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The RACGP strongly supports the role of nurses in general practice, and has undertaken a project with the Royal College of Nursing Australia (RCNA), to investigate the educational needs of General Practitioners and nurses in general practice. 37
It is not appropriate or effective for health outcomes or workforce utilisation to use nurses in general practice in place of providing the community with effective access to general practitioners. Nor is it acceptable to use general practice nurses to stream patient care where this has the effect of reducing health care access or outcomes. 
The opportunities to improve patient care and workforce and financial outcomes through the increased use of nurses and non-GP staff can be best achieved where they support and enhance the role of GPs. The NSW Health Department has considered the role of the GP and allied health staff in multi-disciplinary teams and supports the position that the role of GPs as the leaders and coordinators of general practice care needs to be maintained. The NSW General Practice Policy states:
“General practitioners’ daily work gives them a good understanding of the patterns of illness in the community, the networks of care, and weaknesses in community support systems. General practitioners are also in an ideal position to act as advocates and coordinators of care and to contribute to population health outcomes.”
Cheek, et al, showed in their study that consumers also do not wish to have direct access to GPs limited, unless the patient chooses this. These authors also report that consumers do not want nurses to be responsible for diagnosing ‘life threatening or serious conditions’. They report that consumers, although having misconceptions and gaps in their knowledge around the actual and potential roles of nurses in General Practice, see nurses as adding value to General Practice by carrying out a limited number of roles. Cheek et al report that:
“For follow up nursing after a doctor’s visit, e.g. dressings or removal of stitches, (consumers) want this to be an MBS item or incorporated into the cost of the initial doctor’s visit.” 
In a systematic review of research on changing the skill-mix of the health care workforce, Sibbald, Shen and McBride conclude that some outcomes of care provided by nurses in primary care may be good and that satisfaction with nurses was generally high. However they also concluded that:
“Compared with doctors, nurses had longer consultation times, carried out more investigations and often recalled patients at a higher rate so eliminating net savings in salary costs. From the perspective of the health economy as a whole, it was generally cheaper to train nurses than it was to train doctors; but savings were again eroded because nurses tended to have lower lifetime workforce participation rates than doctors.”
Additionally, Horrocks, Anderson and Salisbury, in their review of the research on nurse practitioners in primary care indicate that none of the studies reviewed was adequately powered to detect rare but serious adverse outcomes, and there are a number of methodological limitations in the studies reviewed. 
Nurses in general practice can be distinguished from nurse practitioners. The research around the role of nurses and nurse practitioners is conflicting and requires critical analysis in the Australian context. Any extension of the role of general practice nurses or nurse practitioners must follow the results of robust Australian research. 
As a result, the RACGP takes the position that workforce substitution proposals need to be very carefully analysed, as they may not bring the patient-care or economic benefits often proposed. 
In addressing the challenges of providing universal access, the RACGP adheres strongly to its longstanding position on the safety and quality of general practice care; and the integrity of the craft of general practice. Reliance on overseas-trained doctors and nurse practitioners is not acceptable to the RACGP. 
The benefits of well structured and selected general practice teams can also be achieved through increasing the contribution of practice managers to general practice and thereby decreasing the time GPs would otherwise spend in managing finances, supplies and human resources. Through this role, practice managers can free up GP time enabling increased time for GPs to do general practice work more focused on clinical care, education and research, thus making better use of this workforce. 
In the area of Aboriginal and Torres Strait Islander health the utilisation of non-medical health providers including allied health providers such as dentists and optometrists and in particular Aboriginal Health Workers can contribute to the effective and efficient structuring of the health workforce for these communities. The establishment of Aboriginal Community-Controlled Health Services has been demonstrated to be appropriate and encourages equitable access to and outcomes from services. This is consistent with the recommendations from the Aboriginal and Torres Strait Islander Health Workforce National Strategic Framework discussed previously in relation to funding. The RACGP strongly supports community-controlled models, and strongly recommends that the report of the Productivity Commission give detailed consideration to strategies that will make a difference in this area of health care. 
In this area, particularly, health workforce planning needs to be informed by discussions about the role and demand for a workforce which is not traditionally seen as ‘health’, but is central to the effective functioning of the core ‘health’ workforce. 
General Practice must be an attractive career option for Australia’s brightest and best medical graduates if the value of the health workforce is to be optimised
The RACGP’s position is that Australia must continue to focus efforts on generating and maintaining its own GP workforce. The National Health Workforce Strategic Framework reflects this need for the workforce to be sustainable. 
The RACGP is keen to ensure that being a General Practitioner is an attractive career. An inefficient use of the health workforce would result from the most capable doctors differentially choosing to practice in better-remunerated crafts, rather than to pursue general practice. Currently, the RACGP would argue that appropriate recognition and reward for high quality general practice care is not reflected in the relative value of general practice services. This provides a disincentive to pursue this important medical discipline, and needs to be addressed if the workforce is to be used optimally.  This disincentive also applies to other primary care disciplines and needs to be considered and addressed to overcome barriers to recruitment and retention. 
General practice can and should be a viable career choice for recent medical graduates. If workforce policy undermines this, then there is a real likelihood that the net effect will be a decrease in new General Practitioners, rather than an increase in new Australian-trained General Practitioners. The National Health Workforce Strategic Framework has acknowledged this as vital. The Framework identifies that health and medical professionals need to be feel valued for the workforce to be sustainable.
Research into prevocational doctors considering general practice indicates that a number of factors attracts them to general practice including an interest in helping people, domestic circumstances, flexibility of hours, exposure to general practice and the number of years required to complete the program. Any strategy to attract more GPs should attend to these factors.
The very real reasons why recent medical graduates are reluctant to take on careers in disadvantaged areas include professional isolation, partner career, children’s education needs, high on-call burden, and difficulty gaining access to local hospitals. In a survey of former general practice registrars 79% of respondents identified family/domestic circumstances as the most influential factor in their decision-making.  It is also the RACGP’s position that the solutions to achieving appropriate access to general practice for patients in Australia cannot rely heavily on overseas doctors, whether or not they train in Australia. Australia has an ethical obligation to contribute to the overall supply of doctors, proportionate to its demand for doctors. Policies that would create strong incentives for GPs in poorly serviced countries to migrate to Australia are not acceptable. 
The RACGP acknowledges that whilst many international medical graduates arrive in Australia with excellent and highly regarded medical knowledge and skills there are some who require assistance and support to attain the level of knowledge and skills required for safe and effective general practice. 
Doctors who have not yet met the equivalent of the Fellowship of the RACGP must be assessed for entry to general practice, be supervised, mentored and supported in their education to the national standards of the RACGP. Adequate professional and personal support for the doctors entering general practice is critically important and a high priority for Government funding. Workforce recruitment measures must protect against any shift of workforce away from areas of greatest medical workforce need. Any additional funding should be coordinated with the current recruitment and support structures and the endeavour not be duplicated. 
As a result the RACGP actively supports medical practitioners who have come to Australia. The RACGP has worked with the Australian Government to identify international medical graduates in Australia who are not in the medical workforce. Assistance has been provided to those doctors, where they chose to, to complete education and training to enable them to undertake the AMC Examination to practice in Australia. In addition to this support, the WA Faculty of the RACGP has established a mentor network to pair international medical graduates with Australian GPs to enable them to come together, share ideas and learn from each other’s experiences.
The RACGP notes that the Australian Medical Workforce Advisory Committee (AMWAC) is currently undertaking a survey of doctors working in rural and remote locations under Australia’s five year overseas trained doctor recruitment scheme.
General practice vocational training must also an attractive option for doctors. Educational needs must take precedence over workforce policy in decision-making concerning registrar positions. 
To apply geographic requirements to general practice vocational training makes this training less attractive. It also makes it more difficult to fill training positions. The RACGP’s position is that appropriate incentives will result in sufficient number of general practice vocational trainees in rural placements. 
The role of medical colleges in socialisation of medical practitioners into the profession and in the areas of ethical professional behaviour, identity, motivation, altruism and attributes of the craft translates into improved service and workforce efficiency. Robinson has noted that these non-price mechanisms in the health system support effective use of health dollars. 
Quality education, training and registration systems enable high quality of care and maximise health workforce utilisation
It is the position of the RACGP that the most appropriate model on which to base considerations regarding health profession education and training is one focused on primary care. This reflects the position of the RACGP that primary care is pivotal in improving quality and efficiency of health care. 
The RACGP is unique amongst Australian medical colleges in the degree to which GP education and training is provided across both the public and private health sectors. The result of this is to increase effective utilisation of the training opportunities available in the private sector. This model will be increasingly important as the number of university graduates in medicine grows, as there are significant constraints in the public system. 
Research supports targeted education for rural GPs to improved GP retention in rural locations. A review of the RACGP Graduate Diploma in Rural General Practice has shown that 70% of graduates continued to practice in rural locations. 
The RACGP believes that addressing the factors negatively affecting workforce recruitment and retention will assist substantially in achieving positive workforce productivity and health outcomes. A study into the career choices of medical graduates has demonstrated that a number of factors prove a disincentive to medical graduates to practice in rural and remote locations. Measures addressing these disincentives hold the promise of improving workforce distribution, efficiency and health outcome equity in the short and long-term workforce. 
Non-medical General Practice workforce education and training 
As considered previously in this submission, there is a trend toward use of multi-disciplinary teams for health care delivery in the primary care setting. As also mentioned, a review of current research on changing skill mix in healthcare has not yet demonstrated sufficient evidence, reflective of the Australian health system, to support other health care providers taking on core GP activities. Given this, the RACGP strongly opposes any shift away from providing sufficient GPs. Australian research has also shown that patients strongly support the RACGP position and indicated they do not wish to have their care principally provided by other health providers or for nurses to limit direct access to GPs unless patients choose this. 
The RACGP considers that there are important opportunities to increase the role of allied health and other staff in the general practice setting. In considering the health workforce the RACGP encourages the Productivity Commission to give consideration to the supply of General Practice staff more broadly. This includes practice managers, practice nurses and other staff where this can result in increased efficiency and quality of care provided by GPs. 
The RACGP, in collaboration with the Royal College of Nursing, Australia (RCNA) completed a report in 2003 into General Practice Nursing in Australia. This report discussed, among other issues, the unique education needs of nurses working in general practice and provided recommendations for improved education and training. 
The report found that the education currently available for nurses in general practice is in the main ad hoc, informal, poorly evaluated and inconsistent. It noted also that there are no systems currently in place to assess and ensure the quality of care provided by general practice nurses. General practice nurses and GPs both indicated, through the report, their strong support for improved education for practice nurses.  
In considering further specific education and training for nurses working in general practice the report identified the concomitant need for GPs working with practice nurses to receive additional education in relation to the practice nurse role.
As previously mentioned in this submission, the RACGP strongly supports the Aboriginal and Torres Strait Islander Health Workforce National Strategic Framework. This Framework recommends that the workforce providing services to Aboriginal and Torres Strait Islander communities be:
“…transformed and consolidated to:
Increase the number of Aboriginal and Torres Strait Islander people working across all the health professions;
Improve the clarity of roles, regulation and recognition of Aboriginal and Torres Strait Islander Health Workers as a key component of the health workforce, and improve vocational education and training sector support for training for Aboriginal and Torres Strait Islander Health Workers…”
Education and training for non-medical general practice positions such as nurses, allied health professionals and Aboriginal Health Workers must be undertaken by an appropriate and registered training body with course content informed by the needs of general practice in a strengthened primary care environment. It is considered by the RACGP to be critical that all positions align the key elements of education, training, competence and registration. The alignment and application of these elements for the role of Aboriginal Health Worker is supported by the Aboriginal and Torres Strait Islander Health Workforce National Strategic Framework. These elements provide the basis for identifying high quality training and competence for practice and professional accountability.
From a productivity perspective the elements, when linked, provide an assurance of high quality and appropriate care and service and thus improved efficiency and equity of workforce utilisation and more effective health spending.
The RACGP urges caution in the consideration of common training, early specialisation, multi-skilling and exchangeable roles, and recommends that examination of these options be based on the best available evidence and take into account potential disadvantages and problems in these approaches.
The National Health Workforce Strategic Framework reflects this by stating that the health workforce must be suitably trained and competent. These requirements not only ensure high quality health care they also assist to prevent poor health outcomes and inefficient health spending. 
The further Framework requirement that members of the health workforce be employable is also supported through these characteristics, as they are a standard against which professionals can identify themselves.
Expediency of education and training
It has been proposed that there are more efficient ways for medical practitioners to receive their training that would see them providing services earlier and thus enabling a more rapid increase in GP numbers. 
The RACGP considers it critical that any discussion regarding education and training first and foremost consider quality and safety and ensure that these are not eroded through a more rapid education program. To do so has the very real potential of decreasing health outcomes and increasing health costs to address health problems created. 
Currently training for general practice occurs across 18-24 months in general practice locations. Reducing the time for this training would result in insufficient time to appropriately cover the breadth of additional knowledge needed for safe, independent practice. It would also result in erosion to the perception of general practice as a defined skill and knowledge base amongst the medical workforce and the wider community.
Any consideration of any further changes to current training arrangements would need to be based upon sound evidence that the proposed changes will result in improvements. 
Sufficient funding will enable multi-faceted benefits from strong general practice to be reaped.  
The improvements to the structure of the health care system discussed in this submission will be fully achieved if they are adequately funded. When implemented these changes have been empirically demonstrated to result in significant returns including financial. 
Reducing funding to improve cost effectiveness can have the opposite effect and result in significant decline in benefit.
Not only do the changes themselves need to be appropriately funded to achieve success, members of the general practice team also need to be financially acknowledged for their efforts to implement the change. Sibbald et al explain:
“…successful implementation of change requires payment systems which reward staff for making the desired changes to their working practices”
Caution is urged by the RACGP where consideration is given to co-payments for medical care as research in the area of pharmaceuticals has shown this can result in significant reductions to usage of essential medications amongst socioeconomically disadvantaged populations. The outcome of this extends beyond decreased health outcomes to increased morbidity and corresponding increased use of health services. These results are counter to the health, workforce and financial efficiencies gained through the approaches detailed in this submission. 
General Practices in or near hospitals do not assist to reduce emergency department demand
This submission would now like to discuss item five of the Terms of Reference which considers the placement of general practices or general practitioners in or near hospitals.
Strong general practice services are those that are located within the community they service and are tailored to the needs of that community. This includes providing appropriate after hours services. Research in the Australian environment has not demonstrated health or financial benefits from the placement of general practice in or near hospitals. 
The Australasian College of Emergency Medicine last year undertook a comprehensive review of the relationship between emergency department overcrowding and alternative after-hours general practice services.  Based on the results, the study concluded that alternative after-hours GP services do not address the problems of access block and overcrowding in emergency departments.
The study found the number of patients visiting emergency departments who could be considered to be suitable to be seen in general practice was small and did not change significantly across the seasons. On average, the study found that emergency departments see less than 10 “GP-type” patients a day. At an operational level this means that emergency departments are seeing no more than 1 ”GP-type” patient an hour. 
Planning of general practice services needs to be considered in the wider context of Primary Care planning rather than simply a band-aid measure where it has been shown to have no real benefit for the community or hospitals. 
The RACGP has a long history of involvement in setting and maintaining quality and safety standards for general practices through the RACGP’s Standards for General Practices. It is important that general practices established in any location, including in or near hospitals, be accredited against these Standards. The Standards provide a mechanism by which to ensure practices provide their patients with comprehensive, appropriate and safe care delivered by doctors specifically trained in general practice. 
Like any other general practice in Australia, practices in or near hospitals need to meet local needs and link with and be near other heath providers such as pharmacists and allied health professionals. A practice that is distanced from the intended patient population or which is difficult to access is unlikely to appropriately serve the community it is intended for. 
As an integral component of meeting local community needs, general practices need to ensure they have in place arrangements to provide their patients with after-hours care. This is required under the RACGP Standards for General Practices, the benchmark against which general practices in Australia are accredited. 
As a result, the RACGP would suggest that the complete cost of providing general practice care in a facility collocated with a hospital be considered, should this option be canvassed; and that more limited forms of primary care which do not demonstrate the characteristics of comprehensive, coordinated and continuing care be distinguished from general practice. These forms of primary care that do not exhibit the characteristics of general practice care may bring other costs associated with the risks arising from fragmented, rather than comprehensive, continuous care. 
Conclusion
The RACGP in this submission has demonstrated the substantial benefits to health outcomes and the health workforce and financing through implementing strengthened primary care principles within general practice. These benefits can be augmented through optimising GP time by reducing unnecessary administrative burden and substantially by reviewing financing arrangements so that they provide the positive incentives necessary for high quality, effective and cost efficient care.  
An increase in GP workforce numbers is considered by the RACGP to be one of a number of approaches necessary to address the identified GP shortage. Appropriate and safe utilisation of non-GP staff as part of an integrated general practice team has been demonstrated empirically to provide opportunities for more efficient and equitable workforce utilisation. 
Support structures for general practice such as IT have been discussed within this submission as having significant potential benefit for health outcomes and health workforce efficiency. 
Against this the RACGP has asked that the Productivity Commission consider the significant issues of appropriate financing for these improvements as insufficient funding has been shown to result in significant reductions to effective implementation and thus reduced benefits. Co-payments systems have been discussed and were also noted to be of significant concern for the RACGP given research showing clearly the effect such payments can have on utilisation of essential medical services and medicines, leading to reduced health outcomes and increased utilisation of the health system for socioeconomically disadvantaged groups. 
The RACGP, in accord with the characteristics identified in the National Health Workforce Strategic Framework, has identified in this submission a means for Australia to achieve a strong, efficient and equitable health system. The RACGP is pleased to have the opportunity to make this submission.