Over time, Australia’s health workforce will need to adapt to change as our population ages, patient treatment needs become increasingly complex, and technology develops. The way we educate and train our workforce must respond to these changes if we are to maintain the quality and safety of our health care system. Today I would like to talk about the challenges the health care system faces in terms of service delivery and then focus on initiatives developed to reform the health workforce.

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:

Australian states and territories showing land area.

Slide 3:

Figures are for 2003, from the OECD 2005 Health Data.
Comparisons are with 9 similar OECD countries – figures for Japan and United Kingdom not available for 2003

Slide 4:

Australia’s health spending as a percentage of GDP has been steadily increasing since the early 1990s.

Expenditure on pharmaceuticals (PBS) is the fastest growing component of total expenditure on health (10.1% between 1993-94 and 2003-40). This is due largely to more expensive technologies and increases in consumer demands. Over the last ten years, PBS expenditure grew by an average 11.4 per cent per annum. (p.22)

Over the last ten years, the area that attracted the most rapid real growth in government funding was private hospitals (22.4%). (p.20)

Slide 5:

The split between public and private sector funding of health services has remained fairly constant over the last 15 to 20 years.

The split in 2003-04 was 68% public (Australian Government and state government expenditure, including Australian government expenditure on the private health insurance rebate) and 32% private (mostly private health funds and out-of-pocket payments by individuals). (p. 18)

The components of these sectors are shown in more detail on following slide.

Slide 6:

In 2003-04 the Australian Government spent $35.7 billion on health which was about 46% of total health expenditure. This includes expenditure on the PHI rebate.

The state/territory and local governments spent $17.5 billion, or 22% of total expenditure.

Non-government sources spent about $25.1 billion, or 32% of expenditure - Individuals’ out-of-pocket costs account for a significant amount of private sector funding.

“Other non-government” means compulsory motor vehicle, third-party and workers’ compensation insurers. (p. 18)

Total funding for 2003-04 was $78,369 million.

Slide 7:

There are three levels of government: federal, state/territory, and local. Local government plays a minor role in health.
The Australian Constitution specifies the broad role of Commonwealth and State/Territory Governments:

The Commonwealth is responsible for direct funding of individual health benefit programs; and
The states/territories are responsible for delivery of a large proportion of health services.

The Australian Government takes a leading role to provide universal and affordable access to high quality medical, pharmaceutical and hospital services. States and territories have primary responsibility for the provision of health services, including most acute and psychiatric hospital services.

Formal Commonwealth/state partnerships exist for hospital funding and for public health.

The private sector also plays a significant role in funding and provision of health services.

Slide 8:

For decades, governments have worked with the medical profession to underpin training at an undergraduate and vocational level. The Australian Government provides approximately $15,500 per year per medical student to universities to educate our future doctors. This is around $77,500 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 9:

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 practise 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 10:

Far from being true, there has in fact been a strong increase in vocational training opportunities. Colleges have estimated that this year (2006) there are 1,898 first year advanced vocational training places available, an increase of 39% on the numbers available in 1997. This compares with the current Australian medical graduate cohort of around 1,448 in 2005. 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.

Slide 11:

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 12:

I’d like you for a moment to consider the challenges we face in health service delivery.

Our aim is to provide equitable, accessible, sustainable, timely and safe health care.
To do this we must understand and respond to changing patterns of disease.
We have an ageing population and an increase in focus on chronic disease.
There is an increased need for complex disease management.
Services are being provided in different health settings and these changing models of care are information dependent.

Slide 13:

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. Chronic disease prevention and management is complex and cannot be addressed by one single health discipline. Reform to the delivery of health care services needs to be undertaken, and these services must be delivered to all on an equitable basis.

Slide 14:

A National Chronic Disease Strategy has been developed by the Australian and State and Territory Governments. This provides national policy directions to improve chronic disease prevention and care across Australia. National Service Improvement Frameworks for asthma, cardiovascular disease, diabetes, cancer and arthritic conditions have been developed as part of the National Chronic Disease Strategy.

Implementing the Chronic Disease Strategy will require:

Building workforce capacity by providing the skills to work effectively in a multidisciplinary team;
Establishing strategic partnerships between government and peak industry bodies to facilitate work across the funding and service delivery boundaries that currently exist;
Enhancing investment and funding opportunities that allow multidisciplinary and integrated care, self-management and health promotion; and
Investing in information systems and technology to enable efficient electronic management of patient’s 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. Treatment will need to be provided across a range of different settings, including community care clinics, private specialist rooms, general practice and residential aged care as well as inpatient acute facilities. Treatment will also need to be provided increasingly by multidisciplinary teams and the coordination of care will be critical to patient outcomes.

More service providers will be involved in the care of each patient and a team approach to case management will be essential. That will involve I.T. 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.

Slide 15:

As health care becomes more sophisticated and depends more on multidisciplinary teams, as settings for delivery of health care services expand, clinical excellence will become much harder to achieve without link-up information systems.

I.T. will become an integral feature of a doctor’s work routine. Integrated health records will help stop teams getting caught up in cycles of meetings and missed phone calls. They will reduce repetitive history-taking and invasive diagnostic tests of chronically ill patients and assist seamless transition from primary care to acute care to residential care. Furthermore, an integrated health record could prevent some of the estimated 3,500 avoidable deaths a year in hospitals due to inadequate record keeping and incomplete information.

Slide 16:

As well as strong skills in treating chronic disease, the future medical workforce will need skills to deliver interventions which 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 implementing change strategies.

I would now like to turn our attention to medical workforce challenges.

Slide 17:

The challenges currently faced by the health workforce have prompted a number of initiatives. Demand and need for health services may outstrip supply unless innovative ways of managing the health needs of the population are developed and implemented. We need to ensure we have enough doctors to meet the health care needs of people across the nation, regardless of where they live, and we need all doctors to be equipped with the right skills to meet the situations they may face.

The strategies which I will now outline are all aimed at building flexibility and capacity into the health workforce in order to meet the challenges that have been identified.

I would like to assure you, as our future medical leaders, that the Australian 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.

Slide 18:

The first challenge to be addressed is one of supply. When the Council of Australian Governments, COAG, met in February this year, it announced 400 new medical school places. When COAG met again in July, it announced a further 205 new places. The impact of these places is shown on the graph.

Following these major new investments being undertaken by the Australian Government in undergraduate medical education, the number of Australian students completing university medical studies will increase from around 1,448 in 2005 to an estimated 3,431 by 2015, a growth of more than 137%.

Governments are planning 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; and
A significant number of the additional training positions needed must be established outside of metropolitan public teaching hospitals so as to provide an adequate training experience.

I’ll talk in more detail shortly about how this might be done.

Slide 19:

The second challenge is to ensure that issues of equity and accessibility are considered. The need for more doctors in rural and regional Australia is widely recognised and the Australian Government is committed to providing continued access to health care services. In particular, people living in regional, rural or remote locations must have access to aged care and maternal services. The question is – how do we educate, train and support our rural health workforce?

The Government is investing around $250 million over the period 2001-02 to 2007-08 in the Rural Clinical School network to ensure students are well supported and trained. Universities are reporting that the overwhelming majority of students who have undertaken rural clinical training have achieved equal or better examination results in comparison with their metropolitan based peers.

A national network of 11 clinical schools has been established in regions such as Rockhampton, Wagga Wagga, Whyalla, Shepparton and Kalgoorlie. From July 2006, this network will expand to 14 schools, reflecting the success of the program since its implementation.

These Rural Clinical Schools are part of the infrastructure needed to ensure long term service provision in rural areas. Importantly, research shows positive learning experiences in regional and rural areas results in more doctors choosing to practise 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.

In fact, demand for placements in rural clinical schools has increased to the point where many universities are now 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 Government acknowledges that the success of programs such as the Rural Clinical Schools Program is reliant on strong partnerships with government and non-government stakeholders. The establishment of ‘Community Advisory Boards’ for each of the Rural Clinical Schools is testament to the importance the Government places on working constructively through partnerships with organisations such as universities, State and local health departments, and importantly, the community.

Slide 20:

As I mentioned earlier, education and training has traditionally been conducted in metropolitan public teaching hospitals. This training will need to respond to the impact changing patterns of disease, increasing complexity of treatment and advances in medical technology are having on the way services are delivered.

Many more services are now provided outside of public hospitals.
These changes are borne out by the following statistics:

Only 26% of health expenditure related to hospitals (Source: AIHW 2005, Australia’s Health)
Private hospitals account for 23% of hospital expenditure (Source: AIHW 2006, Australia’s Health)
59% of all same day separations took place in private hospitals (Source: Australian Hospital Statistics 2004-05).

Slide 21:

In public hospitals, the average length of stay has fallen from 5.2 days in 1991-92 to 3.9 days in 2004-05 (Source: AIHW Hospital Statistics 2004-05).

This has implications for training across the continuum of service delivery – that is, pre and post operative care.

Slide 22:

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 must keep pace with these changes in the way services are delivered – but to date it has not. 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).

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, although this is about to change. But before we address how, let us look at a discipline which delivers care across a most diverse range of settings – in public hospitals, private hospitals, in community centres, in rural and regional settings and in private practices.

Slide 23:

Although people with mental health illnesses are being treated in a diverse range of settings, training for psychiatry has traditionally been conducted in the psychiatric wards of public teaching hospitals.

These settings provide treatments for high acuity mental health problems, which only affect a low proportion of the population. However, common mental illness, such as depression and anxiety disorders, are usually treated in private practices, or in community centres. Supplementing traditional settings where trainees are exposed to severe health problems, with training in private practices, as well as community settings, would better prepare trainees for the range of experiences they are likely to encounter throughout their careers.

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. I am pleased to say that the government has recognised the importance of this issue and is implementing a range of reforms.

Slide 24:

I mentioned earlier the COAG announcement in July to increase the number of medical school places. At that time COAG also announced that, in order to ensure medical specialist trainees have appropriate skills and experience, the Commonwealth, State and Territories will establish a system for these trainees to undertake rotations through an expanded range of settings, beyond traditional public teaching hospitals. Once fully established, the settings available for medical specialist training will be diverse and range from public settings, for example public hospitals, regional, rural and ambulatory settings, the private sector, which could include hospitals and private practices, community settings and non-clinical environments.

This initiative will enable medical specialist training to be provided in settings which match the current and longer term service delivery requirements of the community.

The system for medical specialist trainees to undertake rotations through an expanded range of settings beyond traditional public teaching hospitals will be established by 2008. Full implementation of the system is expected from 2011. This will build capacity within the health care system to take on new specialist trainees at a time when there is a significant increase in numbers of medical school graduates.

Slide 25:

The decision to expand settings for medical specialist training is a considered response to changing heath care needs. When COAG made its announcement in July, it stated that implementation would be guided by the work of the Medical Specialist Training Steering Committee. The Steering Committee was established by the Australian Health Ministers’ Advisory Council, AHMAC, in November 2004, specifically to identify how to implement training across a broad range of settings.

The work of the Steering Committee has been informed by earlier studies. For example, an AHMAC working party developed a discussion paper in relation to medical specialist education and training in 2002, and from this a taskforce developed the framework for expanding training settings. In 2004 the Steering Committee began investigating issues associated with implementation and, to assist with this task, three Reference Groups were formed. These Reference Groups have identified curricula issues and implications for public sector service delivery, as well as conducted a cost/benefit analysis. The reference groups held consultations with medical specialist colleges, jurisdictional health departments and a range of health care service providers from all states and territories. Information has been collected on:

potential additional costs and benefits associated with expanding medical specialist training beyond public teaching hospitals
the proportion of time that trainees could spend in each setting;
feasibility and industrial issues; as well as
key educational goals and competencies which may be attained in potential settings.

Reports from the three reference groups have been submitted to the Steering Committee. The Steering Committee’s report will be considered by AHMAC in October, and final determinations made at that time.

I am chairing the Steering Committee, and am 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 26:

It is clear that expanding the range of settings where medical specialist training can take place will ensure that training reflects the diversity for professional experience on offer.

Expanding settings for medical specialist training will also:

expand training to match the service delivery to the community;
improve training opportunities and experiences available to trainees;
increase capacity of the health system to train an increased number of medical school graduates;
improve the standards of care in the new training settings; and
facilitate the revision of college training programs to utilise the learning opportunities of a broader range of training settings.

Through its consultations, the Steering Committee has become aware of some key issues, in particular the need to ensure enough training positions are available for the rapidly increasing number of medical school and Australian Medical Council graduates. It is important to make sure there are quality teachers and facilities available. It is important to establish a system that is flexible and can respond to the individual variables within each jurisdiction, setting and discipline. The time between now and 2011 will be a time for building capacity within the health care system to absorb the increased number of graduates seeking specialist training.

Slide 27:

Providing health care to meet the needs and priorities of individual communities cannot be realised without effective links and relationships between local, regional and national stakeholders. Health is a rapidly growing sector in terms of cost as well as technological and scientific advances, particularly in the context of an ageing population. Addressing these issues depends largely on the effective participation of government agencies, community representatives and health stakeholders in developing policy to maximise community health outcomes. As a key part of the future workforce, participating in these partnerships will be an integral part of your professional lives.

The challenges facing the health care system are considerable and considerable reforms are taking shape. There is a strong collaborative effort being made between key medical stakeholders and Government.

We have seen a strong increase in vocational training opportunities, across many disciplines. We have seen how trainees will be able to access patient care when and where it is needed.

To meet the changing realities of health service delivery in Australia we need health professionals capable of working effectively as part of multi-skilled teams, with the interpersonal skills to work in a variety of health settings to deliver the highest quality care to patients.

As future medical leaders, I look forward to you engaging constructively with the Australian Government on these issues.

Thank you.

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