|ORIGINAL RESEARCH PAPER
|Year : 2007 | Volume
| Issue : 2 | Page : 50
Population Health and Public Health Training for Australian Rural General Practice Registrars: A Six Year Program 2000-2006
Hunter New England Area Health Service, Tamworth, Australia
|Date of Submission||14-Jun-2007|
|Date of Web Publication||21-Aug-2007|
J D Fraser
Hunter New England Area Health Service, Tamworth
Source of Support: None, Conflict of Interest: None
Background: In Australia, population health and public health are core aspects of postgraduate general practice training.
Aims: This paper describes an academic general practice training post in population health and public health for rural GP registrars in North Western New South Wales. Furthermore, this paper describes how this training post incorporates the principles of "Towards Unity for Health".
Methods: In 2000, a collaborative reference group of local and national organisations advised on curriculum development. During training, GP registrars conduct a research project applying population health and public health principles in a rural community. Content and thematic analyses of research documents and GP registrar evaluations were used to provide examples of how this training post incorporates principles of "Towards Unity for Health".
Results: The posts have been evaluated and were viewed favourably by registrars, local and national organisations. Six GP registrars have been recruited to undertake this training post since 2001. Their research projects include: smoking cessation, childhood obesity and hepatitis C. After completing this form of training, two registrars have become involved in medical education and three have remained to work in the region. The educational model developed in this project has similarities with "Toward Unity for Health" with partnerships developed between academic institutions and health managers.
Discussion: This paper presents a feasible model to train GP registrars in population health and public health skills in a rural region. Further research is required to assess the applicability of this model to other regions of Australia and internationally.
Keywords: General Practice, Public Health, Population Health, Rural, Medical Education
|How to cite this article:|
Fraser J D. Population Health and Public Health Training for Australian Rural General Practice Registrars: A Six Year Program 2000-2006. Educ Health 2007;20:50
Integration between general practice, population health and public health is promoted internationally (Mant & Anderson, 1985; Towler, 1999; Koperski, 2000; Kamien, 2002; Iliffe & Lenihan, 2003; Campos-Outcalt, 2004). Advocates of this process consider these approaches can improve health outcomes (Mant & Anderson 1985; Towler, 1999; Koperski, 2000; Kamien, 2002; Iliffe & Lenihan, 2003; Campos-Outcalt, 2004). This is consistent with the concept of “Towards Unity for Health”, an international movement which fosters improvement in health services directed to peoples’ needs based on a partnership of medicine and public health (Boelen, 2000).
At times the paradigms of medicine and public health have been traditionally viewed as being in competition and in a state of “schism” (Boelen, 2000). Key stakeholders, including health professionals, government and the community often differ in their viewpoints about what constitutes an appropriate interface between general practice with population health and public health. “Towards Unity for Health” recognises this observation graphically by use of a partnership pentagon. Working relationships between community, health managers, policy makers, academic institutions and health professionals are needed to optimise health outcomes (Boelen, 2000). Differences between organisations can be minimised by developing a set of common values and shared vision for health services (Boelen, 2000).
Divisions of General Practice are Commonwealth-funded support agencies for Australian GPs. They are playing an expanding role in supporting the health of populations and communities within which they are located in Australia. The reason for this approach is an increasing recognition that environmental and social determinants affect the health of these communities and is reflected in the nature of clinical presentations of all patients. Consequently, it has been proposed that “public health to be a core component of general practice” (Royal Australian College of General Practitioners, 1997).
Recognising this in 1998, the Royal Australian College of General Practitioners (RACGP) introduced a new curriculum emphasising population health for all General Practice registrars within the RACGP training program (Royal Australian College of General Practitioners, 1999). In addition, the RACGP has identified public health training as an important goal in its strategic plan.
The broader role of general practitioners to work in population health and collaborating with other health sectors is endorsed by a recent discussion paper of the Department of Health and Aged Care (Towler, 1999). The fact that environmental and social determinants of health (Labonte, 1993; Wilkinson & Marmot, 1998) are intrinsically linked to the clinical presentations of patients creates a synergy between the roles of medicine and public health. General practitioners trained in population health and public health have the skills and the opportunity to work with key stakeholders within communities (Campos-Outcalt, 2004; Fraser, 2005). There are opportunities to conduct applied research in order to plan, develop and evaluate preventive and health promotion programs in the general practice setting. This combination of skills has great potential to influence and advocate for improvements in health status (Best, 2000; Australasian Faculty of Public Health Medicine, 2002).
This is particularly true in rural Australia (Australian Institute of Health and Welfare 1998) where the high morbidity and mortality of the population emphasises the importance of this approach. In order to meet the health needs of populations, workforce shortages have (due to necessity) lead to synergic clinical, population health and public health roles for many health professionals in rural and remote Australia (Humphreys & Rolley, 1998; Best, 2000; Wakerman & Humphreys, 2002; The Australian Medical Council Specialist Accreditation Committee, 2004).
This paper describes an academic general practice training post in population health and public health for GP registrars in a rural region of New South Wales, Australia. Furthermore, this paper describes how this training post incorporates the principles of “Towards Unity for Health”.
Description of Population
This project is based in North Western New South Wales, in the former New England Area Health Service Area, a rural farming area with population of 174 000 covering 98 000 km2. In 1997, 129 full-time equivalent GPs worked in the region resulting in a relative shortage of at least 30 full-time equivalent GPs based on recommended population to GP workforce ratios (Alexander 1998). The population has excessive premature adult mortality and morbidity from preventable diseases, particularly cardiovascular and suicide. The region has a higher number of Aboriginal residents (5.8% of population overall) and has many small towns with declining rural economies and ageing residents (Public Health Division 2000). Consequently, North West NSW offered many training opportunities for a GP registrar in population health and public health.
Rationale for development of advanced training in population health and public health for GPs: National and regional factors
National policy initiatives promoting integration of general practice with public health and the development of local divisions of general practice created an opportunity to evaluate models to offer training for GPs to work in population health and public health with other organisations (Towler, 1999).
Within the local region, medical workforce shortages prevented any expansion of existing health programs that required GP input in the public health unit and local divisions of general practice. It was hoped that offering advanced training in public health and population health would be attractive to some GP registrars.
GP registrars who developed skills in this area had the potential to work in projects aimed to improve the health status of the population working collaboratively with divisions of general practice and public health units. Additionally, these organizations would benefit from the input of GPs in the development of programs. Increased retention and recruitment of an adequate Australian GP rural workforce increases the capacity of this workforce to meet the acute and chronic clinical demands of rural areas. This allows GPs with a special interest to develop extended skills in population health and public health. This complements the core skills in population health which are required by all GPs reflected in the domains of the RACGP curriculum (Royal Australian College of General Practitioners, 1999).
During 2000, recruitment to a medical educator position and a public health officer training position in this region both remained unfilled, despite extensive advertising in the region. The local public health unit was interested in developing links with general practice to improve health promotion opportunities. The local division of general practice was also planning a number of health promotion projects requiring medical input. This included immunisation, men’s health, cervical screening, diabetes and Active Australia (exercise) programs. These local and national issues fostered a collaborative network with stakeholders to be developed to offer this training post.
Description of Stakeholders involved in Project
Local Stakeholders initially included:
North West Slope Division of General Practice (NWSDGP): a support organisation for local general practitioners funded by the Commonwealth Department of Health and Ageing;
Hunter New England Area Rural Training Unit (NEARTU): a health workforce agency with aims of recruiting and retaining the rural workforce;
New England Public Health Unit (NEPHU).
A nominal group process (NSW Department of Health, 2002) between NEARTU, NEPHU and NWSDGP identified that a GP registrar program in population health and public health could be mutually beneficial by raising public health’s profile and training GP registrars in population health and public health. A reference group of stakeholders in postgraduate training in general practice and population health and public health was established, with national representatives from the Royal Australian College of General Practitioners (RACGP), Australasian Faculty of Public Health Medicine (AFPHM), University of Newcastle, and New England Area Training Services (NEATS), a consortium responsible for training general practice registrars in North Western New South Wales.
The reference group endorsed a program of learning based on the registrars’ current knowledge and projects that focused on the local Division’s key priorities, consistent with the region’s identified public health needs. An application to the Commonwealth Department of Health and Ageing, Rural Health Support Education and Training Scheme (RHSET) was successful in funding a pilot in 2000.
In brief, the training post aims to:
- improve the skills base and training of rural general practice registrars in applying a population health and public health approach to improving the health of smaller rural communities; and
- facilitate more GP registrars to consider a career in academic general practice (teaching and research).
A description and evaluation of the initial training pilot is reported elsewhere (Fraser, 2002).
Broadly, the reference group agreed that an academic post should deliver varied opportunities for a GP registrar to undertake and experience supervised projects in population health and public health. To facilitate this, a learning plan was negotiated and developed based on the registrar’s present knowledge and skills base in population and public health. Assessment of the term was based on a learning portfolio of activities undertaken. The reference group endorsed this education methodology as the best method to implement and evaluate the post, rather than a prescriptive curriculum of competencies to be achieved. This was because the previous experience of the registrars could vary widely and this methodology had been used successfully before in medical education in rural areas (Royal Australian College of General Practitioners, 2000).
During their training period, the GP registrars work part-time in their academic post; the remainder of the time is spent in clinical work in general practice. The GP registrar is supervised and mentored by the author who has skills in general practice, population health and public health.
Exploration of principles of “Towards Unity for Health” developed in this project
A thematic and content analysis of term evaluations, research notes, papers and reports of GP registrars (Lupton, 2004) was used to evaluate this project and to develop examples of how this project embodies the key principles of “Towards Unity for Health“. The roles of “health service providers, health professionals, the community, policy makers and the academic community” (Boelen, 2000) are described using a thematic and content analysis of archives from these research projects. Findings were validated by another researcher with a limited supervisory role for GP registrars in their research projects.
Benefits of the Academic Posts
The posts have been viewed favourably by registrars and other stakeholders in terms of the educational program offered and the potential to facilitate partnership between regional organisations. Registrars report developing skills in project design, data-gathering, analysis and report-writing implementing population health and public health projects in these posts (Fraser, 2002). Qualitative data supporting this is presented in Table 1.
Table 1: Benefits of the Post for the Registrars and Other Stakeholders
NWSDGP division has found benefits in this project, in terms of “value adding” by the involvement of the registrar in the public health projects of the division (Fraser, 2002). NEPHU recognized the benefits of broadening the “exposure of registrars to a public health focus” (Fraser, 2002). Qualitative data from the initial pilot and term evaluations are presented in Table 2.
Table 2: Facilitating Factors to Partnership
Issues with Integration of Public Health with General Practice During the Posts
Despite the benefits of collaboration, a number of barriers did arise in a placement around issues of control, roles and ownership of the project. Registrars also commented on issues around integrating clinical and population health work (Table 3).
Table 3: Restraining Factors to Partnership
Description of Registrar Projects
Six GP registrars have been recruited to undertake this training post since 2001. Since the initial pilot, competitive funding grants were obtained from General Practice Education and Training, a national funder of GP education. In 2001, one GP registrar was involved in a smoking cessation project (Wong & Fraser, 2004). In 2003, one GP registrar conducted a quantitative cross-sectional survey of primary school children in North Western New South Wales schools and compared this with parental assessment of their child’s adiposity (Fisher et al., 2006). Over half of parents in this study failed to recognise their child was overweight or obese. Another registrar from 2005 to 2006 conducted a qualitative study of rural parental knowledge, beliefs and attitudes towards childhood overweight and obesity. This project is in the final stages of submission for publication. Another project has been conducted into the quality of life of rural patients with hepatitis C. Table 4 summarises numbers of applications for posts, status of projects and funds received.
Table 4: Academic Post in Population Health and Public Health 2001-2006.
None of the registrars involved in these posts had published prior to being involved in this form of training. All have completed a research report as part of the post. Three of the six registrars who have undertaken this training continue to work in the region providing clinical services. Significantly, one registrar who has undertaken the post has developed an interest in academic general practice and has accepted a position as a regional medical educator increasing capacity to deliver GP training in the region. Another registrar who has undertaken this training has become a GP supervisor of GP registrars.
A description of “Towards Unity for Health” Sustainable Partnerships Involved and Impact of the Project
“Towards Unity for Health” defines a framework for describing sustaining partnerships. This ranges from ad hoc arrangements, the development of a demonstration project, to a longer-term commitment with stakeholders reviewing their mandate, and long-term commitment with expansion of the pilot project (Boelen, 2000). Evidence of impact in a “Towards Unity for Health” project ranges from dissemination of lessons learnt in a project, to advocacy and to ultimate expansion of a model.
This paper describes the development of a project linking local and national stakeholders in 2001. This project has been feasible in a rural area in continuing to provide this form of training from 2000-2006 with ongoing demand for this type of training from GP registrars. The project has required ongoing cooperation between local stakeholders with accreditation of the training by the RACGP and funding obtained from General Practice Education and Training, which funds GP training nationally in Australia. In terms of the project’s impact, major findings have been disseminated via publication (Fraser, 2002; Fraser et al., 2004)
To-date, the project has been recognised as having potential for expansion to other areas of Australia. This type of training model is cited as a model of best practice to upskill GPs in public health in a report to the Commonwealth to promote a dual training pathway between general practice and public health (Cheffins, 2004). Due to this experience, Hunter New England Area Rural Training Unit has been invited to be a member of a dual training pathway (general practice and public health) advisory group nationally in Australia. This represents a form of advocacy for this training model. Some efforts have been made to reach the final stage of sustainability, longer-term commitment and expansion, which to-date has not been fully achieved.
Since the development of this project, a similar training opportunity has been developed for GP registrars in the Northern Territory (Morgan and Kelly 2004). Similar to the findings of this project, they report positive learning outcomes for their registrars.
Towards Unity for Health recognises that integration between public health and medicine requires partnership between five key stakeholders: policy makers, health managers, health professionals, academic institutions and communities. The registrars involved in these research projects developed and managed their research projects. They had to engage stakeholders recognised in the “Towards Unity for Health” framework to enable these projects to be conducted successfully. The registrars recognised this role, as reflected in the quotes made by this group.
Locally, health managers of the public health unit (NEPHU) and division (NWSDGP) liaised with me as director of the academic institution (NEARTU) to coordinate the program. A regular training session with the registrar was conducted with me as supervisor. Restraining factors to the local partnership were identified at these contacts and discussed with managers from the respective organisations (Table 4). This included managing the balance for the registrar between clinical and public health work. Local organisations (NWSDGP and NEPHU) identified suitable projects for the involvement of a registrar. They recommended suitable community partners on the basis of the nature of the project. The registrar contacted communities involved in projects by contacting relevant individuals and groups, such as school principals and community controlled health boards.
Linkages with national funding and standards setting organisations such as the RACGP and AFPHM were coordinated by the local academic organisation (NEARTU).
This paper presents a feasible educational model to integrate general practice with population health and public health training in a rural area of Australia. This educational model promotes collaboration between GPs and other stakeholders, promoting a career pathway in academic general practice, population health and public health to more rural GPs. Previous models of joint training between general practice and public health had been piloted internationally (Brenner et al., 1994). This, to my knowledge, was the first post of its type to be offered in a rural area.
A major limitation of this project is that it involves small numbers and we lack a control group. We lacked the resources to undertake a controlled educational intervention. As a result, I am unable to determine what results are attributable to the education intervention, in terms of workforce retention and linkages between stakeholders.
Despite this, this project shows significant linkages between local health managers and academic institutions. The “Towards Unity for Health” partnership pentagon recognises that this relationship is conducive to the training of a health workforce which is responsive to regional health needs (Boelen, 2000). This project involves partnership with all five key “Towards Unity for Health” stakeholders. The involvement of these stakeholders is not equal, without linkages directly between some stakeholders. This is common and a fully linked pentagon partnership as promoted by “Towards Unity for Health” is found infrequently in health care (Boelen, 2000).
This paper shows that this educational model to teach GP registrars population and public health skills is consistent with the aims of “Toward Unity for Health” and is feasible in a rural area of Australia. Next steps include trial of this project in other settings of Australia and internationally.
I wish to acknowledge the input of NWSDGP, NEPHU, FAFPHM, RACGP, GPET, NEATS, University of Newcastle and the GP registrars involved in this project. Sections of this paper have been reproduced from the publication: FRASER, J., ALEXANDER, C., KERSHAW, G. & WONG, B. (2004). General practice training in public health: Two parallels converging. Finalist, Education and Training. In, NSW DEPARTMENT OF HEALTH (Eds.), Baxter 2004 NSW Health Awards: Winners and finalists (pp. 161-163). Sydney: NSW Health with the permission of NSW Health.
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