Australian General Practice - A celebration
Medical practice in Australia began with the First Fleet in 1788. The evolution of the practice of medicine in the world had been slow up to this time. The study of medicine had long been an academic subject with universities offering doctorates in this branch of knowledge. From early records, different branches of the profession were not regularly distinguished in England until the sixteenth century. The Royal College of Physicians was founded in 1518 to bring together those who practised medicine. This distinguished its members from other healers and practitioners and bestowed upon them certain exclusivity. The surgeons on the other hand had come from the Company of Barber Surgeons (1540) to establish the Company of Surgeons in 1745. Stimulated by the energy and research of John Hunter – who had been influenced by the work of his older brother William Hunter, a physician and a graduate of Glasgow University – the Company sought academic status and became the Royal College of Surgeons in 1800 soon after John Hunter's death.
Another group of practitioners, the apothecaries, had 'after a long struggle moved out from their original place as spicers in the Company of Grocers'1 formed the Society of Apothecaries in 1617, to regularise their dispensing of physic. This society was recognised by the Apothecaries Act in 1815 to license apothecaries in the field of medicine and were the forerunners of the discipline of general practice.
When the First Fleet arrived in Australia, it brought convicts, sailors and soldiers but also other functionaries to service the fledgling needs of the new colony. These included naval and military surgeons to meet the medical requirements of the settlers. There appeared to be a policy in place in the British Colonial Office that provided for the transportation of convicted professionals such as doctors, architects, engineers and others to meet the growing demands for the development of the colony.
William Redfern, a surgeon, was convicted and transported in 1801. He was immediately sent to work on Norfolk Island. Later he became the first superintendent of the Rum Hospital and personal physician to Governors Bligh and Macquarie. Like others in the colony he practised as a physician and surgeon, an appellation assumed by early GPs. This is reflected in the memorandum of association of our college which refers to the practice of medicine and surgery in general practice. Initially the colony was essentially a garrison situation and in its earliest days 'local measures were introduced for formal recognition of acceptable status'.1
With the settlement of other colonies and the discovery of gold, 'medical registration was not too long delayed, not too lax, to permit reasonable control over the situation, so that with the stimulus of strong competition, satisfactory standards were in the main soon established and maintained'.2
Practices were established far and wide and as they expanded took on 'assistants with a view' to learn the art. Medical education received a further stimulus with the establishment of medical schools in Melbourne and Sydney early in the second half of the nineteenth century. These schools taught the basic sciences and the clinical skills of medicine, surgery and the other modalities of medical practice, thus graduating undifferentiated doctors. Nevertheless, registration was not entirely confined to medical graduates until late in the nineteenth century and early twentieth century in some states. Many had received their training and registration through attachment as assistants
General practice became a primary source of teaching and learning. Before 1900, specialists and specialist teaching positions were recruited mainly from overseas – although increasing numbers came from the ranks of general practice where one partner or a number of partners would train and study in a particular specialty. Higher qualifications were obtained with additional training overseas. This situation continued well into the twentieth century.
The Royal Australasian College of Surgeons was formed in 1927 and the Royal Australasian College of Physicians in 1938, and both introduced formal qualifications in their specialities. Some specialists retained a small nucleus of a general practice until after the Second World War.
In fact a number of teaching hospitals prior to that war had very competent specialists on the staff who were also in general practice. This of course resulted in a high standard and competency in teaching good general practice. The patient's recovery depended as much on the interpersonal and clinical skills as well as the care and comfort provided by the doctor as on any medical treatment that was offered. Lodge or panel practices that paid an annual fee for patient care provided the doctor with a security of income. This was the basis of many ethical standards as well as being a form of goodwill.
The caring nature of general practice as well as its clinical acumen has been well illustrated through many anecdotes. It was widespread throughout the length and breadth of Australia. Even in isolated areas, doctors were found practising with a wide range of skills and the assistance of bush nursing and district hospitals. A flying doctor service covered the areas too sparse to support a doctor.
The situation changed with the Second World War. Many GPs as well as specialists joined the armed services. The services set about training many of these GPs into specialists. At the end of the war, general practice was denuded of these veterans' skills as they entered their chosen specialty. Specialist training became exclusively confined to teaching hospitals. Specialists were no longer mainly recruited from the ranks of general practice. Suddenly GPs were referring patients to specialists who had no experience and little knowledge of general practice. They were also deprived of the previous input from their colleagues in general practice who were training to be specialists. This was nearly akin to what had been happening in Britain for the previous 150 years.3
Australian Joseph Silver Collings published a survey of British general practice in 1950. He wrote of his 'condemnation of general practice in its present form; but (my observations) have also led me to recognise the importance of general practice and the dangers of continuing to pretend that it is something which it is not'.4 He concluded that there were no standards in general practice apart from those that depended almost wholly on the doctor's own conscience. This report led to the formation of the College of General Practitioners (later Royal) in 1952 to establish and improve the appropriate standard of general practice.
On 1 January 1953, when there was a call for membership, a number of Australian GPs applied and became Foundation Members. Later that year the New South Wales Faculty of the British College was formed. This was followed early the next year by the formation of the Queensland Faculty. There was some opposition by the Federal Council of the British Medical Association. In 1955 these two faculties resolved, on the initiative of the Queensland Faculty, to form the Australian Council of the College of General Practitioners. Western Australia, Victoria and Tasmania then formed faculties of the College of General Practitioners so that by 1957 the Australian Council decided that the time had arrived to form an Australian College of General Practitioners. The British College was in favour of the idea and supported it.
On 4 February 1958 the Australian College was incorporated under the NSW Companies Act in response to a memorandum of association dated 17 December 1957 with an interim council. The South Australia Faculty was formed four days later. Thus each state had a faculty. The officers of the interim council of the new college had been the driving force for the formation of the college.
This interim council decided that the Australian College of General Practitioners should function from 1 July 1958. William Arnold Conolly was elected as president. He together with Stuart Patterson and Howard Morris ('Shad') Saxby had done prodigious work to bring about the establishment of the college. All members and associates at 1 July 1958 were designated Foundation Members.
By today's standards the requirements for membership were quite rigorous. An applicant for membership had to have been qualified for seven years and have been in general practice for five years. Faculty censors approved applications. It was not until 1962 that the first censor-in- chief was appointed. In addition there was a requirement to undertake continuing medical education and certain standards of medical education were to be met. Two referees who were members of the college were required to support the application. Doctors who did not fulfil these criteria could be elected associates of the college until the criteria could be achieved. Members and associates numbered 874 on the register of Foundation Members.
The college's early aims were to establish:
- general practice education for undergraduates
- regular continuing postgraduate education
- research in general practice
- guidelines and standards for preventive medicine
- practice management skills.
The college was led by experienced GPs with strong affiliations with the British Medical Association (BMA), which later became the Australian Medical Association (AMA). However, GPs were divided in their attitude; not all of them were supportive of a college for general practice and some vigorously opposed it. Still, there was a nucleus of practising GPs who could see the advantages of an academic college for general practice.
Each state faculty continued to function as an individual unit, and combined to function as a federation through the College Council. The faculties were the powerhouses that drove the college with a continuous input of ideas and initiatives from their standing committees. They also had independent financial arrangements to support their individual aims and objectives, at the same time paying a college subscription as well. This contributed to their individualism and their drive.
At a national level this was reinforced when the chairmen of these faculty standing committees had a seat on the Australian college national standing committees, the chairmen of which in turn had a seat on the College Council. The initial standing committees were:
- undergraduate education
- postgraduate education
- preventive medicine.
Later, practice management, medical organisation and, much later, accreditation committees, were established.
The college was granted a coat of arms by the College of Arms together with its appropriate documentation on 15 May 1961.
Research was encouraged early and various prizes were awarded. This was further stimulated by FH Faulding Pty Ltd setting up the Francis Hardey Faulding Memorial Awards in 1964. The original award was for £500. These awards for research in general practice were given by the company annually. The selection for the award was in the hands of the Research Committee of the South Australia Faculty. Faulding was most generous in their support, increasing the award to $5000 over time. In some years more than one award was made for meritorious research.
College members took up Nuffield Travelling Fellowships to study abroad and bring this knowledge back to the college. These Fellows spent six months overseas to study and report on:
- content of general practice
- continuing and postgraduate education
- evaluation as it related to the discipline of general practice
- research methods in general practice.
The injection of these skills into the developing enthusiasm for improving the standards of general practice was invaluable to college members as they delineated this discipline that was becoming specific and defined. This acquired knowledge was put to good use in developing educational and evaluation methods, and particularly the college examination, which was established in 1968 after a trial of the methodology in the previous year. There were some members and other GPs who did not see the need for an examination at that time.
Early in its life the college realised that it needed funds to carry out its objectives. It began with an appeal to members who donated £5000 in 1962. This was followed by a public appeal that raised £100 000 pounds for an educational and research foundation. From these funds, postgraduate fellowships were set up in New South Wales, Queensland, South Australia, Tasmania and Victoria. The role of these Fellows was to assist and advise members. They would organise educational facilities for GPs to learn to teach the art of general practice, and to liase with other educational and professional bodies. They received training in what was required of them. The positions attracted experienced GPs who stimulated, assisted and advised members. Unfortunately the Foundation could only fund the positions for a period of up to two years. In New South Wales however, additional state government funding supported the position for about 30 years and did valuable work. The Family Medical Care Education and Research Foundation was also used to fund educational and research projects throughout the college up until 2004 when the Research Foundation replaced it. Many aspiring researchers in general practice were supported with grants from the foundation.
In 1965 the criteria for admission to college membership were amended so that a candidate was required to have undertaken a rotating internship or its equivalent as a resident medical officer for two years in an approved hospital, undergone a further three years approved training in general practice and satisfy the censor-in-chief of his proficiency by submitting case reports with commentary or other forms of thesis.
The college was granted its Royal Charter on 24 March 1969, allowing it to use the prefix Royal.
The introduction by the Commonwealth Government of differential rebates for the cost of patient care left the RACGP carrying the fight for the patients of GPs to secure a better deal vis-à-vis their specialist colleagues who were treated handsomely in the negotiations. As a result of the poor treatment given to GPs during these discussions in 1970, the RACGP disaffiliated from the AMA. This was just the beginning, as two years later it was the RACGP and its research that obtained better remuneration for longer GP consultations.
Each faculty developed their own innovative educational programs. Victoria set up a rotating residency program, the Hornsby Training Scheme was instituted in New South Wales, and similar schemes began in other faculties to train GPs. At the same time, continuing education was provided. Through these program the faculties promulgated their individual philosophies concerning training for general practice and teaching the discipline. Self directed, interactive, experiential, discovery, group, problem solving and didactic learning all had their protagonists and antagonists.
In 1973 the Commonwealth Government requested submissions for a program of training for general practice. A submission that was created mainly within the Victoria Faculty was submitted by the RACGP. It contained a number of studies. 'Study 10', which set out a plan for training for general practice, was selected as the most appropriate form and a grant of $1.1 million was offered by the Commonwealth Government to start it. This was far greater than the entire college budget at that time. College Council after some hesitation accepted the grant.
It appointed three directors to run the program known as the Family Medicine Program (FMP). These three directors who reported directly to council were:
- director of training, who was chairman
- director of education
- director of administration.
As well as a national office, state offices were established with a state director, educators and support staff.
Faculties had no direct input to the FMP. The faculty training programs had created a ready supply of members who had been trained as teachers and were prepared and willing to take trainees, as they were known, into their practices. Similarly there were a large number of young doctors who wanted to be accepted into the FMP for training.
The college found that the FMP occupied a great deal of its energies and time. This is referred to in our published histories and annual reports. It also meant that for a time continuing education was put on the backburner.
The college finance department was set up in Melbourne to administer the FMP together with a library and resource centre.
The FMP grew in size and over time refined its assessment, educational and research methods. Satisfactory completion of training became another pathway to membership of the college. In addition, FMP administration changed a number of times to reflect the needs of the Commonwealth as the funding body and the college's evolving standards.
The totality of training was initially hampered by the refusal of the Commonwealth to allow the Fellowship of the Royal Australian College of General Practitioners (FRACGP) as an endpoint in training. It was not until 1987 that this endpoint became a reality.
At about the same time, the government in 1973 adopted another of the college's recommendations to set up university departments to teach general practice in each medical school. These were variously known as departments of general practice or community medicine. In some cases members of the RACGP were founding professors.
The Practice Management Committee developed a medical record system and established standards in manual and computerised health records. It developed surgery design plans, research into the future of general practice, set up computer conferences and published handbooks that stimulated and updated the use of computers in general practice. It also spawned the services division as well as a number of other valuable initiatives.
A good deal of valuable research was activated and supervised through the Research Committee, which published a monograph on the research that was undertaken. It offered supervision for research and its publication by individual members. In 1981 the General Practice and Primary Care Research Unit was formed. An ethics committee was appointed in 1985 to ensure an ethical basis for all college research.
The original faculty publication prior to the formation of the college was Annals of General Practice. On the formation of the college it became a national publication. From it emerged the Australian Family Physician, check and a burgeoning publications division that continues to expand in print and online. This successful enterprise has had its financial ups and downs over the years and is now thriving.
The Preventive and Community Medicine Committee produced a number of worthwhile policies on lifestyle, diet, immunisation and medicines in the home. It made recommendations on alcohol limits for driving before random breath testing was introduced and developed other preventive measures.
The Medical Education Committees had been a force for teaching and learning in all faculties up to 1973, when suddenly most of their personnel were absorbed into the activities of FMP. The education committees struggled for a time but found new direction with local learning groups and focussed educational activities. Visiting professors were sponsored on its recommendation. This proved very instructive and informative because they brought knowledge of the efforts to improve the standards of general practice being undertaken in other parts of the world.
The RACGP grew in size incrementally. It had some opposition at times from the AMA, the General Practitioners Society and some GPs who considered that it was elitist. A survey of members in 1981 enabled the college to determine its priorities. One of those was to increase membership. In 1985, it was decided to admit as eligible associate members all those participants in the FMP who applied. Within two years, our associate membership more than doubled. Two further spurs to membership were the government's acceptance that the FRACGP would be the endpoint of training following the Abrahamson Report in 1987 and the introduction of Vocational Registration in 1989.
Eligible (registrar) associates were given voting rights and representation on council in 1997. More recently new categories of membership have been established with practice managers and nurses becoming affiliate members. A medical student category was added. These categories account for a little over 15% of the membership of 17160 in 2007.
The RACGP had always had a good relationship with and support from the RCGP, who had initiated the Rose-Hunt awards in 1972. The World Organization of General Practice (Wonca) was formed the same year. The RACGP has played a prominent role in Wonca's functioning, with members of the college administering its secretariat over the first thirty years and working on its various committees.
The college also began to develop closer relationships with sister colleges. The first was with the New Zealand College with which it instituted regular visiting and reciprocity with its diploma, then with the Malaysian College in 1978 and again with the Hong Kong College in 1987 by setting up a conjoint examination for the FRACGP. At the same time, College Council resolved to allow any overseas candidate who fulfilled the requisite criteria and was a member of the GP college in his own country to sit for the conjoint examination in his own country.
Medical manpower came to the fore when the College began to assess how many doctors were enough. Committees were set up and research was undertaken. It was soon recognised that sectional interests in the medical profession were not as interested in the manpower and the distribution problems of GPs as the RACGP. Unfortunately the early predictions of our manpower studies are proving correct. The college reluctantly became an advocate to government on issues that would have been more properly undertaken by other medical organisations. The age and distribution of GPs is an issue that is not necessarily shared by some other specialist colleges to the same extent.
As the college developed and expanded, changes were made to its administration to adapt to its expansion. In 1972, it was decided, after investigation, to reduce the College Council size from 23 to 12 and eventually to 10 by the year 1976 in order to streamline its decision making. Instead of the president and treasurer being elected by the council, both were elected by the membership of the college as a whole. in addition to the executive of president, chairman of council, censor-in-chief, treasurer and honorary secretary, each faculty was reduced to one representative and the chairmen of standing committees were reduced to observer status, while they continued to attend council meetings.
The RACGP established a number of subfaculties in provincial areas of Victoria, New South Wales, Australian Capital Territory and Queensland to decentralise its focus and to provide stability for general practitioners who were removed by distance from the state faculties. Later some subfaculties would provide offices for FMP.
Difficulties in finding rural GPs became apparent in the 1960s. The college addressed this with educational programs for rural areas. One of the initial objectives of the FMP was to encourage rural practice and, for a time, conditions improved. In 1988, the Rural Doctors Association became active in seeking a resolution of the problems that rural doctors were facing and it felt that it was not being heard. The RACGP responded by offering educational support through various modalities including distance learning and then the formation of the Faculty of Rural Medicine in 1992. This faculty (now the National Rural Faculty) has made significant progress since that time and now offers a Fellowship in Advanced Rural General Practice. It has a membership of nearly 6000 members.
In 1980, methods of quality assurance were studied and developed by the Medical Education Committee. In 1987, College Council resolved that participation in a quality assurance program should be a prerequisite for continuing membership of the college. It was one of the first colleges to adopt the concept. In 1992, College Council combined two committees to form the Quality Assurance and Continuing Education Committee to refine and develop the activity further.
The initial models have gradually evolved into a modern educational program – the RACGP Quality Assurance and Continuing Professional Development program – through a process that is undergoing continuous refinement using a number of modalities including online tools for education and evaluation.
After 35 years of rapid expansion, the college began a phase of refining its early initiatives. Quality assurance, the examination, a training program, vocational registration, publications, standards of general practice, Aboriginal health, services division, joint consultative committees with other colleges, as well as other projects and enterprises were introduced. These numerous committees and working parties with which the college became involved required an expansion of the number of its special departments. In the main these had college members as directors.
During the previous 40 years, through prudent management, the college had acquired a national headquarters in Sydney and another property in Melbourne to house the Training Program. It had purchased faculty headquarters in Queensland, Victoria, South Australia and Tasmania. In the meantime, the RACGP faced great challenges with the government funding of divisions of general practice and alternative pathways of general practice training, as well as being supportive to the formation of another academic college for rural general practice.
This led to a change in the administration of the College with the appointment of a chief executive officer, who was not a college member but had a business background. The structure of the administration of the college changed, creating a more centralised control of business reducing the influence of the faculties.
Then, in 1999, RACGP Council decided to concentrate all the college business in one area. This had been considered on numerous occasions previously but had been adjudged too difficult. The national headquarters was transferred to Melbourne. As very few staff transferred to Melbourne, this resulted in a loss of corporate knowledge and some dislocation of college services. At the same time, council introduced a Strategic Planning Unit to implement ways of going forward to influence and support general practice. All this change resulted in substantial financial cost, the loss of the Training Program, disposal of some college real estate and the disturbance of its core business of services to members.
With assistance from the Commonwealth Government, a consultancy was set up to recommend to the college a way forward to bring it into line with present commercial practice. Princes Hill presented its report in 2001. Council adopted and put into practice many of the recommendations of the report that fundamentally changed the college's previous structure. The government, at the same time, set up an independent organisation to supervise the provision of general practice training. This involved a scheme of regional training providers, leaving the college to set the standards and examination for entry into general practice.
The college adjusted to the loss of the Training Program, and set about creating a new committee structure as recommended by the report. This was not without some difficulty, but as a result the college became accredited by the Australian Medical Council and the new standing committees –Education, Quality Care, Research, National Expert Committee on Standards for General Practices, General Practice Advocacy and Support, and the National Research and Evaluation Ethics Committee – drove the college to greater heights of achievement. This has led to the development of a modular assessment pathway to the FRACGP and enhanced learning opportunities for international medical graduates and all GPs, as well as the publication of handbooks on college standards for different areas of general practice.
The last five years have seen the college refocus onto its mission to 'benefit our communities by ensuring high quality clinical practice, education and research for Australian general practice and support our current and future members in their pursuit of clinical excellence'. This has been achieved by the national standing committees with the support of well-resourced departments and the strengthening of education, publication, assessment, financial, membership and other arms of the college. The college purchased a property to house the NSW Faculty in 2007.
As our president says, the RACGP membership base has broadened and the college is transforming itself from being a GP college to becoming a college for all general practice. All members of the practice team are now welcome to join our college. Our structure has been significantly reformed to recognise the many unique and diverse interests of our members, while retaining our focus on the generalist skills that mark our profession as being unique among medical specialties.
17 February 2008
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- Encyclopaedia Britannica
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- The Royal Australian College of General Practitioners. The Royal Australian College of General Practitioners, 1978-1988. Jolimont: RACGP, 1988.
- Wilde S. 25 years under the microscope: a history of the RACGP training program, 1973-1998. South Melbourne: RACGP, 1998.
- Annual reports of The Royal Australian College of General Practitioners