6. Benefits and barriers to an Expanded Specialty Network Model (ESNM)

6.1 Potential benefits
6.2 Potential barriers
6.3 Overcoming the barriers

6.1 Potential benefits

ESNM training programs have the potential to better align training curricula with settings for delivery, whilst the development of training modules that can be provided collaboratively between colleges and across settings have the potential to maximise resources, increase the efficiency of training and delivery, and to reduce costs. This will be particularly effective where they can be provided by any Australian Medical Council accredited provider, such as a specialist college, university, or other appropriate body. For trainees, working in a network can provide the opportunity to follow patients from acute care settings (hospitals) to subsequent treatment settings (private practice, community-based teams, non-clinical settings).

Benefits for training

• More efficient, targeted training
• The portability of training and recognition of prior learning between medical specialist colleges will be enhanced
• The movement of trainees from one environment to another will be better coordinated
• Trainee learning will be enhanced through shared learning opportunities and greater interaction with fellow trainees from different colleges, simulating the multidiscipline approach of current and future practice
• Specialist colleges will be encouraged to share their training approaches, for example, assessment techniques, training approaches, and/or courses
• Trainees will learn about and experience a wider range of community resources and better understand health service delivery systems.

Benefits for hospitals

• In a training setting all employees could access standard resources, allowing expenses to be compensated for by the broader benefits provided to everyone, not just to specialist trainees
• Resources and infrastructure could be shared by sites across settings, rather than individually provided
• A wider group of staff will be influenced to continue professional development activities
• Enhanced service provision affords prestige and recognition of that training setting
• Public hospitals will gain an advantage because competitive recruitment processes will be the responsibility of the network, rather than individual hospitals
• In private hospitals and other rural and community settings trainees may be able to take responsibility for some time-consuming tasks not requiring a specialist's personal supervision, and as such are likely to contribute to an increase in the quality of patient care.

Benefits for the system

• More efficient training, and the potential to increase the number of trainees, will contribute to relieving the specialist workforce shortages
• The provision of adequate and consistent training underpins the prospect of a long term sustainable workforce
• Enhanced capacity for health promotion and early intervention in community settings
• Improved identification of responsibilities among the various training stakeholders would decrease fragmentation in the training sector and improve efficiencies
• Wider community contribution to the training of the next generation of specialist doctors, including patients across the clinical and societal spectrum, and their doctors and health.

6.2 Potential Barriers

Training outside public teaching hospitals presents many challenges, including maintaining the service delivery capacity, supervision and assessment of trainees; industrial issues; patients' expectations; and infrastructure requirements.

General barriers for training

• There is a need for clear articulation of how employment in the diversity of settings meets training criteria
• Competitive, yet fair, management of trainee rotation and retention across a number of settings may be difficult to coordinate
• To ensure that trainees taking up non-metropolitan rotations are not disadvantaged, travel, relocation and accommodation expenses will need to be considered. Trainees need to be given early notice and understand the educational purpose of such rotations
• In both private and community settings, there needs to be a guarantee of continuity of trainees’ employment and industrial conditions
• More supervisors, especially in the non-traditional settings, will need to be trained
• High quality supervision may not be universally available
• Patients in private hospitals and offices have not generally expected to be involved in training, or treated by trainees.

General barriers for hospitals

• If supervision is recognised as important then those providing training need to be supported and, in some settings, there may not be enough resources
• Public teaching hospitals rely on trainees to deliver service requirements. Simply rotating the current number of trainees through more settings will result in a decrease of service provision in the public teaching hospitals. It is imperative to enhance the numbers of trainees to ensure that service provision remains adequate
• There may be a potential risk of loss of VMOs who currently provide an important public/patient patient mix. If they are able to contribute to training in private settings they may withdraw from public service, thus further widening the growing gap between public and private
• In private hospitals there is a need to manage expectations of private patients against the benefits of trainees being involved in their treatment. There is some evidence that patients in private health care are more resistant to receiving care from trainees than people in the public heath. Appropriate communication can alter such attitudes
• Different training settings may have unique physical and infrastructure needs and attributes
• Different training settings may have different salaries and conditions. This may inhibit the uptake of training in some areas
• Without the establishment of ESNMs large public teaching hospitals have a strong competitive advantage in attracting the best trainees and may push to retain their trainees by offering better wages, benefits and conditions than are available in other settings

6.3 Overcoming the barriers

Of all of the barriers, one of the easiest to overcome is the development of training curricula by medical colleges that transcends the current public teaching hospital settings. Curricula development will be based on sound educational goals and supported by the AMC process for accreditation of specialist training, just as the analogous accreditation of medical schools by the AMC has encouraged educational innovation in universities. Education innovation will require educational expertise, much of which may need to be gathered externally by the specialist medical colleges. In this regard, besides the inter-college sharing of material on generic competencies, it may be appropriate for some of the smaller colleges to work together and share the necessary costs for educational expertise.

Because training is expected to occur in diverse settings, improved communication and further partnership building between health care providers, employing authorities, colleges and other educational providers, is required. Accountability arrangements, including the roles and responsibilities for financial controls and performance outcomes need to be specified across training settings. This may need an element of central coordination and agreement to ensure the goals and objectives of the large number of diverse stakeholders are achieved. However, identification of responsibilities among the various training stakeholders would decrease fragmentation in the training sector and improve efficiencies.

Whilst employment and conditions of employment are outside the parameters of this committee, the establishment of the Expanded Specialty Network Model as advocated may offer a solution to the identified differences and/or difficulties for trainees in employment conditions.

In relation to the need for cultural change to ensure training is effective in private institutions, there are already some private hospitals which have developed alternative approaches to patients which has been effective in breaking down expectations. For example, in both Epworth Private Hospital in Victoria, and Greenslopes Private Hospital in Queensland the trainees are introduced as part of the medical or surgical teams which are responsible for the care of the patient. In each instance, specialist team leaders have taken the initiative to advocate the advantages to the team, and to the patient, of having additional team members who can take on some areas of responsibility including more frequent, (if not constant) attention to patients in ICU or recovery.

Trainees may need to be enculturated into recognising and appreciating the benefits of training in a more flexible, multi-disciplinary and diverse environment. Just as some of the supervisors have assumed that training is best carried out in the traditional, specialty specific approach, trainees have accepted this as the norm. For them to gain the most benefit of working in diverse settings, trainees will need to see the value and appropriateness of those experiences. This will be the responsibility of the colleges and will be addressed through the clear articulation of training objectives and/or requirements matching the range of settings in which trainees in that specialty will be placed.

In relation to supervision, the issue of greater expense because of the need for more supervisors and the possible need to pay supervisors is acknowledged. However, the concept of remote supervision offers potential efficiency in the provision of supervisors, whilst another possibility for efficiency is in shared supervision (based on assessing non-technical competencies) across specialties, in the smaller settings. The need to provide additional training for supervisors offers a further opportunity for cross-specialty collaboration because the content of virtually all of the identified training areas is not specialty specific. This means that supervision training could be developed, under guidelines from the colleges, by a wide range of training providers and offered within a network, or across networks, in multidisciplinary forums.