AMA submission on the GP Rural Incentives Program redesign and on opportunities for junior doctors to train in rural areas

7 Jan 2015

Thank you for the opportunity to comment on the application of the Modified Monash Model (MMM) classification system to the General Practice Rural Incentives Program (GPRIP), and what strategies could be pursued to provide exposure to rural general practice for junior doctors.

From the outset, it must be highlighted that the AMA is providing these comments on the basis that the new MMM classification system and reforms to GPRIP will not be used to reduce overall funding for GPRIP. While it may be possible to use the funds more effectively, this is not an area where we can afford to diminish our effort. 

We would also make the observation that, in the absence of specific scenario modelling or advice on funding parameters, it is very difficult to give informed advice on the questions that have been put to us. We would recommend that the Panel, after considering the submissions, undergo a further round of consultation with stakeholders that can focus on more specific options that have been modelled and costed. 

For many years there have been significant concerns over the sustainability of the rural medical workforce and the obvious adverse implications for the health of rural Australians. Many rural and remote communities are finding great difficulty in attracting and retaining doctors with the right mix of skills, including procedural skills, to meet their health needs. 

It is now well known that under the  Australian Standard Geographical Classification - Remote Area (ASGC-RA) classification system (used to determine the level of incentives available to doctors who relocate or continue to practise in regional, rural and remote areas), numerous large and well-serviced regional cities are classified as being more remote than many smaller rural towns. 

The AMA welcomes the reform of the geographic classification system to remove much-criticised anomalies and develop a fairer model for determining incentives that will encourage a strong rural medical workforce to better meet the health needs of Australians living in rural and remote areas, particularly those in small rural communities. We believe there is an urgent need for targeted supports that provide appropriate financial and non-financial incentives for doctors to live and work in rural and remote areas. The introduction of the MMM and reform of GPRIP is one component of this.

The application of the Modified Monash Model classification system to the GPRIP

The AMA supports the Modified Monash Model classification system, which appears to be strongly evidence-based, incorporating other factors such as population size in classifying rural communities. We believe the introduction of the MMM classification system will allow better differentiation between locations, which are currently considered equivalent for incentive purposes but which have very different service level challenges. Importantly, this approach would allow funding to be reprioritised towards smaller locations and more remote areas, and address many of the concerns of the ASGC-RA system. 

According to the Mason review of Australian Government health workforce programs, continued support for rural doctors, including targeted financial incentives, should remain a key component of the Government’s health workforce strategy to address the serious ongoing maldistribution of health professionals. 

In this regard, the redesigned GPRIP must have as its key focus the attraction and retention of doctors to rural and remote towns, be simple to understand and to implement, and must give a clear signal that doctors who work in rural and remote areas are valued. It must prioritise incentives so that the more isolated the practitioner the higher the incentive payment provided, and ensure that grants are fairly allocated according to need. 

However, any reforms must also recognise that GPs have made business decisions based on current incentive programs. The reforms will be more effective and win broader support if they are backed by appropriate transition arrangements for GPs and registrars already practicing under the current programme. For example, for areas that might transition from an ASGC-RA classification to a lower MM classification, there should be grandfathering arrangements to ensure that they do not face the immediate loss of incentives. 

In order for the programme to have the greatest impact, it is important that incentive payments are indexed annually to keep pace with cost of living increases and are granted tax free status.  

As outlined in its Regional/Rural Workforce Initiatives 2012, the AMA believes there are five key priority areas in which the Government could act to help attract medical practitioners and students to regional and rural areas. These are:

  1. provide a dedicated and quality training pathway with the right skill mix to ensure GPs are adequately trained to work in rural areas;
  2. provide a realistic and sustainable work environment with flexibility, including locum relief;
  3. provide family support that includes spousal opportunities/employment, educational opportunities for children’s education, subsidy for housing/relocation and/or tax relief;
  4. provide financial incentives including rural loadings to ensure competitive remuneration; and
  5. provide a working environment that would allow quality training and supervision. 

It is important that the redesigned GPRIP operates in a complementary way to these principles. 

While the AMA supports the broad thrust of the GPRIP, it is aimed primarily at GPs and does not sufficiently assist rural and remote areas to access other specialist medical services. In this regard the AMA and the Rural Doctors Association of Australia (RDAA) have developed a comprehensive proposal for financial incentives to encourage GPs, other specialists and junior doctors to work in rural and remote areas.

This is known as the AMA/RDAA Rural Workforce Rescue Package. This would require additional funding, if it were to be implemented. Nonetheless, it includes some important principles that are relevant to this review. In particular, it recognises that incentives need to be properly structured so that they recognise the isolation of rural and remote practice as well as the need for the right skill mix in these areas. It proposes a two-tier incentive model consisting of:

  • a rural isolation payment to be paid to all rural doctors (including GPs, specialists and registrars) to reflect the isolation associated with rural practice; and
  • a rural procedural and emergency/on-call loading to better support rural procedural doctors. 

Efforts to attract and retain doctors to rural and remote areas could be significantly enhanced with the adoption and implementation of the AMA/RDAA Rural Rescue Package. 

In responding to the specific questions posed in the GPRIP discussion paper the AMA provides the following comments:

Retention Payments

1. Who should be eligible for GPRIP payments under the Modified Monash Model?

All doctors in MM 2–7, with a stronger emphasis on encouraging doctors to MM 4-7 areas. Consistent with the AMA/RDAA Rural Rescue Package, we recommend that the Panel explore the feasibility of structuring the payments in such a way that they not only recognise the isolation of rural and remote practice, but also the need for the right skill mix. 

2. When is a suitable time to commence retention incentives?

Retention incentives should be commenced after 12 months for all categories except registrars, who derive benefit from the existing 6-month payment in the first year. 

3. How frequently should retention incentives be paid?

Retention incentives should be paid quarterly. 

4. Should the current policy of scaled incentives be maintained? If scaled incentives continue, at what point should they reach a maximum?

Scaling (by years of service) should be replaced by a flat rate with escalating significant lump-sum bonuses at five year intervals. However, in the case of registrars, scaling payments are useful to encourage rural training. 

If scaled incentives continue, the current maximum at five years should be retained. 

5. Should the current minimum and maximum billing thresholds be revised?

We understand that the current thresholds have not been indexed for 13 years, which brings into question their relevance. Consideration should be given to indexing these thresholds to ensure that GPRIP remains targeted at doctors who can deliver sufficient services to meet local community need. 

If a decision is taken to extend GPRIP to doctors who do not bill Medicare, then a proxy measure of service will need to be determined. 

Currently GPRIP includes a flexible payment system (FPS) for those doctors, such as GP Registrars, whose services (and/or training) are not adequately reflected in Medicare records. This payment system should be retained. 

6. Should retention payments be limited to doctors who live in rural areas?

GPRIP incentives should continue to be based on the practice location. 

7. How long do you think GPRIP payment levels should be maintained for doctors who take extended leave from their rural practice?

The AMA maintains that it would be reasonable to allow leave of up to five years before reverting to the lowest payment level when/if a doctor returns to rural practice. We suggest a staged decrease in payment levels for periods of absence less than five years. For example, if a doctor is absent for 2 years the payment level should fall by one year level, for an absence of 3 years the payment level should fall by two year levels, and so on. 

Extended leave provisions should remain for upskilling and secondary training and other, approved, special circumstances. Extended leave provisions for maternity leave should be broadened to also include paternity leave. 

8. Do you agree with the current Medicare services that contribute to the quarterly billing calculation?

It is vital that recognition of non-Medicare hospital services delivered by GPs be included when calculating incentive payments. 

9. Do you agree with current policy to determine payment rates for doctors working in multiple locations?

A more accurate assessment would be to calculate the percentage of services provided in each location and provide incentive payments accordingly. However, the AMA acknowledges that this would also complicate the understanding and administration of payments. 

Relocation Payments

1. Do you think that relocation grants encourage doctors to move to a rural or remote location?

It may help to reduce the financial disincentive to relocating for the more remote categories. However, for the less remote categories, or when moving from a less remote category to a more remote category, when taxed, the payment may barely cover the costs of relocation.

The Mason review of Australian Government health workforce programs found that only 33 doctors qualified for relocation payments in 2011-12, against a target of 70, citing the strict eligibility requirements (including the need to apply for the relocation incentive prior to commencing work at a rural location rather than seeking these funds retrospectively) and a frustrating and overly bureaucratic process, as reasons for the limited uptake.

The Mason review also highlighted the need to address the fact that around 50 per cent of applicants who received initial approval for relocation incentives then withdrew from the programme, primarily due to them not meeting the minimum level of service requirements in order to receive their first and second grant payments.

The AMA is of the view that relocation grants should be repaid if relocation occurs for less than five years. 

2. What categories of the Modified Monash Model should be deemed eligible for relocation grants?

MM 3-7. 

3. Do you agree with the current eligibility criteria for relocation grants?

The AMA disagrees with the unfair requirement that overseas trained doctors must have completed the 10 year moratorium to be eligible for a relocation grant. The AMA does not support the 10 year moratorium on Medicare provider numbers for international medical graduates and has called for its abolition in favour of a robust package of incentives and support mechanisms to encourage locally trained doctors and appropriately skilled IMG doctors to voluntarily consider a career in regional and rural Australia. 

4. Do you think the current locum rule is fair?

No. This rule potentially excludes doctors genuinely interested in rural and remote practice who have used locum work to assess whether one or more locations are suitable for them to settle in permanently. 

Strategies regarding the provision of rural exposure for junior doctors 

The AMA welcomes the commitment as part of this review to look closely at the value of exposure of junior doctors to rural practice. It is important that we have a strong rural and regional generalist and specialist workforce to meet the health needs of Australia. 

Prevocational training

One of the major programs providing exposure to rural general practice for junior doctors was the Prevocational General Practice Placements Program (PGPPP). The Government’s decision to cease the PGPPP from 1 December 2014 has effectively withdrawn the Commonwealth from any role in providing support for junior doctors to work in general practice before they choose a vocational training pathway. 

While concerns about the costs and utility of the PGPPP were being discussed for some time, the PGPPP was a valuable program for many reasons. It supported efforts to deliver more training and care in the community, supplementing the traditional hospital based approach to medical training. Through careful targeting, it also boosted access to GP services in rural and remote communities. 

While some might suggest that oversubscription to the AGPT GP registrar training program is evidence that PGPPP is no longer needed, we should not underestimate the need for prevocational doctors to have exposure to general practice. 

The PGPPP gave junior doctors a valuable insight into life as a GP and informed their career choice. While it encouraged some participants to enter GP training, it also helped others to decide that general practice was not for them. Both are equally valid objectives, with the latter helping to avoid the investment of Commonwealth resources in people who enter and then later drop out of the GP training program. 

The program also helped build an understanding of how general practice works, and this informs future practice in other specialty areas. With a deeper appreciation of the role of GPs, other specialists can make better decisions about patient care and work more closely with their GP colleagues. 

The loss of PGPPP rotations also has the potential to place even more pressure on access to prevocational training places for PGY2 and PGY3 doctors in the hospital sector. The AMA understands that a number of state/territory Governments are looking to continue supporting a limited number of PGPPP type places, particularly in rural and remote areas. This is a welcome move, although we would prefer a more structured, national approach. 

We recommend establishing a new program to support prevocational doctors with exposure to general practice. Any funding model should support the placement of prevocational doctors in general practice, including support for supervision appropriate salaries. Access to A1 Medicare rebates should also be permitted. In relation to the latter, this would encourage the involvement of practices and, from a health financing perspective, ensure that patients are treated equally regardless of whether they see a prevocational trainee, GP trainee or fully qualified GP. 

We think that it is possible to develop a more cost effective model than the former PGPPP programme, enabling  prevocational doctors to provide patients with much needed services, particularly in regional and rural Australia. This represents a better option than continuing to rely on international medical graduates to fill these gaps in services. 

The AMA would be very pleased to work with the Government to develop a new model/s to provide junior doctors with prevocational experience in general practice, particularly in rural areas. Funding for a new model/s must be new funding and not funding taken away from pre-existing programs or funding commitments. 

Specific attention must also be paid to ensuring there are sufficient numbers of supervisors and that they are well supported. Reports suggest that the supervisor pool in general practice is approaching, if not at, capacity and is under increasing strain from increasing supervisor commitments for medical students and GP registrar training. To enable sufficient numbers of practices to be recruited to training and supervision roles, measures such as infrastructure support grants are needed to improve infrastructure in general. 

Specialist training

Alongside this, there is an urgent need for the development of models for regionally based specialist medical training that meets the needs of regional and rural communities and provides a valuable and meaningful career pathway for junior doctors. Available evidence shows that one of the most effective policy measures to address rural workforce shortages is the delivery of training in rural areas. 

The AMA has recently released a positive proposal for the development of Regional Training Networks (RTNs). The AMA is calling on all Australian governments to collaborate on the creation of RTNs to maximise resources and expertise to produce a high level medical workforce in sufficient numbers to meet the future healthcare needs of rural and regional Australian communities. 

The AMA would like to see Federal Government agencies and Learned Colleges implement vertically integrated models of prevocational and vocational training in regional and rural areas, including through networking of health services and regional training hubs for generalist and specialist training. 

Government funding for innovative models of medical training must be prioritised for the implementation of RTNs and for the number of accredited regionally based generalist and specialist medical training places to be increased. 

This would be one part of a comprehensive set of policies to address regional and rural workforce shortages, including the development of an advanced rural general practice training pathway, and incentives for rural trainees to train and live in rural centres. The development of RTNs will help to promote careers in regional and rural centres and improve patient access to medical care. 

While many medical students have positive training experiences in rural areas, prevocational and specialist medical training often requires a return to metropolitan centres. At this point many trainees develop personal and professional networks that are important to their future life and career path and are less likely to return to practice in rural areas. RTNs would enable junior doctors to spend a significant amount of their training in rural and regional areas, and only returning to the city to gain specific skills. They would build on the investment we have already made in training medical students in regional centres and extend that to trainee prevocational and specialist doctors.  

We currently recruit almost a quarter of medical students with rural backgrounds and almost a quarter of Australian students go through Rural Clinical Schools. HW2025 projections indicate that we are now training sufficient numbers of medical graduates to meet the community’s health care needs. We now need to develop effective training pathways to convert them into a well-distributed workforce for the future. 

An example of a Regional Training Network is the South West Victorian Regional Training Hub (WVRH), which was established by the Royal Australasian College of Surgeons (RACS) for general surgery. 

Using the principle that people trained in regional areas are more likely to remain or return to regional areas, the Hub involves four regional hospitals - Geelong, Ballarat, Warrnambool, and Hamilton. 

Metropolitan partnerships have been developed with St Vincent’s Hospital and the Alfred Hospital providing further specialised rotations.

Thank you for the opportunity to make this submission.