1. Executive Summary

1.1 Background

This report proposes that there are two types of expansion of specialist medical clinical training which need to be accommodated and two types of pressures upon existing training resources.

1.2 The changing health delivery environment

It has become increasingly clear that the location and provision of specialist medical clinical training needs to expand. With the changing role and capacity of public teaching hospitals, they are becoming less able to accommodate some aspects of vocational training and some requirements for training are not being met. There is therefore an educational imperative to expand into other settings to meet all training requirements.

1.3 The shortage of medical specialists

There is growing concern in the community about the shortage of medical specialists and, according to the research of the Australian Government Productivity Commission, this problem will increase rather than diminish into the future. Currently there is an increased number of students enrolled in medical degrees. Expanding the range of available training settings is necessary both to accommodate these potential trainees and to ensure that the health system has the capacity to appropriately train existing and increased numbers of medical specialists.

1.4 Estimates of potential expansion

Most colleges believe there will be a relatively modest increase in training across the alternative settings. Some colleges, such as the Australasian College for Emergency Medicine and the Australasian College of Dermatologists, project that their greatest increase will be into public rural hospitals, whilst the Royal Australian and New Zealand College of Radiologists indicated it was expecting a substantial change in the balance of its training programs towards private ambulatory care. For all of the other colleges the greatest increase in projected training settings is into the metropolitan private hospitals and into private and/or community ambulatory care.

1.5 Key elements required

The colleges identified six main resource and infrastructure elements which need to be provided to facilitate the provision of effective training, adequate exposure and experience for trainees to develop competence. They are:

1. appropriate supervision, teaching, and feedback, plus training for less experienced supervisors
2. protected time for supervisors and trainees
3. professional support
4. equitable access to educational resources
5. recognition by institutions and managers of the value of training to service provision and quality, and
6. provision of setting-specific physical infrastructure requirements where needed.

1.6 Accreditation of settings and of programs

It was noted that standards for accreditation of private settings need to be explicit, should continue to be met in current training sites as well as new ones, and that alternative training settings will be judged against established and accepted standards to ensure they provide adequate training opportunities.

1.7 Benefits

Diversifying training across a range of settings will bring four major benefits to trainees, specialist medical practitioners, the training settings, and the community:

• for trainees there will be improved training opportunities and experiences available, ensuring that as independent practitioners they will be competent to address the widest spectrum of practice in their specialty
• both trainees and medical specialists will benefit because training will become more targeted. It will also create opportunities to expand training to match service delivery and the community needs, and more closely align the provision of high standard, multi-discipline patient care with community expectations
• patients will benefit because there will be more specialists working in rural public hospitals, private hospitals, community and private ambulatory centres
• the expanded settings will increase the health system's capacity to take in more trainees without increasing pressure on public teaching hospitals

1.8 Issues to be addressed

There are a number of issues that will need to be resolved to ensure that the diversification of training settings does not impact negatively on the quality of service offered in those settings, or on the quality of training. At the system level it is essential that safeguards are put into place to make certain that:

1. High quality training in public teaching hospitals is not compromised
2. Teaching and infrastructure in public teaching hospitals is maintained, if not bolstered
3. The process does not exacerbate inequalities in access to care
4. Potential patients (both public and private) are educated about the benefits.

At the same time specialist medical colleges will need to:

1. Define the goals for training, and develop precise curricula
2. Ensure that appropriate training is provided for supervisors
3. Develop mechanisms for receiving regular, confidential feedback from trainees about their training experience.

1.9 Implementation

Overall this Reference Group advocates a step-based approach to change over a defined period of three to five years so that all of the required infrastructure, resources, cultural changes, and training can be put into place without putting at risk the high standards and current gains that have been achieved to date.