Want a different tomorrow? Ask for different things

Did the GP Crisis Summit achieve anything new and should the eerie quiet around the GP training transition be bothering us?

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Before I start whingeing this week, getting up to 150 of the most important movers and shakers in primary care to make the trip to Canberra for one day in the name of GP-dom was probably never going to be a bad idea.

Interesting people talk and new ideas emerge at occasions like this, and it’s likely a few politicians even noticed how many high-level people went to the trouble.

Outside of these two upsides though, the GP crisis summit always had the whiff of Groundhog Day to it, something which seemed to be confirmed by the lack of a purpose-driven agenda going in, and the lack of any really meaningful outcomes or new initiatives coming out.

The media weren’t allowed to attend the summit, which initially we were a little peeved about – we were all in for helping if we could – but we figured that some secrecy is probably needed if you are going to develop radical new plans.

But as things turned out, we seemed to have saved ourselves some time and money.

Nothing happened.

Well, when I say nothing, RACGP president Adjunct Professor Karen Price did say this at some point: “We are calling for an immediate and substantial increase in Medicare patient rebates, and an increase to the bulk-billing incentive by at least two to three times.

“We are also calling for appropriate and ongoing indexation for MBS items in line with the real-world costs of providing high-quality care in communities across the country.

“The time for talk is over. We need immediate action to ensure the future of patient care in Australia.”

So, nothing new happened.

Nearly everyone in that room in Canberra would have known that given the current state of the federal budget, the storm rigging going on in Canberra for a possible global recession, and what’s already been promised and said in terms of healthcare by a new government (which has been a lot more than the opposition was ever offering), there was precisely no chance of “immediate action” on those demands.

And, potentially, at this point of time, little chance of mid to long-term action either.

Part of the problem here is that much of the thinking on fixing general practice so far is all “inside the box”.

It’s based on general practice not changing how it has operated for decades despite so many aspects of healthcare changing around it.

A key “inside the box” piece of thinking is that most of the problems facing general practice can be fixed by getting more money from government.

Apart from ignoring that the government hasn’t got the money to give, this premise tends to take focus away from the myriad substantive changes affecting the profession and the healthcare system around it – technological, societal and economic changes.

What else is “inside the box” beyond the idea that everything will be fine if the government just throws a lot more money (which it doesn’t have) at the profession?

• A disjointed small-business community GP practice model where many small businesses don’t have the scale or capital to navigate change easily or organise
• Legacy technology platforms that don’t share data easily whether it be with patients, other providers or payers and regulators
• A funding paradigm for both tertiary and primary care that can’t deal with the change in system need towards chronic care management
• A political paradigm that rewards building more big shiny new hospitals
• GP member organisations (the colleges and the AMA) that are beholden to the federal government first and their members second
• A federal government, even a new one, that doesn’t have a plan for changing the whole healthcare system
• GP pay, which is not very good in comparison to other specialist doctors but pretty good in comparison to the rest of the community, which will always make getting community support for being paid better hard

Practically, you can probably see why there’s not a great deal of thinking going on outside this box.

Most of the key elements aren’t within the control of your average GP or GP practice owner.

You will always have the more entrepreneurial ones that probably don’t care and are going to seize levers like technology and economies of scale to make a future for themselves, but quite feasibly these pesky types may even create even more pressure on the core GP community.

The key elements that could swing things substantively over time for general practice remain mostly within the hands of the federal government.

It’s not like the government doesn’t recognise that the needs in the system are shifting inexorably and significantly towards a requirement for much better chronic care management, which means a much higher functioning community healthcare sector (fewer shiny hospitals too probably), most likely underpinned by general practice, and probably funded far more based on outcomes (data driven by better technology platforms likely), not fee for service.

So there is a way through for GPs here, albeit it’s going to be a long-term play.

Is there any outside-the-box thinking to be had here if ultimately the power for change does rest with government?

If we all see the need to shift the entire system, then instead of asking for more money just for GPs in an old and increasingly unworkable system, why not start asking for whole-system change instead?

When you ask for more money, the government can always frame doctors as being greedy, in relative terms to the rest of the community.

Ask instead that the government get its act together and come up with a whole-of-system, whole-of-country plan for the very obvious problems the system is facing.

Start by pointing out to the community that as far as our healthcare system is concerned, Rome is burning, and GPs want to help.

This is a very different message to “general practice is woefully underpaid and if it keeps happening, Rome will burn”.

Put the question to the community: why is there no overall plan here? One that maps out over 10 years how the system can change to move the funding paradigm to where it can adequately deal with the shift in need to manage chronic care in the community.

Start positioning your profession with the community.

It’s one means of  building some genuine political power, something which for various reasons general practice doesn’t have at the moment.

Just an idea.

And certainly oversimplified and contemplating a very long game, when there is a crisis now, so not easy or perfect in any respect.

But even if this is a bit of an oversimplified and unrealistic idea, it can’t be much dumber than repeatedly asking the government for money it has very clearly indicated to you it can’t or won’t give you.

There needs to be a new approach.

GP training transition and the sound of silence

A bit over a week ago we sat down to develop a list of what we felt were fairly curly questions for the RACGP on the upcoming GP training transition, due to take place on 1 February 2023.

We asked the RACGP and not ACRRM because the RACGP seemed to have the lion’s share of the problem, having to take on the management of 1350 of 1500 new trainees, come the handover, especially given ACRRM already managed some of its own trainees and already has taken on all those previously managed by Synergy (NSW).

We published the questions and the answers from RACGP CEO Paul Wappett earlier this week.

It’s a long list of questions and we asked them late afternoon amid the release of the college’s Health of the Nation report, so they were already very busy, and we were duly warned that it might take a while to get back to us with all the answers.

But the next morning at 10am, all the answers were there. And they were clear, transparent and comprehensive answers.

Paul Wappett almost certainly burnt some after-hours oil getting us those answers, something that probably points to how high in his set of priorities getting this transition right might be.

Certainly his answers, which are worth taking the time to read, make it feel like what was always a nightmare of timing and disarray between the various RTOs and the colleges in coming together is somehow under control.

But as much as Wappett’s answers instil some faith that things are far better than some of the dysfunctional circumstances around the transition made seem likely, there’s quite an eerie silence behind the scenes now on this major transformation project.

Twelve months ago there was a lot of noise and fuss around the timing and the manner of the transition.

In particular there was a lot of worry about just how hard the stop on RTOs being demanded by the Department of Health appeared to be.

Famously one very senior figure in the process described the timing and plan back then as trying to build a new jet airliner as it was taxiing along the runway for takeoff.

Even the colleges weren’t comfortable with the hard stop, preferring instead to start by contracting the services of many of the RTOs in the changeover.

This seemed a sensible approach given the more than 20 years of regional IP and networking that many of the RTOs had built in their organisations.

At one point in the process it looked as though the colleges might even back out of the transition altogether, at least in the short term.

Both must have had the size and the complexity of the transformation weighing hard on their minds before they were being forced by the DoH to take the job on with a hard kill date for most of the RTOs.

A hard kill date on the RTOs – 1 February – still has a lot of potentially catastrophic ramifications for the transition plan if things don’t go to plan.

Which makes you wonder why the DoH felt the need to extinguish the RTOs so quickly and so thoroughly.

If you don’t manage to transition most of key staff and key IP before the kill date, and that staff start scattering to the winds, you are going to end up as a very big shag on a very small and isolated rock.

You’ll have lots of regions where you need to manage GP training with not enough local knowledge or staff or will to do it.

Even if you do manage to transition the key staff, you have to quickly make them comfortable and happy, or their IP won’t be applied effectively in an ongoing manner.

There’s a lot that can easily go wrong still.

Wappett does specifically say it’s a very big transformation task so we can’t expect everything to go right, but he also says that it’s largely in hand so far.

Those nine RTOs which will shut up shop on 1 Feb next year (GPSynergy which does NSW is now a wholly owned RACGP group, and James Cook University, which does North Queensland, is somewhat strangely the only group the DoH allowed to continue and be sub contracted by the colleges) all have organisation charts on how their key staff will fit into the new organisation, and how things will run, and all key staff all have offers, apparently.

But all up the RACGP is trying to hire over 900 staff in about 80 working days – so about 11 new staff per day, and all this through the Christmas period. And they don’t have a full management team in place yet. They also have to negotiate leases for all its regional offices and get them set up in time, presumably for some staff to walk from their RTO office down the road to their new RACGP office.

You can see why the RACGP might have been wavering in its determination to take training back, and why it negotiated a lot longer with the DoH before formal contracts were signed, only in late August (which provided everyone with even less time to succeed).

It’s not that hard to work out why there is no noise or fuss any more over just how high risk the transition process seems to have been made by its timing and the insistence of the DoH to expunge RTOs quickly from the scene.

Once the colleges signed on the dotted line with the DoH there was nowhere for anyone to go, but with the risky plan.

Wappett quite rightly isn’t wasting any energy or time looking back now. He’s all in, as the colleges are.

And with that, the RTOs, are largely all out.

Except we need them to help a lot before they go.

The colleges, to their credit, did not want the plan to be so risky and difficult.

But in the end they made an assessment that they could pull it off.

A lot of the noise from the past was surreptitiously coming from the RTOs.

Of course there was some conflict in that noise, as naturally most would not have wanted their roles and long term history to end so abruptly.

But some of them were making good points about IP, people networks, local knowledge and the ultimate well being of the registrars.

Interestingly, amid the noise being made, most had acknowledged that there were problems with the RTO network, and that the sort of centralised college management that was being proposed, which contemplated better economies of scale and alignment of purpose and governance, were essentially good ideas.

Their main worry always was for the wellbeing of their registrars.

A possibility here is that a lot of the quiet now is the sort of quiet you get when some people in the process (quite possibly some very important ones) are shrugging their shoulders in resignation feeling that having not been listened to, things will be what they will be and you can’t help, so you should just move on.   

A problem might be that that some of the shrugging from within the RTO network is by people with really important IP and network knowledge and relationships.

This is not to say that the RTOs are entirely checked out and aren’t going to help.

All of them want the best for their registrars and the sort of alignment that Wappett details in his answers describes RTOs that are going to do their best before they go to help.

But there’s a giant residual risk here that we are going to lose too much IP that will take us years to get back if we can get it back at all.

If in a year’s time we end up in some sort of crisis because the transition runs off the rails, the ramifications for the future GP workforce aren’t going to be good, and if you add that to the crisis already facing the GP profession, well, you are multiplying mistakes too many times.

You do get the sense that the transition has to be made to work, and you certainly get a sense from the colleges that they are doing everything in their power to make it work, and most parties around them, realising the situation, are pitching in to help.

But you have to wonder here why the DoH forced the whole process to be so wildly risky by forcing a hard kill date on the RTOs, and not listening to either the RTOs or the colleges in their wish for a plan that had more time, more back up, and more common sense.