21 January 2022
How, when and why GP training will run off the rails – Part I
Last May we wrote that the transition plan was like building a plane during take-off; now things are looking worse.
Imagine you are Denzel Washington in a runaway-train movie.
The train has your daughter on board (along with 5099 other GP registrars), the engineer has died of a heart attack, and it’s running without brakes for a bridge that is out, over a giant ravine, high in the Rocky Mountains, in a once-in-a-century blizzard.
If you are planning on being a GP registrar from 2022 through 2025, you are a GP trainer or mentor, you run or own a practice that runs registrars as an important part of your business, are senior management in the RACGP, ACRRM, the Department of Health (DoH) or a PHN, you work in an RTO currently, or any one of a few other related entities, you are in this movie, all cast as extras playing passengers on the train.
You’re all going to die (don’t look at me, it’s in the script).
What are Denzel’s options here?
‘GP trainees win record class action against Dept of Health’ – Guardian, May 2025
For the DoH, this train disaster might easily manifest itself one day in the headline above, for surely, after the train has dived into a deep ravine with all the subsequent explosions, destruction and metaphorical loss of life, some smart lawyer in the future is going to work out that at some point of time through 2017-22, the department somehow forgot that it had a duty of care to the 6,000 or so GP registrars who, at any one time, are in training to be a GP, and are spread all over the country, in all sorts of weird and wonderful set-ups.
The said smart lawyer will work backwards to find that the responsibility for registrars having no meaningful framework in their training regime to be looked after properly during their placements belongs to the DoH and its two tenders for how the new training regime for GPs would work from 2023.
Part of our smart lawyer’s calculation will be that in this new regime, registrars will have found it almost impossible to identify any organisation (the colleges will be the major players) to directly blame for what happens to them as things go wrong.
The new training regime hasn’t stipulated any clearly identified lines of responsibility to, or implications for, the colleges as far as trainee wellbeing goes.
It has lots of fluffy, ill-defined objectives and goals, but nothing that holds the new organisations overseeing trainees legally responsible for making sure they are OK in their training journey. This was once very clearly the responsibility of an RTO.
Worse, where we have enjoyed a peace treaty of sorts between the two GP colleges for the past 20 years, largely as a result of the government creating a buffer between these once warring tribes on training, the buffer – RTOs – has now gone.
It seems entirely feasible that, as much as each college says it has the best interests of its members (including registrars) and the community at heart, the war is going to come first and will result in a fair bit of collateral damage to registrars, GPs and their practices, and the overall quality of delivery of community-based health.
Maybe, if the scenarios painted in this article are realised in some manner one day (I sincerely hope they aren’t), our lawyer will use this very article as evidence that any idiot (me, for example) could have seen this train was going to crash spectacularly and affect all those on board, and therefore those that could have done something to stop it, and had an obvious duty to stop it, should have done something.
They (the DoH mainly, but management in colleges as well) should have shown more due care.
How did we get here, and why is it getting worse?
There are many reasons given as to why the DoH decided to disband the current RTO network for GP training, but the simple reason we are where we are is that it did.
It decided as far back as 2017 that training should return to the colleges, so the RTOs had to go, probably as part of the 2017 compact with the colleges. We all thought the colleges had negotiated a bad deal back then, but we didn’t realise they had traded a lot for getting training back.
No one gave serious thought to the size of the task of disbanding the RTOs and not much happened in subsequent years and eventually we were up against deadlines.
After some timing delays, a sensible initiative emerged to novate all the RTO contracts to the colleges to give all parties time to understand what the RTOs really did, and how.
And then mid last year, inexplicably, this idea was off the table. The colleges would have to take over with no visible means of understanding how RTOs actually worked, and not much access to the local management networks that the RTOs had built up over 20 years.
ACRRM has been running an independent pathways program for up to 40% of its yearly crop of registrars for some years now. Given this, and that ACRRM only has 150 of a total of 1500 AGPT placements to take over before February 2023, you might say that ACRRM registrars are at least in the back two cabooses of the train, giving Denzel much better of odds of saving them (he disconnects their cabooses).
Some fast-approaching realities of the new regime
There is now a hard stop for all RTOs in February 2023.
After that, everything they did will be managed by the colleges (ACRRM and the RACGP), and a series of other entities, to be determined by the DoH, which will be selected to advise on regional needs for GP placement, and local strategies for success in placement and management.
No matter what the RACGP tells you in their up beat press releases, they have no management expertise, capability, experience or structure to take over this complex whole-of-country management job, at the scale needed, in the timeframe they’ve been given
ACRRM has far fewer placements to wrangle (only 150 vs 1350 for the RACGP) and it already runs training programs for non AGPT trainees, so it is slightly better positioned possibly.
But the degree of difficulty created by timing and the money and power imbalance between them and the RACGP, is huge.
Two tribes go (back) to war?
In a move that recognised that they wanted and needed RTO help to transition, last December the RACGP announced a partnership with the largest RTO in the country.
Here’s part of the announcement:
“On 1 December, GP Synergy and the RACGP announced a strategic partnership that will ensure a smooth transition towards the future of community-based profession-led training in NSW and the ACT.
“Under the proposed partnership, the RACGP will become the sole member of GP Synergy for the duration of the 2022 transition to profession-led training until February 2023.
“At that point, Federal Health Minister Greg Hunt’s vision of bringing Australian general practice training and education under the umbrella of the RACGP and the Australian College of Rural and Remote Medicines (ACRRM) – first announced at GP17 – will be fulfilled”
It’s a typically sanitised press release. It’s either ripe with naivety and wishful thinking, or the RACGP knows the size of their problem and it’s quite simply a highly sanitised press release attempting to control the narrative.
GP Synergy is one of the worst-performing RTOs of the nine in the country.
Even if they were the best, GP Synergy is not going to help the RACGP manage a GP training placement in the Kimberly, far Northern Queensland, Kangaroo Island or Mallacoota.
There are nine RTOs in Australia. The RACGP is working closely now with one. Registrars for 2023 will be chosen by RTOs within 5 months. The RACGP takes over 7 months later.
The GP Synergy deal is a Band-Aid on a gaping wound, at best.
Enter ACRRM this week, announcing in its sanitised press release the following:
“In a move that provides certainty and support for ACRRM registrars, supervisors and training facilities, the Australian College of Rural and Remote Medicine (ACRRM) and GP Synergy have today agreed to an early transition of the ACRRM Fellowship program in NSW and the ACT.”
ACRRM, understandably upset with GP Synergy for striking a deal with the RACGP without it, has decided they can’t trust GP Synergy anymore because of its RACGP deal.
But without any visible plan, it seems to have decided to take what bat and ball it has – its 110 registrars – and go home today.
ACRRM will now directly manage all its 110 registrars, from January 20, without much if any preparation and without any of the IP, local management networks and synergy that GP Synergy built over 20 years or so.
ACRRM says that it’s all going to be OK because it has been running the same program for its independent pathway’s candidates for years, which it has. This week they said they needed to do it at some point of time, so they may as well do it sooner rather than later.
But so suddenly taking 110 registrars and cutting ties with GP Synergy is not a “nothing to see here” situation.
ACRRM has in many respects been forced to the position by a deal that looks like it may have locked it out of access to GP Synergy.
Why couldn’t the colleges have shared GP Synergy somehow. With the RACGP deal there is a board comprised 5:4, RACGP:GP Synergy, as proudly announced in this press release yesterday. Why wasn’t there a deal to have a board that is 3:3:3 – RACGP:ACRRM:GP Synergy?
The RACGP press release is pretty ominous, spruiking that it more or less has GP Synergy to itself now, and that this somehow is a good thing.
It’s an early warning sign for everyone that the two colleges are recommencing the hostilities of 20 years ago over who gets what part of the funding pie for training.
Twenty years ago, the government got upset that that the fighting between the colleges often took precedence over the wellbeing of trainees, and took training out of their hands.
Taking 110 registrars so suddenly out of their training ecosystem because you don’t trust that system in the hands of your arch enemy college has the whiff of such activity.
Are these registrars really better off now being directly managed by ACRRM?
ACRRM asked all there registrars first, got their approval, and promised them they’d be OK.
But while ACRRM has its own training program, all the IP and knowledge of GP Synergy is lost to them now, and technically, they are taking all these AGPT trainees without the funding to manage them. So far at least.
Who is to say they will actually end up better off in this situation?
Essentially, ACRRM and the RACGP have just redeclared war on each other, and have started staking ground for a battle we all thought had finished 20 years ago.
They are going to say this isn’t the case. That they’ve been working hard together in Canberra to sort all this out with the DoH.
But it’s eyes on the prize stuff going on here. If you really want something enough as an organisation it’s very easy to lose perspective and convince yourself, and your board, that you are doing the right thing, when you aren’t.
The tone of recent college press releases feels like they may have lost perspective. They all say that what they are doing is wholly trainee focussed, is well planned and under control. But it isn’t.
The battle for the bush in GP-dom is an emotional and political one with a lot of historical scar tissue. It’s hard to see how that battle won’t somehow create collateral damage for trainees, doctors and the community if it plays out anything like it did in the past.
There’s plenty of reason to think it could.
If GP Synergy is what has happened in NSW and the ACT, and with eight RTOs left around the country to be divvied up, are we going to see each college battle for ground with those RTOs in the same manner?
How would that improve the system and help future trainees?
It doesn’t feel like it will.
Why put out a tender to only two organisations?
The main tender for the work of the RTOs can be applied for only by ACRRM and the RACGP. Why a tender for two organisations that you’ve already declared are going to win the contract (that is, the DoH has made it clear training it going to the colleges)?
ACRRM insists that 30% of the funding from the old RTOs should go to it because rural and remote is harder to do (it is), and the RACGP says 90% should go it because it runs 90% of the doctors (it does).
The colleges couldn’t sort it out, so the DoH gave up and put it to tender to see what each college could offer, before it decides on the funding split.
This isn’t going to sort out the problem though.
The problem is both colleges are not going to co-operate with each other in dividing how training resources should be applied across the country because they fundamentally disagree on how much of the pie each should get to manage their trainees.
They say they are co-operating, and you suspect they think at board level that they are. But if this was happening, why couldn’t they sort out first base in this whole set up : who get’s what percentage of the overall funding pie, and why.
The GP Synergy debacle is a good example of what can go wrong.
It looks like the beginning of where politics trumps common sense in what is actually best for the trainees.
A very directive and controlling grant contract
It gets worse.
What the DoH is asking the colleges to do moving forward in its tender is far more complex, directive and difficult than it ever asked of the RTOs in the past.
One senior RTO executive told me that if it all falls over at the last minute and someone rings them up to pick up the pieces, they will regretfully decline, based on the grant opportunity guidelines (GOGs) being largely unrealistic and unworkable.
“Anyone in an RTO will tell you that these tender documents overlook so much in terms of the detail of real-life problems out there in the regions that what they’ve specified as requirements in these GOGs is largely undeliverable,” this person said.
Does this RTO executive have an axe to grind, though, given they are losing their job of many years soon?
The DoH hasn’t run training ever, so what does it know about on-the-ground and day-to-day management of trainees in far-flung geographies?
The RACGP hasn’t run training for 20 years, so what do they know?
ACRRM has run at least 40% of its trainee crop directly for some time now, so they might just have a clue. But if you look at what has already happened in NSW, where ACRRM has lost any IP, local knowledge and network advantages bestowed by GP Synergy, the prospect of them starting a long way behind the eight ball come February 23, is high still.
The DoH’s two tenders to replace the RTOs detail what is an “idealistic” new regime.
But it hasn’t tested the ideas in this new regime, and there is no provision or time to test the ideas before exposing a crop of new trainees to it.
They will be guinea pigs.
A new regime with new and largely inexperienced managers running it.
What could possibly go wrong with that?
I think that RTO executive might have a point.
Next week …
There’s a lot to say here and I want you to stick with me, so in Part II I’m going to come back to the question of what could possibly go wrong next week, along with the difference between ‘college led’ and ‘college delivered’ training; the timing (who set the April Fools Day deadline?);stings in the tail of the DoH tenders – and of course, how Denzel might be able to stop the train.
If you’re into homework, you can read the two DoH tenders here if you are interested :