The Australian health care system provides a consistently high standard of care, training and research. Both hospitals and specialist medical colleges have kept pace with evolving community expectations, maintaining their impressive standards in the face of changing service delivery environments and improvements in technology.
While the public teaching hospital is still the focal point of medical specialist training in Australia, the changes - some gradual, others less so - in health care provision suggest that there is an argument for some accompanying changes in the arrangements for medical specialist training.
Length of stay in public metropolitan teaching hospitals is decreasing, while the acuity of many in-patient episodes is increasing. Innovations, such as the advent of day surgery, have altered the casemix profile within hospitals. Coupled with the absence of pre- and post-procedural care from many acute settings and the increase in ambulatory care provided in other settings, it is clear that some adjustment in the training for some medical specialties and sub-specialties is now required.
Many of these changes are at the margin. This report indicates that, for most specialties, no more than 10-20% of specialist training time would need to be spent outside the major metropolitan public teaching hospital. Indeed, this report finds that such an expansion of training settings already exists across a range of specialties, settings and jurisdictions, albeit on an informal basis.
During the life of this steering committee, two major announcements helped shape the direction of its work.
Firstly, the number of places in Australian medical schools has increased dramatically. While the impact of this significant boost to the medical workforce will not be fully realised for more than 10 years, it provides another reason to expand specialist training settings and provide some guidance for the timing of any expansion.
It is clear that any expansion of training settings should not adversely affect the capacity of the public teaching hospital system. Therefore it is important that the years leading up to 2011 - when the additional medical school graduates begin to emerge - are years of capacity building and development. While the expansion proposed in this report is not a radical overhaul of the current training arrangements, it nonetheless identifies implementation issues - such as accreditation and infrastructure development - that will take time to address.
Secondly, the Council of Australian Governments (COAG) met in July 2006 and, among other initiatives, agreed that the Commonwealth and the states and territories will establish by January 2008 a system for specialist trainees to undertake rotations through an expanded range of settings beyond traditional public teaching hospitals. This could include a range of public settings (including regional, rural and ambulatory settings), the private sector (hospitals and practices), community settings and non-clinical (for example, simulated learning) environments.
It was noted by COAG that implementation of this initiative should have regard to the work of the medical specialist training steering committee.
This announcement provides a platform for discussions between the Commonwealth, state and territory governments, as well as the medical profession and training providers. These discussions will be informed by the findings in this report.
It is recommended that a governance structure be established to oversee this process which has regard for the need for strong stakeholder involvement to ensure success. A set of principles has been proposed by the committee concerning the role of the governance structure. The committee has also suggested overarching and operational principles to guide its activities while still accommodating the needs, priorities and capacity of individual jurisdictions, specialties and settings.
This report does not propose a new training model. Rather, it proposes a modest and gradual expansion of training settings which seek to build on the achievements of the parties currently involved in medical specialist training. Health care consumers can only benefit from the gains to the quality and capacity of the health system that will emerge from these developments.
Professor John Horvath AO
Chair, Medical Specialist Training Steering Committee