Single Employer Model

2.1 SEMs have a role to play as local responses that may be useful in addressing specific areas where workforce need has been difficult to meet.

The SEM refers to a training approach where a registrar is employed by a single general practice for the entirety of their training program. This is in contrast to the multi-site training model where registrars rotate through different practices.

The reason for implementing the SEM is to address an inequity in trainee salaries and entitlements for GP registrars and their hospital-based peers. It is intended that this program will contribute to building a more sustainable primary health care workforce into the future, with only 13% of medical students in Australia seeking a career in general practice.

Implementation of a SEM was a recommendation to the National Rural Health Commissioner in Australia in December 2018. Pilots are currently underway in Murrimbidgee NSW (MRGTP), the Riverlands South Australia and across Tasmania, with plans for other states and territories to follow. Tasmania is the only model that includes Modified Monash Model (MMM) 2-3 regions, all others are from MMM4 and above. The Department of Health and Aged Care (DoHAC) has announced another 10 regional jurisdictional pilots will be supported. Leading this change is part of a larger program of work to implement the National Rural Generalist Pathway.

The RACGP provided formal responses to DoHAC SEM Jurisdiction-Led Trial Parameters and Market-Based SEM Trials and considers highly targeted implementation of a small number of pilot SEMs may be appropriate where they seek to address prioritised areas of workforce need and are delivered in concert with the colleges.

2.2 The need to undertake a comprehensive evaluation of existing SEMs

The RACGP has recommended, and is supporting, comprehensive evaluation of existing SEMs as a necessary first step to design an evidence base and evaluation process for the proposed scale-up of the model.

In the absence of a formal evaluation of the existing initiatives, feedback from the RACGP’s Workforce team contributed to the Jurisdictional SEM Response by observing that two of the main SEM trials have so far ‘failed to attract junior doctor favour’ with- neither program successfully filling available places despite purporting to solve junior doctor perceived barriers to entry into GP training. The Riverland Academy of Clinical Excellence (RACE) program in South Australia has an annual intake of 13 registrars across the hospital and community (4 RACGP, 9 ACRRM in the last intake) and a current Registrar load of 25; the MRGTP has an annual intake of 8 and a current load of 16.

Neither of these programs have filled their available places in any intake, with only one Fellowing a registrar’³. The evidence points to’ inefficiency – rather than attract additional registrars, the SEM trials appear to provide an alternate vehicle for the same registrars’⁴.

However, given there is only modest evidence that these models are successful and scalable, their expansion should be framed as a broader pilot rather than as any system level solution to portability of entitlements.

As cited above, currently, the RACGP does not support the implementation of a national Single Employer Model. Rather, the RACGP supports the recommendation made by KPMG in its Employee Entitlement Portability for GP Registers Report for the implementation of incentive and parental leave payments paid directly to registrars (via the existing Nationally Consistent Payments mechanisms) to be the most expeditious, effective and efficient pathway to improving the conditions of registrars, preserving the direct engagement of relationships between registrars and practice owners and boosting the long-term GP workforce.

3.1 Interfaculty consultation

Interfaculty consultation across the RACGP has allowed a range of viewpoints to come together in producing this RACGP Position Statement on SEM that not only aligns strategically but also addresses practical matters at ground level.

In particular, the GPiT and Rural Faculties invest time and effort to ensure external stakeholders hear a considered and supportive response on SEM by stipulating that all training practices, posts and registrars (including those locations where SEM is delivered), will be supported under the Australian General Practice Training (AGPT) program. They endeavour to work constructively with the Lead Agency in each jurisdiction to inform SEM development and delivery regarding:

• quality education and training outcomes
• workforce distribution obligations
• registrar and practice/supervisor support functions

The GPiT and Rural Faculties acknowledge that SEM and the AGPT program can be effectively aligned to meet these desired outcomes.

3.2 Broader issues related to SEM

The GPiT and Rural Faculties also ensure that registrar needs are met by exploring necessary improvements in the SEM model by highlighting the following issues:

• The lack of an 'off-ramp,' where doctors may be reluctant to leave the Single Employer once they achieve Fellowship. This has been observed in Queensland, leading to clustering in hospitals and acute settings.
• General practices may face funding challenges and might have to increase patient fees to compete with SEMs, potentially impacting revenue.
• The removal of incentives for service provision can result in decreased productivity.
• Acknowledging a general concern that SEMs could unintentionally solidify general practice as the lowest-paid specialty in Australia, contributing to long-term workforce challenges.
• Shifting to state-based SEM models may compromise the national consistency of general practice, which is federally funded via Medicare. This could impact the standardised conditions outlined in the National Terms and Conditions for the Employment of Registrars.

The proposed RACGP Single Employer Model Position Statement is aligned with the two previously Board approved RACGP SEM submissions.⁵