GP Link Lunches – Dr Michael Bonning

Dr Kenneth McCroary, Chair of Sydney South West GP Link, hosts a series of meetings with clinical/ political/regional individuals or organisations to discuss issues and solutions for GPs working in South Western Sydney.

Ken McCroary – Welcome everybody to a further edition of GP Link Lunches. Today we feature Dr Michael Bonning. I interviewed Michael a couple of months ago, just as the last Omicron wave was about to hit. He is now the president AMA (NSW). Remember if you are not yet a member of GP Link visit the website at https://sswgp.link

As part of GP Links ongoing advocacy for general practice in the South West of Sydney I was recently able to agitate for the founding of a working group dedicated to prioritising and push methods of GP support and funding particularly in relation to the recent COVID outbreak and increased numbers with the corresponding increased demands upon GP time, and management and monitoring positive COVID patients in the community. 

Michael was instrumental in bringing together the major GP groups of NSW including the AMA, RACGP and various PHNs around the state. The group was able to present our consensus thoughts for GP support in NSW which was tabled to the GP Synergy group that recently meet with former Health Minister Mr Hunt. 

GP Link has been a member organisation of GP Synergy and with the recent extraordinary meetings of GP Synergy and the ultimate handing over of memberships solely to the College of General Practitioners, GP Link was able to further expand our advocacy roles with Michael’s support through the GP Synergy group.

Dr Michael Bonning is a GP involved with the teaching of registrars and medical students in Balmain. He is the Chair of AMA in NSW and Deputy Chair of GP Synergy. Michael has a strong interest in doctors’ health and wellbeing and sees many doctors and medical students as patients, and previously he was a full time Medical Officer in the Royal Australian Navy. 

I thought today would be a good time to talk to Michael about his work with both the AMA and also GP Synergy particularly with the transition of General Practice training moving towards the two main colleges during the next 12 months, and discuss GP Link’s firm commitment to continued education and development of our local General Practitioners.

Ken McCroary – Thanks again Michael, I was just wondering if you could enlighten us with some of your COVID experiences in the last year or two?

Michael Bonning – It is coming up to almost two years now, I was in the position as a GP in my local area to express interest to the PHN to run one of the Commonwealth Respiratory Clinics which we set up in Balmain, so I have had a bit of a different experience.

Our sole focus of developing the respiratory clinic was to actually focus on the GPs of our region so copying in GPs on results, sending letters where we made meaningful changes to management in peoples care, and also because we suspected this was going to take a while, really focusing on lots of the things we could do. 

Because sometimes with COVID there were things we could not do, so what we can do is we can work towards better management of peoples chronic cough, or we can identify there is a transition and identify their new additional lung disease or work with a broader team which we have done for a number of patients where we have been in a position to diagnose and identify peoples lung cancers and other things. We have probably had a bit of a wild ride in that regard. The organisation is a group that is starting to pride itself I think more on our respiratory services as a whole rather than thinking of it in a narrow band of COVID.

More recently, especially when we got to the larger outbreaks last year and then transitioning into Omicron before Christmas, the respiratory services has just been very, very  busy. Before you and I were talking today, we were organising for a patient to get sotrovimab, and that I think has been important now we have real tools to develop some confidence in the community, that there is a lot we can do that GPs have real access to.

I certainly want to be in a position to want to be able to give oral antivirals to people in the not too distant future. They are accessible and available within our clinical space. Because that again removes one more barrier for some of the pain patients who I think are at most risk who don’t really want to go to hospital because it is a big challenge for them and are quite limited to where they can get to, accessibility wise ,in their local communities. So those things have been good in terms of new things we can do. I also think overall, especially the respiratory clinic service, there is going to need to be ongoing support for general practice tomanage through this because it is not going away and we as clinicians have to be able to run our practices, our regular general practice, we also run that risk of what happens when we get COVID? What happens when we get exposed? What are our risks to other vulnerable patients we need to see later on in the week? How do we offset that against needing to see people who are likely walking around COVID positivewithout even knowing it? So still lots of challenges.

One of the things that came out of our respiratory clinic is we actually set up a second site. Our respiratory clinic is an independent site from our regular practices and then we set up another independent site out at Sydney Olympic Park from last March where we introduced the Commonwealth vaccine program, so we were the offshoot of the respiratory program and we ended up being across the road from the giant NSW health hub signifying how good it was as a location and a site but in western Sydney being a general practice-led service to deliver vaccine was really positive, as well it was one of the first times in the pandemic I felt like we could actively take action that people were positive about. They were always nervous and worried when we were trying to work out whether they had COVID or not, when you are in a position to give a vaccine and to provide advice to patients about preventing COVID they were really appreciative of the help we could provide, so overall I was lucky enough to see some of the real benefits and thingswe could do to access community during the pandemic and recognise there is still quite a way to go.

Ken McCroary – Yeah, it has been an interesting ride hasn’t it, so I know you have an interest in GP wellbeing and doctor wellbeing as well and with all of these changes throughout the pandemic and the new waves of practising with your groups, how have you been able to manage the pressure and stress on your team and have you been putting anything into place that would help with that?

Michael Bonning –  Yes we have and again sometimes clinical service need has been everything when everything has been incredibly busy and COVID has been running a bit wild but we’re putting more time into getting people together for social reasons for when we could and how we could, whether it was outdoor or in small groups and things so we could remind everyone we are a team and we are together. 

One of the other focuses, and it was more around everyone’s professional development planning last year, was to recognise there was this big thing that was going to make their practising lives challenging and so as a practice, and also as colleagues, what could we do to progress people’s careers and help them launch new things within the practice we want to do more of, whether it is weight management in a comprehensive multidisciplinary way well, how can we do that, you know. 

We are struggling more with and I think all practices have seen this with the weight of uncertainty anxiety, moods, conditions in our patients. I think this in some ways this makes the practice of  medicine much harder and so how are we actively setting up our service to try and better manage our patients so that in the end we also look after ourselves? And so that single practitioners don’t end up with a large number of a certain type of patients, and so a lot of that almost load-sharing in the practice has been something we have had to take much more active care about these last two years. Some of it doesn’t cost a thing apart from a little bit of time.

I like to get to work early on a Tuesday and just across and hour-and-half or two hours just try and talk to everyone. Tuesday is our busiest day in practice all of our rooms are full and on that day some people starting, some people finishing, you just get a chance to catch up with everyone you get a chance to have a chat about things, have a laugh, a couple of people go and grab a bite and those little things. I would probably be doing administrative work anyway so why not make it a bit more fun and enjoyable by sitting together with a few others looking through mail or talking about some cases in the practice. It does require a bit of effort but it certainly does not cost much to kind of look out for everyone else and for them to look out for you because that cultural part is what you want just as much as you want to put into it, you want everyone to look out for one another so we have really tried to demonstrate that over this period of time and then to recognise that people need to make changes. 

One of my colleagues just really needs to take some time out, a lot going on in their life and the first response from us as a practice is ‘great let’s pare things back for the next three months and work with you on how you want to play this and how we best look after you and the patients you see. So it’s pretty multi-pronged but certainly again any little active step I think is greatly appreciated by your colleagues and it is one of those things you pay forward because you know you are going to need it at some point whether it is this year or next year or years down the track but you are doing it for everyone you are doing it for the culture that will help you as a practitioner in the future as well.

Ken McCroary – Yes I commend you on instilling that sort of culture in the group, that inclusivity and that support working in all directions. It would certainly be a positive step and I am sure all of the staff would be appreciating the support and time they would get and that team building – it has been a very protective mechanism throughout the pandemic. I was really impressed too the way you mention the support for the solo practitioners as half of our practices in South Western Sydney are solo practitioners so that is something we have had concerns for with their wellbeing and support and so we appreciate that insight. Now apart from COVID we have spent a bit of time in the last few months talking about GP Synergy as well, you being Deputy Chair of GP Synergy and GP Link being one of the member organisations. I know there has been a bit of concern and worry particularly with the training of future GPs. Have you got any insight you can share with our members and readers about the whole transition with the college membership of synergy and also what your thoughts are with the future of general practice training?

Michael Bonning – There was a commitment made that we should have professional-led training and I am a huge supporter of that. I find it unusual that as a profession, and as a specialty area in medicine, we are the only group that doesn’t run its own training through our professional bodies. So those two colleges I think are the best places for this to occur. That commitment was made. There have been some real teething issues with understanding just how complicated training is and one of the reasons for some changes to our constitution and through member votes to get to that point, was for both the organisations the future ongoing involvement in training. So RACGP and AHPRA, they were in a position to actively transition because as it suggests it is not just we finish the end of 2022 training year and we hand over a bunch of documents to both colleges in February next year and then wash our hands of the situation and move on. It has got to be the people and relationships being the processes and the systems so everyone can get on with doing general practice training because that’s what as supervisors and registrars is what happens, we need to train and learn together. Through all of that our registrars that are in our practice are in a similar boat they need to know that there is a training continuum and there will be as close as possible a seamless handover transition to that training for next year. 

We have really good news for practices that have ACRRM trainees. We are making really rapid and positive progress with ACRRM we plan to have all of their registrars handed over by August this year so a full transition to their organisation of all the registrars in NSW/ ACT. Then with the RACGP, that is still helping them to develop their internal organisation and management of training, but as 90 per cent plus of GP Registrars are RACGP registrars that is a huge undertaking and what we always put into the centre of what we are trying to achieve was that there would be continuity for registrars, supervisors and practices and to maintain a lot of the relationships that have been built.

As much as there was a change in the membership of GP Synergy there has not been a change in the day-to-day interaction and how we work with our stakeholders, whether that be GP organisations, universities, PHN lots of other groups that fill out what used to be considered our members are actually our stakeholders, are people who invested in training. That part is still going, I think it is going well and all supervisors and registrars there should not have seen any change to how they interact with us as an organisation. 

So we are moving ahead to try and ensure that is maintained for when the training program is transitioned over to the RACGP because registrars in NSW and ACT make up almost 40 per cent of the total registrar pool of the country. Getting to a position to where we could hand over a lot of how we do things and how registrar and supervisors are supported and treated through the program and what policies and all of those other things mean our registrars and supervisors are in a great position so they don’t have to deal with so much upheaval because most of the things that have been taken onboard by the RACGP are actually things that are coming from GP Synergy, so for us that is why there was a strong undertaking to transition and to work through it and make it a kind of team process with the two colleges.

We think that is working out and in speaking with our CEO recently we were working with the regional training organisation network so the network of all RTOs around the country, their ongoing process of transition and working with the colleges and the departments to make sure we keep taking steps forward because we have to. There is already not enough registrars that come into general practice training we have got to create a future and a pathway so that as many as we can bring in are able to be trained.

Ken McCroary – Absolutely, speaking of someone who completed his fellowship under the college-run program back in the day I think it was a no-brainer for the colleges to take back over training and I certainly commend all you have been doing to make that seamless for everybody, supervisors but especially the registrars training as general practitioners moving forward, so good job there mate. We also spent a bit of time hanging out at the AMA, you are Chair of NSW AMA and we chat on the GP Council, now GP Link is a small local group in South West Sydney I am just wondering with your AMA hat on, do you know much about problems facing GPs in South West Sydney and GP practices and how your organisation would be able to help and support GPs in the region?

Michael Bonning – I think I am lucky that I have worked down at Tharawal Aboriginal Cooperation, so their medical centre is down there with Tim Senior, who is a great GP in the region. I also worked in Lurnea just near Liverpool over the years and I think some of that experience reminds me of how different the experience can be between different parts of even greater Sydney and that there are things we find easy to do with our PHN or with our LHD, certain areas that are less so in other regions and that is one of the things with the Council for General Practice or AMA or generally they have been really trying to hone in on. Which is that the organisation gives real hands and a big set of shoulders to help support local issues being sorted out and whether it is directly meeting with PHNs with local GP representatives or with LHD CEOs around some of the work we do with the hospital sector, the AMA is there to kind of bring more firepower to some of those discussions were we cant get people to move, sometimes the AMA can.

The other part is being able to bring ideas from other parts of the state of the broader AMA family around the country or what can we do that will assist here and we will try and facilitate that together. And the last part I think is always around the future of general practice looks like.

So lots of what the AMA does is really high level lobbying at a Commonwealth level but also thinking about what does it look like in terms of our relationship with the state as a whole. The former Secretary of the Department Elizabeth Comp has been a really big believer in co-commission models, adding partnerships for primary care between government and local GP groups and we have got to get more of that to happen, we have got to make it so that our sector in primary care which does things longitudinally, very cost effectively, and with a huge amount of trust from our patients, is actually resourced appropriately to take on the more and more complex stuff that hospitals don’t love dealing with because it is highly expensive and doesn’t have great outcomes. But also that the MBS doesn’t fund, you know there are so many things we do as GPs that there is not great funding for and as much I think that getting more money in the MBS is part of the solution it is not the only part of the solution when we talk with GP groups like GP Link that also with forward thinking PHN CEOs with others in the sector.

Ken you and I are on with Walid Jammal, on with Charlotte Hespe and Danielle McMullen and many others, it is about really getting down to the problem, the integration between primary care and other parts of care for the patient and lots of that bridging is done by GPs out of almost like shoe leather you know, we are out there, we are getting out to see our patients whether it is in their homes in residential aged care facilities we are doing outreach to them which we actually need some help and support for and I think that’s one of the things the AMA is seeing as much more significant part of integration which is to listen to what GPs have to say and to try and direct and help government to see that for what it is, not just a contention that they need more money but actually that money is an incredible application of funds really effectively in a space where GPs know what is going on in their local community, they are the people who are we talk about frontline but they are the people who really know what is happening at a community health level but even at commutable disease level, and a healthy ageing level at a…. Ken we have talked about this as well at a COVID care level – what works, what doesn’t, and what does my community need because it is not a one size fits all model and I think that is where the AMA has really been getting involved recently.

Ken McCroary – Yes there has been a lot of work going through a lot of groups a lot of committees but as a GP in the South West I have really been impressed by the coming together of everybody and the sort of groups aims and everyone working more closely for more outcomes both for us as a general practices and for the patients in our region and wider communities as well so that is something I have been really impressed I know you have had a lot to do with that as well so yes that has been interesting to watch.

Michael Bonning – Yes and it is not without its frustrations. Don’t get me wrong, sometimes you want to feel like there is light at the end of the tunnel and sometimes that light moves a little further away and sometimes it gets a little closer.

The things we are already hearing that we really want to take and push at the highest levels is a lot of good things in both the primary care reform process that has been going on and we need to see those enacted so that GPs are actually getting thought of as the main and primary managers and clinicians for chronic disease and thinking about ways more in which the patients stays in the community.

We through general practice and through not just ourselves as GPs but also through our nurses and allied health staff and even our admin and reception staff, are able to wrap more care around the patients and also get the patients to be more involved in their care because you know we can do things with them we have the resources and the funding to do that.

And that is the model I kind of really want to push is that there is more flexibility. If I come back to what we do in a respiratory clinic for a moment, we are a group that really wants to focus on deep diagnosis there and because we are unburdened by the Medicare Benefits Schedule we can do that in innovative ways and we can bring in other clinicians we use nurses we have other inputs allied health and other specialists and we pay that out of the same bucket of money without having to worry about who exactly saw the patient who is allowed to bill and who isn’t and we think that some of those changes in models are needed for general practice so we can use our best team member for the thing the patient needs, rather than having to rely on well the GP has to bill that item so that is some of the reform I would like to see over time.

Ken McCroary – And yes I would support that exactly. That is what states have been doing at their hubs and everywhere else makes so much sense, the community care, through LHDs, through COVID, people that transition to us we are running different models we don’t have the ability to have nurses take the calls and monitor COVID we don’t have to do it not in real time and we don’t have the capacity to do that and do our regular GP job and do everything else so yes supporting that change in thinking is really important.

Michael Bonning – It is terrible it took a pandemic for this to happen but at least it has accelerated both these conversations but also the underlying infrastructure we need to actually make it happen, the utility of telehealth, the accessibility of e prescribing, the work towards structural frameworks between state and community care and actually primary care to get things done.

Ken McCroary – Yes you are right they were coming but at least they are getting here a bit quicker now and the experience has been successful and positive for everyone I believe. Now before we wrap it up one other interesting part of your career history has been the time that you have spent as a medical officer in the Royal Australian Navy so if you have some time just to give us a bit of information on that experience, I think that would be quite interesting to hear?

Michael Bonning – I still describe it as the best job I have ever had. It was at times very much focused on when you are alongside and you are in Australia you fulfill the role of a GP with a strong occupational health vent to your practice, so lots of times ensuring people are fit for the duties they are about to be deployed to. But the part I love was the ability to be deployed and I was lucky enough to do things off Australia and in South East Asia and in the Pacific the search for MH370, and to do things with the Indian Navy across to the Middle East and doing counter piracy, counter smuggling work there, the centenary of ANZAC the International Fleet Review here in Australia in 2013 for the 100th anniversary of our Navy and it is just this incredible amount of camaraderie but also there is that organisation that wants doctors to play their part and it is a very different space to being healthcare organisation. Doctors are the very pointy end of the service where as in the military you are very much a support service but you learn to make that so important to see how well the organisation works when you do your job really well and so does everyone else  – that team component.

We are looking at some things here and on my desk at home of a memorial service  we conducted through the Centenary of ANZAC but also a great group of friends I stay in touch with, amongst

the officers on one of the ships I served on, HMAS Success, and there is a lovely photo of some of the boarding operations, we were there to assist people, people on the high seas who were sick or injured because seafaring can be pretty dangerous at times and they all are just fantastic memories and I am very proud of the decision I made to join the Navy when I was a Medical Student you know as part of the medical scheme so that bonding program, and for them to extend my career with them to be able to do more diverse things and now days there as a fairly inactive reserve but certainly someone who still wants to put the uniform back on again once we are out of this part of the pandemic and hopefully give a bit more service.

Ken McCroary – That is excellent, very interesting and inspiring words there so well done we are obviously very proud of you and the rest of our Defence Forces without a doubt.  So this has been really interesting Michael I really appreciate your time.

Michael Bonning – Thank you, Ken, really nice to talk to you have a great day.