New models of training are gaining traction among registrars, but the path is still unclear for those who want to continue working across settings post-fellowship.
Single employer models for GP and rural generalist registrars don’t appear to be going anywhere soon – but they’re no panacea for the primary care workforce woes.
Last week, GP and rural generalist leaders gathered in Emerald, Queensland, for a forum on the training model hosted by veteran rural GP Dr Ewen McPhee.
Trials vary from state to state – sometimes even within states – but the basic premise of a single employer model is that a GP or rural generalist registrar retains one employer across fellowship training placements.
More often than not, that employer is a state health service and the rotations involve a mix of hospital-based and community GP-based training within one rural or remote region.
It’s largely sold as a win-win; registrars get to retain the same pay and entitlements as a hospital-based trainee, and underserviced regional areas receive doctors and reduce reliance on locums.
“It is just a tool, and it’s not going to be for everybody,” Dr McPhee told The Medical Republic.
“It’s not going to solve global warming or all the world’s problems, but it gives us another tool to enable better access for clinicians to training and gives them visibility of primary care as well as hospital-based care.
“The clinicians in my town have all got fractional requirements between hospital and general practice now, working across that continuum.”
Right now, he said, the model being run in South Australia’s Riverland district was the strongest example of a single employment model nationally.
The program, which is connected to the Riverland Academy of Clinical Excellence, has produced a 98% retention rate and increased the region’s medical workforce by 25%.
“There’s been a real fundamental shift in thinking around how you build and structure rural hospitals and rural medical workforce around primary care, rather than centring everything on the hospital,” Dr McPhee said.
“[Riverland is] the most mature one of the [single employer models], and it’s revealed some significantly positive outcomes … [as well as] increased its attraction of medical students in their pre-clinical years, and then their clinical years, so that they actually have waiting lists now for GPs and for medical students and registrars to join their program.”
Interest among registrars and pre-vocational doctors may be on the up, but that is not to say that there are no lingering questions.
“You’ve got GPs working in a hospital system who are coming out to work in a general practice, but want to maintain their full entitlements with the hospital,” Dr McPhee said.
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“And this is what we call the post-fellowship single employer model, and that is a lot of work to think about.
“If a registrar has just gone through fellowship and they don’t really want to work privately, but they’re happy to have a fractional role, then what does that look like?
“We’re still trying to think that through at the moment.”
Central West Queensland is the only jurisdiction in the country to have a working post-fellowship single employer model, which came about after market failure forced all privately-owned GP clinics in the region.
“The challenge is we don’t necessarily want to go down the path of the state governments running all general practice in each state,” said Dr McPhee.
“It’s trying to understand how we maintain and grow traditional general practice in the face of [challenges to] viability, accessibility and other matters for rural communities.
“I think there’s been a real retreat of viable general practice from rural and remote areas, and in western Queensland that has absolutely been the problem – nobody ever works as a GP exclusively or owns a practice.
“The response in Central West Queensland is a response to the failure of general practice, but I really don’t think we should be planning on going 100% down that route either.”
ACRRM president Dr Rod Martin, who attended the Emerald forum, said single employer models have good potential, but must be flexible enough to meet the needs of individual rural communities to ensure long-term success.
“The success of these models depends on collaboration with rural communities, training colleges, and local practices to ensure they truly strengthen, not weaken, the rural health workforce,” Dr Martin said.
“We look forward to learning from the trial outcomes—both positive and challenging—and working with stakeholders to ensure these initiatives lead to lasting improvements in rural healthcare.”
