Increasing funded ACRRM training places will bring highly skilled First Nations doctors to rural and remote communities.

In a strong sign of confidence in the College’s Fellowship program and under a supportive program from the Department of Health and Aged Care, ACRRM has exceeded its current registrar quotas under both the Australian General Practice Training (AGPT) program and the Rural Generalist Training Scheme (RGTS), by 10% and 90% respectively, to achieve a total intake of 350 registrars.

Building on this achievement and supported by clear evidence of increased interest in the College Fellowship program, ACRRM now seeks recurrent funding to allow the College to train an annual intake of up to a total of 500 funded registrars across a single integrated pathway for the next five years.

The significant increase in interest in the RGTS in particular, is clear evidence that this is seen as an attractive career pathway which improves recruitment and retention of medical practitioners in rural and remote areas.  A further consequence of this increased interest is improved access to services and better health outcomes for rural and remote and Aboriginal and Torres Strait Islander people.

ACRRM Fellows are specialist General Practitioners trained to practise as Rural Generalists. The College has been delivering its bespoke medical training nationally for over a quarter of a century and has trained over a thousand rural doctors. It is a recognised national and international leader in all aspects of Rural Generalist practice.

ACRRM training is the best possible investment to build a long-term, highly-skilled, rural doctor workforce, with approximately 80% of ACRRM Fellows currently practising rurally. The 2023 national Medical Training Survey found nearly all ACRRM registrar respondents confirmed interest in rural careers; they were 50% more likely to do so than medical trainees on average; and 45% more likely than other general practice trainees. They were 18% more likely to be interested in First Nations health than other trainee doctors, and 13% more likely than other general practice trainees to be interested in training the next generation of doctors.¹

Increasing funded ACRRM training places will bring highly skilled First Nations doctors to rural and remote communities.  Improving First Nations health is implicit to any commitment to improving rural and remote healthcare. In rural and remote areas, First Nations peoples commonly represent a substantial component, if not the majority, of the patient population and they have particular socio-cultural and healthcare needs. 

From its inception ACRRM has included First Nation Peoples’ health in its core curriculum, assessment and training, and supported First Nations Peoples’ representation in its governance structures. The College consistently enrols above population parity numbers of First Nations doctors to its training programs with First Nations registrars currently comprising approximately 4% of all College registrars.

As Rural Generalists, our First Nations Fellows are uniquely positioned to offer care by First Nations doctors to First Nations communities, spanning the rural and remote hospital, retrieval service, GP clinic, and Aboriginal Community Controlled Health Service sectors.

Rural and remote training is complex and challenging. ACRRM programs support registrars dispersed across vast distances with minimal local facilities, training supervisors and colleagues. The College’s systems, expertise and networks are well developed, but while its relatively small size has ensured a specialised approach to designing and delivering fit-for-purpose training and support for registrars, there is the potential for the current quotas to impede potential expansion and discourage prospective applicants.

A single integrated, larger scale program will maximise the Government’s return on investment by building the critical mass to allow strengthened training, whilst maintaining the current rurally-focussed, registrar-centred approach.

A cohort of 500 funded annual enrolments would promote economies of scale and create a sustainable scope of training capacity to enable generational transfer to the future rural and remote workforce.  This would represent an increase of 250 annual funded training places and facilitate the unification of four discrete administrative programs under a single strong and integrated training pathway.

¹ Medical Board of Australia and Ahpra (2023) Medical Training Survey https://medicaltrainingsurvey.gov.au/Results/Reports-and-results

ACRRM contends that the Rural Generalist (RG) model of care is key to the delivery of the best possible healthcare services in rural and remote communities, including maximising the care that can be provided locally.

The Cairns Consensus definition of Rural Generalist Medicine describes the discipline as the provision of a broad scope of medical care by a doctor in the rural context that encompasses the following:

• Comprehensive primary care for individuals, families, and communities
• Hospital in-patient and/or related secondary medical care in the institutional, home, or ambulatory setting
• Emergency care
• Extended and evolving service in one or more areas of focused cognitive and/or procedural practice as required to sustain needed health services locally among a network of colleagues.
• A population health approach that is relevant to the community
• Working as part of a multi-professional and multi-disciplinary team of colleagues, both local and distant, to provide services within a ‘system of care’ that is aligned and responsive to community needs.²

ACRRM Fellows (FACRRMs) achieve a specialist general practice qualification and are trained to practise as Rural Generalists. FACRRM training, in addition to generic general practice education, includes mandatory training and assessment in obstetrics, emergency medicine, hospital inpatient care and population health.  An additional one to two years of assessed Advanced Specialised Training (AST) in a selected field is also required. All Rural Generalist assessment measures capacity to apply skills within the clinical context of rural and remote settings.

The joint application for recognition of Rural Generalist Medicine as a specialist field within general practice is now well advanced and a final determination by the Health Ministers’ Committee is likely to be made in 2024.

Should this be successful, this recognition would provide a consistent and clear basis for MBS item numbers and industrial awards which recognise the distinct training, assessment and professional development associated with the Rural Generalist scope. This could significantly add to the attractiveness of a Rural Generalist career and appropriately recognise and remunerate the Rural Generalist training and skill set.

² Murray R (2014) Cairns Consensus: International Consensus Statement on Rural Generalist Medicine. Retrieved at: https://ruralgeneralist.qld.gov.au/wp-content/uploads/2017/07/Cairns-Consensus-Statement-fd.pdf
² Australian Institute of Health and Welfare. (2022). Rural and remote health. Retrieved from https://www.aihw.gov.au/reports/rural-remote-australians/rural-and-remote-health

The College believes that the future Rural Generalist workforce should be trained by current Rural Generalists as much as possible. This includes the key training periods which are undertaken in rural general practice and other primary care settings.

All strategies to increase the interest in, and uptake of, careers in rural generalism and general practice are dependent on the availability of accredited and appropriately skilled and experienced supervisors for registrars who are undertaking the general practice placement component of their training.

This is also the case for other healthcare professionals such as Nurse Practitioners and Pharmacists, who could benefit from accredited Rural Generalist supervision and consultation arrangements as part of a multidisciplinary, team-based approach to the provision of care.

College members acknowledge the benefits provided by accredited supervision, not only of registrars, but also medical students and other healthcare practitioners. These include the overall enjoyment and rewards of teaching; the stimulation of new information and ideas that can be provided by registrars; and potentially securing a future workforce for their practices or for rural communities more broadly.

ACRRM is committed to providing high quality, contextually-based training for its registrars and strong support for its accredited supervisors. The College believes that the future Rural Generalist workforce should be trained by current Rural Generalists as much as possible. This includes the key training periods which are undertaken in rural general practice and other primary care settings.

There are a number of challenges associated with the recruitment of supervisors. The rural workforce is ageing and while there is a strong cohort of emerging Fellows, there may be shortfalls associated with the retirement of existing supervisors before the new influx is ready to replace them.

The challenges of rural and remote general practice have increased over time, with increased imposts in workload and associated implications for practitioner wellbeing, administrative burden, and practice costs which have not been adequately reimbursed through MBS and other funding arrangements.  There is an intrinsic undervaluing of the clinical consultant role of the supervisor in private and community clinics, relative to non-GP specialist consultants performing similar roles in hospitals. This is particularly relevant in rural and remote areas where the supervisor is one of few readily available clinical consultants.

In some cases, the ongoing challenges are resulting in supervisor retirement or scaling down of activities earlier than previously anticipated, with the associated inability to take on the additional work and responsibility required of registrar supervision. This includes the necessary professional development which often requires time away for the earning capacity of general practice.

The role of Rural Generalist and general practice supervisors goes beyond merely supporting learning and ensuring patient safety. It extends to taking on a clinical consultant advisory role, where the supervisor may be called on to draw on their advanced clinical knowledge and experience to advise, and on appropriate request, take over the management of a patient in the same way that a consultant in a hospital might advise an intern or junior doctor. A similar situation could occur where an ACRRM-accredited Rural Generalist is called on by a Nurse Practitioner or other healthcare professional, to provide management or advice in a clinical consultant capacity.

These clinical consultancy services are critical to the provision of safe, high-quality care in rural and remote areas in addition to enhancing registrar knowledge, but the current MBS delineations are in need of review to ensure they fully acknowledge the time and skills of the supervisor or appropriately accredited Rural Generalist in this important area.

The College acknowledges the existing support provided to general practice supervisors and practices; however, given the workforce and financial imperatives, additional recognition for supervisors is warranted. The potential for accredited Rural Generalists to provide specialised clinical consultancy advice and management in specific situations should also be investigated. This additional individual support would provide recognition for the clinical consultancy skills provided by supervisors, with the intention of retaining existing, and encouraging new, supervisors.

To inform a broader review and provide some indications of costings, ACRRM recommends that initially several pilot sites be established in communities located in MMM 4 and above, with priority given to sites to which it has historically been challenging to recruit both supervisors and registrars.  The pilots could provide additional incentives for accredited supervisors who could provide supervision either face-to-face or remotely under certain circumstances, with registrars motived by the availability of better support and the availability of a skilled supervisor.

As part of the strategy to support a strong end-to-end medical training framework, additional programs should be funded to generate interest in medical careers and support students along these career pathways.

These programs should start in secondary school and continue through to university.  They should target students from a rural and remote background, noting that these students are more likely to return to a rural medical career.

Currently there is a continuity gap in terms of programs to inform and provide ongoing support to rural secondary school students through their pre-tertiary journey. There is a particular need to inform students about Rural Generalist Medicine and encourage them to consider this as an interesting and rewarding career path. Many rural students do not have medical role models within their family or wider contacts. Consequently, they either do not consider Rural Generalist Medicine as a career path because they are unaware of its existence, or because they believe that it is unattainable within their particular circumstances or context.

To be effective, a program must be appropriately funded; based on strong local relationships appropriate for local circumstances; and provide continuity of contact and support for students throughout their high school years and beyond.

An ACRRM-led project implemented in collaboration with key stakeholders, would provide a seamless training pipeline from rural secondary education through to Rural Generalist training with the College.

ACRRM has staff and members, including First Nations members, living and working in rural and remote locations across the country. They are at various stages of their careers, with diverse backgrounds and experiences. The College is able to leverage these networks, together with its range of community and stakeholder contacts, to engage directly with rural and remote school students and provide advice and guidance, as well facilitating access to as role models for the next generation.