4. Methodology, trainee numbers and costs

4.1 Background

This project aimed to assess the extent to which training should be provided in a diverse range of settings - the 'educational imperative' - and apply costs to this expansion based on the additional number of specialist trainees that would be required to maintain the public hospital workforce as well as use additional settings. These analyses were conducted for 10 sample specialties.

The same methodology was used for each specialty, but the resultant changes to trainee numbers and the costs varied across specialties, jurisdictions and settings. It should be noted that these results are broad approximations, given the variable nature of the medical workforce and the factors that influence its supply and demand.

The variable nature of the medical workforce and the unstructured training system has not allowed for a rigorous sensitivity analysis to be undertaken by PwC, the consultant to this project. They were particularly concerned that a mechanical quantification of the sensitivity of the models used would imply an unrealistic level of precision relative to the large level of uncertainty found throughout the actual overall training system. This uncertainty can be inferred to some extent from the substantial range of outcomes associated with the various scenarios presented.

4.2 Estimating workforce numbers and distribution

The methodology adopted for this project depended on estimating workforce numbers and distribution in the following way.

• Estimates of current numbers of trainees - in total and year by year - were obtained from the Medical Training Review Panel (MTRP) and the relevant specialty college.
  
  
• An assessment of whether the current workforce numbers are satisfactory, or whether the specialty workforce is in undersupply or oversupply, was based on advice from the relevant college and the most recent AMWAC report for that specialty.
  
  
• An assessment of the importance of expanding training into settings outside the major public hospitals to meet the educational imperative for that specialty was based largely on advice from the college.
  
  
• Information about the current distribution of trainees between major public teaching hospitals and other settings was obtained from the college.
  
  
• An assumption was made that the number of trainees for the relevant specialty currently working in public hospitals would need to be maintained because of their importance to the overall public hospital workforce. Various allowances were made for maintaining the distribution of trainees between early and advanced years in the hospitals.
  
  
• The desirable distribution of trainees between settings was drawn up based on the previous information. In most cases this did not vary markedly from the current distribution, but added between 5% and 10% of time to expanded settings.
  
  
• The percentage distribution was converted to actual trainee numbers in each setting based on the workforce projections and the assumption of a constant public hospital trainee workforce.

4.3 Use of 'scenarios' to reflect the most appropriate situation

The estimated increases in the number of trainees under each of the three PwC modelling scenarios are shown in Table 3. These are based on the stakeholder perceptions of the current workforce situation. They do not take account of the prospective increase in medical graduates from about 2011 on.

In scenario 1, the overall trainee FTE workforce is held constant in the lead public teaching hospital settings, in total across all training years, after first setting the model to a steady state - that is, the same number of trainees in each year.

In scenario 2, the overall trainee workforce is held constant in the lead public teaching hospital settings, separately for basic and advanced training, after first setting the model to a steady state. The model is then re-set to steady state again - that is, set at the higher of the basic or advanced yearly training numbers.

Scenario 3 contains PwC selected results, based both on the results of the first two scenarios and additional information about the overall requirement for extra specialists. In general, for this scenario, PwC picked the highest results from the other scenarios which they believed could be reasonably supported by the overall medical system. However for paediatrics they selected no overall increase - due to a lack of additional overall need for specialists - and for pathology they selected an increase of 500 trainees, in line with both AMWAC recommendations and feedback from the college.

Overall, PwC consider the results of Scenario 3 reflect the most reasonable balance of competing system issues and pressures.

Table 3: Projected increase in number of trainees due to the educational imperative (Scenarios 1 and 2) and due to the educational imperative and major current workforce shortages (Scenario 3)

Reviewed specialty	Current no. of trainees	Current no. of trainees (steady state)	Increase in trainee numbers over current system at steady state
			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
Orthopaedic Surgery	170	180	26	26	26
Obstetrics & 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	1,319

Please note that the results for gastroenterology, paediatrics and the surgical subspecialties in Table 3 are for advanced training only. Additional trainee numbers will need to flow through from the basic paediatric, basic adult medicine, and basic surgical training programs to support these advanced program increases.

4.4 Estimating the costs of the new training system

The salary for a first-year trainee was estimated at $90,000, increasing by $10,000 in each year of training.

The on costs associated with training such as supervision, facilities, insurances and administration were estimated separately for each specialty because the type of setting, facilities required and the contribution of the trainee to the work in expanded settings varies between specialties. In most cases, the on costs were around 60% of the trainee salary.

The total cost for each specialty for expanding training was estimated by multiplying the estimated additional numbers of trainees by the estimated individual trainee cost.

In most cases, a range of costs were estimated based on what was considered to be the likely range of future trainee numbers.

Table 4 shows PwC's estimated conversions of the increased number of trainees into estimated increases in annual overall training system costs.

Additional training costs may be required to support additional trainees in the basic paediatric, basic adult medicine, and basic surgical training programs to support the advanced program increases.

Table 4: Projected increase in annual training costs due to the educational imperative (Scenarios 1 and 2) and due to the educational imperative plus major current workforce shortages (Scenario 3)

Reviewed specialty	Increase in estimated total training costs ($000s) over current system at steady state
	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

4.5 Impact of increases in the number of medical graduates

These results have been driven by a combination of educational imperative, the need to maintain current trainee workforce levels in public metropolitan teaching hospitals, and the need to address current levels of workforce need for additional specialists and specialist trainees.

In addition to this primary methodology, PwC were asked to model how the ten specialties reviewed in this study relate to and compare with the overall increase in the number of trainees that is likely to occur in the future as a consequence of the planned increase in medical graduates.

The results of the analysis undertaken for this study suggest a required increase in training numbers for the 10 reviewed specialties of between 616 and 1,319, from a current base of 3,141.

In contrast, the overall total number of vocational trainees in the system can be expected to increase by over 7,000 from the current total of 8,712 to over 16,000 by between 2015 and 2020. This includes basic and advanced trainees and general practice trainees, but it was not within the terms of reference of this study to estimate the vocational distribution of these trainees. Even if training numbers in the 10 selected specialties are required to grow by significantly more than projected in this study, the overall growth in vocational trainees will far outpace this.

The cost of increasing the number of training positions within the public hospital system to accommodate new specialist trainees will be significant, regardless of whether any expansion of training settings occurs - the number of training positions, and thus funding, would need to be nearly doubled.

Figure 2: Costs of training increased medical school graduates

Source: Analysis undertaken by DoHA

If an expansion of training settings is implemented on relatively small scale indicated by the ten sample specialties, the pressure exerted on the public system by the doubling of medical specialist trainees would be mitigated. Whilst at the same time, only marginal extra costs would be incurred by providing training in these expanded settings.

These effects are hypothetically demonstrated in Figure 1, which show that the costs of training in the public sector without an expansion will increase significantly (blue line). The costs to the public sector would increase slightly with an expansion of training settings (orange line) due to greater management and administrative costs of more trainees and more diverse settings. The private and community sector would also absorb a small amount of the costs of expanded settings, as these settings would be required to contribute to the direct salaries and other costs of trainees (green line). The lines in Figure 1 diverge as implementation increases at a gradual rate.