Special treatment: Improving Australians’ access to specialist care

2.2 Why we’re not training the specialists we need

Persistent shortages of some types of specialists, and in many rural areas, are caused by problems with the way we plan, fund, and accredit specialist training.

2.2.1 Poor workforce planning

Australia needs a comprehensive, long-term workforce plan to ensure we have the specialist workforce to meet our healthcare needs. At the moment, there is no comprehensive national workforce planning mechanism.

Planning is important because of the long time lags and many players involved in training specialists.

It takes at least 12 years to train a medical specialist (Figure 2.1 on page 15), so governments need to look ahead to identify what specialists will be needed to meet our future health needs.

Governments, universities, medical colleges, and health services all make decisions on how many and what types of specialists are trained in Australia. Without a plan – backed by funding and accountability – their decisions on training volumes, skills, and locations won’t be aligned to each other, or to community needs.

But, since the national planning and advisory body, Health Workforce Australia, was abolished in 2014, supply and demand modelling has been ad hoc and fragmented.

There is very limited system-wide data on workforce supply, workforce demand, training activity, or training capacity. Governments, medical colleges, and regulators use different data and methods to forecast specialty supply and demand. As a result, Australia does not have a shared understanding of what the workforce should look like or the changes needed to secure it.

2.2.2 Funding for specialist training is disconnected from workforce needs

Box 1: Hospitals’ reliance on registrars skews training places

Historically, all medical students followed a clear path from junior doctor, to registrar, to specialist. Now, health services increasingly rely on a large cohort of ‘middle-grade’ trainee doctors – rather than specialists – to deliver 24/7 acute care.

This means that in some specialties, such as emergency medicine, hospitals fund more training positions than there is future need, or jobs, for fully accredited specialists. In contrast, training positions in under-supplied specialties such as dermatology often go unfunded.

Health services are also employing more unaccredited registrars who complete similar tasks but are not recognised as trainees and cannot progress towards fellowship. Unaccredited registrars have fewer protections than trainees and are more likely to feel dissatisfied or burn out.

The registrar workforce model should change, to create attractive alternatives to specialist accreditation. A new model should support sustainable, long-term, non-specialist medical roles that attract non-accredited doctors in fields with high demand for registrar workers. The Department of Health and Aged Care is developing a framework for service registrars and career medical officers to help address this.

The lion’s share of specialist training funding comes from public hospital budgets. This funding is mostly dictated by how many services hospitals deliver — through Activity-Based Funding — and how much training they deliver, through Teaching, Training, and Research funding. Neither of these funding sources is linked to workforce planning, and both lock in the current distribution of training places, disadvantaging rural areas.

Hospitals increasingly rely on registrars (see Figure 2.1) to deliver core services. But the immediate need for hospital trainees does not match the long-term need for these specialists (Box 1). This contributes to too much training in some areas, such as in emergency medicine, and too little in others, such as dermatology.

The federal government’s Specialist Training Program (STP) aims to address these imbalances by funding new positions in under-supplied specialties and in rural, remote, and private hospitals. But the program is too small and inflexible to enable the training system to respond to workforce needs.

Some states have their own targeted funding programs to boost training in under-supplied specialties and regions. But this funding is also too small to make much difference.

2.2.3 Specialist colleges aren’t delivering the workforce Australia needs

Specialist colleges control crucial steps in the training process for Australia’s specialists. But they are not set up to take into account the interests of the community as a whole. Their processes often add red tape and complexity, stymieing supply.

Colleges’ interests and expertise don’t align with community needs

Colleges are not set up to solve workforce shortages. They are led by members, whose interests may not align with broader system goals. And colleges’ expertise is in their specialty’s skills and knowledge, not the system-wide effects of training and accreditation decisions.

Colleges are accountable to the Australian Medical Council (AMC), an independent regulatory body that sets the standards colleges must meet to be accredited. But the AMC’s standards are often vague and disconnected from community needs.

Most day-to-day college work is completed pro bono by fellows, and operations are largely funded by trainee and membership fees. This means colleges have limited resources to develop new training models or adapt their practices, and their funding is not linked to clear targets or performance indicators.

To address this, the federal government provides some funding to colleges under the Specialist Training Program (STP) and the Flexible Approach to Training in Expanded Settings (FATES) program. But these programs are currently too small to have a big impact.

Accreditation is inconsistent and inflexible

Hospitals or health services that wish to host a trainee must be accredited by the relevant specialist college, to ensure they can provide a safe, high-quality training environment. But the process is flawed.

Colleges’ accreditation rules vary significantly. Some lack transparent policies and adequate procedures. And internal politics can affect accreditation decisions.

Accreditation is inflexible, with strict requirements about the types and volumes of care seen during training, and how trainees are supervised (Box 2). Requirements are often based on historical practices rather than evidence, limiting the uptake of successful flexible and remote supervision models. This puts a handbrake on new training places, particularly in rural areas.

Box 2: Barriers to accreditation for training sites

There are many examples of how the inflexibility of college rules and a lack of accountability can limit training opportunities.

The Northern Territory has no accredited training sites for facial trauma, despite having a similar volume of cases to Victoria. College requirements that each training location have four trainees are not feasible for NT health services.

In rural NSW, a health service faced resistance to establishing a training position because other specialists did not believe a
regional centre was suitable for training. The site met accreditation requirements, but when the health service wrote to the college to establish the position it did not receive a response. Later, when the NSW government intervened, the college assessed the site and it was eventually accredited..

A proposal for an innovative Basic Physician Training in
Paediatrics and Child Health post in Far North Queensland
received positive feedback from Brisbane’s Directors of Physician Education. But the The Royal Australasian College of Physicians
rejected the post because it did not align with the existing training model.

Trainee selection is focused on the wrong things

Colleges put too much weight on narrow academic metrics such as publications and higher degrees when selecting trainees. These requirements are expensive and burdensome for junior doctors, and risk excluding applicants from poorer and rural backgrounds, with no evidence that they make for more competent trainees.

Colleges also haven’t fully integrated broader health system goals, such as increasing rural training, into their selection processes.

Trainees are at risk of burning out and dropping out

Specialist trainees are at high risk of burnout and psychological distress. Training program demands contribute to this risk.

Many trainees lack support at work, particularly on rural rotations and in new jobs, and bullying and discrimination are common. Trainees often work long and unpredictable hours, while studying for high-stakes exams, increasing the risk of stress and burnout.

These factors contribute to high rates of attrition and failure in some fields, such as surgery and ophthalmology. And they help to explain the gender gap in some specialties. Long and inflexible hours are particularly difficult for people with child-caring responsibilities, which often fall to women.