5. Qualitative assessment of workforce benefits and costs

The extensive consultations with colleges, jurisdictions and other stakeholders - together with the analysis of trainee numbers and costs – have been used to estimate the overall benefits and costs of expanding training into diversified settings.

There are common themes among some of these results, but also a diversity of issues facing the 10 sample specialties. Although it is not within Reference Group 1's terms of reference to comment on implementation, it is clear from these results that a 'one size fits all' approach would not be the best way to promote specialty training in diversified settings. In particular, the benefits and costs are very different between sectors.

5.1 Features and issues for the public sector

The public sector currently provides most medical specialist training and recognises trainees as an important part of the workforce. Most jurisdictions plan for training numbers to increase in the future to continue to meet service delivery.

Training in the public sector includes trainees conducting treatments and procedures under supervision. These public teaching hospital services tend to be the most acute aspects of each specialty.

5.2 Features and issues for the private sector

The private sector consists of private hospitals, private medical practices, health insurers or medical indemnity insurers. These could be small, medium or large businesses that seek to make a profit for shareholders and owners. This factor has a great impact on how training could be provided and managed.

Services within the private sector consist of mostly elective or less acute treatments and procedures. They therefore provide a different casemix for training opportunities than public teaching hospitals.

Private hospital patients usually have private health insurance and have specifically chosen their hospital and doctor.

A limited amount of training is currently provided in the private sector. This tends to be on an ad hoc basis, or where training is favourable to the overall operation and goal of the organisation.

5.3 Common features and issues for both sectors

There is overlap between doctors who work in the public and private sectors, and both sectors have doctors who may willingly provide training. Training in the public sector is often provided on a pro bono basis. However these same doctors may be reluctant to introduce trainees into their private practice, possibly because of perceived patient resistance or the impact of training time on productivity and revenue.

In both sectors, workforce distribution is skewed towards the major metropolitan centres with regional workforce shortages of varying levels of severity.

Irrespective of the sector, it was reported that training requires additional funds and - in many cases - increased resources and facilities.

There seems to have been relatively little analysis of the implications of the major expansion in the number of medical graduates seeking specialty training that will occur from about 2010 onwards.

5.4 Summary of specialty results

Although they share common themes, the ten sample specialties are more characterised by their diversity than their similarities. Using the following definitions of drivers and barriers, the sample specialties have been separated into five major categories.

The drivers to expand training to other settings are:

• A case mix gap in which the type of patient presentations or procedures currently seen in major metropolitan teaching hospitals does not allow curricular and experiential objectives to be optimally met.
• A continuity gap in which the entirety of 'the patient journey' was not seen by trainees in major metropolitan teaching hospitals.
• A perceived need to expand the specialist workforce.

Barriers to expanding training are:

• The perceived issue of trainees treating private patients.
• The need to maintain services in public hospitals.
• The issue that expanding training settings would lead to an increase in trainee numbers, and subsequently increased specialist numbers which might be inappropriate on the basis of workforce predictions.
• The difficulty with attracting sufficient numbers of trainees in the short term.

Category 1

In this category, definite but not critical educational imperatives were identified in conjunction with a moderate need to increase the workforce. The specialties falling into this category included obstetrics and gynaecology, dermatology, anaesthetics and gastroenterology.

For obstetrics and gynaecology, the drivers to expanding training included both a case mix gap (especially for gynaecology) and a continuity gap. Barriers to expanding training included problems with trainees treating private patients and the difficulty of attracting sufficient trainees, particularly for obstetrics.

It was recognised that there is tension between what is perceived as a reasonable overall current workforce - although with significant geographic maldistribution - and the fact that expanding training would lead to a possibly inappropriate increase in the workforce.

For dermatology, a case mix gap was identified as a driver to expanding training while the barrier was primarily that of trainees treating private patients. Private rooms were identified as the setting to which expansion would mostly occur, and some workforce need was also identified - once again with a focus on geographic maldistribution.

A relatively minor case mix gap was identified for anaesthesia, although the specialty also faces a barrier relating to the treatment of private patients by trainees. Once again, a relatively modest workforce shortage would not allow a significant expansion of trainee numbers.

Gastroenterology suffers from a significant case mix gap which should primarily be addressed by training in private rooms, but the logistics of public hospital service delivery would need to be considered. The current workforce was not seen as requiring significant expansion.

Category 2

The second identified category is relevant for rehabilitation medicine and pathology - with a similar educational imperative to Category 1, but a more marked workforce need.

While there is some case mix gap for rehabilitation medicine, the main barrier is in attracting sufficient numbers of trainees. The settings requiring expansion included both regional hospitals and, to lesser extent, private hospitals while an increase to the workforce was seen as a critical issue for the specialty.

Of the ten sample specialties, the workforce need is the most severe for pathology. Although extensive use of private pathology laboratories for training would be educationally unnecessary, the lack of barriers to expansion presents a clear opportunity for increasing training capacity through private laboratories.

Category 3

Significant educational imperatives but a relatively minor workforce need was the third category and it applied to general paediatrics. There is a significant case mix gap which is seen as being remedied by an expansion of training to community settings. While there is reportedly some need to expand the workforce, it was recognised that the current overall balance is probably satisfactory – although there is a geographic maldistribution.

Category 4

The fourth category was defined as significant educational imperatives and generally significant workforce needs. These issues were found to be relevant to orthopaedic surgery and general surgery.

In orthopaedic surgery, there is a major case mix gap and at least a moderate gap in continuity. The primary barrier is the treatment of private patients by trainees. It was felt that this would be best addressed in private hospitals and to a lesser extent in rooms. There was also a moderate workforce need.

For general surgery, there was a less significant case mix gap but a greater continuity gap - particularly in New South Wales. General surgery appears to share the same significant barrier as orthopaedic surgery - that is, trainees treating private patients. The settings requiring expansion include both private rooms and private hospitals and there was at least a moderate workforce need, once again to address the current geographic maldistribution.

Category 5

The fifth category for expanding training - a significant educational imperative and a critical workforce need - was relevant to psychiatry, which has major case mix and continuity gaps.

The only current significant barrier to expansion is managing the logistics of rostering and backfilling in public hospitals to maintain service delivery requirements. The primary sites for expansion of training are private hospitals and private rooms. Overall, there is a critical workforce need and a significant shortage of trainees.