On 14 July 2006, the Council of Australian Governments (COAG) announced the agreement of the Commonwealth, States and Territories to establish a system to enable specialist trainees to undertake training rotations in an expanded range of settings. The range of settings identified included public settings (including regional, rural and ambulatory settings), the private sector (hospitals and practices), community settings and non-clinical environments (for example, simulated learning centres).
COAG further agreed that this system would be established by January 2008. The principle was reiterated that implementation will be managed to ensure no reduction in service capacity in the public health system.
In addition to this announcement, COAG agreed to the establishment of 205 additional Commonwealth funded medical school places, to be implemented from 2007 adding to the 400 medical school places announced earlier in the year.
The work informing the report of Reference Group 2 was undertaken prior to the COAG announcements. The feedback received in stakeholder consultations was therefore provided without knowledge of these COAG decisions. However, it is nonetheless anticipated that the outcomes of the Reference Group’s consultations and report recommendations will provide useful data to inform the strategy for implementing the COAG decisions.
Specialist trainees are a key part of the public hospital workforce. One of the main issues arising from the Australian Health Ministers' Advisory Council’s (AHMAC) consideration of the Medical Specialist Training Taskforce report in 2004 was, therefore, how an expansion of specialist training settings would impact on the service delivery capacity of public hospitals.
Reference Group 2 has examined this issue with the support of an external consultant, and undertaken significant consultation with a broad range of stakeholders seeking information on how the expanded training arrangements are expected to impact on health care delivery.
The Reference Group confirmed that there was support amongst stakeholders for expanding training settings and acknowledgment of the education and training benefits.
It also confirmed the very important role trainees (registrars) have in the public hospital workforce, and that movement of registrars to other settings would be likely to have a detrimental impact on major public hospital service delivery capacity unless those registrar positions can be adequately backfilled.
The ability to backfill is largely dependent on two key issues - maintenance of funding for registrar positions and the ability to attract suitable candidates to fill those vacancies. Acknowledging that funding considerations are a matter for governments, stakeholders held mixed views on the capacity of hospitals to fill vacancies created by the rotation of trainees to other settings. Some respondents believed that the combination of the current trainee supply along with the forecast increase in graduate numbers would be sufficient. Others also considered that alternative forms of labour (such as visiting medical officers or career medical officers) could be found in specific circumstances. Generally stakeholders emphasised that, without the anticipated increase in trainee numbers, suitable candidates to occupy vacancies would be hard to find and potentially expensive.
In light of this feedback and the outcomes of projections estimating future supply of medical trainees, the Reference Group recommends that an overarching principle guiding implementation should be that the expansion of training settings be phased in over a number of years. Full scale implementation should be managed to coincide with the increase in trainee numbers and to ensure no detrimental impact on major public hospital service delivery capacity.
Projections estimating future supply of medical specialist trainees indicate that there will be a significant increase in the number of graduates entering specialist training in coming years. Phased implementation will build on existing arrangements and provide the opportunity to establish the infrastructure and administrative arrangements required to support wider implementation. In some specialties, more rapid implementation may be appropriate and possible.
Reference Group 2 recommends several options for suitable governance and administration arrangements to manage the formal expansion of specialist training settings. Development of these options has been informed by the findings of the Applied Economics' report. It is also noted that an appropriate governance and administration structure will need to be developed in recognition of the source(s) and quantum of funding, stakeholders involved, and the desired program outcomes.
Relevant considerations include:
- Responsibility for allocation of funds
- Accountability for utilisation of funds
- Evaluation of program outcomes including:
- monitoring utilisation of funds
- monitoring quality and consistency of training in the additional settings, and
- Linkages between education/training and service requirements.
Given that major teaching hospitals and specialist medical colleges will continue to have a prominent role in specialist medical education, any governance and administration structure will need to take account of their interests.
It is further recommended that a review of the structure and function of any governance arrangements would be required following the initial years of operation. This review will consider the appropriateness of the chosen structures and their effectiveness in managing phased implementation with the increase in graduate numbers. The initial governance structure could therefore be established as a transitional arrangement, with the subsequent arrangements informed by the progress and outcomes achieved in the initial years of implementation.
The Reference Group recommends that implementation be undertaken on the basis of agreed national principles, with flexibility to respond to speciality, setting and jurisdictional requirements.
The Reference Group notes the significant increase in specialist trainee numbers once individuals begin to graduate from the additional medical school places and it commends the expansion of training settings as one important mechanism to allow these new graduates to receive the necessary specialist training.