Embarrassing problems

May 2013

Research

Who will be running your practice in 10 years?

Supporting GP registrars’ awareness and knowledge of practice ownership

Volume 42, No.5, May 2013 Pages 333-336

Martin Liedvogel

Emily Haesler

Katrina Anderson

Background

With a declining Australian general practice workforce, succession planning for practice owners is a pertinent concern. Limited previous research and anecdotal evidence suggests there is minimal interest from general practice registrars in practice ownership.

Objective/s

We conducted a web based survey to investigate the interest of general practice registrars in the Australian Capital Territory and southeast New South Wales in practice ownership, perceived barriers to becoming an owner-operator, and preferred educational activities on this subject.

Discussion

We found more interest in practice ownership than previous research suggests. Insufficient knowledge, workload, bureaucracy and finance issues were perceived as barriers to ownership. The registrars favourably rated mentoring, release workshops, and an extended skills post as educational activities through which they prefer to attain skills in this field. Further investigation into effective practice ownership education delivery is warranted.

Australia has a dwindling general practitioner workforce considered insufficient to meet primary care needs. This is projected to worsen over the next 5–10 years, contributed to by an ageing workforce considering retirement.1–3 While approximately 25% of GPs were aged over 55 years in 2003 workforce analyses,1,2 by 2011 this had risen to over 40%.4 Concurrently, there are a declining number of private practices, with 8% fewer in 2002 compared to 1995.1 This trend is related to increased corporatisation and reluctance of younger GPs to invest in practice ownership.1 This highlights the need for effective succession planning, and empowering the next generation with the skills necessary to be practice owner-operators.5–7

No data exists regarding who takes over ownership and clinical leadership when established practice principals retire. Anecdotally, it is difficult to find a successor in the current climate of primary healthcare.1 In our region (the Australian Capital Territory and southeastern New South Wales), less than 1% of recently fellowed general practice registrars have gone on to become owner-operators within 10 years. Only one Australian study1 has previously investigated registrar interest in practice ownership. In 2003–04, the Australian National Health Workforce Secretariat held consultations with GPs, registrars and consumers to investigate the GP workforce. In one registrar focus group, discussions on career intentions confirmed the observed decline in private practice ownership, and none of the registrar participants expressed a desire to own their own practice.1 Buying into or establishing a practice was seen as an unattractive option, incompatible with the desire for greater work flexibility and improved work-life balance.1

At present there is minimal formal opportunity for Australian registrars to acquire skills associated with being an owner-operator, including financial management,8,9 cost effective healthcare provision,8,10 resource allocation,9 strategic planning,9 legal and insurance issues,8,10–12 and quality assurance.10 Practice management is identified as a part of The Royal Australian College of General Practitioners (RACGP) curriculum;13 however, regional training providers (RTPs) offer few opportunities for acquisition of the necessary skills to be an owner-operator.

Aim

The aim of this project was to explore the interest of general practice registrars in becoming practice owner-operators and the barriers they face with respect to practice ownership. We also investigated the interest of registrars in various education delivery models that could assist in promoting an interest in practice ownership and the skills to confidently perform the owner-operator role.

Methods

We administered an anonymous, web based survey (Survey Monkey) developed through pilot scoping with a convenience sample of registrars and supervisors. All general practice registrars (n=93) in the Australian Capital Territory and southeastern New South Wales training region were invited via email to participate. One reminder was sent 4 weeks after the initial invitation. An additional verbal reminder was made at an educational event attended by some potential respondents. Consent was attained from participants, and no incentives were offered.

The survey consisted of multiple choice questions and Likert scale scoring of statements that explored previous exposure to and interest in practice ownership, perceived barriers to becoming an owner-operator, and preferred educational delivery models for improving knowledge in this area. The survey design prevented progression without completion of questions. For ease of use respondents were able to save responses and continue at a later date.

Likert scores were analysed using Microsoft Excel and findings are presented in a descriptive analysis. We used SPSS software to compute correlation co-efficients (Pearson’s r) to assess the relationships between registrar characteristics and both interest in owning a practice and desire to acquire practice ownership knowledge.

Results

About 68% (n=63) of registrars in the region commenced the survey and of these, 82% (n=52) completed the entire survey (56% complete response rate). This compares favourably to response rates reported in a meta-analysis of web based surveys in which the mean response rate from 56 online surveys was 34.6% (SD 15.7%).14

Forty-six percent of respondents were in their first 2 years of registrar training; 65% were completing the general training pathway. These demographics are reflective of the full cohort of registrars in our training region (Table 1).

Table 1. Respondent demographics
Respondents (n=63)Training region comparison
n % n %
Age range (years) <31 16 25 NA NA
31–40 32 51 NA NA
41–50 12 19 NA NA
50+ 3 5 NA NA
Training pathway General 41 65 60 65
Rural 22 35 33 35
Year of registrar training First two training years (hospital, GPT1, GPT2) 29 46 38 41
Subsequent training years (GPT3, extended skills) 32 51 55 59
No response 2 3 NA NA

Forty-nine percent of respondents had no previous exposure to business ownership (Table 2). Of those with some previous exposure, this was generally knowing a business owner (27%) or having their own previous experience (21%).

Table 2. Previous exposure to business ownership and management
Statement (n=63 respondents)n%*
I have had no previous exposure 31 49
Respondents with some previous exposure 32 51
Someone I know has/had their own business 17 27
I have had previous experience with my own business 13 21
I have completed a tertiary business course 2 3
I have made enquiries with potential practices/business partners 2 3
I have read literature related to owning a business 1 1.5
* Respondents could select more than one option

The registrars were not complacent about the potential of being an owner-operator: 24% totally disagreed, 31% disagreed that they had given no thought to the prospect (Figure 1), and only 23% indicated that they had no desire to own a practice (Table 3). There were no significant correlations between desire to own a practice and previous exposure (r=0.16, n=56, p=0.25), age (r=–0.00, n=56, p=0.99) or training term (r=–0.16, n=54, p=0.25).

Table 3. Interest in practice ownership
Statement (n=number of respondents)Yes (%)Undecided (%)No (%)
Would you like to own your own practice in the future? (n=56) 32* 43 23
Do you think you currently have sufficient knowledge to own your own practice? (n=52) 11 27 62
Would you like to learn more about being an owner-operator during your training? (n=52) 65 23 12
Would you consider doing a special skills term in practice ownership? (n=52) 42 33 25
* This includes 4% who responded that they would consider being an owner-operator in the future only to prevent closure of the practice in which they work

Insufficient knowledge received the highest level of agreement (35% agreed, 36% totally agreed) as being a barrier to ownership. Issues of workload (including time) and bureaucracy were considered to be barriers by the majority of respondents. Just fewer than half of the registrars (33% agreed, 16% totally agreed) viewed financial issues as a barrier (Figure 1).

Figure 1. Barriers to practice ownership (n=55, % of respondents)

Figure 1. Barriers to practice ownership (n=55, % of respondents)

The majority (65%, Table 3) of registrars were interested in learning more about practice ownership. There were no significant differences between desire to learn more and age (r=–0.01, n=52, p=0.99), training term (r=0.05, n=50, p=0.74) or whether they believed their knowledge was already sufficient (r=0.15, n=52, p=0.92).

When asked about preferred education delivery options, registrars responded favourably to mentorship by their current GP supervisor (33% agreed, 35% totally agreed) or another practice owner (29% agreed, 34% totally agreed); educational releases (31% agreed, 35% totally agreed); formal qualifications (31% agreed, 29% totally agreed) or optional study modules (40% agreed, 10% totally agreed) (Figure 2). A reasonable proportion (42%) would also consider undertaking a special skills term in practice ownership (Table 3). Participants were less favourable toward online or self directed learning.

Figure 2. Perceived benefit of education options (n=52, % of respondents)

Figure 2. Perceived benefit of education options (n=52, % of respondents)

Discussion

This survey provides unique data exploring general practice registrars’ interest in, and exposure to, practice ownership and preferences for developing knowledge in this area. Previous anecdotal evidence and survey1 findings have highlighted a perceived lack of interest in practice ownership among recently fellowed and current registrars. This has implications for the future of privately owned general practices, and potentially for general practice training through reduction in available training places. In contrast, our study revealed that a reasonable number of registrars would consider owning a practice, with only 23% indicating a firm disinterest in this career opportunity.

Previous research has suggested that finance, time commitment and lifestyle factors were barriers for registrars buying or establishing a practice,1 and the response in our research supported this sentiment. However, our research shows that insufficient knowledge of practice ownership and negative perceptions of associated workload and bureaucracy are additional barriers.

The registrars we surveyed had an interest in expanding their knowledge. Currently RTPs, third party providers, and the RACGP deliver practice ownership education in the form of self directed learning or online modules. Our survey indicated that these delivery styles are least preferred by registrars. 

Registrars indicated positive interest in attending workshops focused on practice ownership. By including the option of practice ownership workshops in release programs, RTPs could increase exposure of the next generation of GPs to being an owner-operator. The interest in such an option warrants further research into appropriate content and structure of a workshop designed to both increase interest in practice ownership, and to improve related skills.

Our respondents identified mentorship as a favourite learning model. The GP supervisor has already been recognised as having a key role in providing mentorship and role modelling,15 and it appears that this is suited to the preferences of registrars with respect to practice ownership.

One unique educational delivery model we proposed was an extended skills post in practice ownership. This model received favourable interest from almost half of the registrars. Such a post could incorporate a formalised process of in-depth mentoring in which registrars have the opportunity to learn practice ownership skills ‘on the job’, with supervision from an experienced practice owner (similar to the academic skills post funded by General Practice and Training). The RTPs are uniquely placed to provide organisation and support for such a program. Further investigation into practical models (eg. funding and curriculum) for such a term, and the interest of GP supervisors in engaging in mentorship in this field, is warranted.

This research was conducted in only one Australian training region, however, a wide range of registrars were represented with respect to age, training pathway and level of training. The decline in private general practice ownership observed throughout the country is of concern to general practice, and development of strategies to increase interest and skills in this field is pertinent to succession planning. We hope our findings provoke consideration of this concern in other training regions.

Key points

  • A reasonable number of general practice registrars are interested in practice ownership.
  • Insufficient knowledge of what is needed to own a practice is a previously unmentioned barrier for registrars considering practice ownership. Supervisors could consider discussing practice ownership with registrars.
  • Practice owners/supervisors could consider mentoring a registrar interested in practice ownership as a form of succession planning.

Competing interests: None.
Ethics approval: Australian National University Human Research Ethics Committee.
Funding: CoastCityCountry General Practice Training. The funding body was neither involved in data collection, analysis or interpretation nor in manuscript development.
Provenance and peer review: Not commissioned; externally peer reviewed.

References

  1. Australian Medical Workforce Advisory Committee. The general practice workforce in Australia: supply and requirements to 2013. AMWAC Report 2005.2. Sydney, 2005.
  2. Joyce C, McNeil J, Stoelwinder J. More doctors, but not enough: Australian medical workforce supply 2001–2012. Med J Aust 2006;184:441–6.
  3. National Health Workforce Taskforce. Health workforce in Australia and factors for current shortages. KPMG, 2009.
  4. Britt H, Miller G, Charles J, et al. General practice activity in Australia 2010–11. General practice series no.29. Sydney: Sydney University Press, 2011.
  5. Bower F. Succession planning. A strategy for taking charge. Nurs Leadersh Forum 2000;4:110–5.
  6. Collins S, Collins K. Changing workforce demographics necessitates succession planning in health care. Health Care Manag 2007;26:318–25.
  7. Stanton J. Planning for physician succession: no longer a luxury. Med Group Manage J 1995;42:68–70, 72–3.
  8. Frank R. Practice management education-are residency programs properly preparing physicians for the 21st century? Coll Rev 1993;10:22–47.
  9. Gilmore A. Taking care of businesss: MDs in search of management skills turning to MBA courses. Can Med Assoc J 1992;146:743–7.
  10. Junker J, Miller T, Davis M. Practice management: a third-year clerkship experience. Fam Med 2002;34:87–9.
  11. Bayard M, Peeples C, Holt J, David D. An interactive approach to teaching practice management to family practice residents. Fam Med 2003;35:622–4.
  12. Young M, Hough D, Peskin M. Outcomes of a program in business education for physicians and other health care professionals. Southern Med J 2003;96:1000–6.
  13. The Royal Australian College of General Practitioners. Practice management. The RACGP Curriculum for Australian General Practice 2011. Melbourne: The RACGP, 2011.
  14. Cook C, Heath F, Thompson R. A meta-analysis of response rates in web- or internet-based surveys. Educ Psychol Meas 2000;60:821–36.
  15. Morgan S. A balancing act: the role of the general practice trainer. Aust Fam Physician 2005;34(Suppl):19–22.

Correspondence afp@racgp.org.au

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Research

2013