This chapter provides an overview, nationally and by jurisdiction, of the feedback collated by Applied Economics Pty Ltd in their consultations with a range of stakeholders throughout Australia. The summaries are derived from the consultant report.
5.1 National Summary
Stakeholders consulted expressed a wide range of views about the proposed expansion to training settings. These views contained a reasonable amount of support for more diversified training settings, which were seen as offering two main benefits:- Exposing trainees to educational and training experiences in regional, private and community settings that have become less available in metropolitan teaching hospitals to due changing patterns of service delivery, reduced length of stay and reduced outpatient services. In particular there was concern that a great deal of diagnosis of illness and ongoing treatment, including after in-hospital procedures, takes place outside hospitals and trainees would benefit from greater exposure to these experiences.
- More equitable geographic distribution of trainees could improve services in outer metropolitan, regional and rural Australia and could encourage more trainees to continue employment in these settings.
While identifying the benefits above, most public hospital administrators considered that (given the close connection between specialist training and service delivery) the proposed expansion of training arrangements would result in a substantial decrease in major public hospital service capacity (broadly pro rata with the loss of employee time in the hospital) unless public hospital funding for trainee positions was maintained and the vacancies were able to be backfilled.
5.2 Summaries of feedback from stakeholders by jurisdiction
New South Wales
NSW Health representatives indicated that the proposed training arrangements would result in a significant loss of services unless trainee positions were backfilled; options canvassed included registrars, staff specialists, visiting medical officers and career medical officers. However, the Department was not able to provide more detailed estimates of the implications in the absence of precise information on the proposed training arrangements, including speciality-specific information.NSW hospital and medical administrators considered that any decrease in the current number of trainees in major public hospitals would almost certainly affect their service delivery capacity. One medical administrator at a large teaching hospital described trainees as 'the backbone of service delivery'.
Overall there was a view that if the trainee positions were not back-filled, the loss of service capacity could be estimated to be over half of the trainee time lost to the relevant institution. For example, if a major hospital were to lose six months of a trainee's time, the effective loss of service delivery could be over three 'person' months.4 The proportionate loss of service time would increase as the medical trainee progressed through the advanced training years and became more proficient and spent an increasing proportion of their time in service delivery of one or other kind. In the latter years of training increasingly trainees perform independently (this is intended to heighten the value of the training experience) and any reduction in their availability would be directly equivalent to the loss of consultant labour.
The effect on service delivery would also vary with the type of service area, the availability of funding for substitute labour and the availability of that labour, and the number of trainees in each Area Health Service or hospital. Top of page
Victoria
The Victorian Department of Human Services noted that the delivery of public medical services in Victoria depends critically on specialist trainees. This applies to nearly all areas of medicine and surgery with some exceptions, such as dermatology.Any reduction in the supply of trainee labour would have an impact on service delivery. Service demand is unlikely to be modified and 'follow' trainees to their new service context. Some stakeholders observed that service demand is insatiable; therefore creating a new service option (for instance a registrar enhanced private hospital service option) would simply increase total demand for services.
The Victorian Department of Human Services also indicated that it would be very difficult to backfill any losses to labour supply which may be generated as a consequence of a reduction in specialist trainee numbers in public hospitals. However, it is noted by the Reference Group that this feedback was provided prior to the COAG announcement of further increases to medical school places.
It was also noted that in some specialty areas there were several prospects that could backfill effectively whilst 'standing in line' in unaccredited registrar posts. This was most likely to be the case in attractive disciplines (generally procedural areas such as cardiothoracic and orthopaedic surgery) where demand for training opportunities outstrips supply of posts.
Department of Human Services representatives also noted the possibility of employing CMOs. Also, increased use of CMO-type labour in the private sector and the growth of locum service options in private hospitals had made the CMO career pathway much more lucrative. However CMO labour is not a universally acceptable backfill option; it works best for those areas where hours of work can be controlled most easily such as in an intensive care unit (ICU), emergency medicine and medical wards.
Third, the use of VMOs to backfill for trainees appears more feasible in some circumstances in Victoria than in other jurisdictions. This is because VMOs are generally paid on an hourly or sessional rate in Victoria, which includes an allowance for teaching time. In some smaller metropolitan hospitals where trainees have been removed partly or wholly from service delivery, they have been replaced by VMOs working on a fee-for-service payment basis. While the fee-for-service payment can be higher than the sessional payment arrangement,5 in the opinion of interviewed hospital administrators the increased efficiency of the VMOs makes this backfill option cost effective.
However, advice from the Victorian Department of Human Services provided another perspective from that of the hospital / medical administrators. This advice argued that there was a long standing policy directive from the Auditor General opposing fee-for-service payments on the grounds that the long term budget implications were at best ambiguous, and at worst cost the State more to deliver less services. The key would be how low a fee can be negotiated and to what extent efficiency in service delivery is realised.
There appears to be a widely held view that advanced trainee labour is inequitably distributed in Victoria. The Medical Workforce and Training Advisory Committee in Victoria has formed ‘consortia’ which intend to plan and recruit for the Basic Physician Training Program from 2006. A key objective of the consortia is to distribute trainee labour equitably across training opportunities and not just allow the teaching hospital environments to be satisfied. Plans exist to extend the consortia concept to other disciplines and to advanced training.
The Victorian Department of Human Services highlighted that capacity within the public sector to expand training opportunities should be maximised before extending specialist training in private settings. Top of page
Queensland
Most stakeholders consulted in Queensland expressed the view that the proposed training arrangements would not impact adversely on delivery of public health care services.Queensland Health expressed the view that diversification would not necessarily affect the delivery of services in public hospitals, particularly if trainees were backfilled by a mixture of VMOs, staff specialists and non-accredited registrars. There was also thought that in disciplines with bottlenecks in providing sufficient case-mix for trainees to progress through training programs, the diversification of training into private settings would reduce pressures on the public system.
One regional stakeholder thought that any impact of diversification on metropolitan services would depend upon the amount of labour 'redundancy' in the existing training pool. In some disciplines such as obstetrics and gynaecology, even without backfill, removal of trainees may not compromise service delivery. However, for anaesthetics, it was claimed that there is a shortage of staff at all levels and any reductions to the metropolitan teaching hospitals' registrar workforce would affect the amount of public service delivery. It would also affect the willingness of VMO anaesthetists to work in the public system, many of whom work in the public system only because of the opportunity to be involved in training.
The Australian Salaried Medical Officers Federation of Queensland (ASMOFQ) and Queensland Public Sector Union (QPSU) had a different perspective about redundancy in the training pool. They believed it would be difficult to obtain more work from the existing stock of trainees. They were concerned with issues about reasonable workloads, access to prescribed amounts of training, the allocation of time for study, and observance of 'safe trainee working hours'. There was also concern about supervisors possibly leaving the public system and moving into private settings.
Many disciplines, including surgery, obstetrics and gynaecology and psychiatry thought that by exposing trainees to different and clinically relevant case-mixes, diversification would improve the quality of training. For instance in obstetrics and gynaecology, IVF treatment is confined almost wholly to the private sector. In the case of psychiatry, trainees in the public system encounter almost exclusively chronic mental illnesses, whereas in the private sector trainees encounter different conditions, such as depression and neuroses.
Private practice training would be invaluable for trainees to gain insight into how private practices operate.
Regional hospitals in Queensland saw regional diversification as a potential recruitment and retention mechanism for specialists in regional hospitals. Labour increases in rural areas may potentially divert rural patient flows from metropolitan to rural hospitals. There could also be better access to services in regional and rural settings where some services are not currently provided. Diversification could thus assist in restoring the quality of service access in regional areas.
Regional hospitals also saw merit in the diversification of training into community settings. The benefits for trainees identified included experience in:
- the continuity of care and chronic care management;
- communication and team work with community resources such as general practitioners, community nurses, allied health, etc; and
- undertaking secondary consultation.
Western Australia
The Western Australian Department of Health expressed strong support for expanding specialist training settings, including regional and remote areas and the private sector. The drivers for expansion include addressing the gap in trainees' exposure to certain procedures and the continuum of patient care, a shortage of specialists, and the need to increase the training capacity of the system to accommodate the increase in medical school graduates.However, public hospital medical administrators noted that trainees would need to be adequately replaced, given their crucial role in service delivery. They argued that if the trainees were not replaced the length of patient stay would increase, as trainees are most actively involved in ordering and completing tests and in discharge planning.
Stakeholders indicated that a relatively high proportion of the Western Australian population (nearly 50%) is privately insured, and the capacity of the private system and the case mix in private hospitals has changed over the last 10 to 15 years. Respondents thought that the volume of work in the private sector would continue to expand with the introduction of training and consequentially increase capacity in the sector.
Metropolitan hospital administrators suggested that the proposed training arrangements would impact most greatly on general and orthopaedic surgery, anaesthetics, gastroenterology and paediatrics. There would be little impact on dermatology and psychiatry services as these services are already provided to a large extent outside public hospitals. Apart from Hollywood Private Hospital's rehabilitation unit, which caters mostly for Veterans, it was also claimed that specialist rehabilitation services do not exist outside the public system.
Private hospital administrators felt that gastroenterology, general surgery and orthopaedic surgery training could be readily expanded into private hospitals. They were also of the opinion that psychiatry and rehabilitation training would remain in public hospitals, and, because of the high cost of indemnity insurance, obstetrics and gynaecology and neurosurgery training would also remain in the public system.Top of page
South Australia
A number of stakeholders noted that the public hospital system in South Australia provides a high quality health care service and noted that implementation would need to be undertaken gradually to ensure that it is not put at risk. While the South Australian Department of Health was supportive of an expansion of training settings, a major hurdle facing the state is the difficulties experienced in filling existing training places.In general, respondents considered that the impact on service delivery would be greatest for procedures which rely on inpatient care, such as surgery, anaesthetics, obstetrics and gynaecology and gastroenterology. In their view, there is a shortage of trainees in radio-oncology, rehabilitation medicine, psychiatry, neurosurgery and thoracic surgery, and the public system could not afford to lose trainees in these specialties.
The services least affected would be those with a high ambulatory care component, such as dermatology and psychiatry, which would benefit from training in private settings. But because of the general shortage of trainees, even in these two specialties trainees would have to be replaced to maintain service volumes.
Public hospitals reported that they would seek to fill vacant positions with registrars, overseas specialist trainees, by increased overtime and with doctors currently not in the training program. The capacity to fill the gap would be limited as few trainees wish to work overtime or after hours for family and lifestyle reasons. The conditions of service also limit the hours that trainees can work.
Some administrators and specialists were concerned that increasing training in private hospitals could provide further reasons for specialists to leave the public system over time, but there were mixed views on this issue. The Department of Health did not regard this as a major issue, as the public sector in South Australia is considered a good workplace. Top of page
Tasmania
The Tasmanian Department of Health and Human Services was supportive of expanding training settings and identified that opportunities exist predominantly in the private sector. The drivers for expansion were noted as addressing the gaps in training due to the migration of some services to the private sector, demand for an increase in specialist supply, and the need to increase the training capacity of the system to accommodate more medical school graduates.The Department of Health and Human Services also expressed that, depending upon their level of experience, the delivery of public sector medical services is critically dependent on specialist trainees, and this is the case for nearly all areas of medicine and surgery. Any extension of training to the private sector would need to be carefully managed to ensure no detrimental impact on service delivery in public hospitals.Top of page
Northern Territory
Although Royal Darwin Hospital is a large tertiary teaching hospital, it differs from most metropolitan teaching hospitals because it is relatively remote. On the one hand it represents a regional hub that benefits from rotations from other states. In most disciplines it is a recipient of other hospital rotations and does not have its own training schemes.Representatives of Royal Darwin Hospital indicated that any diversification of the existing specialist training positions into remote hospitals would result in a considerable loss of patient care in Royal Darwin Hospital unless the positions were backfilled. However, it was noted that many cases treated by Royal Darwin Hospital are patients who have travelled from remote locations. Expanding training opportunities in rural areas would reallocate some of these cases towards rural locations. This would and save travel costs for patients and could assist recruitment and retention of specialists to remote locations.
Representatives from Darwin Private Hospital expressed that Darwin Private Hospital could offer useful training opportunities in general surgery training, obstetrics and gynaecology, orthopaedics, paediatrics and plastic surgery.Top of page
Australian Capital Territory
ACT Health expressed the view that the proposed training arrangements could have an adverse effect on service access in the very short term, but that it should be able to find alternative labour supply by using overseas trained doctors (OTDs) and Career Medical Officers within about a 12-month period.The main exceptions would be psychiatry and rehabilitation medicine. Also, in the surgical disciplines, and to some extent in pathology, it was suggested that workloads could follow trainees if the trainees provided services in other settings.
Other stakeholders in the ACT stressed the importance of ensuring that hospitals had the capacity to respond to diversification without backfilling or filling positions with other trainees. Stakeholders at The Canberra Hospital were clear that the status quo would need to be maintained by backfilling with nothing le
4 This feedback is provided with reference to the assumed average shift of training time by settings used by Applied Economics in its consultations.
5 The Victorian fee-for-service payment is generally based on the Commonwealth Medical Benefit Schedule (CMBS) fee for the equivalent service, or a closely negotiated fee level. In most other States fees are set independent of the CMBS and can be considerably higher.