Getting governance right for a sustainable regionalised business model

From the 1970s through the 1990s, all decision-making responsibility rested with the federal government (ie, the previous incarnations of the Australian Government Department of Health and Ageing) and the Royal Australian College of General Practitioners (RACGP).2 They exercised direct decision-making powers over funding and training delivery, respectively — the federal government provided funding and the RACGP managed funds, delivered training and developed the curriculum. During this period, the federal government extended its role when it linked training with quality by making changes to sections 19AA and 19AB of the Health Insurance Act 1973 (Cwlth) and by establishing vocational registration.

A third player entered the general practice education and training environment in 1997 with the establishment of the Australian College of Rural and Remote Medicine (ACRRM). The ACRRM arose from a belief by some that rural and remote medicine was a broad but discrete form of general practice,3 and from a dissatisfaction with the way the RACGP related to its Rural Faculty members. The ACRRM adopted a similar governance and direct decision-making role to the RACGP, but without the legislative recognition as a training program that is required for granting independent vocational registration status as a general practitioner.3

This model of general practice training had several successes during this period, with the increased recognition of quality general practice through vocational registration, the recognition of the wider scope of general practice with the establishment of ACRRM, and recognition and support of general practice as a vocational specialty with changes to the Health Insurance Act in 1996.

The 1998 review of general practice training led to the introduction of a regionalised model of general practice education and training using regional training providers (RTPs). In 2001, the Commonwealth Department of Health and Aged Care established a Commonwealth-owned company, General Practice Education and Training (GPET), to establish the new training environment for general practice vocational training.4

In 2002, the newly established GPET and the RTPs significantly changed the business model of general practice vocational training. The regionalised model now included additional organisations in the governance of general practice education and training, and shifted decision-making responsibilities so that they involved direct, delegated and consultative processes (Box 2). For example, funds management, as a key decision-making responsibility, was delegated to GPET, which in turn delegated aspects of this role to the RTPs. This new model also shifted decision making related to education and training development and delivery — previously held predominantly by the RACGP — to the RTPs.

During the establishment phase of the new model, there was confusion and mistrust regarding the demarcation and devolution of governance and decision-making roles for both new and old organisations, but most notably the colleges, GPET and RTPs. The roles of the new organisations (GPET and RTPs) were evolving and the roles of the old organisations (RACGP and ACRRM) were in a state of flux. With the establishment of the AGPT program, the RACGP vocational training program that had been in place for nearly 30 years was deemed to be at risk, particularly by those who perceived they were losing governance and decision-making roles and responsibilities to new players.5 However, nearly 10 years on, each organisation’s role is becoming better defined and delineated. Box 2 provides a matrix of the current integrated distribution of governance and decision-making roles across the key organisations — from an RTP perspective.

The current regionalised model for general practice education and training has achieved a number of successes. These include regionalisation of training,6,7 general practice exposure during hospital training years,8 increased rural training,9 the formal inclusion of Aboriginal and Torres Strait Islander health training in education and training syllabi,10 and, most recently, the introduction of a streamlined training post/supervisor accreditation process.

The decision to regionalise the general practice vocational training program in 2002 resulted in the creation of 22 RTPs, which were charged with delivering general practice training throughout Australia. In 2011, the number of RTPs was reduced to 17 but still had the same coverage responsibility. Recent reviews indicated that the current training model provides optimal benefits to the Australian community and demonstrated that the current distribution of registrar training is a good match to the distribution of the population (in contrast to the distribution of GPs).6,7

Since 2005, there have been expanded opportunities for junior doctors to be exposed to general practice during their hospital years of general training, through the introduction of the Prevocational General Practice Placements Program (PGPPP). This has built on its much smaller but successful predecessor program, the ACRRM’s Rural and Remote Area Placement Program. As an example, in South Australia, the PGPPP annually allows over 110 interns and residents to undertake at least one of their junior rotations in general practice.11,12 The intern component equates to at least a third of the intern cohort in SA. A study conducted in 2007 confirmed that the inclusion of general practice as a junior doctor rotation was perceived positively by trainees and deemed to be of equal value to hospital-based rotations.8 Further, supervision and teaching in general practice rotations were deemed to be of superior quality.8 In 2010, the opportunities through PGPPP were expanding significantly across the nation, at equivalent and higher levels than those in SA.13

Available data indicate that the current training model has increased the number of registrars training in rural regions (Box 3).9 The rural pathway is now a distinct path that registrars can select from entry, regardless of their fellowship intent, and is available through most RTPs. In 2006, the ACRRM successfully gained recognition of its fellowship as a legislative end point for independent status as a specialist GP. At the same time, the RACGP strengthened its approach and support of rural-oriented registrars.

The formal inclusion of Aboriginal and Torres Strait Islander Health training in RTP education and training syllabi continues to be a work in progress, but some achievements have occurred as part of the new regionalised model. During this period, GPET developed a Framework for general practice training in Aboriginal and Torres Strait Islander health10 and, more recently, a draft guide to general practice training in Aboriginal and Torres Strait Islander health, which will act as a regional component to the framework. GPET also established the Aboriginal and Torres Strait Islander Health Training Advisory Group14 as a subcommittee to its Board, and, in 2008, created an ongoing professional support network for Aboriginal and Torres Strait Islander GP registrars. Additionally, the number of registrars undertaking training in accredited Aboriginal and Torres Strait Islander medical services has increased from 65 in 2003 to 141 in 2009.9

Most recently, the RACGP and the ACRRM have been working in a tripartite relationship with RTPs to introduce a streamlined and delegated training post/supervisor accreditation process. This process replaces the previous college-directed and -controlled process of assessing and accrediting practices and supervisors for the colleges’ training standards. The governance bodies of both colleges have approved an accreditation framework whereby this assessment and accreditation process has been streamlined and delegated to the RTPs. The colleges’ responsibility has shifted to endorsement of the RTP’s recommendations, with a bolstered responsibility for the accreditation of RTPs that includes reviewing the methodology used to conduct this delegated work. This arrangement allows for a more straightforward and ongoing quality assurance process conducted by RTPs to determine the accreditation eligibility of training posts and supervisors — an innovation that came from on-the-ground supervisor feedback.

Implementation is a work in progress, but the decision by the colleges to delegate this important decision making to RTPs, while retaining overall governance responsibility for this area of work, is an important achievement. It also forms a possible template for how future changes can be determined and implemented.