2.2 Changes in the delivery of health care

There is a growing mis-alignment between the settings in which health care is delivered and those in which medical specialists are trained. This could lead to specialist trainees being inadequately or inappropriately prepared for their future clinical practice.

Australians require vastly different health care now than 25 years ago. Changing patterns of disease have affected the ways in which health care is delivered and chronic health conditions have become the dominant focus of the health system.⁷

The illnesses burdening our community are frequently multi-system, chronic and complex and cannot be addressed by one health discipline or only in an acute tertiary hospital setting.

Changes to health care delivery are most notable when looking at data on where services are delivered. For example, 75% of all health care expenditure is now outside of public hospitals⁸ and 40% of all surgery is now day stay surgery.⁹ The average length of stay in a public hospital fell from 5.2 days in 1991-92 to 3.9 days in 2000-01.¹⁰

The ramifications for training of a decreasing length of stay in hospital are that specialist trainees are less involved in continuity of care, including pre- and post-procedural care.

In the past, public hospital outpatient clinics provided excellent and efficient learning opportunities - especially for specialist trainees in the more advanced stages of their training. However in many parts of Australia public hospital outpatient clinics are being reduced or closed, and patients are now seen in private settings.

This significant gap in training exposure is particularly important, given that a specialist trainee will become responsible for the entire continuum of a patient's care once he or she has obtained college fellowship. For example, a woman with a malignant breast lump may spend only one day as a hospital in-patient, but the total length of her treatment from diagnosis to eventual cure or death may be more than five years. Patients with dermatological problems, such as skin cancers, receive most of their treatment in the private sector.¹¹

The increased uptake of private health insurance has also provided people with greater control over their health care, including the ability to choose to receive treatments outside public hospitals. The private sector is becoming increasingly important for the delivery of health care services, as the following statistics show.

• In 2003-04 private hospitals accounted for approximately 39% of total hospital separations. Australian Institute of Health and Welfare, Australian Hospital Statistics (2003/04).¹²
  
  
• Of all procedures undertaken, 43.5% were performed in the private sector.¹³
  
  
• From 1993-94 to 2001-02, separations for chemotherapy increased fivefold in the private sector and decreased by 2% in public hospitals. The proportion of separations for chemotherapy that were in private hospitals increased from 15% to 51% over this period.¹⁴

The survey of specialist medical colleges by Reference Group 3 showed that colleges are already recognising the potential of diversifying training opportunities and are seeking to increase the proportion of training in settings beyond public teaching hospitals.

7 Australian Institute of Health and Welfare, Australia's Health (2004)
8 Australian Institute of Health and Welfare, Health Expenditure Australia (2005).
9 Ibid.
10 Ibid.
11 The Australian Medical Workforce Advisory Committee report The Specialist Dermatology Workforce in Australia (1998) indicates that 96% of dermatologists report their main location of practice as private rooms.
12 Australian Institute of Health and Welfare, Australian Hospital Statistics (2003/04)
13 Australian Institute of Health and Welfare, Australia's Health (2004)
14 Ibid.