6.3 Findings

Much of the feedback from the three reference groups overlaps and addresses similar themes. The findings are therefore reported against specific themes that became apparent in analysing the data, rather than according to the reference group that provided the comments.

Overall the broad areas relate to benefits resulting from expanding training settings, barriers that need to be overcome before expansion can occur more widely and their proposed solution, and other issues that need to be addressed in the future.

It should be noted that training in expanded settings currently occurs for all specialties and in all jurisdictions, mostly successfully, but on an ad hoc and relatively informal and unstructured way. Therefore there is a need for the lessons already learned to be promulgated widely.

Perceived benefits of expanded training

Wider exposure to patients, procedures and settings

Nearly all of the twenty one stakeholders questioned by Reference Group 1²³ identified that there were benefits to the expansion of specialist training beyond public hospitals. The most commonly identified benefit (16 out of 19 responses) was in the area of providing specialist trainees with wider exposure to a greater range of both patients and patient settings. For some specialties, the public hospital system did not have sufficient numbers of some procedures and conditions, usually cases that are less acute or non-life-threatening, that have now migrated increasingly to the private sector:

"The minor procedures allowing trainees to learn basic skills and core competencies have migrated to the private sector, for example, varicose vein procedures, haemorrhoids, hernias and ‘lumps and bumps'." (Medical college)

Other conditions that previously prolonged hospital admission are now treated as day admissions, including in private settings. Another trend of decreased length of stay in public hospitals is also affecting specialist trainees’ exposure to patients over the full patient journey from consultation, to admission, treatment, recovery and follow-up. Many of these stages are now undertaken by specialists located outside the public hospital.

There were also arguments made that a wider range of settings would allow specialist trainees to have ‘hands on’ experience rather than just observing procedures undertaken by qualified specialists. This includes participation in non-procedural tasks such as consultations and developing and running a medical business.

A number of respondents identified that many specialist trainees wish to work in the private sector when qualified and exposure to other settings is an essential part of their training experience. For a number of specialties, the majority of practise now occurs in the private sector yet training settings do not reflect this reality. Examples given include psychiatry, cardiac surgery and dermatology. There are also many specialists who work in a combination of settings – that is, public, private and rural – and wider availability of training settings are seen as important for these people.

Another six respondents identified other potential benefits in having specialist trainees including attracting good specialists who wish to work with trainees outside the public system and the chance to attract trainees and retain them once they are qualified. Some private hospitals also perceived that taking on specialist trainees would raise their profile and improve the quality of patient care. One private hospital also identified that nursing staff and patients would benefit from the presence of specialist trainees because they are more accessible than specialists in answering questions. Finally, one respondent felt that expanding training settings would be necessary as well as desirable as it will become increasingly harder to accommodate larger numbers of specialist trainees in the public hospitals.

Perceived barriers to expanded training and proposed solutions

Funding and indemnity

Sixteen respondents identified financial barriers as a concern when considering training for medical specialists outside public hospitals. Concerns included that the current system is already under strain and more specialist trainees could not be accommodated without increases in funding. Funding would be needed for places for specialist trainees in all settings, for back-filling of trainees' public positions while they had a placement in another setting and to compensate private settings for the 'slow-down' in throughput as a result of having specialist trainees.

"Private hospital surgeons can churn through the patients' operations because they don't have to teach (and therefore make more money). Increasing teaching will involve an opportunity cost of the number of procedures that will be foregone in the private setting." (State health department)

The need for other resources for specialist trainees such as access to equipment, space, research facilities and accommodation (in the case of rural areas) were also mentioned as additional costs by some respondents.

Also, a number of respondents raised concerns about whether specialist trainees in other settings would have access to indemnity cover and the employment conditions from public hospitals. Funding was also an issue as lack of funding by state governments affected the number of procedures that could be performed and the number of specialist trainees that could be employed in public hospitals.

A few proposed solutions to the funding issues included allowing specialist trainees and supervisors to access Medicare to claim for procedures performed or a higher rate of reimbursement if training was involved. It was also suggested that specialist trainees in private settings could offer patients reduced rates for seeing them rather than the specialist.

Patient attitudes

Thirteen of the respondents raised patient attitudes as a potential barrier to training expansion. Some felt that patients who are in private settings expect to see a specialist and are resistant to specialist trainees especially if their condition is not acute and they are well-informed, while others reported that this was not an issue, especially if patients felt confident that the specialist was supervising the trainee.

"Trainee participation requires full disclosure to patient. Generally patients do not object (although we thought they would), as they assume that the specialist will be there with the trainee." (Medical college)

Patients in public settings are generally seen as more accepting of specialist trainee input and care. Some private specialists were also perceived as insisting that their patients are not seen by specialist trainees. Specialist trainees may be acceptable as observers of procedures but not in performing them. Another option is to offer patients services by specialist trainees with the assurance that fully qualified specialists are on hand to supervise or step-in if there are problems. One respondent also raised concern that patients would be negative if specialist trainees were only in place for a short time or infrequently.

Time constraints

Eight respondents identified time pressures as a barrier to training expansion. Time constraint issues applied both to specialist trainees in terms of amount of time available to spend in alternative settings, supervisors who may be looking to reduce their hours as they age and the fact that insufficient time is given to training in all settings. Some argued that public hospitals focus on service provision at the expense of training and private hospitals are likely to do the same. Specialists who operate across multiple settings are seen as being less likely to take on training roles due to time commitments. Rostering was also raised as a potential difficulty for specialist trainees who are expected to work across multiple settings, along with the need to maintain safe working hours. Finally, a few specialties were concerned that current training opportunities were not allowing specialist trainees sufficient exposure to some conditions and patients and that more time was needed in these areas.

Other potential barriers

Ten respondents identified a range of other potential barriers to expanded training settings. Some felt that shortages of equipment, accommodation and facilities would inhibit expansion into other settings. Also, specialist trainees in the early stages will only be able to observe and assist rather than conduct treatments and procedures, restricting the effectiveness of a non-public hospital setting and reducing the desirability of having specialist trainees for these settings. Restrictions preventing specialist trainees claiming Medicare funding for procedures is also an issue in some specialties. One respondent felt that private sector services are only available where there is a profitable market for them and some areas that need them are therefore not serviced by them:

"The private hospital sector is shaped by price and markets, it is not a sector planned for the delivery of government services (eg medical workforce issues). There are certain specialties who will therefore not have private practice facilities in some geographic areas despite a need for them." (Private health provider)

This has implications for the ability of specialist trainees to be placed in regional and rural private settings. Also, having more specialist trainees may mean that a specialist has to reduce the number of patients they can see with implications for hospital workloads. Further investment in hospital infrastructure will be required if more specialist trainees are taken on in non-public settings.

Issues to be addressed

Supervision

A number of respondents identified that the quality and amount of supervision currently available in private settings is variable and this situation would need to be addressed if expanded training is to be a reality. Specialist trainees themselves are concerned about the amount and quality of supervision available and one respondent suggested that these should be regulated before the expansion takes place.

"Need to reward practices that actually teach and teach well. Supervision will be more robust if there are quality controls and rewards." (Medical practitioners representative organisation)

Respondents identified that shortages of some types of specialists and specialists in general in rural areas meant that current training options were restricted and a large increase in the number of specialist trainees would exacerbate this situation. The lack of a culture of teaching and supervision in some private settings was also identified as an issue that would need to change. There are also different levels of supervision required for specialist trainees at different stages eg new specialist trainees require far more than advanced trainees and this needs to be taken into account. Some respondents felt that the presence of specialist trainees while requiring time for supervision also allowed specialists to delegate work to them and therefore service more patients and this needed to be highlighted in order to encourage more to take on specialist trainees. One private hospital respondent suggested that commitment to training may become a criterion for specialists practising at their hospital in the future if training were to be further expanded.

A number of respondents felt that payment of supervisors would be necessary for the expansion of training settings. Supervision in the public sector has traditionally been seen as a way of returning something to the system but this is not believed to be as strong in the private sector, in settings that are fee for service or among younger generations of specialists.

"Supervisors are facing increasing demands; it is anticipated that if supervision demands in private settings were to increase, remuneration for supervisors who are not staff specialists may become necessary or requested." (Medical college)

However, one respondent identified that if payment is given directly to private supervisors, this will put pressure on the public system to do the same.

Some respondents suggested that supervisors did not necessarily need to be located in the same setting as the specialist trainees but some system of coverage and remuneration would be needed to make this workable.

Accreditation

The issue of accreditation of settings and/or supervisors to provide training to specialist trainees is seen as important and fifteen respondents identified it as a concern. Many felt that current accreditation processes would need to alter to allow more diverse settings to provide training although all but one of the colleges who responded to Reference Group 3 felt that accreditation requirements would be almost identical regardless of the setting. They also stated that it was unlikely that changes in training settings would have implications for Australian Medical Council accreditation.

Like most supervision, accreditation is usually carried out by qualified people on a pro bono basis and an increased requirement for accreditations will have cost and time implications for them. There is variation among the specialties as to whether it is individual training positions or settings such as hospitals that are accredited to provide training. Some state health departments perceive that the medical colleges use accreditation as a means of rationing the supply of specialists by only accrediting fixed numbers of settings or people. The colleges disagree with this perception, with some stating that they accredit institutions rather than places and focus on the need to ensure that training is of high quality, and that accreditation is a means of ensuring this fact.

"Standard and quality of training will be affected by expanding settings unless standards are protected (Note: Colleges are the best maintainers of the standards)." (Medical practitioners representative organisation)

Problems with obtaining accreditation are seen as particularly acute in rural settings where the lack of specialists to supervise or suitable infrastructure are key factors. However, in the longer term, more accredited places or settings in rural areas may lead to more specialists being willing to locate there. One respondent suggested that accreditation could be given to a partnership of sites as a network rather than a single site as a way of addressing some of these issues.

Ten respondents raised the number of patients available to specialist trainees as needing to be addressed through the accreditation process. Some felt that private settings, especially smaller ones, would not have the number and variety of patients required for trainees in some specialties while others identified that it was difficult at present for specialist trainees to see enough patients in all settings and more trainees would exacerbate this problem. It was also identified that some experiences can only be obtained in a high throughput public setting and that this must be retained eg highly acute patients and training in administration. Two respondents identified the importance of settings providing specialist trainees with sufficient experience and opportunities to pass their college exams. In some areas, there were concerns that this would be difficult in non-public hospital settings.

"Expanding training into the private sector may not solve the reduced opportunities to train in some modules, as the presentations in the private sector are not consistent and are generally ad-hoc (eg a trainee may spend three months on a rotation in the private sector and still may not leave with the required experience)." (Medical college)

One respondent also identified that significant differences in the types and numbers of patients seen in private versus public hospitals may have negative impacts in that specialist trainees may order unnecessary tests for non-acute patients or not have access to all the equipment available in public hospitals.

Workforce demographics and specialist trainee supply

All 21 respondents identified some impacts and concerns regarding workforce numbers and structures that would influence the ability to expand training settings. Many respondents identified that the ageing of the specialist workforce and impending retirements was occurring at the same time as increased numbers of medical students will be seeking positions as specialist trainees. This creates concerns about 'bottlenecks' where there are insufficient supervisors and procedural and consultation work to provide adequate training for specialist trainees in any setting. At the same time, changes in the demographics of specialist trainees and in their aspirations also impacts on training. A number of specialties identified that increasing numbers of females are entering specialty training programs and seeking part time positions, while newer specialist trainees of both genders place far higher emphasis on achieving work/life balance than was the case with previous generations. This means that, in some cases, more specialist trainees are required to cover the same amount of work while needing increased supervision and other resources. Also, the need for work/life balance is also affecting current specialists who may opt out of being involved in supervision and training as a way of achieving this.

"There is a current shortage of specialists as a result of:
• ageing medical workforce
• Decreased work output amongst new specialists in comparison with new specialists previously, due to feminisation, safe working hours etc
• Growth in demand in the public health system.
The distribution of specialists across the state is a particular issue with a relative over supply of specialists in metropolitan areas, and a significant undersupply in outer metro and rurally." (State health department)

A number of state government health departments expressed the view that there are not enough specialist trainees in public hospitals at present and if training settings are expanded, they will lose out to the private sector.

"Training in the public sector has not reached full capacity, especially in non-metropolitan locations. Colleges are not offering adequate opportunities through accreditation of rural posts to train in non-metropolitan locations." (State health department)

"If private sector continues to grow and takes on training (and research), there is little incentive for doctors and trainees to remain in the public sector." (State health department)

Most respondents agreed that there are great variations in the number of trainee positions according to specialty and problems that arise from this. For example there is a lack of take-up of specialist trainee positions in smaller states/regional areas and maldistribution in urban areas. Many areas have trouble retaining specialist trainees as they have often become far more mobile and will move interstate or overseas to continue training. Specialties such as dermatology, paediatrics and orthopaedics have no difficulty filling trainee positions but rehabilitation medicine and psychiatry experience unfilled traineeships in a number of areas. One respondent also identified that an increase in sub-specialisation has led to fewer general medicine specialists and more demands for coverage for on-call among sub-specialists. It was argued that some specialties are more popular due to a relatively higher rate of remuneration for procedural than consultative items through the MBS.

Current arrangements supporting training outside public hospitals

Seventeen respondents identified one or more current arrangements where specialist trainees are working outside the public hospital system. It is clear from these responses, and those given to the consultants assisting Reference Group 2, that there is an array of such arrangements that run within and across states, specialties and health sectors. Such arrangements appear to have an ad-hoc nature and have arisen as a result of local conditions or requirements. However, it is possible that some of these arrangements could be adapted to other areas or used as a basis for future models.

One of the most common current models involves specialist trainees working across co-located private and public hospitals. Trainees in specialties such as surgery may have this opportunity because their supervisors are specialists who are working across both sectors, often on specific days, allowing planning in advance. Some respondents feel this offers specialist trainees excellent exposure to the different types of patients seen in the two settings. There are also some instances of specialist trainees working in private clinics or practices that are based within public hospitals eg pathology. There are also examples from psychiatry and paediatrics where trainees work rotations in public and private community based clinics while still employed by a public hospital. Procedural specialists are able to bill Medicare for the work done by trainees as assistants. Also, some trainee psychiatrists are able to use a GP provider number to bill for psychiatry type services undertaken in general practice while they are training. Some respondents felt that the current general practice training system was worth examining to see if it could be used as a basis for streamlining specialist training placements.

Suggested future mechanisms for expanded training

Twelve respondents offered suggestions as to how expanded training arrangements could be implemented in the future, including utilising some of the current models mentioned above. Many were in favour of the public/private mix model where specialist trainees work one or two days per week in a private setting instead of full time rotation. It was felt this would offer the greatest opportunity for exposure to the widest range of patients and conditions. Another suggestion was that specialist trainees could rotate through the private rooms of specialists who are attached to their public hospital.

Suggested ways of funding expanded training included a trial of offering specialist trainee services at a reduced cost and an evaluation of the results, a reduced HECS debt for specialist trainees who take up places in areas of need such as outer metropolitan and regional areas, and the increased use of simulated training centres funded through public/private partnerships.

There was widespread agreement that the particular needs of each specialty needed to be taken into account. Also, the needs of basic specialist trainees compared with those who are advanced are likely to be quite different. Many health departments were in favour of arrangements that included a compulsory regional/rural component for more senior specialist trainees and suggested networked arrangements for supervision and placement may make this feasible, especially in the smaller states.

23 All quotations of numbers of respondents refer to the respondents from Reference Group 1.