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The future of health care and the role for medical leaders

Presentation by Professor John Horvath, Chief Medical Officer, to the Australian Medical Students Association (AMSA) Leadership Development Seminar, 7 September 2005.

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7 September 2005

Slide 1: Introduction

Thank you for the opportunity to speak with you today.

The Australian Government has a long history of working constructively with the medical profession. While you, as the future leaders of the medical profession, will have various concerns about the future, I want to start by assuring you that the Government highly values the contribution you make, and is committed to continuing to work in partnership with the profession to meet the many challenges which our health system faces.

Slide 2: Financial Support

The Australian Government support for university medical training includes: $16,000 per year or $80,000 per student for a 5 year program.

For decades, governments have worked with the medical profession to underpin training at an undergraduate and vocational level. The Australian Government provides approximately $16,000 per year per medical student to universities to educate our future doctors. This is around $80,000 per student for a five year course. In addition, governments contribute considerable sums by way of capital contributions to establish medical schools and to operate our postgraduate and vocational training system.

The young doctors being produced by this education and training system have the responsibility, in partnership with Government, to provide leadership in the provision of quality health services to a demanding, ageing population.

The importance of this responsibility should not be underestimated - the Australian community consistently ranks the provision of quality health care at or near the top of its priority list.
There is a misunderstanding among some doctors that governments are hostile towards them. This is far from the truth. There are a couple of myths in particular that I would like to dispel.

Slide 3: Medicare Provider Number Legislation

• Changes introduced in 1996
• Require doctors to complete vocational training to access Medicare payments

The first myth concerns the Medicare Provider Number Legislation introduced by the Government in 1996. This legislation requires doctors to obtain Fellowship of one of the medical colleges before accessing the Medicare system to practice on an unsupervised basis.

At the time of its introduction, it was predicted by some that there would be restrictions on access to vocational training opportunities for medical graduates, resulting in extended periods of service in public hospitals for junior doctors.

Slide 4: Growth in Vocational Training Posts

Far from being true, there has in fact been a strong increase in vocational training opportunities. Colleges have estimated that this year (2005) there are 1,782 first year advanced vocational training places available, an increase of 30% on the numbers available in 1997. This compares with the current Australian medical graduate cohort of around 1,300. The number of vocational training places is set to continue to increase as governments move to expand vocational training posts to address the medical workforce shortages we are now experiencing.

We know from the Australian Medical Workforce Advisory Committee’s recent Careers Choice report on junior doctors that 94% of doctors who applied for vocational training were training in their preferred discipline. We also know that the Clinical Assistantship Program, established under the Provider Number Legislation to support doctors that could not access vocational training, has never been used.

By linking Medicare access to vocational training, the Provider Number Legislation has ensured that doctors obtain sufficient training and support to develop the skills and knowledge for safe and independent professional specialist practice. The legislation ensures that young doctors are not required to undertake tasks that they are not properly trained for, and as such, it has made an important contribution to improving the quality of medical care in this country.

The second myth is that the Government is exploring ways to replace doctors with other health professionals who take less time to train and can be employed on lower levels of remuneration.

It is true that health care is dynamic and continues to change and improve. The health workforce, including doctors, needs to keep pace with these changes and adapt. For example, in decades past, blood pressure monitoring was considered so ‘technically challenging’ that it was only performed by doctors. Similarly nurses couldn’t give intravenous injections, although this is now routine.

Highly trained doctors should not be required to routinely carry out lower order skills tasks. We need to focus the work of doctors on higher level clinical tasks which make the best use of their training and experience. This is not about replacing doctors, but allowing them to work in ways which maximises their contribution to the delivery of health care and ensures that they are fully professionally challenged.

More generally, all health professionals should be encouraged to develop and use their professional skills to their full capacity. The focus should be on competency, teamwork and multi-disciplinary care rather than traditional professional boundaries. Doctors, as leaders of the health care team, have responsibilities to engage with and assist in this process.

Slide 5: Health System Changes

• Changing patterns of disease
• Services provided in different health settings
• Increased focus on chronic disease
• Increased need for complex diesase management

There is a growing recognition that medical specialist training in Australia needs to adapt to changes in the way health care is delivered. This is an important issue for leaders of government, and for you as future leaders of the medical profession.

Slide 6: Changes in service delivery models

The changing patterns of disease, increasing complexity of treatment, and advances in medical technology, have altered the way services are delivered. Many more services are now provided outside of public hospitals. These changes are borne out by the following statistics:

• Over 75 per cent of all health care expenditure is now outside of public hospitals (Source: AIHW 2002-03)
• 45 per cent of all same day separations took place in the private sector (source: AIHW 2003-04).
• In public hospitals the average length of stay fell from 5.2 days in 1991-92 to 3.4 days in 2003-04 (Source: AIHW).

Slide 7: Length of Stay in Public Hospitals

In addition to the procedures in private hospitals, a large number of procedures now take place outside of the hospital setting in specialist rooms such as dermatology, IVF and gynaecological procedures.

Medical training has not kept pace with changes in the way services are delivered. It is still ‘teaching hospital’ centric – despite the service delivery models not being adequate in the traditional ‘teaching hospital’ system to support a comprehensive learning experience.

It is clear that undergraduate and vocational trainees gain limited exposure to important clinical material in their current teaching hospital environments.

Two examples demonstrate this point further:

• A women with a breast lump: Total time in hospital = 1 Day, Total length of treatment = 5+ years.
• Patient with a dermatological problem (eg, skin cancers). Treatment occurs 96% in the private sector (Source: AMWAC Dermatology report, 1998).

It is critical that trainees are given the opportunity to access patient care when and where it is occurring. Otherwise, we are in danger of compromising the very high standard of medical training which has been achieved to date.

Opportunities for training in the private sector and community health care settings currently occur on an ad hoc and often voluntary basis. To date, there is no national, systemised approach to support medical training in private settings.

Slide 8: Medical Specialist Training

Training outside of existing teaching hospitals has the following major benefits:

• expands training to match service delivery and community need
• improves training opportunities and the range of training experiences available to trainees
• improves the standards of care in new training settings
• facilitates the revision of college training programs to utilise the learning opportunities of a broader range of training settings

In 2004, a Taskforce I chaired developed a new training model for specialists. This model provides for training through a network of settings, including private hospitals, private practices and community based settings, depending on specific clinical training requirements. Under the model, trainees would be able to rotate through the settings and to broaden their training experience without the loss of industrial entitlements.

Slide 9: New models of specialist training

• A networked training model for specialist trainees based on clinical training requirements
  • public hospitals
  
  
  • private hospitals
  
  
  • private practices
  
  
  • community-based settings
  
  
  • non-clinical settings
• Trainees rotate through settings broadening scope of training experience with loss of industrial entitlements.

This training model will have the following benefits. It will:

• expand training to match the service delivery to the community
• improve the training opportunities and experiences available to trainees
• improve the standards of care in the new training settings
• facilitate the revision of college training programs to utilise the learning opportunities of a broader range of training settings

Following consideration of the model by the Australian Health Ministers Advisory Council, the Medical Specialist Training Steering Committee was established to report back to Health CEOs in the first half of 2006 after further development of the proposal.

I am chairing the Steering Committee, and delighted to say that it is an enthusiastic body strongly committed to reform in this area. It includes widespread representation from the medical profession as well as Australian and State and Territory governments. I am pleased that representatives of medical students and doctors-in-training are contributing to this process.

Slide 10: Medical graduate numbers

A key issue being examined by the Steering Committee is the need to ensure the availability of adequate positions over the next 10 years for prevocational and vocational trainees.

Following the major new investment being undertaken by the Australian Government in undergraduate medical education, the number of Australian students completing university medical studies will increase from around 1,300 in 2005 to around 2,100 early next decade, a growth of more than 60%.

Governments will need to plan for the additional supervised training places that will be required. What is clear is that:

• There will be no shortage in demand for these trainees, given current and prospective pressures on our medical workforce
• A significant number of the additional training positions which will be needed must be established outside of public hospitals so as to provide an adequate training experience.

Australia has an enviable and well-earned reputation for the high quality of our medical professionals. It is essential that government and the medical profession work together to realise the changes needed.

Slide 11: Chronic Disease

• Chronic disease represents the greatest overall burden of disease in Australia
• Frequently, people have more than one condition

Chronic disease now accounts for more than 80% of Australia’s overall disease burden. The major shift in emphasis which has occurred from management of infectious diseases to chronic disease is necessitating a number of changes to the way services are delivered and how our health professionals are trained.

Ministers and local members are increasingly focusing on the factors that cause chronic disease and on prevention and better management.

A National Chronic Disease Strategy is being developed by the Australian and State and Territory Governments. This provides a framework for management across a broad range of diseases, including asthma, cardiovascular disease, diabetes, cancer and arthritic conditions.

Slide 12: Implementing the National Chronic Disease Management Strategy

Implementation of the Chronic Disease Strategy builds on four enablers:

• Building workforce capacity by providing the skills to work effectively in a multidisciplinary team
• Strategic partnerships between government and peak industry bodies to facilitate work across the funding and service delivery boundaries that currently exist
• Enhance investment and funding opportunities that allow multidisciplinary and integrated care, self-management and health promotion
• Investment in information systems and technology to enable efficient electronic management of patients records, recall systems and secure transfer of patient records

Chronic disease management will impact on future practitioners in a number of ways. Firstly the patients that you will be treating will be older and sicker because of co-morbidities. The treatment will need to be provided across a range of different settings, that includes community care clinics, private specialist rooms, general practice and residential aged care as well as inpatient acute facilities.

More service providers will be involved in the care of each patient and a team approach to case management will be essential. That will include systems for efficiently transferring patient information between service providers.

Doctors will need to be fully prepared to work in this environment and this preparation needs to be embedded in existing university training programs.

As well as strong skills in treating chronic disease, the future medical workforce will need well developed skills in delivering interventions to address the major risk factors for chronic disease including smoking, poor nutrition, risky and high alcohol use and physical inactivity.

Changes around chronic disease management are likely to be ongoing. Governments will be looking to you as the future medical leaders to be aware of the need for change, be technologically proficient to help direct the changes and take an active part in the implementation of change strategies.

I want to conclude by assuring you, as future medical leaders, that the Australia Government is committed to implementing its medical workforce policies in ways that do not compromise education and training imperatives. To do so would be short-sighted and counterproductive.

Take for example, the Rural Clinical School initiative, which is part of a range of policies being pursued by the Australian Government to improve access to medical services for people in rural areas.

Slide 13: National Network of Education Facilities

A national network of 10 clinical schools has been established in regions such as Rockhampton, Wagga Wagga, Whyalla, Shepparton and Kalgoorlie and will soon expand into the Northern Territory. These Rural Clinical Schools are part of the infrastructure for ensuring long term service provision in rural areas. Importantly, research shows positive learning experiences in regional and rural areas results in more doctors choosing to practice in these areas.

Around 25% of Australian medical students from participating universities are now undertaking at least one year of their clinical training in rural areas.

The Government is investing $250 million over the period 2001-02 to 2007-08 in the Rural Clinical School network to ensure that students are well supported and trained. Concerns expressed by some about the quality and scope of the training in rural clinical schools is not borne out by the results. Universities are reporting that the overwhelming majority of students who have undertaken rural clinical training have achieved equal or better examination results in comparison to their metropolitan based peers.

In fact, demand for placements in rural clinical schools has now increased to the point where many universities are finding that their programs are over-subscribed. Growing proportions of students are selecting rural clinical experience as their first preference for clinical training and looking for opportunities for additional placements.

The challenges facing the health care system are considerable. Adequate progress on meeting these challenges will only be made if there is a strong collaborative effort between key medical stakeholders and Government. As future medical leaders, I look forward to you engaging constructively with the Australian Government on these issues.

Thank you.