Views on the costs and benefits of specialist training in an expanded range of settings were obtained from a wide range of individuals and organisations with major interests and commitments to specialist training.
The stakeholders who were consulted included college representatives of the 10 sample specialties, a number of jurisdictional representatives, the Australian Medical Association, the Australian Private Hospitals Association, the Australian Health Insurance Association, the Medical Indemnity Insurers Association of Australian, public hospital health area administrators and several private hospitals engaged in specialist training. Informal discussions were also held with a number of senior doctors closely linked to various aspects of medical training. Most of the consultations were led by PwC with departmental representatives in attendance. A small number of consultations were carried out directly by DoHA, for logistical reasons, and these are identified in this report.
The settings that were considered appropriate for an expansion of training had already been identified by the Medical Specialist Training Steering Committee. These were confirmed during the consultations and divided into the following four groups:
- regional and rural hospitals
- private hospitals
- private consultative practice - the main type of patient encounter with a significant ongoing element and, for procedural specialties, includes pre- and post-procedural consultations
- community settings.
Participants in consultations also expressed the need for increased funding of specialist training and concerns about medical workforce supply outside major capital cities.
The following sections summarise the views of the key stakeholder groups.
3.1 Royal Australasian College of Physicians - Gastroenterology
3.2 Royal Australasian College of Physicians - General Paediatrics
3.3 Royal Australasian College of Physicians - Australasian Faculty of Rehabilitation Medicine
3.4 Royal Australasian College of Surgeons - General Surgery
3.5 Australian Orthopaedic Association - Orthopaedic Surgery
3.6 Royal Australian and New Zealand College of Obstetricians and Gynaecologists
3.7 Royal College of Pathologists of Australasia
3.8 Australian and New Zealand College of Anaesthetists
3.9 Royal Australian and New Zealand College of Psychiatrists
3.10 Australasian College of Dermatologists
3.11 Jurisdictional views 3.12 Australian Medical Association, Council of Doctors in Training
3.13 North Shore Private Hospital (NSW)
3.14 Catholic Health Australia
3.15 Epworth Hospital
3.16 Australian Health Insurance Association (AHIA)
3.17 Medical Insurance Industry Association of Australia (MIIAA)
3.18 Australian Private Hospitals Association (APHA)
3.19 Summary of stakeholder views
3.1 Royal Australasian College of Physicians - Gastroenterology
Although there is considered to be only a small overall shortage of gastroenterologists across Australia, there are significant pockets of workforce need - particularly in regional areas.Gastroenterology is a specialty that includes both procedural and consultation elements for acute and chronic conditions. The chronic conditions often require on-going consultation with a specialist, which can be particularly difficult for regional and rural patients.
There is therefore some compelling evidence for a limited expansion of training into private settings. An educational gap for gastroenterology is emerging, driven largely by those areas of diagnosis and treatment that have been phased out of public hospital outpatient facilities. This has resulted in a marked decrease in trainee exposure to the ongoing consultative aspect of practice. Gastroenterology services within the public health system are generally relatively acute and registrars may need more training exposure to the high-volume and low-acuity caseloads commonly found in private settings.
Potential barriers for an expansion to private settings include the treatment of private patients by trainees and funding for private setting supervision. In addition, the current heavy public hospital reliance on the gastroenterology trainee workforce will make rotations to other settings difficult, particularly in the absence of significantly higher trainee numbers.
In summary, an increase in private sector training would enhance the quality of specialist education for this specialty, but it is not at a critical stage.
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3.2 Royal Australasian College of Physicians – General Paediatrics
The general consensus is that the overall supply of general paediatricians is reasonable, although there is significant geographic maldistribution by region, as with most other areas of medical practice.The three main areas of paediatric practice are general paediatrics (around 50%), neo-natal paediatrics (around 25%) and other paediatric subspecialties (around 25%). This report only covers general paediatric practice.
General paediatrics has changed significantly over the past two generations. Paediatrics has traditionally been associated with acute physical presentations dominated by acute illness or minor trauma. Today, as many as 40% of early childhood paediatric presentations are primarily due to developmental and behavioural issues, and these issues are a significant co-contributor to the vast majority of other early childhood presentations. There is therefore a serious need for increased training opportunities in community settings where trainees can gain significant exposure to the underlying issues involved in behavioural and developmental problems.
The Division of Paediatrics and Child Health of the Royal Australasian College of Physicians (RACP) recommend that all general paediatric trainees spend six to twelve months in community settings. This would increase the total proportion of training time spent outside major public teaching hospitals from 40% to 60%.
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3.3 Royal Australasian College of Physicians - Australasian Faculty of Rehabilitation Medicine
There is a significant and growing need for more rehabilitation trainees and specialists in all geographic areas, especially regional and outer metropolitan areas. However, rehabilitation medicine is not as widely understood or as recognised as other specialties. It is also a relatively new specialty that has generally had chronic problems with creating and funding sufficient training places as well as attracting sufficient trainees.Rehabilitation medicine is generally practised in hospital settings. There is a mild casemix gap emerging between public and private hospitals, supporting some level of continued private hospital training. More significantly, there is need for greater training exposure to hospital administration and logistics.
There are excellent opportunities for the large-scale expansion of rehabilitation training into regional settings, although mandatory rotations may exacerbate the problems associated with attracting sufficient trainees.
In summary, the expansion of training for rehabilitation medicine is seen as necessary but driven by workforce needs rather than any significant educational imperative.
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3.4 Royal Australasian College of Surgeons - General Surgery
Although there is currently only a small overall need for increased numbers of general surgeons, a shortage is looming in the near to mid-future. This upcoming shortage is based on the current workforce being relatively older and imminent large-scale retirements.General surgery training is seen by the college (RACS) as appropriate, with no serious casemix gaps. However a continuity gap is emerging for pre- and post-procedural consultations in areas that have closed outpatient facilities, particularly in NSW. Closure of this gap could be achieved by expanding training into private consultative settings.
The primary barrier to this expansion is the issue of the treatment of private patients by trainees. It was also reported that the funding of supervision costs in private consultant practice would be necessary. The reported short-term sufficiency of the supply of general surgeons may make it difficult to increase trainee numbers. This will subsequently make it difficult to expand training to other settings while still maintaining the public teaching hospital trainee workforce.
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3.5 Australian Orthopaedic Association - Orthopaedic Surgery
Consultations with the Australian Orthopaedic Association (AOA) indicated that there was no overall deficiency in clinical caseload material in the current public teaching hospital training system. However the quality, volume and scope of procedural opportunities in this setting have decreased in the past five to ten years, and is now balanced at a threshold level of overall appropriateness. Overall supply of orthopaedic specialists and trainees seems to be roughly in line with supply needs, although some regional areas are seen to have strong levels of unmet demand.A modest level of educational benefit could be realised through a small expansion of training into private settings. This would increase exposure to assisting surgery in a different mix of procedures to public hospitals, and fill the important and widening continuity gap for pre-and post-procedural consultations.
As reported for general surgery, an expansion into private consultative practices would have to overcome significant administrative and cultural barriers regarding the treatment of private patients by trainees. This issue is the main barrier preventing any meaningful procedural training experience in private hospitals.
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3.6 Royal Australian and New Zealand College of Obstetricians and Gynaecologists
There is no clear overall workforce shortage of obstetricians and gynaecologists (O&Gs), but there are serious shortages of obstetric services in regional areas - and these are expected to worsen due to a regional workforce that is older than average.There are a number of distinct O&G practice segments in Australia, and the situational mismatch between segments presents difficult logistical problems for training.
Gynaecology practice has largely migrated to the private sector and there has been a dramatic decrease in surgical presentations due to a variety of clinical factors. There is currently a relative oversupply of gynaecologists in metropolitan areas and a significant gynaecological casemix gap for training in public hospitals.
Only a small number of specialists practise purely in obstetrics, although a growing number sub-specialise in reproductive and maternal and foetal medicine. The public hospital obstetric casemix is seen as appropriate for training, with good procedural volume and usually more complex cases.
There is generally not enough clinical exposure for trainees to gynaecological procedures in private settings. However funding and cultural barriers make trainees treating private patients problematic. Heavy public hospital reliance on the obstetric trainee workforce would also make rotations to other settings difficult, particularly in the absence of significantly higher trainee numbers due to a lack of overall need for additional specialists in the short term.
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3.7 Royal College of Pathologists of Australasia
There is a severe and clearly recognised overall workforce need in pathology. In line with AMWAC indications, the RCPA has indicated a need for an additional 100 training places per year for at least the next 5 years. This includes a total of 40 Commonwealth funded private places. The labour shortage in public laboratories makes increased private rotations problematic without increased trainee numbers.There is some minor casemix gap for training in public laboratories for certain types of pathology testing. More significantly, there are often important casemix gaps for training in private laboratories as many of these tend to specialise in certain areas. Trainees sometimes worry that too much private laboratory exposure early in the training process will not sufficiently prepare them for exams.
The main barrier for expanding pathology training is overall funding levels as there does not seem to be any shortages of trainee applicants, training facilities, supervisory resources or clinical training material.
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3.8 Australian and New Zealand College of Anaesthetists
Under current practice models, the overall anaesthetist workforce is seen as roughly in balance - that is, supply is meeting requirements. Although there are fewer anaesthetists in regional areas, surgical specialist availability seems to be more of a limiting factor in terms of patient access. However anaesthetist workforce levels will come under pressure if current trends in the expansion of private sector procedures continue without a commensurate reduction in public sector procedures.Alone among all the specialties reviewed, the college of anaesthetists (ANZCA) did not identify any significant educational gap for trainees within the full training program. However it is important to note that there are significant trainee access issues for a few of the compulsory training modules - paediatric surgery, cardiac surgery and neurosurgery - which could be improved through the use of additional training settings. Expansion of current training programs in private hospitals is also seen as potentially beneficial to provide exposure to training in practice management and efficiency issues.
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3.9 Royal Australian and New Zealand College of Psychiatrists
The RANZCP outlined a compelling educational case for expanding training into a diverse range of settings based on significant differences between settings in casemix, presentations and treatment methods.The proportion of psychiatric specialist training that should occur outside major public teaching hospitals may increase in the future by as much as four-fold - across regional, private hospital and private practice settings. At the same time the public sector, which includes public hospitals and associated community settings, generally requires an increase in trainee service resources.
Mental health has been clearly identified as a national priority in Australia. The significant need for growth in the mental health system creates a directional alignment between the overall workforce and training expansion needs of the psychiatric profession.
Expansion of psychiatric specialist training will not be without its challenges. The profession has had chronic difficulty in attracting sufficient trainees, although this is improving. The college considers that overall funding levels both for training and specialist practice need to be reviewed and bolstered.
Public hospitals are very reliant on the trainee workforce, but the difficulty and stress of public hospital rotations in psychiatric wards are a significant deterrent to sufficient trainee numbers. There is a need for a large increase in trainee numbers with a more appropriate spread of settings from the start of training to break this cycle.
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3.10 Australasian College of Dermatologists
Dermatology is a relatively small profession with only 343 practising dermatologists in 2003. There is a need for a significant increase, with both AMWAC and the Australasian College of Dermatologists (ACD) considering that there is a serious shortage of dermatologists in rural and some urban areas. Waiting times for dermatology consultations across the board are also significantly higher than average.Almost all dermatology training occurs in public hospital settings. This may include associated outpatient clinics, many of which have been privatised. Trainees in these settings are exposed to a more complex and generally more severe set of patient presentations than that normally experienced in private practice.
While there are no serious educational gaps in dermatology training some additional training in private consultative settings could be beneficial, particularly in terms of the overall continuity of patient care. An expansion of training settings could also help provide additional training opportunities that may help bolster the workforce. There is also a marked need for more regional training opportunities to address the serious geographic workforce maldistribution problem.
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3.11 Jurisdictional views
Consultations were undertaken with the health departments of six jurisdictions - New South Wales, Victoria, Queensland, Western Australia, South Australia and Tasmania.The majority of the states were generally supportive of expanding medical specialist training. In some states, such as Queensland and Victoria, expansion would primarily be welcomed in the public sector through expansion to regional and remote areas. In Tasmania the greatest opportunities for expansion were identified to exist within the private sector and in South Australia and Western Australia expansion to both regional and private settings would be supported. New South Wales required further detail regarding competencies among settings before it would support an expansion.
New South Wales
Although the NSW Department of Health recognises that there is a shortage of medical specialists, they consider there is no overall compelling argument for expanding medical specialist training to private settings. Before such an expansion was implemented, New South Wales would require evidence that there are competencies not being attained in public teaching hospital settings. It was suggested that statements of competencies should be developed by each medical specialist college.As with other jurisdictions, New South Wales faces an increase in medical school graduates in future years but anticipates that this increase will not meet the growth in service demand within public hospitals. It is therefore expected that this increase in graduates will be easily accommodated in the current public system. Although it was recognised that specialist trainees have an important workforce role, their training - leading to increased numbers of specialists - was identified as being of at least equal importance.
Victoria
In Victoria the primary drivers for expanding training include an existing training gap - particularly for dermatology, pathology and some aspects of surgery - and the need for an increased supply of trainees and specialists in regional areas.Apart from psychiatry and pathology, there is no overall shortage of specialists in Victoria. There is however a significant maldistribution of specialists. This factor underpins the belief in Victoria that there is capacity within the public sector to expand training, and opportunities within the public sector should be maximised before using the private sector.
Although it is recognised that training in the public sector has not yet reached full capacity, lack of accreditation of regional settings by colleges was identified as a current barrier to expansion. Additional barriers to expanding training include lack of supervision and the potential need for remuneration of supervisors if the supervisory workload is to grow. The impact of private sector growth on training and research, and the potential for this to detract specialists away from the public sector, also needs to be considered.
Queensland
Many of the key drivers for expanding specialist training exist in Queensland. For example, there is an identified training gap within the specialities of surgery, anaesthetics and psychiatry and a shortage of specialists overall, particularly in regional areas. For these reasons Queensland is supportive of expanding specialist training, but believes that there are greater opportunities and a greater need for expansion in regional settings rather than in private settings.Some of the issues to be resolved for the expansion of training in Queensland include:
- Newly qualified supervisors may be needed for the expansion of training to regional settings. It was also suggested that the development of alternative models of supervision would be supported to facilitate expansion to regional areas - such as supervision by specialists who are not fellows of a college.
- Many specialists are attracted to the public sector for the teaching opportunities. The expansion of training opportunities to private settings would need to be managed to prevent disincentives to working in the public sector.
- Training should be successful in private settings where trainees can work as procedural assistants. This is not the case for consultation based specialties where it is believed that the introduction of trainees may slow down specialists and reduce revenue.
- Community attitudes towards trainees treating private patients need to be explored.
- Support for the accreditation of training places in regional areas may need boosting by some specialist colleges.
The costs associated with expanding specialist training to regional areas could be offset by new differential Medicare benefits for education and research in under serviced areas. The costs associated with training in private settings could be offset by private sector contribution.
Western Australia
The West Australian Department of Health is strongly supportive of expanding medical specialist training to a diverse range of settings, including the private sector and regional and remote areas. There are many drivers in Western Australia for expanding training including a gap in trainees' exposure to the full spectrum of patients and procedures - particularly in surgical specialties - a shortage of specialists, and the need for additional training places to accommodate the anticipated increase in medical school graduates.Some of the issues to be resolved in Western Australia for the implementation of expanded training settings include the following.
- It may be best to provide trainees in procedural specialities with exposure to private settings earlier in their training when they will get more benefit as observers than in later years of training.
- In regional and rural areas specialists operate on a remuneration basis. This may be impacted negatively by increasing the training component of specialists' roles.
- The need for supervision mechanisms while there are shortages of specialists.
It is anticipated that the expansion of specialist training will lead to increased costs for the state, in terms of supervision and increased travel and accommodation costs. It is expected that where training is expanded to private settings the private sector should contribute financially.
South Australia
The South Australian Department of Health is supportive of expanding medical specialist training and identified a number of drivers underpinning the need for expansion. These include an existing training gap from the migration of particular services out of the public system, increasing pre- and post-treatment taking place in the private sector, and the need for an increased supply of specialists.While the need to expand specialist training is acknowledged, a major hurdle facing South Australia is their inability to fill existing training places. Additional barriers to expanding training include lack of supervision resources and potentially reduced throughput and revenue for the private sector.
It is anticipated that increased costs will be incurred as a result of expanding training in the form of trainee salaries, additional training facilities in the expanding settings and administration costs. It was suggested that there may be an opportunity to look at funding through Medicare.
Tasmania
The Tasmanian Department of Health is supportive of expanding training and identified that opportunities for expansion in Tasmania predominantly exist within the private sector. The drivers for this expansion are the existing training gaps as a result of the migration of services to the private sector, demand for an increased supply of specialists, and the need to accommodate the expected increase in medical school graduates.The main barrier to expanding training in Tasmania is supervision. Visiting medical officers working in the private sector usually also work in the public sector and already have a training workload. Expanding training to the private sector would increase this workload and may reduce productivity. It may be necessary to offer remuneration to facilitate increased supervisory workload and/or seek other models of supervision – such as giving advanced trainees supervisory roles.
The department perceived that there would be advantages to a coordinated approach to training across all specialties, such as improved coordination of trainee accommodation.
The Tasmanian government currently provides a small amount of funding for medical specialist training in terms of accommodation and some interstate travel for conferences. There would need to be some injection of infrastructure into private settings to facilitate training, and Tasmania considers that it would be reasonable to expect some level of funding contribution from the private sector. However it is expected that the private sector may argue that trainees reduce their productivity.
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3.12 Australian Medical Association, Council of Doctors in Training
Consultations with the Australian Medical Association, Council of Doctors in Training (AMACDT) provided views on a range of issues affecting current and future doctors in training. However the AMACDT have advised that the consultation forum included a number of ‘observers’ and therefore the opinions expressed cannot exclusively be attributed to the AMACDT – but are representative of a sample of doctors in training.The opinions expressed during the consultations are consistent with the specialty sections of this report. Some of the key points made are summarised below.
- There was unanimous agreement that the proposed changes to medical specialist training should be driven by educational benefits, not workforce distribution benefits.
- The educational gap is different within each specialty and therefore a 'one model fits all' approach would not work.
- There are very different training implications depending on whether the specialty is procedural or consultative or other.
- Quite often, trainees are relegated to the 'bottom of the food chain' in the private sector and end up doing the routine work of residents in a public hospital.
- The private sector may not provide opportunities to develop people management skills which are gained in the public system through managing residents.
- The private sector has less access to research facilities.
- Employee entitlements should be transferable to all training settings.
- A consistent administration body may be necessary to coordinate and organise training.
- The costs of training are offset to a degree against revenue from services provided by trainees.
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3.13 North Shore Private Hospital (NSW)
The participants involved in the consultation at North Shore Private Hospital said that they could provide training in the specialties of general surgery, orthopaedic surgery, neurosurgery and cardiothoracic surgery.This training would consist of trainees assisting in theatre and receiving the applicable Medicare rebate. These fees would largely cover the costs of the trainees to the private hospital. The trainees would remain employed by the public sector and receive reimbursement from the private hospital for their time.
Participants suggested that indemnity insurance issues are not insurmountable, but would require ongoing negotiations with the public hospital.
Patients in the private hospital expect that the consultant will be providing the treatment, but they are happy for the trainee to attend and to take care of out of hours consultations, under VMO supervision. In the public sector, senior registrars are able to carry out the procedures.
The North Shore Private Hospital has a full time ICU position filled by registrars 24/7 on rotation. For patients in the ICU, private health insurance pays for the procedures that are performed and these can be billed by the intensivist. Private health insurers pay for the ICU based on the type of procedure that is involved.
It is generally up to the surgeon whether or not he or she wants a registrar and the only limit is on the availability of funding. Normally, the registrar is the surgeon's assistant.
The ICU positions are accredited by the colleges. For surgical assistants, accreditation comes as part of the public work but the colleges still check that procedures in the private sector are adequate and the overall public/private training is sufficient.
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3.14 Catholic Health Australia
Background
Training is already being offered in some private Catholic Health Australia (CHA) facilities as part of CHA's strategic direction. The CHA network is also currently setting up educational infrastructure for undergraduate and graduate medical training - particularly with private medical universities such as Notre Dame.Benefits of expanding training
CHA is operating on the strategic assumption that there is fundamentally not enough training in the private sector. This assumption is accompanied by the reality that some medical procedures and conditions have shifted from the public to the private sector.Private sector rotations are attractive to trainees and CHA derives cultural benefits from having trainees. CHA facilities attract good specialists who want to train and work with trainees. Many CHA trainees go on to work in the same private setting.
As opportunities grow for private sector trainees, negative attitudes towards training in the private sector will change. Markets will also arise within the private hospital sector - private hospitals will want to employ trainees so they can secure future specialists.
Barriers to expanding training
The private hospital sector is shaped by price and markets. It is not a sector planned for the delivery of government services. There are certain specialties that will therefore not have private practice facilities in some geographic areas despite a need for them. For example, there are no private sector practising psychiatrists north of Geraldton in Western Australia.Some specialists wish to reduce their FTE load as they get older and will be subsequently less likely to give time to train. Others however are keen to pass on their knowledge and 'give back' these specialists need to be engaged in training programs.
It is infrequent for trainees to experience a rural rotation and want to stay there. This is also true for overseas trainees and doctors. Training in rural and regional areas is therefore unlikely to provide a workforce distribution solution.
Future model of expanding training
Most of the CHA private hospitals have a relationship with a large public teaching hospital and are often co-located - such as St Vincent’s Hospital in Sydney. In these cases, private hospitals are able to provide trainees' salaries within cross charging arrangements with the associated public teaching hospital.Insurance and funding arrangements could be managed through state government requirements. It was suggested that a single, non-governmental coordinating structure would be needed to liaise and negotiate with stakeholders.
Trainees treating private patients in a private setting
All CHA hospitals have the same issues with procedural training as other hospitals. For example the cost proposition of trainees performing procedures, particularly in a market where the private sector operates on the premise of 'queue jumping'.Many patients have concerns about trainees operating in the private sector. The CHA suggested that these concerns may be remedied by explicitly reassuring patients that specialists are supervising and acting as a 'safety-net'.
It was noted that emergency and urgent acute care services may not raise a response from patients who are treated by trainees, because patients are satisfied with the immediate provision of services and pain relief. However, it is acknowledged that there may be ethical issues with this approach. Planned services, such as obstetrics, more frequently involve researching the qualifications and attributes of the specialist before admittance. These services face greater cultural resistance for training in the private sector.
Additional points
The CHA conveyed that their large metropolitan and regional hospitals have sufficient casemix to provide trainees with adequate private sector opportunities. However it was acknowledged that other private facilities, especially those with less than fifty beds, may be highly specialised and limited in their training capacity.Back to stakeholder list
3.15 Epworth Hospital
Background
The number of registrars in training is increasing at the Epworth Hospital, and the Royal Melbourne Hospital runs rotations at Epworth for some registrars in their final year of training.Epworth has utilised about 15% of its training capacity and has excess infrastructure and specialists ready to provide teaching and training.
Benefits of expanding training
Each specialty will have different training needs in private hospitals and, as a result, will add value to the hospital in varied ways.Epworth provides training to raise the profile and interest in the hospital in the belief that there will be benefits for future recruitment. They also consider that the presence of trainees raises the quality of care, as a result of greater interaction of trainees with other health professionals such as nurses. The interaction between patients and trainees, in addition to patients' normal doctors, also gives patients a greater sense of care and increased opportunities to ask questions.
Barriers to expanding training
Although Epworth has sufficient casemix to expand its current training activities, training is limited by the provision of funding and hampered by not being geographically co-located with a major public hospital.Trainees' salaries are the biggest barrier to increasing the provision of training. Also, if the productivity of operating theatres decreased by having additional trainees with limited experience, the revenue of the hospital would be affected - as would bed occupancy rates. It was estimated that 30% more time is needed for the supervision of training and that results in 30% less procedures and 30% less revenue.
Future model of expanding training
Epworth is the only private hospital to have an accredited emergency department position for trainees. A trainer is employed specifically for this purpose.Currently, the Epworth pays trainees' salaries whilst Medicare fees are also claimed where possible - for example, surgical assistance fees.
The hospital suggested that this funding model could be developed further. Alternatively, funding for trainees' salaries could be provided through a central authority which would allow for rotations to other settings. A third funding suggestion was that trainees self-fund their training program.
Trainees treating private patients in a private setting
Patients at Epworth who have accepted the option of being treated by a trainee have given positive feedback. In Epworth's experience, and contrary to expectation, it is very unusual for a patient to refuse treatment from or contact with a trainee.Some private doctors are reluctant to be involved with trainees as they believe that private patients would be dissatisfied. Others say that trainees successfully learn incrementally in the public sector and the same method could be provided in the private sector.
The following consultations were undertaken solely by DoHA
3.16 Australian Health Insurance Association (AHIA)
The AHIA expressed concerns about the cost impact of expanded training settings and the subsequent effects on insurance prices and costs. Increases to insurance prices could have ramifications for the uptake of insurance policies by consumers.The AHIA suggested that greater consideration be given to factors that could influence costs such as:
- increasing payments for the gap between Medicare and private specialist/trainee fees
- the flow of training costs on to insurance premiums
- reduced specialist productivity, resulting in higher costs.
The AHIA concluded that significant work suitable for training is still undertaken in the public sector, and medical workforce training was not the financial responsibility of their members.
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3.17 Medical Insurance Industry Association of Australia (MIIAA)
MIIAA members are able to provide indemnity insurance for supervisors and trainees in expanded settings but require clear information about the pre-existing indemnity status of the person undertaking training. This is particularly so in situations where public sector indemnity may extend to the private sector. The MIIAA also questioned who has responsibility for funding the necessary cover.The MIIAA emphasised that the supervisor and trainee would need to be involved in an accredited training scheme, but they would not be concerned about the accreditation of a particular site or component of the program.
Trainees who are generating Medicare earnings do not present a problem for indemnity arrangements - unless this results in relatively high earnings and greater responsibility affecting the classification of the trainee. For example, an advanced trainee close to the end of training may be working similarly to a fully qualified specialist and, as insurance premiums are related to private income and the amount of private work, this could affect the level of premium.
These issues are also summarised in the MIIAA submission to the Productivity Commission Health Workforce Inquiry which gives examples of the relatively low levels of premium that would normally apply to trainees.
The establishment or funding of specialist training arrangements in the private sector would require further liaison with the relevant medical indemnity insurer to ensure that adequate indemnity coverage is being provided.
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3.18 Australian Private Hospitals Association (APHA)
APHA is interested in facilitating greater involvement in training and has commissioned a consultancy report on the current contribution levels.APHA members are supportive of training in private hospitals, but would require external funding sources to ensure that the costs do not adversely affect profit. Hospitals would be able to assist with the provision of supervision and facilities, but would require funding for trainees' salaries.
An ideal arrangement would be the co-location of public and private facilities, with funding being provided to trainees as they move between sectors.
There were concerns that the indemnity insurance of private hospitals could be affected by the provision of specialist training, and it was agreed that the relevant insurance companies be contacted to resolve this issue.
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3.19 Summary of stakeholder views
The logic of training specialists - for all or part of their speciality training - in the settings where they are likely to subsequently practise is almost universally accepted. However New South Wales is not entirely convinced that the current system does not provide a satisfactory training experience. Only the RANZCP felt that there needs to be a major change from the current arrangements, with other colleges reporting a small but important need.The issues of providing specialist services to rural areas and the overall workforce situation for specialties such as psychiatry, rehabilitative medicine and pathology were seen as much more concerning issues than providing training in expanded settings.
Despite some scepticism in a couple of states, the jurisdictions broadly support expanded training but noted that funding issues need to be resolved. Funding is also a key issue for the other stakeholders.
Private hospitals with experience in training are supportive, and believe that the barriers would be overcome provided that funding issues were resolved. The private health insurance industry is satisfied with expanded training settings, provided the arrangements do not have an impact on industry costs. The medical indemnity insurers would require that explicit arrangements be established about the responsibility for trainees' indemnity.
Throughout the consultations, a range of opinions were expressed about the treatment of patients by trainees, and patients' consent. Treatment by advanced trainees is accepted practice in public hospitals - including undertaking significant operative procedures - but the situation is quite different if the specialist is seeing the patient in a context in which a Medicate rebate is involved. Firstly, it is felt that if the patient is seeing the doctor in a private capacity - particularly when the doctor is also undertaking an operative procedure or the patient has private health insurance - the patient will insist that the specialist undertake the procedure. Secondly, it may be illegal if the patient claims a Medicare rebate when the specialist has not undertaken the consultation or the procedure.
Anecdotal experience suggests that, in the case of consultative practice, patients may be willing to see a trainee - when overseen by a consultant - particularly if the waiting time to see the consultant can be shortened. On the other hand, those involved with performing procedures on patients in private hospitals were generally of the opinion that private patients would not be prepared to have procedures undertaken by trainees, particularly if this risked breaching Medicare legislation.
What is clear is that there is very little of a true 'evidence base' about private patient expectations. A study on this issue has been undertaken by a general surgeon in Western Australia on just over 100 consecutive patients referred to his private consulting rooms. Sixty-five percent of patients said they would be prepared to see a trainee and have the trainee undertake an operative procedure, as long as the supervisor was in immediate attendance and the trainee was at an appropriate stage of their training.
It is likely that, in the future, these matters will need to be addressed in each particular setting and specialty through an appropriate education campaign, together with consumer focus groups.
None of the stakeholders have really started to address the issues arising from the very significant increase in medical school graduate numbers that will take place over the next few years.