to help you do that. But take the RTOs with you on the journey.
It still won’t be easy. It’s still a degree of difficulty in management terms in the high nines. But it probably isn’t impossible.
- Blow up and replace the entire management team of the RACGP, and the management and governance, and replace it so that it has the right structure, skills, management and governance to manage such a complex business transformation, and maintain it going forward.
Something tells me that EY won’t be recommending door No 2 here. But I’d bet that once it understood truly what the degree of difficulty was here and all the behind-the-scenes going on, it’d be thinking it was one option.
There is another problem with throwing all the smart consultants at this problem and expecting it to work out.
This technique rarely does work out with such massive transformations.
Consultants are extraordinarily clever at dissecting problems and mapping out solutions. But they don’t do execution. Most of the smart people you work with in consultancies never actually worked as senior management and leaders who actually got big things done. The two skillsets are very different.
A great plan is one thing.
The RACGP blueprint for the future of GP training put out last week (HERE) is pretty good, if not a bit vague in certain parts. There is a lot of logic to bringing the whole system under the colleges over time. There is logic in how the RACGP is continuing to pursue to cut the problem by tapping into local communities, but in a more organised and even more concentrated manner.
But execution is everything.
Execution requires not just the right management team in the right frame of mind with the right plan; it also requires a whole lot of other things to get aligned and go right, and these are rarely identified at the beginning of a big change such as the one that has been planned here for GP training.
How did we get here?
Why did the DoH decide it wanted to move training mostly all back under the RACGP after all these years?
To start with, it makes good sense – on paper at least.
Vertically integrate the whole process of branding, recruitment, training and continuing professional education under the one group that has the most buy-in and organisational IP to do it.
In doing it, if there are large inefficiencies in the independently run RTOs, as the DoH thinks there are, and as seems likely, if you have nine completely independent cultures and regionally run organisations, you might be able to achieve significant efficiencies in running the system into the future. Common data sharing platforms and more streamlined management lines all makes good sense.
All good so far.
Why the hard stop then? Why do we have to rub out the RTOs as they existed so quickly?
One theory goes that the current RTO system is the major reason we have a rural GP crisis, and why graduating doctors are starting to abandon in droves the idea of becoming a GP, and this is threatening the future viability of the entire healthcare system, which, as chronic care takes hold, needs a cohesive and well-supplied network of GPs into the future.
It’s true that the RTOs have a big role in the recruitment of GPs but to lay most of the blame at their feet for the current looming GP shortage crisis is way too simplistic. There are a lot more components to the equation of where we find ourselves on a good supply of quality GPs into the system.
The most obvious, of course, is that GPs aren’t paid too well these days, and if you look at the history of the government’s attitude towards that – the notorious Medicare freezes – that’s a brand stain on the profession that is only the government’s fault. And they aren’t showing a great deal of enthusiasm for fixing it, perhaps with the exception of letting telehealth fly during COVID and promising to continue it.
But there are more systemic issues as well that are likely to be a big part of the overall problem and not related really to RTOs as such.
Part of solving the long-term GP supply problem was expanding significantly the footprint of medical schools across the country, with some emphasis on regional schools, such as those in northern Queensland, or country NSW.
One of the ideas here was that if you took in students from the local community, they’d be far more likely to “stay in town” in the long run. That theory seems to have run into a few problems:
- As things turn out, staying in town isn’t the intent of most locals, as the big city will always have an attraction to anyone brought up in the country.
- In some regional medical schools, the competition for places isn’t what it is in the cities, so students from the city apply to regional. But they don’t ever have the intention of staying. This seems to be borne out by the numbers of registrars some of the RTOs manage to get out of their regional universities, which tend to be very low.
- Some of the universities with new medical schools are enamoured of the prestige that comes with having a closely associated local hospital in which their students can do their initial training. Macquarie University once didn’t have a medical school or a hospital. Now it has both. This is all fine, but it tends to push the emphasis of doctor training away from the community-based training that GPs really need. It warps the system to a larger degree towards more broadly and comprehensively trained doctors, which of course as a student, you’d obviously prefer for your overall employability. But this actively works against a system in desperate need of more GPs. None of the new medical schools are actively seeking to develop appropriate post-school training that suits life as a GP.
Primarily blaming RTOs for the problem is clearly overly simplistic. It’s a multi-factorial problem the healthcare system is facing.
Which might mean that blowing up the RTO system in such a short time, with a view to solving the GP supply problem into the future, is too simplistic as well.
Certainly, no one quite gets why there is such a hard stop on the RTOs, given the degree of difficulty of change process that is being proposed here.
No one seems to dispute too hard that the system needs to change or that moving the RTO system under the colleges is a bad idea.
But why force the change in such an explosive and risky manner?
Some people posit that within the DoH there are certain managers of influence who’ve had it in for the RTOs for a long time. These managers allegedly cite huge inefficiencies in the RTO system, fiefdom-like behaviours, and even conflicts of commercial interest in how supervision is organised among the practices in the regions.
This might be happening. You’d be surprised, in such a complex set of organisations, if there wasn’t some element of politics and management dysfunction that resulted in some of these issues.
But as things stand on the current DoH roadmap, with the theoretical end to RTOs as we know them in early 2023, the GP training plane we’re still building as we get set to take off looks highly likely to crash. Probably on take-off.
In GP Land, when big things go wrong in big ways there are usually only two sources of blame: the DoH or the RACGP (and to a lesser extent ACRRM) – split something like 60/40 in terms of whose fault things might be.
At this time, the DoH would be carrying the can for the most blame in the future if this plane does go down in flames.
There’s a bit of an irony here in that today the leadership and management of the DoH, notwithstanding a few hiccups in the current vaccine rollout, has earnt itself perhaps the best reputation for management of the healthcare system in a few generations, based on its management of the COVID crisis.
But the management of COVID may have created quite a big distraction for the department in getting right on top of what is actually a much bigger potential disaster.
If the department doesn’t revisit the issue, and things pan out as the current set of circumstances suggest they easily might, then the legacy of our current health leaders – Minister Greg Hunt, Secretary Brendan Murphy and a few on down the management list – will be that they oversaw the circumstances in which the whole future foundation of our healthcare system was blown up.
Note: The DoH also provided the following positioning statement when some of the questions raised in this article were put to them.
“The Department has been working with sector through the General Practice Training Advisory Committee to develop the Outcomes Framework for College-led GP training. These outcomes will form the basis of a grant opportunity for the GP Colleges which will require a far more detailed funding proposal and evaluation framework. The Department will assess any proposed training models developed by the Royal Australian College of General Practice (RACGP) and the Australian College of Rural and Remote Medicine (ACRRM) against the outcomes framework. The grant agreements with both colleges will include mechanisms to evaluate the colleges’ performance against the outcomes to ensure that the Australian Government’s investment in GP training will achieve the desired outcomes.”