There is a definite crisis in general practice at the moment in Australia. Fewer and fewer young doctors are choosing general practice as a career. There is increasing demand on general practitioners in the role. There is increasing demands on them in the government's expectation and in red tape. As a result, doctors are making the choice not to become general practitioners. Those of us who are general practitioners are finding that the numbers do not add up. The business model is failing, especially if that business model is centred on bulk billing. Whilst well-intentioned, a lot of the schemes that we see that are meant to help general practice in fact just create more red tape and more confusion. Sadly, they are creating a disincentive instead of an incentive.
3.1
Medical students are increasingly expressing interest in careers in non‑general practice specialisations and sub-speciality practice. The number of medical students expressing an interest in a career in general practice upon graduation has declined from 17.8 per cent in 2015 to 15.2 per cent in 2019, and the committee heard that this decreased from around 50 per cent over the past 30 years.
3.2
Throughout this inquiry the committee received evidence on the factors which influence career choice, in terms of deciding whether to become a general practitioner (GP) or other medical specialisation, and whether to practice in a metropolitan or non-metropolitan area.
3.3
This chapter discusses the key issues raised with medical education programs and training pathways, as well as other factors that influence the decision to become a GP and live and work in non-metropolitan areas.
Prevocational medical education and training
3.4
This section focusses on the 'prevocational' aspects of medical education and training. This refers to the time an individual spends at university as a medical student and following graduation the time spent training as an intern and resident. It discusses the following issues in relation to prevocational medical education and training:
the availability of Commonwealth Supported Places (CSPs);
the nature of the current prevocational medical education and training system; and
the lack of exposure to non-metropolitan clinical experience and general practice.
Commonwealth Supported Places
3.5
Medical students are generally accepted into university on a CSP. CSPs for university medical school places have fluctuated over the years. In 2009 the Commonwealth Government commenced removing the caps on the number of university places and from 2012 provided a place for every domestic bachelor student. However, caps were retained for medical degrees.
3.6
The current caps are set through agreements between the Commonwealth and universities through the 'Commonwealth Grant Scheme'. For 2022 there are 13 516 CSPs for medical programs at the undergraduate and postgraduate level. This is expected to rise slightly to 13 556 CSPs in 2023.
3.7
In relation to other primary health fields, such as nursing, midwifery, pharmacy and allied health professions, universities can choose how many CSPs they offer within their Commonwealth Grant Scheme funding.
3.8
The committee received mixed opinions regarding whether the current number of CSPs for medical degrees was sufficient. Some inquiry participants suggested that substantial increases in the number of medical graduates are required to ensure the future workforce, whereas others did not think that increasing the number of places available would solve the problem.
3.9
The Department of Health stated that the problem is not the number of medical students, but the decreasing number of students picking general practice. The Department of Health also clarified that the Government's goal is to have 50 per cent of domestic medical graduates become a GP.
3.10
The Department of Education, Skills and Employment (DESE) explained that the Government regulates CSPs in medicine to manage clinical training capacity, projected workforce requirements, and the impact on the health and education budgets. DESE further said that the Government is projecting a national oversupply of 7000 doctors by 2030.
3.11
While this figure relates to the total number of doctors, it is not broken down by medical speciality. For example, it does not state how many of those doctors are predicted to be GPs.
An education and training system focused on other specialisations
3.12
Inquiry participants informed the committee that the current medical education and training system is dominated by non-GP specialists, and that clinical exposure predominantly occurs in secondary or tertiary care settings such as hospitals.
3.13
The committee heard that most lecturers in medical school are non-GP specialists and that jurisdictional issues arise both in the employment of GP specialist training lecturers, as well as the clinical experiences medical graduates receive in a hospital setting.
3.14
Dr Toby Gardner, Lecturer in General Practice and Community Care, Tasmania School of Medicine, University of Tasmania, explained that:
The thing about GP teachers in universities is that they're all funded by the universities. All the universities are aligned to a hospital, and all the specialists are paid by the state government to work and do lectures and sell their profession to the students. If the universities are the ones having to cough up the salary of the GP, even though it's not much, they tend not to want to do it. So there are not a lot of GPs in universities, working in academic or influential positions.
3.15
Professor Lena Sanci, Chair, General Practice and Head, Department of General Practice, University of Melbourne, told the committee that there is a 'crisis of general practice leadership' and that nationally there are approximately seven professors of general practice that have retired and have not been replaced with junior staff.
3.16
Submitters and witnesses stated that while hospital-based training is important, the dominance of metropolitan based hospital training and the lack of exposure to general practice and community-based care in the early stages of study and professional life can act as a deterrent for choosing a career as a GP.
3.17
For example, Medical Deans Australia and New Zealand submitted that:
Medical students and prevocational trainees need to be learning in all the environments where health care is provided, and be able to envisage a rewarding and fulfilling career in community-based practice. Longitudinal and well-supported clinical experiences in non-hospital environments allow students and prevocational trainees to apply and further develop their skills in a range of settings with a diverse patient mix, particularly as these are the settings where we need more doctors to be working. It also provides access to positive role models for students and trainees to aspire to. Put simply, you cannot be what you cannot see.
3.18
Professor Lucie Walters, Director, Adelaide Rural Clinical School, stated that in Australia, medical students could experience as little as two to six weeks of general practice training, whereas in other countries where general practice is required as a part of the internship period, almost 50 per cent of graduates are choosing general practice as a career.
3.19
Professor Michelle Leech, Deputy Dean of Medicine, Health Faculty, Monash University, also spoke to the committee about the influence hospital training has over student's specialisation choice:
I speak all the time to medical students in years 1, 2, 3 and 4, who say, 'I want to be a GP.' They really do. They love their GP term. But then it gets '[hospitalised]' out of them, to be completely honest with you. What happens is they then start to be what they see.
3.20
These inquiry participants were supportive of increasing the opportunities for medical students and prevocational trainees to gain exposure to general practice but emphasised that these experiences need to be a positive well‑support placement to encourage more people into the profession.
3.21
Several inquiry participants also noted that it is common for university students and prevocational trainees to be sent to busy or 'churn and burn' general practice clinics where the student has a negative experience as they are unable to fully experience general practice, or the student is seen as a burden to the clinician. The committee heard that this can turn people away from a career in general practice.
Outer-metropolitan, regional, and rural exposure
3.22
In addition to exposure to general practice, submitters and witnesses emphasised the need to increase the opportunities for medical students and prevocational trainees to gain experience of clinical settings in outer‑metropolitan, regional, and rural areas. They also raised concerns that these early experiences needed to be positive and well supported.
3.23
There is strong evidence which shows that junior doctors from regional and rural backgrounds are more likely to work and live in these areas. Numerous inquiry participants stated that one of the most effective ways to improve the distribution of primary health professionals is to provide positive training experiences in non-metropolitan areas and to support students with a rural origin with rural practice training opportunities.
3.24
Dr Toby Gardner reflected on his experience of being exposed to regional general practice and the positive impact this had on his career:
I was sent out of my comfort zone in South-East Queensland to Rockhampton, Gladstone, Bundaberg—places I'd never really spent any time in. As a vegetarian moving into the beef capital of Australia, I was really apprehensive, but it was the best training and inspiration I ever had, and it's what got me to love regional towns. So that exposure, I think, needs to start even at the undergraduate or intern level.
3.25
Similarly, Dr Ruth Stewart, National Rural Health Commissioner said:
You can turn a rural-origin student who has had six years of rural medical education into an urban doctor by giving them a year of internship in a metropolitan hospital. I put to you that we [are] haemorrhaging the investment that we are putting into the education of these young people by not providing them with rural internships and rural training opportunities. If we can significantly increase—double, triple—the number of internships in rural and remote communities for junior doctors, we would translate that 35 per cent into a much large cohort of rural doctors within four to five years.
3.26
Increasing the opportunities to train in outer-metropolitan, regional and rural areas has benefits in terms of the exposure to the lifestyle in these areas as well as critical practical skills, as the work conducted in these areas is often different to the work experienced in metropolitan hospitals. For example, Dr Sarah Chalmers, President, Australian College of Rural and Remote Medicine, described how:
To be a doctor in a remote area, you practise medicine differently to what you do in an urban area because you don't have specialists nearby. You don't have access to tests. I used to work out in a really remote community where it took three days to get a normal test result, whereas in the city you can get that back in an hour.
3.27
The committee also heard from several universities which are providing opportunities to students to participate in regional, rural and remote placements. These inquiry participants spoke of the importance of an integrated approach to training in non-metropolitan areas and immersion in communities to create positive training experiences.
3.28
For example, James Cook University (JCU), has an integrated approach to medical education and training. It supports students from regional areas from the commencement of a medical degree through to fellowship. Around 70 per cent of students admitted to the JCU medical program are from non‑metropolitan locations. The program provides medical students with extensive exposure to rural clinical practice (around 20 weeks), and as a result approximately 75 per cent of JCU medical graduates go on to work outside of major cities with around half pursuing training as GPs or rural generalists.
3.29
Several programs have been implemented at the Commonwealth level to increase the opportunities for medical students to experience general practice in outer-metropolitan, regional, rural and remote settings. One such program is the Rural Health Multidisciplinary Training (RHMT) program. The RHMT (funded by the Department of Health) currently has 21 participating universities and is targeted at medical, dental and allied health students.
3.30
The committee heard from several representatives of universities and other medical practitioners who participate in this program and were told of the success of this initiative. Associate Professor Lara Fuller, Director, Rural Community Clinical School, Deakin University, told the committee that students who have completed their RHMT longitudinal program based in rural primary care and then do a second rural clinical school year are seven times more likely to end up in rural practice.
3.31
In 2019, the Department of Health commissioned the consulting firm KBC Australia to conduct an evaluation of the RHMT. The evaluation found that the RHMT has been an 'appropriate response and important contributor to addressing rural health workforce shortage' and that the program had increased the number of medical students undertaking rural placements. The audit also found that there is 'considerable variability' in the quality of the placements and raised concerns about financial and accommodation support for medical students and the need for high quality supervision and mentorship.
General practice prevocational opportunities
3.32
Inquiry participants also discussed the impact of the cessation of the Prevocational General Practice Placement Program (PGPPP) in 2014. The PGPPP provided short-term supervised placements in general practice for prevocational doctors. Medical students on this program were placed into a rural community for two weeks per year for four years in an effort to encourage engagement with the local community and allow the student to experience life as a rural doctor. At the height of the program, up to 1200 placements were supported annually.
3.33
Following the Mason Review, the funding for the PGPPP was redistributed to the Australian General Practice Training program (AGPT) as there were concerns about the cost of the program and oversubscription to GP training.
3.34
The cessation of this program left general practice as the only major medical speciality without the ability to offer junior doctors a prevocational training experience before making a career choice.
3.35
In describing the loss of this program, the Australian Medical Association said it had the effect of reducing the 'legitimacy of the general practice' as a career choice.
3.36
Several witnesses spoke of the success of the program in supporting early exposure to general practice and general practice in rural areas. Witnesses commented that without the program there is a lack of funding and opportunity for prevocational doctors to gain these experiences.
3.37
A new program, the Rural Junior Doctor Training Innovation Fund (RJDTIF), was established to replace the PGPPP. The RJDTIF had a core and rural generalist funding stream. The Department of Health submitted that:
The RJDTIF was welcomed by those practices involved but does not provide the same level of funding to enable GP supervisors to provide such intensive supervision of juniors. It is limited to rural areas and at present provides places for fewer doctors.
3.38
Under the Stronger Rural Health Strategy, the John Flynn Prevocational Doctor Program (JFPDP), has been developed to provide prevocational training opportunities. The JFPDP will commence from 1 January 2023 and consolidates the RJDTIF.
3.39
It aims to increase the number of prevocational doctors gaining experience in rural areas and is eligible to doctors in their first five postgraduate years. The JFPDP will support 440 rotations in rural hospitals in 2023, and this is set to increase to 800 rural hospital rotations by 2025.
3.40
Regarding this program and the impact of prevocational training opportunities, the AMA submitted that:
… the [John Flynn Prevocational Doctor] program will only provide up [to] 800 rotations by 2025. Australia currently graduates around 4,000 medical students per year. If more Australian graduates are to pursue general practice as a career, there must be more positive, structured exposure to general practice before doctors in training make decisions about their specialty.
Stigma in the medical community
3.41
The committee received evidence that general practice as a profession is viewed as 'lesser' within the medical community and the views of senior medical professionals can dissuade medical students from pursuing a career as a GP.
3.42
In discussing this issue, Dr Ameeta Patel, Committee Member, Central Coast General Practice Association said that the profession needs to hold itself responsible for the attitude that 'you're just a GP' and that the medical profession has 'a lot to answer' including the way that GPs are spoken about and treated by other medical professionals.
3.43
Several inquiry participants also reflected on their experiences in medical school and how they were told to be 'something special' and not 'just a GP'.
3.44
Many inquiry participants told the committee that the broader medical community needs to recognise the skills of GPs and the value of a career as a GP. For example, Dr Amanda Bethell, Flinders and Far North Doctors Association said:
… I do think that the biggest problem general practice has, at the moment, is the devaluing of it as a specialty, and that has come from all sorts of places. So the more undergraduate students get to see the cutting edge side of general practice—okay, we don't crack chests open in our GP surgeries, but how cool is it to be able to know somebody well enough to help them decide they want to stop smoking, to figure out what it's going to take for them to do that, such that they don't end up having a stroke, heart attack, lung cancer et cetera down the track that they would otherwise have had? How cutting edge is it to help someone finally lose the weight they've been trying to lose for 10 years and get their HbA1c down so that they're finally off half of their diabetes medications?
3.45
The committee also heard that the 'deficit' narrative around rural practice and living needs to change and that the positive stories about rural general practice need to be pushed. For example, Dr Megan Belot, President, Rural Doctors Association of Australia, spoke to the committee what rural general practice has to offer:
… to have the time to actually do the teaching, to take them on ward rounds, to take them in to assist to do the [caesarean], to get them to help when you are doing an intubation, to get the hands-on experience. As a rural doctor—or just as a doctor—that's what we crave, that's what we love about medicine. I think it's about making sure that the systems are robust, that there is adequate time and adequate remuneration for that to happen. You also look at the social side of being in a rural and remote community, because there is that other element.
3.46
The National Medical Workforce Strategy 2021-2031 (NMWF) recognises that there is a need for cultural change in the medical professional and that a stigma persists that working outside metropolitan areas is:
less intellectually satisfying;
representative of substandard practice; and
that practitioners in those areas are inferior to their metropolitan counterparts.
3.47
Priority four of the NMWF aims to 'shift the prestige and value perceptions of generalist practice' and 'will encourage colleges and societies to contribute to this through their curricula and training pathways'. It further notes that:
Medical leaders and the wider health system need to recognise the potentially long-term influence that their values and behaviours can have on the make-up, distribution and capacity of the medical workforce. It takes time for alternative views to influence sector-wide thinking, however participants in the Strategy consultations reported that doctors are increasingly prepared to call out unhelpful views and recognise the need for constructive change.
Vocational training – becoming a general practitioner
3.48
There are numerous pathways to become a vocationally recognised GP. The most common pathway is the AGPT which is offered through the Australian College of Rural and Remote Medicine (ACRRM) or the Royal Australian College of General Practitioners (RACGP) and is currently delivered by eleven Regional Training Organisations contracted by the Department of Health. It offers 1500 Commonwealth funding training places each year.
3.49
The number of applications to the AGPT has been falling for the past five years and in 2020 and 2021, 171 and 66 places were unfilled respectively.
3.50
The RACGP is allocated 1350 places and ACCRM is allocated 150 places. The AGPT has two pathways: a rural pathway and a general pathway. The rural pathway is designed for those wishing to practice in MM2–7. The general pathway is designed for doctors choosing to practice in inner and metropolitan locations. Participants in this program can train in any MM1–7 location.
3.51
Under the AGPT, 50 per cent of registrars must undertake training in MM2–7 areas. Despite this requirement there has not been an increase in the number of registrars returning to practice in these areas.
3.52
The committee heard of three core concerns regarding the current vocational training structure which act as a barrier to doctors deciding to become a GP. These include:
the lack of portable benefits from the public hospital system to private general practice;
negative perceptions of rural general practice; and
difficulties in meeting supervision requirements.
Portability of benefits
3.53
During a medical graduate's prevocational training as an intern and resident in the public hospital system they are employed by the relevant state government. If a medical graduate pursues training as a general practitioner, they transition to a different employment model, which results in a loss of employment benefits, such as annual leave, sick leave and maternity leave, among others.
3.54
The committee has received evidence that this employment model can deter people from specialising as a GP. As explained by Professor Lucie Walters:
… when you're in the hospital setting, you actually accrue long-service leave and, really importantly for women, you're eligible for paid maternity leave, but the way general practice training works at the moment is that you move every three to six months, and each time you move you have a new employer, so you don't even accrue annual leave in the time that you're employed … I know women who like the idea of community practice and have chosen to do paediatrics or gen med [general medicine] with a view to becoming specialists who work primarily in the outpatient consulting-room environment, but they do that because they can have their children while they're studying, with paid maternity leave, rather than leaving the security of a state-funded, employed position to go and spend four years as a casual employee, basically, with three months here, three months there, and no accrual of those.
3.55
Many inquiry participants noted that changes to the employment model, such as the introduction of portable benefits, may improve the number of doctors choosing to become GPs.
3.56
The Department of Health submitted information on two employment models that are currently being trialled. The Murrumbidgee Rural Generalist Training Pathway trial (supported by the New South Wales Government) commenced on 1 November 2020. It tests the feasibility of flexible employment arrangements between the hospital system and community primary care settings in MM4–7 locations. Five trainees have commenced training in the locations of Wagga Wagga, Gundagai, Temora, Cootamundra and Young. A maximum of twenty rural generalist trainees will take part in the trial over four years.
3.57
Additionally, the Commonwealth Government is providing $5 million for the Remote Vocational Training Scheme Extended Targeted Recruitment pilot. The pilot will test the success of wage equalisation by offering additional income support funding to recruit and retain doctors working in rural, remote and Aboriginal and Torres Strait Islander communities that have a medical workforce need.
Rural is lesser
3.58
Submitters and witnesses raised concern that in addition to the stigma about general practice there is an additional stigma about rural practice and the current structure of the AGPT program contributes to this issue.
3.59
JCU submitted that the Government's requirement that 50 per cent of students on the AGPT train outside metropolitan areas is a 'conscription' method and that lower ranking applicants for the RACGP Fellowship are 'generally allocated an unpopular and inflexible' rural pathway whereas higher-ranking applicants 'win the choice pick' of the flexible general pathway. JCU also highlighted that the features of the AGPT create a perception that 'rural is for losers' and that it makes rural GP training unpopular among domestic medical graduates and junior doctors.
3.60
Dr John Hall, Past President, Rural Doctors Association of Australia echoed these concerns and said:
We have been critical of the rural pathway in the past. The rural pathway is a part of Australian general practice training that unfortunately has seen a selection process whereby doctors that performed poorly or least well in their selection process were streamlined through the RACGP into the rural pathway. The rural pathway is geographically constricted, so when they go into the rural pathway they can't come back into the city. But it's created a two-tier system where there's a feeling within the industry that if you choose rural you're choosing substandard.
3.61
ACRRM also raised concerns about the current allocation of places between them and the RACGP. ACRRM submitted that:
[Department of Health] arrangements have restricted ACRRM to no more than 10% of the government-funded General Practice training places with 90% ear-marked for the RACGP. This has made it impossible for the College to grow its programs through the government’s funded national framework and to date 45% of trained ACRRM Fellows completed their training outside the nationally funded framework through its self-funded pathway.
3.62
Additionally, ACRRM has a strong track record of training rural GPs and retention of those GPs in rural. ACRRM told the committee that approximately 80 per cent of their fellows continue to practice rurally and over the past 15 years, of over 900 doctors who have received fellowship with the ACRRM, 75 per cent have remained in rural practice five or more years post‑fellowship.
Supervision requirements
3.63
The committee heard that it is becoming increasingly difficult for senior GPs to provide supervision for registrars given their high workloads and lack of appropriate renumeration for supervision. Additionally, poor supervisory experiences, particularly in regional, rural and remote areas where these issues are exacerbated, can shift GPs to metropolitan areas.
3.64
Dr Peter Rischbieth, President, Rural Doctors Association of South Australia, informed the committee of a recent survey they had conducted across 42 towns in South Australia. He said:
It was one of the saddest surveys that I've ever seen from country doctors in my 35 years. Practices were desperate. Communities were desperate for doctors to stay in their towns. Doctors were saying that they couldn't teach medical students and registrars because their clinical commitments at the hospital and their practices were so much ...
3.65
Inquiry participants stated that placing registrars in situations without adequate supervision can lead to negative experiences in rural general practice and doctors choosing to remain in metropolitan areas.
3.66
The committee also received concerns that the current payment structure for GP supervisors can deter senior GPs from supervising registrars. Dr Emil Djakic, estimated that a doctor's billings without supervision could be $1000 whereas if the GP is required to supervise and train students, that would likely reduce their patient contact for the day and therefore reduce income.
3.67
On 23 November 2021, the Transition to College-Led Training Advisory Committee discussed a plan for a 'National Consistent Payments Framework'. The framework proposed providing payments which increase according to Modified Monash Model classification system for supervisors, practices, and registrars participating in college-led training programs.
3.68
The NMWS recognises the need for positive training experiences and notes that 'investment may be required to increase the number of supervisors to enable training opportunities' particularly in regional, rural and remote areas. The NMWS also discusses the role that technology and remote supervision could play to assist registrars in meeting their training requirements.
Other factors influencing career choice
3.69
The committee heard that there are a range of other factors that influence a doctor's decision to become a GP and their choice of working in a metropolitan or non‑metropolitan location, including:
the current employment model and renumeration for general practitioners;
concerns regarding personal development and isolation.
Employment model and renumeration
3.70
As discussed above, following the prevocational period, if a medical graduate decides to train as a GP they transition to a different form of employment and lose access to benefits such as maternity leave, sick leave, and annual leave. The committee also heard that the current wage structure for GP acts as a disincentive to pursing this career.
3.71
GPs are one of the lowest paid of all the medical specialities. Inquiry participants informed the committee that a full time GP can expect to earn around $200 000. In comparison, other medical specialists, such as a specialist geriatrician in a hospital can earn up to $500 000, and consultant medical specialists can earn up to a million dollars.
3.72
Inquiry participants also stated that deciding to become a GP leads to a significant reduction in pay. The pay difference between a hospital doctor and a first year GP registrar can be upwards of a $50 000.
3.73
The committee also heard that many GPs face challenges in running their private practice and prefer to work as an employee in a private practice rather than establish their own business.
3.74
Many inquiry participants told the committee that the pressures of the lower salary are compounded with other factors, including, the increasing costs of running a practice can act as a deterrent to a career in general practice.
Lifestyle factors
3.75
Renumeration is not the only factor influencing the decision of GPs and primary health professionals to live and work in non‑metropolitan areas. Many inquiry participants noted that other factors such as work-life balance and workload, family considerations and access to appropriate housing were core considerations for where doctors ultimately decided to live and work.
3.76
The committee heard that GPs across the country are under increasing amounts of stress and pressure, and many are leaving the profession due to burnout.
3.77
For example, Dr Christopher Boyle submitted that he has had experience with several high-quality GP registrars who have chosen to leave the primary health care workforce to work in the hospital system as it less stressful and better paid.
3.78
ACRRM submitted that their registrars, in comparison to all general practice registrars, reported working 7.2 hours longer per week and were much more likely to report a heavy workload. They were also more likely to report living away from their families and report that their wellbeing was negatively impacted by overwork, unscheduled overtime and relocation.
3.79
In addition, the expectations around workload and lifestyles for medical practitioners are changing. Many more GPs are wanting greater work-life balance and are opting to work part-time rather than full-time hours to manage their workload. Further, many GPs no longer want to be on call for after‑hours services and are unwilling to undertake overtime to provide services to local hospitals or aged care facilities.
3.80
This issue was also raised in the context of regional and rural practice as many doctors have to overcome the 'tyranny of distance' to provide health care services. For example, the Local Government Association of Queensland submitted that in the Barcaldine Region:
The tyranny of distance between outlying communities is a key cause of fatigue for these doctors, where they are often forced to drive for hours into a rising sun, work a very busy clinical day and then drive for hours into a setting sun to return to Barcaldine.
3.81
Submitters and witnesses also told the committee that employment for partners and spouses, and appropriate childcare and schooling for children are key barriers for GPs moving away from metropolitan areas to live and work.
3.82
The committee also heard that the availability of appropriate housing and accommodation reduces with increasing levels of remoteness. In many rural and remote locations the housing market is in a state of disrepair and health professionals must often share accommodation facilities.
3.83
Dr Jerome Muir-Wilson, GP, Launceston Medical Centre, aptly summarised all the concerns relating to the disincentives to be a GP in a regional or rural area:
A lot of medical students coming through have got a lot of choice because of demand across the medical area. They can specialise in just the eye and be an eye doctor for $550,000, as an average, as a kidney doctor for over $300,000 or as a GP for $150,000; I went through public school, but most of the doctors that I trained with went through private schools and don't want to live somewhere where they can't adequately school their kids and somewhere where, unless they're married to a doctor, like me, their wife can't find employment. In general practice in rural areas, you can't overcome schooling, housing and employment. You've got to have a really big carrot, and there are baby carrots out there for working in rural areas.
Isolation and professional development
3.84
Another factor which influences the decision for GPs to stay in metropolitan areas is the perception of a lack of professional development in regional and rural communities as well as the isolation that professionals face in more remote communities. Several inquiry participants noted that primary health care works best when there is collaboration among all sectors of the primary health workforce.
3.85
For example, Mr Ken Griffin, Chief Executive Officer, Australian Primary Health Care Nurses Association, told the committee:
I think one thing that's worthwhile noting here is that government policy frequently focuses on general practitioners, not general practice, and that forgets about the team in which they work. Importantly, none of the doctors who have spoken here today will tell you that they prefer to work in isolation, professionally or personally. As you get further outside the city areas, the acute professional isolation they have is quite astounding and directly contributes to us losing them from some of those vital areas. So I would say that we need to be focusing very much on the team aspect there.
3.86
On the issue of isolation, Ms Cathryn Blight, General Manager, Regional Services, Novita, also said:
… Isolation is another big thing that prevents people from moving into regional and remote areas. That would be the same, I imagine, for GPs and their families. One of the other things we try and address in our teams is that they all want to work as part of a team and feel like they have a team around them that is supporting them. That isolation is critical to that. I can imagine that GPs would be more likely to move into some of these regional and remote areas, like Wudinna, if they knew that there was this vibrant team around them that were all working, with their different backgrounds and perspectives, to bring real health outcomes to that community. Who wouldn't want that?
Committee view
3.87
GPs are the cornerstone of Australia's health system. They are often the first point of call for primary health needs and help to prevent serious illness, reduce avoidable presentations at hospital, and improve health outcomes for their patients.
3.88
There are a myriad of factors which influence an individual's career choice and decisions about where they will live and work, including personal preference. However, it is clear that the current culture and education and training environment is actively playing a role in dissuading individuals from becoming a GP and living and working in outer‑metropolitan, regional, and rural locations.
Commonwealth Supported Places
3.89
The committee received conflicting evidence as to whether the number of CSP for medical degrees should be increased. On the one hand, the Department of Health advised that the problem is not the number of medical students but the decreasing number of students choosing to specialise in general practice. Moreover, predictions from the Department of Education, Skills and Employment indicate that by 2030 Australia will have an oversupply of 7000 doctors.
3.90
On the other hand, several universities submitted that an increase in the number of medical graduates is required to ensure future demand and called for an increase in the number of CSP for its university.
3.91
The committee has also heard throughout this inquiry that Australia is over reliant on international medical graduates and that the Government has a goal to reduce this reliance. It is not clear if the projected oversupply of doctors considers the Government’s desire to reduce Australia's reliance on international medical graduates.
Education and training of medical students
3.92
The committee notes that the current education and training system is dominated by non-GP specialists and that clinical exposure predominantly occurs in metropolitan hospitals.
3.93
The committee heard anecdotal evidence that medical students are commencing their studies with the desire to specialise in general practice, but years into their degree, this gets 'hospitalised out of them'.
3.94
All evidence to the committee indicates that a lack of exposure to community‑based care and general practice is limiting the ability for medical graduates to experience work in these fields and ultimately impacting on the number of medical students who choose a career in general practice.
3.95
If Australia is to have a strong primary health care system, the education system needs to ensure that all medical students can learn about and experience primary care. As a result, the committee recommends that a review of the medical education curriculum take place.
3.96
The committee recommends that the Department of Education, Skills and Employment, in collaboration with universities, reviews the primary care components of the medical education curriculum, with a view to ensuring that general practice is a core component of the curriculum.
3.97
Similarly, the lack of exposure to primary health care settings in regional and rural environments is also concerning. The committee received overwhelming evidence that one of the most effective ways to increase primary health practitioners in regional and rural areas is to design integrated models to support students from regional and rural areas, and those with rural interest, to have immersive placements and clinical experiences in those areas.
3.98
The committee commends the success of previous prevocational training programs, particularly the John Flynn Placement Program (JFPP). While supportive of the new JFPDP, the committee is concerned that it may not include all successful elements of its predecessor. The committee notes that the JFPDP is due to commence in January 2023 with 440 rotations to rural hospitals and up to 800 rotations by 2025. It is further concerned that 800 rotations is a far cry short of the 1200 placements previously offered under the JFPP.
3.99
The committee agrees with the view of the Australian Medical Association, that if more medical graduates are to pursue a general practice career, there must be more positive and structured exposure to this career path. The committee considers that the program should be significantly expanded to enable more of the 4000 medical students per year to experience general practice in regional and rural settings.
3.100
The committee recommends that the Department of Health expands the John Flynn Prevocational Doctor Program and re-instates the John Flynn Placement Program aimed at attracting medical students to rural and regional general practice.
3.101
The committee is concerned about the current structure and pathway to become a GP, including opportunities to gain exposure to clinical practice in outer-metropolitan, regional and rural areas.
3.102
The committee has heard about the negative perceptions of the rural pathway for registrars in the AGPT program. The committee notes that the Royal Australian College of General Practitioners receives 90 per cent of Commonwealth funded places available under the AGPT whereas the Australian College of Rural and Remote Medicine receives 10 per cent.
3.103
The committee notes that the current funding model appears to be inconsistent with the Government's policy position to increase the numbers of GPs training and working in non‑metropolitan areas.
3.104
The committee commends the Australian College of Rural and Remote Medicine for their success in delivery training in rural and remote communities and the retention of registrars in these areas post-fellowship.
3.105
The committee recommends that the Government investigates the adequacy and suitability of the Australian General Practice Training placements allocated to the relevant general practice training colleges.
Employment model and other factors
3.106
The committee has discussed at length the impact of the current income level of GPs, particularly in relation to current Medicare rebates.
3.107
The committee also notes that there is an issue in the training pipeline where medical graduates lose their entitlements if they decide to leave the hospital system and become a GP.
3.108
The committee would like to receive further evidence about how portable entitlements and a single employer model could work to improve the numbers of medical graduates deciding to become a GP.
3.109
The committee also acknowledges that while income level is important, it is not the only consideration for professionals when deciding to practice in an outer-metropolitan, regional or rural area. Lifestyle factors including work-life balance, family considerations (such as employment for partners and spouses and education for children), along with feelings of isolation and limited professional development can sway people to remain in metropolitan locations.
3.110
Many of the current Federal Government incentives to increase the number of primary health professions to outer-metropolitan, regional, and rural areas focus solely on the income side of the equation and do not provide appropriate consideration to other factors.
Stigma about GPs and rural practice
3.111
The committee was saddened to hear that a career as a rural GP was viewed as lesser in the medical community and among some of the professionals choosing to become a GP.
3.112
The committee also notes that there is a deficiency narrative and negative perception of working life in regional and rural communities. Working in these communities does involve challenges not faced in metropolitan areas but regional and rural areas have strong communities and lifestyles, and these benefits are not being recognised or promoted.
3.113
The committee supports the goals of the NMWS which calls for greater leadership and cultural change within the medical community to support the value of GPs. It encourages all of those within the medical community to reflect on their influence on new medical graduates and the importance of general practitioners.