Executive Summary

Background

There have been a number of previous studies about the need to expand the settings for medical specialist training. In 2001, AHMAC established a working party to research issues relevant to medical specialist training outside teaching hospitals. The working party commissioned Professor Peter Phelan to prepare a discussion paper on 'Medical specialist education and training: responding to the impact of changes in Australia's health care system'. The Phelan report was released in February 2002 and identified some of the challenges relating to the scope of clinical training available at the time - including limited experience in ambulatory settings and limited trainee access to the variety of conditions that are managed primarily in the private sector.

In October 2003, AHMAC established the Medical Specialist Training Taskforce to investigate the provision of training to doctors beyond existing environments and develop a potential training model to enable this to occur. It confirmed the need to provide training in settings that match the current and longer term service delivery requirements of the community - including public hospitals, private hospitals, private practices, community-based practice, rural settings and non-clinical settings. In addition, it identified the need for trainees to undertake training rotations as per college curricula within a network of settings - including a principal health care service entity such as a hospital - and to ensure that the employing health care service entity is responsible for providing the trainees with salary and associated employee entitlements.

The Medical Specialist Training Steering Committee was set up in November 2004 to investigate issues relating to the implementation of the taskforce's findings. In particular, it was to focus on three specific areas - costs and benefits, public hospital capacity and education issues. Reference groups were established to look at each of these issues in more detail and report back to the steering committee. The scope of the steering committee was restricted to specialist trainees, excluding general practice.

The reasons for expanding specialist training settings

For trainees, an expansion of medical training settings will ensure that there are improved training opportunities and experiences available. As independent practitioners, they will therefore be competent to manage the full spectrum of clinical presentations and problems in their specialty.

Both trainees and medical specialists will benefit because training will become more closely aligned with subsequent practice. It will also create opportunities to expand training to match service delivery and community health care needs and expectations.

The expanded settings will increase the health system's capacity to provide clinical placements for more trainees, without increasing pressure on the teaching capacity of public hospitals.

There will be improved safety and quality of health care within the expanded training settings through an increased focus on the patient journey, leading to better trained doctors and an enhanced learning and service provision environment. Patients and the community will benefit from a greater number of specialists available to provide care, and more trainees and specialists working in public, private and community settings.

Current training in expanded settings

Medical specialist colleges are already recognising the potential of diversifying training opportunities and are increasing the proportion of training in settings outside public hospitals.

There are a range of existing and pilot projects around Australia that provide opportunities for specialist training in private hospitals, private practices, community based team practices and non-clinical settings. In particular, increasing numbers of trainees in dermatology, pathology and diagnostic imaging are offered training opportunities in private practices.

Trainees working in settings other than public teaching hospitals gain experience in the diagnosis and management of patients with complex and chronic diseases, as well as common conditions. They also have greater opportunity to develop communication skills in multidisciplinary team care.

Appropriate resources are needed to provide effective experiences for trainees. These resources include high quality supervision and adequate training opportunities, support for the professional development of supervisors and trainees, access to educational resources and setting-specific infrastructure requirements.

It is important that high quality training in public teaching hospitals is not compromised by more diverse training settings, and that the capacity for teaching and infrastructure in these hospitals is maintained.

The effect of expanded training arrangements on public teaching hospitals

The specialist trainee workforce is integral to public hospital service delivery. Given the vital role of public hospitals, expansion of training settings needs to be measured and gradual and designed to supplement public hospitals as the key setting for specialist training. This specialist trainee workforce also plays a vital role in providing training for junior doctors, other health professionals and students and this role must be maintained and supported.

A structured system for the administration and funding of networked training arrangements should be developed and implemented, in line with COAG announcements.

The number of trainees undertaking training rotations within a system of expanded medical training opportunities should steadily increase in line with the growth of medical school graduates. Full scale implementation of expanded training opportunities will occur from 2011. This is when the number of trainees entering vocational training will have increased to a level that allows expansion to occur without a detrimental effect on the public hospital workforce and training capacity. However earlier expansion in some specialties may be both possible and desirable.

Workforce and financial implications

The costs of expanding training settings to meet educational and workforce requirements were determined through consultation with key stakeholders, reviews of AMWAC reports and modelling.

In order to provide training in a diverse range of settings for educational purposes and still maintain the public teaching hospital workforce, an average increase of around 20% in the total number of trainees will be required across the ten surveyed specialties.

The estimated cost of additional trainees - to meet the educational imperative for the expansion of training settings across ten sample specialties - is between $123 and $132 million per annum. Variables such as infrastructure, resources, supervision, insurance (including medical indemnity) and administration were included in this costing. The additional capital costs associated with major developments in particular existing facilities such as private hospitals have not been estimated. An estimate of this amount can only be reached when a complete stocktake of existing capacity, in the light of future requirements, has been made.

In three of the specialties surveyed - pathology, psychiatry and rehabilitation medicine – significant current specialist workforce shortages were noted. Creating additional training positions in expanded settings to meet educational requirements for these specialties would have the added benefit of moderating current workforce difficulties. Similar consideration may apply to some of the specialities not surveyed.

The ten specialties surveyed account for about half the total number of specialist trainees. If the same assumptions are applied, around 1,250 additional trainees would be required to meet the educational requirement across all specialties.

There will be an estimated doubling of the number of specialist trainees by the latter half of the next decade, due to the increased output from additional medical school places. At that time the number of specialist trainees requiring placements outside major metropolitan public hospitals to meet the educational imperatives could be up to between 2,100 and 2,400, depending on the future distribution of trainees among the disciplines (including general practice).

It is anticipated that the resultant growth in medical school graduates will increase the demand for training positions in the public hospitals. An expansion of training settings for educational purposes will partially mitigate this pressure on public hospital training position numbers at only a small incremental cost.

The views of stakeholders

Feedback on the potential impacts of an expansion of medical specialist training to settings outside public teaching hospitals revealed a number of commonalities.

Current and potential arrangements for training outside the public hospitals were identified by many respondents. These arrangements included trainees working across co-located public and private hospitals or in private clinics attached to hospitals, in specialist rooms or in community settings that are networked. There was agreement that each jurisdiction and specialty would have its own needs that would have to be taken into account when planning future arrangements.

The quality and availability of supervision was identified as an issue that will need to be addressed. There was a perception that many specialists in private settings will be reluctant to take on supervision due to heavy workloads, lack of remuneration and the lack of a culture that promotes supervision and teaching. Funding of supervisors - and agreement about and promotion of high quality supervision - may contribute to overcoming these concerns.

There were varying viewpoints about the effect of expanded training settings on accreditation. Some respondents felt that current requirements would apply to all settings, while others felt that changes would be necessary. In any situation, appropriate accreditation standards should apply equally to all training sites. It was agreed that expanded settings would require resources to meet and maintain accreditation standards.

Some specialties are already significantly involved in non-public hospital training although all indicated that they will continue to do most of their training in public hospitals.

Implementation - consumer considerations, timing and options

There is a need to explore the issues that would affect consumers if specialist training was expanded into a broader range of settings. Some key issues to be discussed would include informed patient consent and whether patients with private health insurance would accept treatment from trainees.

A communication and consumer engagement strategy - targeted at patients and service providers - would provide information on the rationale for the program, the skills and qualifications of specialist trainees and patients' right to informed consent, and assurance about continuous quality improvement of care delivery in expanded settings throughout the patient journey.

A structured system for the administration and funding of expanded training arrangements for specialist trainees should be developed and implemented by 2008. However this timeframe should not prevent continuation of existing pilots or the development and funding of new projects before 2008.

There are a number of existing mechanisms that could potentially be used to distribute funding for training in a diverse range of settings. These mechanisms include awards and secondments, grants, Medicare benefits and private sector funding.

The overarching principles and suggested criteria for applications for funding proposed in this report can be used to guide implementation of the expanded training arrangements.

The process for developing a governance and administration structure must recognise the need for involvement of all stakeholders, including consumers of health care, from the earliest stage.

The implementation of each expanded training arrangement will also need to take into consideration the individual circumstances and requirements of the health care system within each state and territory.