GP supervisors in Australia: a cornerstone in need of repair

The general practitioner supervisor is a key element of the apprenticeship model, ensuring the development of a strong and capable GP workforce

Of all medical disciplines in Australia, training for the specialty of general practice has undergone the most change over the past 50 years. Before 1973, there was no training program for general practice at all. Since then, a succession of policy changes will ultimately result in all doctors working in general practice either having a specialty qualification (Fellow of the Royal Australian College of General Practitioners [RACGP] or Fellow of the Australian College of Rural and Remote Medicine [ACCRM]) or being in a recognised program training towards one.

Over a similar duration, policies designed to influence the geographic distribution of doctors working in general practice have been implemented. For example, the Australian General Practice Training (AGPT) Program must deliver 50% of training in rural areas (https://www.health.gov.au/sites/default/files/documents/2020/12/agpt‐program‐policies‐2020.pdf).

These dual strategies have led to a complex landscape of training and workforce programs. There are currently seven ongoing general practice training or workforce programs in Australia (Box 1), as well as several legacy programs no longer taking new applicants. A general practitioner supervisor, long described as the cornerstone of general practice training,1 operates in nearly all of them.

In the training and workforce programs where a GP supervisor is present, they are expected to ensure safe patient care and provide education in response to the supervised doctor’s learning needs. Despite the commonalities of the work undertaken by GP supervisors across all programs, there are differences in clinical oversight standards, prerequisite qualifications, professional development requirements, payment for supervision, and support from medical educators. Our intent is to highlight these inequities and propose some solutions. The cornerstone needs repair.

Clinical oversight standards

Under section 19AA of the Health Insurance Act 1973 (Cth), to obtain a Medicare provider number for general practice, a doctor must either be a registered specialist GP or be in a Commonwealth approved program (under section 3GA of the Health Insurance Act). Whether a GP supervisor is required for a doctor working in a section 3GA approved program depends on the requirements of the training and workforce program (Box 1) and the registration status of the doctor (Box 2). There may be either no requirement for supervision, or supervision under the standards of the ACRRM, the RACGP, the Medical Board of Australia (MBA) or a workforce agency.

In other specialties, the concept of a doctor without specialist qualification working in the community without supervision by an appropriately qualified specialist would be unacceptable. Yet this situation currently exists for some doctors in the Practice Experience Program and the More Doctors for Rural Australia Program (MDRAP).

In the programs where a GP supervisor is required, the standards that apply for clinical supervision are either the outcomes‐based standards of the RACGP and the ACRRM, or the input‐based standards of the MBA and workforce agencies.

The intended outcome in both RACGP and ACRRM standards is similar — a broad requirement that supervision is matched to the registrar’s competence or needs.2,3 However, the standards do not specify how this outcome is achieved, and there are no proposed means of measuring it. Having an oversight structure that lacks specificity or measurement has raised concerns about whether appropriate clinical supervision is occurring in general practice training in Australia.4

In comparison, the input‐based standards of the MBA (Box 3) operating for international medical graduates have more specificity about the supervision task.5 For example, level 1 supervision stipulates all patients seen by the supervised doctor must be reviewed by the GP supervisor who is onsite.

However, MBA‐based programs introduce risks related to undersupervision. After an initial determination by the MBA, the ongoing level of supervisory oversight required depends upon a report from the supervisor to the MBA about the supervised doctor’s readiness to progress. Some supervisors operating under MBA standards are not paid for providing supervision, creating a financial disincentive to continue more intensive supervision. Added to this, a supervised doctor in MBA‐based programs is highly dependent on the supervisor for employment and may not report insufficient supervision. While the MBA advises that they may audit supervision arrangements to detect undersupervision, there are no published reports on the frequency of audits or whether they are conducted randomly or only in response to a whistle‐blower. The accreditation process for MBA supervisors5 is also less rigorous than under RACGP and ACRRM standards.

The solution we propose is that all doctors working in general practice without specialist registration must be supervised by an ACRRM or RACGP accredited GP supervisor under input‐based standards, similar to the MBA approach. The MBA standards should be strengthened by the amalgamation of existing levels 3 and 4, as these currently lack specificity about how clinical care will be monitored when there is no longer a review of all consultations. Specific oversight requirements could be added at this level, such as using random case analysis6 to enable sampling of provided care, and a call for help checklist7 to clarify when supervision should be sought. The initial and ongoing level of supervision should be based on an assessment of the supervised doctor’s competence that includes external assessors. Regular audits of in‐practice supervision should be implemented and reported.

In summary, uniform oversight standards for all GP supervisors operating across all training and workforce programs are required. Safe patient care is more likely to be achieved through consistent measured inputs than through any aspirational outcomes that are not measured.

Prerequisite qualifications and professional development requirements

Currently, MBA appointed GP supervisors are not mandated to have Fellowship of the RACGP or ACRRM. This is historically because of the need to appoint supervisors in areas of high workforce need where there may not be an onsite specialist GP. Remote supervision employing videoconferencing by specialist GPs available at all hours is now possible and should be implemented.

Supervisors in the AGPT Program and Remote Vocational Training Scheme (RVTS) are required and funded to undertake continuing professional development (CPD) as a GP supervisor. This has been called educational CPD.8 For supervisors in all other training and workforce programs, there is no educational CPD requirement or funding. This undervaluing of educational CPD is problematic in terms of equity of access to quality supervision. It may reflect a view that the skills of providing clinical oversight and education are innate or learned through previous experience of supervision. If so, these assumptions are at odds with current views of medical education and the value of a skilled supervisory workforce.9,10

All GP supervisors should be appropriately skilled, adequately resourced, and remunerated for undertaking educational CPD. The 6 hours per year professional development requirements for AGPT and RVTS supervisors falls well below the 50 hours per year requirement in comparable countries11 and should be increased and more rigorously evaluated for impact.

Payment for supervision

AGPT supervisors receive a block payment for teaching and supervision. Recently, a similar arrangement has been introduced for MDRAP supervisors.12 Financial viability is a factor influencing the decision to become a GP supervisor,13 and previous cost–benefit analysis has found employing a registrar is at best a marginally profitable enterprise for practices.14 GP supervisors in programs outside of AGPT and MDRAP are not remunerated for their supervision time. The burden of providing unfunded GP supervision falls predominantly on rural GPs who are least likely to be able to provide the time for supervision, due to competing clinical demands in areas of workforce shortage.

Although block funding in AGPT and MDRAP at least recognises the cost of providing supervision, it is still not linked to the actual amount of time spent on supervision. A perennial problem is ensuring that supervision occurs.4 A fee‐for‐service model available to supervisors in all training and workforce programs would be more equitable and reward supervisory work. A Medicare Benefits Schedule (MBS) item that can be billed when a supervised doctor requires input from their supervisor while attending a patient is a potential mechanism. Block funding has the advantage of cost certainty for government, but an MBS time‐based item number for supervision would appropriately reward the actual provision of supervision and include regulatory oversight through existing Medicare requirements for a doctor to maintain records that justify items billed.

Support from medical educators

An analysis of training and workforce programs reveals that some, but not all, programs involve medical educators. Appropriately skilled and experienced medical educators can assist the GP supervisor in the education of supervised doctors. Medical educators are government funded in the AGPT and RVTS programs and self‐funded by the doctor in the Independent Pathway and the Practice Experience Program. The programs without ongoing involvement of a medical educator are the MDRAP, the Approved Medical Deputising Services program, and Return to Practice. Paradoxically, it is often in programs where GP supervisors are unfunded and lack educational CPD that medical educator support is also lacking. The inequity would be resolved by requiring the provision of medical educators in all training and workforce programs. The increased need for a medical educator workforce will be aided by both the RACGP and the ACRRM clarifying expected skill sets for medical educators and establishing professional development requirements and career pathways.

Conclusion

Wearne and colleagues sounded a clear warning about doctors arriving in general practice in Australia less prepared than previously by their hospital training and experience.15 This increases the load on the cornerstone GP supervisor. Added to this, a complex landscape has arisen in Australia that fails to match the level of support of the GP supervisor to the level of expertise required in all training and workforce programs. Although the changes we are proposing will require significant resources and the support of GP supervisors and other key stakeholders, the goodwill of GP supervisors to continue to labour under current conditions is not limitless. The inconsistencies and inequities that have been allowed to develop require urgent attention.