1.1 Background
Reference Group 1 assessed the costs and benefits of expanding specialist training beyond the public sector metropolitan teaching hospitals by:- Identifying 10 specialties - or, in some cases, subspecialties - that cover a broad range of procedural, consultative and laboratory based disciplines.
- Engaging PricewaterhouseCoopers (PwC) to undertake a detailed analysis of the costs, benefits and barriers to implementing training in a diverse range of settings for each of the 10 sample specialties.
This assessment was done by consulting with representatives of the relevant colleges (or faculties or other associations), private hospitals, jurisdictions and the Australian Medical Association Council of Doctors in Training.
The aim was to establish:
- the improvement in the breadth and depth of training that could be achieved by expanding training settings for each specialty – the educational imperative
- the current workforce shortage or surplus situation for each specialty - the workforce imperative
- the number of trainees required to meet the educational and workforce imperatives
- the cost of such an expansion on the assumption that the public sector trainee workforce would be maintained.
The views expressed during consultations varied from mild scepticism to strong enthusiasm. The vast majority supported the initiative as long as the major obstacles or barriers could be overcome.
- the improvement in the breadth and depth of training that could be achieved by expanding training settings for each specialty – the educational imperative
- Preparing this report to the Medical Specialist Training Steering Committee based on a fair and balanced view of the PwC results and the views and experience of the expert members of the Reference Group.
1.2 Views of the key stakeholders
Medical organisations with a stake in the provision of medical training
Consultations were held with the medical specialist colleges for the 10 sample specialties and with other organisations, such as faculties or divisions of colleges, that provide training. The term 'colleges' is used in this section as a convenient umbrella term for all of these organisations.Most colleges agreed that a 10% to 20% increase in the time that trainees spend in expanded settings would be worthwhile and would improve the overall quality of the training program. Only two specialties (psychiatry and general paediatrics) flagged the need for a major increase in training in expanded settings to meet educational objectives.
Two colleges (psychiatry and pathology) and the faculty of rehabilitation medicine identified the need for a major increase to their workforce. Most other colleges were reasonably comfortable with their current workforce from a national perspective.
Colleges tend to regard their metropolitan workforces as roughly in supply/demand balance. However they nearly all identified serious regional workforce shortages and several identified overall looming shortages in the future.
All colleges regarded funding as a major issue for the expansion of training.
Jurisdictions
The expansion of regional training, particularly in public settings, would be favoured by all jurisdictions. Most jurisdictions agreed with the arguments in favour of expanded training into other settings.A general concern reported by all jurisdictions was the capacity to achieve and maintain an adequate public hospital workforce (both trainees and specialists) to meet the health care needs of both the current and future population. It was acknowledged that an expansion of training settings would be managed in accordance with these concerns.
Private hospitals
Private hospitals supported the formal introduction of training in the private sector provided that infrastructure and funding is available and the issues associated with management, trainee employment, patient consent, trainee supervision and insurance are resolved. The private hospitals that are already engaged in specialist training were enthusiastic about the broad range of benefits that they believe accrue to their organisations, including their patients and staff.Doctors in training
Doctors in training were broadly supportive of expanded training settings if such initiatives are based on the educational imperative, such as in psychiatry. If high quality supervision and training is provided as an integral part of implementation, they believe that training in expanded settings to alleviate workforce shortage would also be acceptable. They also agreed that the clinical experience available in expanded settings can enhance the breadth of training and will be an important strategy to provide quality training for significant future increases in specialist trainee numbers. Top of page1.3 PricewaterhouseCoopers' results
In projecting the numbers of trainees necessary to undertake training in expanded settings while still maintaining the public hospital workforce - and therefore calculating a cost - PwC constructed three scenarios.Scenario 1 was based on the assumption that the number of trainees in the public sector would remain constant across all years. Scenario 2 was based on the assumption that the number of basic and advanced trainees would be maintained at the number that was the higher of the two categories. Scenario 3 calculated the numbers of trainees based on the balance of the current workforce combined with the educational imperative.
On the basis of the educational imperative reported during consultations, PwC estimated that about 650 additional trainees would be required for expanded specialist training in the 10 specialties reviewed. This varied from an extra 8 dermatologists to a maximum of 140 anaesthetists. Most specialty increases were within the range of 10 to 20% (Scenarios 1 and 2).
PwC also identified current workforce shortages in pathology, psychiatry and rehabilitation medicine which, if corrected through an expansion of training settings, would add approximately an additional 700 trainees to reach a total of 1,319 trainees (Scenario 3).
Table 1 shows the projected increase in the number of trainees for each of these three scenarios.
Table 1: Projected increase in number of trainees
| Reviewed specialty | Current no. of trainees | Current no. of trainees1 | Increase in trainee numbers | ||
Scenario 1 | Scenario 2 | Scenario 3 | |||
| Gastroenterology | 76 | 72 | 14 | 14 | 14 |
| General Paediatrics | 182 | 210 | 131 | 131 | - |
| General Surgery | 297 | 360 | 42 | 42 | 42 |
| Orthapaedic Surgery | 170 | 180 | 26 | 26 | 26 |
| Obstetrics and Gynaecology | 350 | 360 | 55 | 77 | 55 |
| Pathology | 294 | 300 | 85 | 85 | 500 |
| Anaesthetics | 795 | 795 | 127 | 140 | 127 |
| Psychiatry | 782 | 780 | 108 | 111 | 470 |
| Dermatology | 65 | 72 | 8 | 13 | 13 |
| Rehabilitation Medicine | 130 | 128 | 20 | 20 | 72 |
| Total selected specialties | 3,141 | 3,257 | 616 | 660 | 1319 |
Table 2 shows PwC's conversions of the increased number of trainees into estimated increases in annual overall training system costs for the 10 specialties reviewed.
If an increase in trainee numbers was fully implemented, while at the same time maintaining the public sector trainee workforce, the additional costs in current Australian dollars would be around $123 to $132 million per annum to meet the educational imperative alone. If specific workforce needs are also addressed, the cost rises to approximately $240 million per annum.
Table 2: Estimated increase in annual training costs
| Reviewed specialty | Increase in estimated total training costs ($000s) | ||
Scenario 1 | Scenario 2 | Scenario 3 | |
| Gastroenterology | 2,438 | 2,438 | 2,438 |
| General Paediatrics | 23,958 | 23,958 | - |
| General Surgery | 10,909 | 10,909 | 10,909 |
| Orthopaedic Surgery | 6,189 | 6,189 | 6,189 |
| Obstetrics & Gynaecology | 12,644 | 16,851 | 12,644 |
| Pathology | 13,797 | 13,797 | 83,608 |
| Anaesthetics | 30,014 | 32,446 | 30,014 |
| Psychiatry | 18,617 | 19,121 | 77,485 |
| Dermatology | 1,452 | 2,282 | 2,282 |
| Rehabilitation Medicine | 3,809 | 3,809 | 13,688 |
| Total selected specialties | 123,829 | 131,802 | 239,258 |
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1.4 Summary of benefits of and obstacles to implementation
Throughout the report there are many references to the benefits of and obstacles to the expansion of medical specialist training settings. These reflect the perceptions of stakeholders, acquired knowledge by PricewaterhouseCoopers, and the expert opinions of Reference Group 1.Benefits
The major benefit of and driver for expanding training is the educational imperative. That is, increasing the exposure of trainees to consultations, treatments and procedures and the capacity to allow trainees to observe and participate in the entire 'patient journey' of continuity of care, including pre-and post-procedural consultations for applicable specialties.The additional number of trainees in an expanded range of settings would boost the medical workforce, including in parts of the public system that are currently under utilised. The introduction of new training settings will also become important as increasing numbers of graduates enter specialist training over the next decade.
Offering trainees access to a broader training program may help to attract additional trainees to specialties that are currently facing shortfalls in numbers of applicants, and to settings such as regional areas that are chronically short of specialists.
The patients of private hospitals, regional public hospitals and other settings that accept trainees are likely to benefit from a more supportive and cohesive workforce, improved staff morale, the maintenance and development of clinical and supervisory expertise, and a strong academic and professional culture.
There is also a growing need to build training capacity in other settings because of the pressure on the public sector as numbers entering specialist training will inexorably increase in the near future.
PwC has estimated the costs of training in an expanded range of settings, but it is important to note that a proportion of these costs would have been incurred anyway - as funding for additional training places would be required to match the increased supply of specialist trainees.
Issues to be resolved
Some colleges believe that there is no significant need for additional specialists in their discipline and many consider that an expansion outside the metropolitan public hospitals should probably not exceed 10% to 20% of total training time.Funding is seen as an issue by all stakeholders, particularly where trainees are currently not able to access Medicare rebates.
There is a view held by some that private patients prefer to be treated solely by a fully qualified specialist of their choice, and that this will limit trainees' learning experiences in the private sector. However the experience of private hospitals already providing training was that most patients appreciate the additional clinical care that is provided through the training program. When the role of the trainee is clearly explained to the patient, objections to trainees participating in their treatment are rare.
The availability of supervisors and their possible cost – as well as an adverse impact on specialist productivity if they are supervising and teaching in the private sector - was raised in a number of consultations.
There are also a range of issues in relation to trainee employment, governance, administration and medical indemnity that will need to be resolved before implementation and these are explored elsewhere in this report. Most private hospitals currently participating in training believe these issues are not insurmountable. Top of page
1.5 The impact of greater medical graduate numbers
The significantly greater number of medical school graduates in the coming years is expected to double the number of medical specialist trainees. This effect will be seen by the middle of the next decade, with the increase expected to plateau towards the year 2020.Substantial investment will need to be made to increase the capacity of the training system, before these greater numbers of trainees arrive. Expanded training settings could be used to supplement the capacity of the public teaching hospital system.
Assuming that the average proportion of training time in other settings (as per the results of this project) also applies across the total specialty workforce, between 3,000 and 3,500 training positions outside major public teaching hospitals may be needed in the future.
If this number of positions can be created it will make a significant contribution to improving training opportunities, while still accommodating a significant proportion of the overall increase in trainees that would otherwise need to be absorbed by the major public hospitals.Top of page
1.6 Conclusions
To successfully implement training in a diverse range of settings, the benefits of having these expanded settings will need to be carefully and strategically introduced to the colleges, jurisdictions and the private health sector.The main benefits will come, in the first instance, from carefully targeted and prioritised training programs that address specific funding, administration and trainee career issues - rather than applying generic arrangements to all specialties, settings and jurisdictions.
There is currently a clear need to substantially expand the overall workforce for psychiatry, pathology and rehabilitation medicine. Of these three, only psychiatry requires a significant expansion into the private sector as an educational priority. While there is a strong educational case for expansion of general paediatrics into community and private practice settings, this specialty has no immediate workforce need.
The additional number of trainees per year required to address the educational imperative within the ten specialties studied is about 650. The cost of this is estimated to be a maximum of $132 million per annum.
If the current workforce situations for psychiatry, pathology, rehabilitation medicine and general paediatrics are taken into consideration, the additional number of trainees required per year increases to 1,319 and the costs to $240 million per annum.
Over the next 10 to 15 years, it is clear that an expansion in the number of training settings outside the major public teaching hospitals would provide improved quality of specialist training and patient care in those settings. This will also absorb a reasonable proportion of the overall expansion in the workforce due to increasing medical graduate numbers. The remaining specialties and subspecialties outside the scope of this project will no doubt also have unique and varying degrees of educational imperative for training in other settings.