Volume 194 · Issue 11 · Supplement

Reflection on past achievements and future challenges 10 years after the establishment of the Australian General Practice Training program On 5 March 2001, the Australian Government established General Practice Education and Training (GPET).1 The main role of this new company was to establish the Australian General Practice Training (AGPT) program. Ten years later, the AGPT is strong, dynamic and continuing to evolve. This supplement was commissioned by GPET to review the activity of the past decade, to examine contemporary issues in general practice education and training, and to explore some of the future directions for the training of Australia’s general practitioner workforce. Capturing past experienceAustralian general practice vocational training has come a long way since 1973, when the Whitlam Labor Government provided funding to the Royal Australian College of General Practitioners (RACGP) to set up the original Family Medicine Programme, (later renamed the RACGP Training Program). In the first section of this supplement, two prominent Australian general practice educators, Willcock and Coote (→ The Australian General Practice Training program — reflections on the past decade)2 and Trumble (→ The evolution of general practice training in Australia),3 look back and provide their perspectives on the evolution of general practice vocational training in Australia, the legacy of the previous RACGP program, the events leading to the establishment of GPET and the AGPT program, and progress made over the past decade. Hays and Morgan examine the general practice training programs in New Zealand, Europe (including the United Kingdom and Ireland), Asia and North America and compare these with the developments in Australia (→ Australian and overseas models of general practice training).4 Contemporary issuesThe AGPT was created with a set of expectations — to establish a regionalised model of training, to improve vertical integration of general practice education, and to foster innovation.5 The second section of this supplement addresses these contemporary issues affecting general practice training. Campbell and colleagues examine whether the regionalisation focus of GPET has succeeded in meeting the needs of rural Australia and addressing maldistribution of the medical workforce (→ Regionalisation of general practice training — are we meeting the needs of rural Australia?).6 Stocks and colleagues describe the scope of vertical integration in Australian general practice through the establishment of regional training providers, and assess the linkages that have developed with universities and their rural clinical schools to improve integration in medical student training with the training of recent medical graduates and general practice registrars (Vertical integration of teaching in Australian general practice — a survey of regional training providers).7 Martin and Reath provide an assessment of innovations in general practice training in Aboriginal and Torres Strait Islander health (→ General practice training in Aboriginal and Torres Strait Islander health),8 while Kitchener and colleagues examine innovations in linking military medicine to general practice education and training (Training Australian Defence Force Medical Officers to civilian general practice training standards — reflections on military medicine and its links to general practice education and training).9 Finally, the current president of the World Organization of Family Doctors (Wonca), Professor Richard Roberts, and colleagues provide a global perspective on the challenges of primary health care delivery to the people of all nations, and the education and training needs of each country’s future GPs (→ Family medicine training — the international experience).10 Future directionsAt the start of the second decade of the AGPT program, Australia is moving through a process of health system reform that promises to shake up the delivery of primary medical care through the transformation of Divisions of General Practice into broader primary health care organisations called “Medicare Locals”,11 through the Australian Government’s investment in a network of “GP super clinics” and expanded general practices for primary care delivery, and through plans to better integrate both community-based health care and hospital care. The establishment of Health Workforce Australia12 has also created an urgent need for clarity around how we educate and identify supervisors for all medical and other health profession graduates. The supplement’s third section looks at the opportunities ahead and how all those involved in general practice training can seize them. Harris and colleagues discuss the trends that are putting pressure on Australia’s primary health care workforce and the implications for future training (→ Strategic approaches to the development of Australia’s future primary care workforce).13 Laurence and colleagues examine the strengths and weaknesses of the current regionalised training model and look at opportunities for expanded roles (→ Getting governance right for a sustainable regionalised business model).14 Emery and colleagues propose a series of training reforms to better meet future professional needs of GPs (→ Future models of general practice training in Australia),15 and Thomson and colleagues examine ways to ensure future sustainability by ensuring adequate support of this nation’s GP teachers (→ Supervision — growing and building a sustainable general practice supervisor system).16 What lies ahead?Reading through the supplement demonstrates many commonalities, with several observers reporting the same events from slightly different perspectives. However, it also reveals some of the challenges for general practice training over the years ahead. It is clear that the enhanced apprenticeship model of general practice training has served Australia well, but by its very nature the apprentice ends up cast in the mould of the master. It is a confronting reality that tomorrow’s GP will look very different to yesterday’s, and even today’s. GP supervisors need the flexibility to train registrars for quite a different role to what their own has been. General practice training must allow registrars to develop into what they need to be to best meet the future health care needs of their patients and their communities. It also appears that a focus on competency-based training is inevitable if we are to produce a sufficient number of GPs with the right skills to meet Australia’s evolving health needs. Clearly defining the outcomes of training by competencies, rather than by time served in a specific location, may be a way to provide future GPs with a myriad flexible, yet integrated, pathways offered by a range of providers that lead to the same professional standard. It could also allow for more contemporary competencies to be added to the GP’s traditional skill set, for example in management, teaching, research, quality and safety, teamwork, e-health and leadership.* At the same time as the vertical integration model needs to be reinforced across undergraduate and postgraduate medical training, better horizontal links must be established with other craft groups. This will strengthen interprofessional learning as general practice moves more to team-based care, to better meet the complex needs of many of our patients and our communities. Perhaps the future lies not in a single, rigid pipeline that delivers a fully trained — yet somewhat startled — new GP to an area of medical workforce need, but in acknowledging that there are multiple ways in which each new doctor can acquire, to established end points, the competencies required for safe, independent and appropriate general practice. * The RACGP will be addressing each of these areas in the development of its curriculum program in 2011.

Michael R Kidd AM, MD, FRACGP · Justin J Beilby MB BS, MD, FRACGP · Elizabeth A Farmer MB BS, PhD, FRACGP · Claire L Jackson MB BS, MPH, FRACGP · Stephen C Trumble MD, FRACGP

How has general practice vocational training progressed towards the original goals established by the federal government and General Practice Education and Training 10 years ago? Over the past two decades, the federal government has used various financial and regulatory levers to influence the organisation and activities of Australian general practitioners.1 A contentious initiative was the 2001 decision to cease funding the Royal Australian College of General Practitioners (RACGP) Training Program and to create a government-owned company, General Practice Education and Training (GPET) to implement a national vocational training program for general practice.2 GPET was created to establish a system of regional training providers (RTPs) and to oversee the implementation of a new system of general practice vocational training, the Australian General Practice Training (AGPT) program. Disentangling and weighting the many influences that led to this decision is best left to other historians. Hayden White, a central figure in academic debate about the nature of history, suggests it is difficult to get an objective history of a scholarly discipline, because if the historian is himself a practitioner of it, he is likely to be a devotee of one or another of its sects and hence biased; and if he is not a practitioner, he is unlikely to have the expertise necessary to distinguish between the significant and the insignificant events of the field’s development.3 However, three broad themes dominated academic, political and policy debate on general practice education in the years leading to the establishment of GPET and the AGPT program. First, reference to fragmentation of the general practice education “continuum” was common. In 1988, the “Doherty Report” recommended that “stronger links . . . be developed between university general practice units and the institutions providing vocational training for general practitioners”.4 In 1991, Kamien and MacAdam listed “cooperation with the RACGP-Family Medicine Program (FMP)” as a priority for general practice undergraduate departments.5 The future of general practice, a 1992 government report, noted the “artificial separation between undergraduate and continuing education” and the “guarded relationship between academic general practice and the FMP” resulting in “little scope for ensuring continuity in what is taught”.6 Second, establishment of the Australian College of Rural and Remote Medicine (ACRRM) challenged the hegemony of the RACGP over general practice vocational education. The ACRRM was incorporated in 1997 by the Rural Doctors Association of Australia as an acknowledgement of: · the importance of rural and remote medicine as a broad but discrete form of general practice · the need for well-designed vocational training and continuing medical education for rural doctors, and · the need to address the shortage of rural and remote doctors in Australia, by providing them with a separate and distinctive professional body.7 Third, the federal government wished to leverage the arrangements through which it funded general practice vocational education and training, to pursue medical workforce policies to manage overall numbers of GPs (and general practice Medicare outlays) and the distribution of general practice trainees. The 1998 report of the Ministerial Review of General Practice Training considered these influences in the context of broader changes in the way medical care was being provided, referring to all these forces as: “environmental barriers and constraints leading to calls for overhaul of the GP vocational training environment”. The report concluded that “the RACGP [training program] is now confronted with myriad conflicting demands brought about by influences that it cannot fully control”.8 It recommended fundamental changes, most significantly “development of local collaborative arrangements, or consortia, in education-service delivery” with a national body to promote “better coordination at all levels of the general practice education continuum”.8 From a political perspective, the establishment of GPET in 2001 was a government response to an astute, coordinated and persistent political campaign by rural doctors’ organisations. Rural doctor advocates wanted more rural influence and control over public funds that support general practice training, arguing that the RACGP Training Program had become “metrocentric”. From a workforce policy perspective, the government instituted measures through GPET to boost the supply of doctors in rural areas. These included an unequivocal requirement that all registrars undertake a minimum 6 months’ training in rural areas, and financial incentives for trainees who undertook additional rural-based training. A key educational aim underpinning the establishment of GPET and the AGPT program was regionalisation to facilitate vertical integration of training, thereby fostering an environment that would encourage innovation and competition between RTPs (over, for example, quality and cost of training and the nature and length of the educational experience). Other outcomes included a well trained, appropriately distributed workforce in sufficient numbers to meet the health needs of a growing and ageing population, and those of Indigenous Australians. Ten years onThe establishment and subsequent history of GPET and the AGPT program between 2001 and 2011 raise many interesting questions. To what extent has vertical integration of general practice training and education actually occurred across medical school, prevocational and vocational training entities in terms of measurable outcomes? To what extent have RTPs been able to innovate, caught as they are between contractual obligations to GPET and the need to deliver training according to, at times, prescriptive college requirements? Has the overall supply of GPs (particularly in rural regions) been boosted by the new arrangements? Regionalisation outcomes — vertical integration, competition and innovationInitial hopes, at least by the federal government, for competition between RTPs did not eventuate in any substantial sense for two main reasons. First, GPET was required to ensure training met existing “college standards”. This was a late addition to the GPET constitution following lobbying by general practice organisations, and significantly defined the educational content of the new program. RTPs were free to explore innovative delivery models, but the curriculum prescribed for all RTPs to achieve these standards was essentially constant. Second, there was an effective exclusion of completely new prime providers by criteria defining governance of RTPs that restricted participation to entities controlled by collaborations of local general practice interests such as medical colleges and Divisions of General Practice. At least two universities sought to become prime providers, but these proposals were unsuccessful. Despite GPET’s development of a vertical integration framework,9 integration of education and training across the undergraduate, postgraduate and vocational spectrum struggled to evolve in the early years of the AGPT program, with the focus on more urgent training imperatives such as registrar selection and recruitment for an increased number of training places per year (rising from 450 to 600 in 2004). Some university-based departments of general practice have been contracted by RTPs to deliver components of registrar training, and many RTP medical educators have university appointments. In recent years, vertical integration has gained further momentum with: the transition to GPET of the Prevocational General Practice Placements Program — an experiential program in community-based general practice for junior hospital doctors;10 and GPET-funded initiatives to foster general practice exposure within medical schools, including support for the General Practice Students Network and GP Compass programs. GPET continues to seek collaborative opportunities with medical schools to foster integration of student placements with prevocational and vocational training. However, this has been hampered by funding mechanisms and incentive schemes for undergraduate student placements that are not sufficiently aligned with prevocational and vocational training supervisor and practice support initiatives. The regionalised model has facilitated local decision making by identifying local health needs, local opportunities for training of registrars by resident supervisors, and more local career development opportunities for supervisors and educators. Many large RTPs have recognised the need to develop regional nodes that address the unique needs of the local population while operating within an overarching governance structure. One outstanding example has been the Kimberley Aboriginal Medical Services Council’s medical education project, which has improved general practice access for area-of-need populations and has provided an effective model for engaging a diverse spectrum of stakeholders.11 Some RTPs, for example, Coast City Country General Practice Training (covering Wollongong, Canberra, the Riverina and the New South Wales South Coast) and Western Australia General Practitioner Education and Training, have developed “nodal” operational models, servicing multiple regional communities while achieving administrative efficiencies. The perennial problem of efficiency versus local representation has continued, however — some smaller RTPs proved unsustainable and the original 22 RTPs (from 32 valid applicants) were reduced to 17 through a series of mergers. Workforce training — capacity, resources and distributionFrom the outset, RTPs across Australia were encouraged by GPET to develop registrar training capacity in areas of medical workforce need. Box 1 highlights significant growth in training service delivery from the initial 2003 AGPT training year — registrars have increased by 88% in metropolitan locations and 102% in Rural, Remote and Metropolitan Areas (RRMA) 3–5. RRMA 6 and 7 also experienced a significant 64% increase. However, the absolute number completing training does not yet meet the demand for additional GPs. Box 2 shows the growth in the number of GP registrars who completed terms in Indigenous health posts by RRMA between 2003 and 2009. The growth in these numbers is broadly in line with the growth in total registrar numbers over that time. The number of Aboriginal and Torres Strait Islander registrars has risen from two to 34 over the same period. In March 2010, the Australian Government Department of Health and Ageing announced that AGPT program places would be doubled to 1200 a year by 2014 to meet anticipated need for 3000 extra GPs by 2020.12 While this is welcome news, it presents a challenge in recruiting additional GP medical educators and supervisors at a time when the general practice workforce is already stressed by service delivery requirements as well as demands for clinical placements in general practice from the undergraduate medical, nursing and allied health sectors. There is, therefore, a need for a comprehensive assessment of training demand in general practice to identify the additional resources required to meet the projected need, particularly in physical infrastructure for clinical training, supervisor support and development, and the establishment of a robust and sustainable workforce of skilled medical educators. Increased demand can potentially be offset by exploring new training models, including integrated, interprofessional models in large community-based clinical facilities with a primary care focus. These larger community-based centres of care would be suitable for group activities, including education programs for patients, students and clinicians. There is also scope to expand the historical model of general practice training from a general practice “consultation apprenticeship” model to include significant time in other domains of practice such as emergency medicine, aged care, palliative care and routine procedural work. The rural generalist training approach, introduced by the Queensland Government in 200513 and implemented in Western Australia in 2009,14 is likely to provide a good model for enhanced diversity in GP vocational training. Indigenous health trainingIn 2003, some 2 years after its establishment, GPET developed its Framework for General Practice Training in Aboriginal and Torres Strait Islander Health.15 Since then, a range of issues and challenges have emerged, with important lessons learned. GPET has recognised the benefit of improved collaboration with Aboriginal and Torres Strait Islander organisations, and these partnerships will continue to inform AGPT’s Aboriginal and Torres Strait Islander health training initiatives. Evaluation of the Framework suggested that the comprehensive, multilevel approach to Aboriginal and Torres Strait Islander health training has been one of the program’s strengths.16 GPET, along with the RTPs, is playing a national leadership role in responding to the specific regional circumstances and needs of Aboriginal and Torres Strait Islander communities in collaboration with the relevant state- and territory-affiliated organisations. While the regionalised training program model has worked well generally, one of the immediate issues that emerged was the uneven capacity to host general practice training in Aboriginal Community Controlled Health Services (ACCHSs) throughout Australia, with a resultant uneven distribution of registrars undertaking the training. Since 2003, the three RTPs with geographical footprints in northern Australia have consistently recorded the highest proportion of their registrars undertaking training in an Aboriginal and Torres Strait Islander health training post. Today, 66% of all general practice training in Aboriginal and Torres Strait Islander health occurs in northern Australia. Some of the challenges to expanding training capacity in ACCHSs in southern Australia include long-term supervisory vacancies and inadequate infrastructure. Solutions may require a review of the scope of current AGPT programs, and will certainly need close collaboration with other agencies involved with health service provision to Indigenous communities. ConclusionsThe AGPT program and its regionalised delivery system are now well established in Australia. It is generally acknowledged as a successful program, and is now broadly accepted by the profession and government. The system continues to be future-focused, and is cohesive, responsive to changing community needs and well positioned for future challenges and opportunities. In retrospect, the fundamental aims and outcomes for GPET and the AGPT program remain relevant today. The decline in general practice workforce numbers in rural and remote Australia has been halted, but an ageing workforce and an underrepresentation in the 35–50-year age demographic due to past restrictions on training numbers mean that we will need to significantly increase our entrants into vocationally registered general practice over the next decade to maintain an adequate general practice workforce in both rural and metropolitan Australia. There remains a need for a well trained and appropriately distributed workforce in sufficient numbers to meet the requirements of a growing and ageing population. While contestability of general practice vocational training has not been achieved to any major extent, there is significant progress towards vertically integrated training. The current cohesion between various general practice organisations is likely to facilitate further integration within undergraduate and continuing professional development sectors. Others aims, including regionalisation, workforce distribution, enhanced training capacity, resource development and Indigenous health training, show pleasing progress but require ongoing review, expansion and further development over time, based on experience to date and the evolving needs and demands of our health care system. Since their establishment in 2001, GPET and the AGPT program have achieved many of the “outcomes for regionalisation” set by the federal government and the GPET Board, particularly in relation to delivery of vocational training and provision of medical education services by GP registrars in areas of greatest need — rural and remote areas, outer metropolitan regions and Indigenous communities. Underpinning these outcomes is the economic question: Have the policy outcomes of GPET and the AGPT program justified the resources required to maintain GPET and 17 regional RTP offices? Finally, the experiences of GPET and the AGPT program should be of interest to the wider profession as components of training in many specialist disciplines move outside the traditional public hospital setting into private practices and private hospitals; and as the health system places increasing emphasis on preventive and primary care. Pressure for a formal process for recognising, meeting and administering the costs incurred by both practitioners and facilities is likely to emerge within other health professions and disciplines. It is reasonable to state that the AGPT program experience provides a useful template for change within the broader professional education and training environment. 1 Numbers of general practice registrars-in-training by RRMA, 2003 and 2009*†‡ 2003 2009 RRMA 1–2 RRMA 3–5 RRMA 6, 7 Total in state/territory RRMA 1–2 RRMA 3–5 RRMA 6, 7 Total in state/territory New South Wales/ Australian Capital Territory 257 167 4 359 502 348 5 756 Victoria 179 165 1 304 285 292 5 512 Queensland 123 121 22 218 248 260 41 474 South Australia 64 37 1 86 141 107 5 210 Western Australia 73 34 17 100 144 61 26 196 Tasmania 13 22 0 33 39 41 0 76 Northern Territory 29 8 31 55 33 17 44 78 Total Australia 733 551 76 1126 1377 1112 125 2237 RRMA = Rural, Remote and Metropolitan Areas. * Source: General Practice Education and Training, unpublished data. † Where registrars trained in more than one RRMA category during the year, they are counted once in each. The totals for RRMA columns and state rows include each registrar only once. ‡ In 2010, the system for categorising remoteness changed from RRMA to the Australian Standard Geographic Classification — Remoteness Area (ASGC-RA). These systems are not comparable and 2010 data are not available in RRMA format. 2 Numbers of general practice registrars training in Indigenous health posts by RRMA, 2003 and 2009*†‡ 2003 2009 RRMA 1–2 RRMA 3–5 RRMA 6, 7 Total in state/territory RRMA 1–2 RRMA 3–5 RRMA 6, 7 Total in state/territory New South Wales/ Australian Capital Territory 5 6 2 13 18 22 2 42 Victoria 4 3 — 7 2 6 — 8 Queensland 7 6 4 17 3 12 16 27 South Australia — 1 — 1 7 7 — 7 Western Australia 2 1 5 7 — 3 19 22 Northern Territory — 6 14 19 — 9 25 34 Tasmania 1 — — 1 1 — — 1 Total Australia 19 23 25 65 31 59 62 140 RRMA = Rural, Remote and Metropolitan Areas. — = Data not available. * Source: General Practice Education and Training, unpublished data. † Where registrars trained in more than one RRMA category during the year, they are counted once in each. The totals for RRMA columns and state rows include each registrar only once. ‡ In 2010, the system for categorising remoteness changed from RRMA to the Australian Standard Geographic Classification — Remoteness Areas (ASGC-RA). These systems are not comparable and 2010 data are not available in RRMA format.

Simon M Willcock PhD, MB BS, FRACGP · William Coote MB BS, FRACGP, BEc

Training for general practice in Australia has undergone a 60-year evolutionary process punctuated by revolutionary events. The discipline of general practice has also evolved significantly over this period. Today’s Australian general practice training program strongly resembles its ancestors, with adaptations that better suit its regionalised environment. General practice training has been affected frequently by political and professional forces. Many of these forces were powered by the government’s need for general practice training to deliver immediate workforce solutions, and the profession’s struggle to respond. Pressure on general practitioners to train increasing numbers of clinical learners is challenging traditional apprenticeship models. The Australian general practice training program needs to continue to evolve if it is to remain successful within its volatile environment.

Stephen C Trumble MB BS, MD, FRACGP

General practice training in Australia continues to evolve. It is now the responsibility of an independent organisation, is delivered by regional training providers, and comprises a structured training program. Overseas, general practice varies in its importance to health care systems, and training models differ considerably. In some cases training is mandatory, in others voluntary, but the aim is always similar — to improve the quality of care delivered to the large majority of populations that access health care through primary care. We review the current status of vocational general practice training in Australia, compare it with selected training programs in international contexts, and describe how the local model is well placed to address future challenges. Challenges include changes in population demographics, increasing comorbidity, increasing costs of technology-based health care, increasing globalisation of health, and workforce shortages. Although general practice training in Australia is strong, it can improve further by learning from other training programs to meet these challengers.

Richard B Hays PhD, MD, FRACGP · Simon Morgan MB BS, FRACGP

This article reviews the history of general practice vocational training in Aboriginal and Torres Strait Islander health, identifies current initiatives and recommends future approaches based on recent evidence. General practice vocational training in Aboriginal and Torres Strait Islander health requires ongoing support and investment from governments and training and general practice organisations if the gains made to date are to be consolidated and health outcomes are to improve. In particular, investment in sustained and respectful partnerships with Aboriginal and Torres Strait Islander peoples and organisations will continue to provide the groundwork for effective training of general practitioners in this critical health area, and will also play an important role in capacity-building in Aboriginal and Torres Strait Islander communities.

Mary E Martin · Jennifer S Reath MB BS, FRACGP, MMed

The concept of “social accountability” has underpinned the development of many medical education programs over the past decade. Success of the regionalisation of the general practice training program in Australia will ultimately be measured by the ability of the program to deliver a sufficient rural general practice workforce to meet the health needs of rural communities. Regionalisation of general practice training in Australia arose from the 1998 recommendations of the Ministerial Review of General Practice Training. The resultant competitive structure adopted by government was not the preferred option of the Review Committee, and may be a negative influence on rural workforce, as the competitive corporate structure of regional training providers has created barriers to meaningful vertical integration. Available data suggest that the regionalised training program is not yet providing a sustainable general practice workforce to rural Australia. The current increase in medical student and general practice training places provides an opportunity to address some of these issues. In particular, it is recommended that changes be made to registrar selection processes, the rural pipeline and vertical integration of training, and training for procedural rural practice. To achieve these goals, perhaps it is time for another comprehensive ministerial review of general practice training in Australia.

David G Campbell MB BS, FRACGP, FACRRM · Jane H Greacen MB BS, FAFOM, FACRRM · Patrick H Giddings MB BS, FRACGP, FACRRM · Lesley P Skinner MB ChB, FRCGP, FRACGP

Objective: To examine vertical integration of teaching and clinical training in general practice and describe practical examples being undertaken by Australian general practice regional training providers (RTPs).Design, setting and participants: A qualitative study of all RTPs in Australia, mid 2010.Results: All 17 RTPs in Australia responded. Eleven had developed some vertical integration initiatives. Several encouraged registrars to teach junior doctors and medical students, others encouraged general practitioner supervisors to run multilevel educational sessions, a few coordinated placements, linkages and support across their region. Three RTPs provided case studies of vertical integration.Conclusions: Many RTPs in Australia use vertical integration of teaching in their training programs. RTPs with close associations with universities and rural clinical schools seem to be leading these initiatives.

Nigel P Stocks MD, FRACGP, FAFPHM · Oliver Frank MB BS, FRACGP, PhD · Andrew M Linn MB BS, GradDipChildHealth · Katrina Anderson BMed, FRACGP, MTh · Sarah Meertens MB BS(Hons), FRACGP

This article examines military medicine and its links to civilian general practice education and training, drawing attention to the variations and difficulties in, and successful approaches for, training Australian Defence Force (ADF) Medical Officers. Military medicine has been an area of change over the 10 years of the Australian General Practice Training (AGPT) program. Crisis situations like those in Timor Leste and Afghanistan have focused attention and recognition on the importance of primary health care in the work of the ADF. To train doctors in military medicine, there are several different models at different locations around Australia, as well as large variations in military course and experience recognition and approvals between AGPT regional training providers. At times, the lack of standardisation in training delays the progress of ADF registrars moving through the AGPT program and becoming independently deployable Medical Officers.

Scott J Kitchener MD, FAFPHM, FRACMA · Elizabeth Rushbrook MB BS, MHA, FRACMA · Leonard Brennan MHA, FRACMA, FACRRM · Stephen Davis MB BS, MHA

Family medicine is undergoing dramatic transformation around the world. Its organisation, delivery, and funding are changing in profound ways. While the specifics of primary care reform vary, a common emerging strategy involves establishment of primary health care teams that provide improved access, use electronic records, are networked with other teams, and are paid using blended payment schemes. More family doctors are needed in all countries. New approaches beyond the traditional apprenticeships or residency programs will be required to meet global demand. Training of family doctors must change to prepare tomorrow’s family physician for a different practice reality. Curricula are more competency-oriented, rather than time-focused. Today’s trainees can anticipate a career that includes periodic reassessment of their knowledge base and competency. This article explores these trends and offers some strategies that have proved effective in various parts of the world for training increased numbers of qualified family doctors.

Richard G Roberts MD, JD · Vincent R Hunt MD · Teresa I Kulie MD · Wesley Schmidt MD · Julie M Schirmer MSW · Tiago Villanueva MD · C Ruth Wilson MD

Shortages in, and maldistribution of, the primary health care workforce will continue to limit access to health care. The current health reform proposals and policies recognise workforce development as a priority, but only partially address the barriers to improvement. In particular, there will need to be more systematic development of interdisciplinary education within primary health care services, and funding to support this.

Mark F Harris FRACGP, MD · Nicholas A Zwar PhD, FRACGP · Christine F Walker PhD · Sabina M Knight RN, MTH

The 1998 Ministerial Review of General Practice Training identified several areas for improvement that led to major changes in the provision of general practice training, including the establishment of General Practice Education and Training (GPET) and the regionalisation of training. The regionalised training business model has been in place for nearly 10 years, and several key organisations have been involved in its evolution, including the Australian Government, speciality colleges, GPET and regionalised training providers. Both the college-focused and regionalised-focused models have had some successes. These include recognition and support of general practice as a vocational specialty, increased numbers of junior doctors undertaking placements in general practice, and increased numbers of registrars training in rural areas. This period has also seen changes in the governance and decision-making processes with creation of a new framework that is inclusive of all the key players in the new regionalised training system. The future holds challenges for the regionalised training business model as the general practice education and training landscape becomes more complex. The framework in the current model will provide a base to help meet these challenges and allow for further sustainable expansion.

Caroline O Laurence BA(Hons), MHlthServMg, PhD · Linda E Black BA(Pscyh), DipAppPsych, MAPS · Mark Rowe BEd, MEd, EdD · Rod Pearce MB BS, FAMA

Current proposals for significant primary health care reform in Australia create a timely opportunity to reflect on the education and training requirements of future general practitioners. Australian general practice will become increasingly team-based, with growing emphasis on coordinated care, chronic disease management, and disease prevention and self-management, while maintaining its focus on delivering high-quality, patient-centred care. This will require cost-effective application of new technologies and information management systems within new models of delivering health care. Future models of general practice training must respond to these new ways of working to ensure general practice remains an attractive career choice and training programs graduate doctors who are equipped to meet the health needs of Australians. This article discusses potential development of new general practice vocational training models in Australia. This includes hospital rotations that are more directly integrated with general practice placements and have greater emphasis on the needs of the future general practice workforce; and an extension of the training program to 4 years with a final year tailored to future career plans including development of expertise in practice management, specific clinical disciplines or academic skills.

Jon D Emery MB BCh, FRACGP, DPhil · Lesley P Skinner MB ChB, FRACGP · Simon Morgan FRACGP, DipRACOG, MPH · Belinda J Guest BMed, BMedSc(Hons), DCH · Alistair W Vickery MB BS, FRACGP

This article explores various models and ideas for future sustainable general practice vocational training supervision in Australia. The general practitioner supervisor in the clinical practice setting is currently central to training the future general practice workforce. Finding ways to recruit, retain and motivate both new and experienced GP teachers is discussed, as is the creation of career paths for such teachers. Some of the newer methods of practice-based teaching are considered for further development, including vertically integrated teaching, e-learning, wave consulting and teaching on the run, teaching teams and remote teaching. Approaches to supporting and resourcing teaching and the required infrastructure are also considered. Further research into sustaining the practice-based general practice supervision model will be required.

Jennifer S Thomson MB BS, FRACGP, MBA · Katrina J Anderson BMed, MTh, FRACGP · Paul R Mara MB BS, FRACGP, FACRRM · Alexander D Stevenson MB BS, DCH, FRACGP