Tuesday, March 16, 2010

Rudd Government's proposals to expand doctor training

The announcement by the Australian Government of additional funding to increase the number of GPs and specialists (here, here, here) with a stated particular focus on regional Australia is an interesting one. Australia has had a shortage of doctors at all levels for some time. This is especially pronounced in regional areas, as well as some of the outer suburbs of the major metropolitan centres.

The questions asked of PM Rudd and Health Minister Roxon at their Queanbeyan door stop on the proposals were fairly shallow. I thought therefore that I should make some brief comments, recognising that my own knowledge is a little dated. 

As I understand it, the critical issues in expanding basic basic medical training all centre on availability and access: availability of people to supply the necessary education and training, availability of supporting facilities, access to hospitals for necessary clinical time.

Similar issues arise in subsequent specialist training. The absolute critical issues here are the availability of registrar (training) positions in hospitals with both a suitable case load and availability of specialists to undertake the necessary supervision. The hospitals themselves must also be available to provide necessary support and back-up to the specialists in training.

You can think of the whole thing as a chain with various critical choke points along it. Simply increasing entry numbers at start does not, of itself, guarantee an increase in numbers down the chain. Further, down stream decisions taken for other reasons can affect supply.

Registrar positions, for example, are generally funded by State Governments and are both training positions and a critical part of service delivery within the public hospital system. Changes to that system affect both the supply and location of registrar positions. In NSW, decisions about location of emergency departments - a general system decision - reduced the number of registrar positions, leading to a reduction in the number of certain types of physicians in training.

Regional areas face particular problems. The lengthening of specialist training, together with the predominantly metropolitan location of that training, created a significant barrier to subsequent movement to regional areas because of, among other things, partner and family relationships formed during training.

A further problem in regional areas lies in the increased technical complexity of medical training. This makes it more difficult to train people at smaller hospitals, public or private. A chicken and egg problem emerges. 

Governments have been searching for ways to overcome the bias against regional areas, while also increasing supply.

In NSW, for example, the NSW Institute of Medical Education and Training (IMET) has formed training networks linking regional and metropolitan hospitals to give specialist trainees regional experience. In similar vein, there is a Rural Preferential Recruitment Program for internships following completion of basic medical training that guarantees applicants places. Eleven hospitals are classified as home hospitals, of which five (Albury, Dubbo, Orange, Wagga Wagga and Tamworth) are in inland NSW.

A very important development in recent years has been the slow broadening of health related training including medical training at non-metro universities. This is important not just because those people are more likely to stay in regional areas, but also because it is actually building (in some cases re-building) the human and physical infrastructure in these areas.

The University of New England, for example, had sought to establish medical training for many decades but without success. Then the growing emphasis on the rural doctor shortage led to the establishment of a tripartite arrangement between the Universities of New England and Newcastle and the Hunter New England Area Health Service that saw the establishment of a joint School of Rural Medicine. The facilities now established in Armidale provide a base for further expansion, while also improving regional medical services.

In similar vein, the teaching of dentistry in NSW was localised in Sydney. As with the UNE case, attempts to establish teaching in dentistry outside Sydney were opposed on grounds of economics. Now Charles Sturt University is in the process of establishing a dental school at Wagga Wagga. As with UNE, once established, the new school will have a variety of spin-off benefits.

These are slow processes.

The interesting thing about the new Rudd Government plans lies in the complexities that will need to be resolved if it is to meet the Government's targets.

There are, I think, inherent tensions within the proposals. For example, they focus on increasing specialist availability in regional Australia and on a greater role for private hospitals in specialist training. Leaving aside the problems associated with an increased role for private hospitals, I am not sure that there are that many suitable private hospitals in regional Australia. So there is going to be a need for a a differential approach if both objectives are to be approved.

I also wonder, and I have not seen this issue addressed, just what the proposals mean for specialist training in New Zealand. The majority of the specialist medical colleges are Australian and New Zealand colleges. Their training programs have always been complicated because they involved delivery across multiple jurisdictions. These complexities have increased as all Governments became more involved in, and prescriptive about, medical education.

The New Zealand issue will seem a second order question to most Australians. Yet a core objective for both Australia and New Zealand over time has been the achievement of greater integration between the two countries in key areas. Australia plus New Zealand is greater than Australia and New Zealand.

I have only just scratched the surface on issues here. This is a Rudd Government proposal that I would dearly like to see work. A lot of work is going to be required to make it happen.     

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