6.1 Overall findings for training programs
Training programs are associated with specialist colleges and are managed either by the College or by designated organisations. This review found that support for doctors on training programs is relatively well funded and supervision is an inherent part of training, although there are differences in how organisations are remunerated for supervision.
Professional bodies highlighted the need to monitor training capacity as well as the demand for and supply of training places.
6.1.1 Stresses on the medical training system highlight a need for good monitoring data on training capacity, and a coordinated approach to medical workforce planning and training
The 2005 Biennial Review emphasised the need for adequate and cohesive planning for medical training: the issue is in sharper focus in 2010. Not only has there been an increase in the number of medical graduates, but the number of doctors seeking vocational training places has more than doubled. Stakeholders suggest that the system has been able to absorb the increased number of medical school graduates because the increase in graduate medical student places has occurred in a staggered way across the States and Territories.
Nevertheless, the increase in university medical places is expected to place stresses on the postgraduate training system in the future, which highlights the need to reform the way planning for workforce and training is conducted. Industry stakeholders said that training and workforce issues have not been addressed in a coordinated way in the last decade.
Managing demand for vocational training places has also required concerted effort, and the Government has established and funded training places on three programs: the Specialist Training Program; the AGPT Program and PGPPP. Two other training programs, the SCTP and the APEDP, enable trainees to work and access Medicare rebates in private hospitals and other non-traditional teaching settings.
For this review, stakeholders expressed concerns about the structural limitations of the training system as a whole, and the limited capacity for providing supervision. Industry stakeholders are calling for deregulation of training to allow greater involvement of the private sector; general practice; international partners; and research institutes. They are also calling for alternative funding options to be considered, such as allowing specialist trainees to bill Medicare for services as already occurs for those undertaking general practice training.
Another broader issue raised by some industry stakeholders is the need for generalist services, especially in regional Australia. Ensuring that more postgraduate training places for generalist pathways are made available may assist in preventing doctors sub-specialising too soon.
It is anticipated that HWA, which was established in 2010 by the Australian Government, will also contribute to workforce planning. The HWA mandate is ‘to meet the future challenges of providing a health workforce that responds to the needs of the Australian Community. [It] will develop policy and deliver programs across four main areas—workforce planning, policy and research; clinical education; innovation and reform of the health workforce; and the recruitment and retention of international health professionals. HWA will also consider the adequacy and availability of workforce data. 32 Another area of effort is research: HWA is leading a collaboration to undertake a substantial program of national health workforce planning and research projects over a three-year period.
A broad range of medical stakeholders, including medical students; doctors in training and their supervisors; medical schools; hospitals; and key health organisations recently issued a joint consensus statement, which echoes the viewpoints of stakeholders consulted for this review. The consensus statement calls for more medical workforce training resources, and lays out a framework for delivering the right number of medical practitioners in the right places. The framework specifies responsibilities and short and medium term tasks for managing the demand for and supply of the medical workforce 33 . The statement suggests a moratorium on new medical schools and no significant increase in medical student numbers before an analysis of demand for medical workforce and associated training infrastructure is completed.
Also included in the consensus statement is a call for a nationally consistent process for allocating intern places; providing places for all currently enrolled international full fee paying medical students and for agreements about providing intern placements for international medical students in the future. The statement is also concerned with improving and specifying training arrangements within the context of the hospital funding reform process.Top of page
6.1.2 Capacity to provide general practice training placements
In Australia, an estimated 1,400 of 7,000 general practices are involved in GP training 34 - an estimated one in five general practices. It’s estimated that by 2012, there will be approximately 900 junior doctors and over 1000 general practitioner registrars requiring placement in general practice each year 35 . The number and type of training places that the practice can take on depends on the practice infrastructure, the practice size and their commitment to GP training. Practices might host medical students, junior doctors or GP registrars depending on factors including practice infrastructure and supervisory capacity.
This review has heard specific concerns about the capacity of the system to provide general practice training. Even though there is currently theoretical capacity in the system, industry stakeholders are concerned that training positions will fall well short of requirements unless more teaching sites are recruited or larger numbers of trainees are placed at each site.
Some of the barriers to engaging more general practices in taking on clinical placements are listed below.
- The financial costs of training medical students. Even though practices are financially compensated for having a trainee, a recent study by Laurence (2010) found that there are net financial losses for teaching medical students, but there can be small (but inconsistent) financial gains from teaching junior doctors 36
- The way the teaching practice incentive is paid. Payment is made in arrears and to general practices as a whole, not to individual supervisors. The payment mode does not recognise the individual doctor’s contribution, which disadvantages contractors.
- The time burden of teaching student doctors. Having a medical student or junior doctor reduces patient throughputs and clinical sessions, and increases time demands on other practice staff.
- The GPs confidence in their own teaching skills.
- The difficulty coordinating placements with educational facilities for medical students.
These barriers will need to be addressed to encourage more general practices to take on clinical training places.Top of page
6.2 Australian General Practice Training Program
This program aims to provide doctors with the knowledge, skills and attitudes necessary to work in unsupervised general practice and meet community health needs. It allows participants to gain valuable practical experience in teaching hospitals, rural and urban practices, and in specialised medical centres that provide healthcare for local communities, Indigenous Australians and people from socially disadvantaged groups.
The AGPT program is a postgraduate vocational training program for doctors who wish to pursue a career in general practice in Australia and is administered by GPET. The program is for three years, full time (four years for rural and remote registrars), and the number of places on the program is capped. In 2010, the cap was 900 placements. The training must be conducted within accredited medical practices, and is supervised and assessed by experienced medical educators associated with a regional training provider (RTP). The training includes a mentoring element and self-directed learning, as well as regular face-to-face educational activities. OTDs who are permanent residents or Australian citizens are eligible for the program.
Towards the end of their training on the program, participants become eligible to sit the RACGP or ACRRM Fellowship exams.
General practice stakeholders have welcomed the expansion of the AGPT. Although there is theoretically capacity in the system to meet the demand for placements, industry stakeholders are concerned that training positions will fall well short of requirements unless more teaching sites are recruited or larger numbers of trainees are placed at each site.Top of page
6.3 Prevocational General Practice Placements Program
This objective of PGPPP is to provide professional, well supervised and educational general practice placements for junior doctors as part of their training. The target group are junior doctors undertaking hospital training but not yet enrolled in a specialty program. OTDs were recently added to the program’s target group.
The PGPPP has been managed by GPET since early 2010. GPET has established a prevocational training committee to address issues such as setting suitable standards for prevocational training and supervision. General practices must be accredited to provide placements.
The emphasis of the program is different depending on the level of the doctor. For interns, the program provides work experience and exposure to general practice as a professional career. Junior doctors in PGY2 or 3 can work at a higher level, and might provide additional service capacity for the general practice they are placed in. Depending on the capacity and infrastructure of the training collaborations more than one general practice placement can be undertaken by junior doctors throughout the year.
Between January and July 2010, 40 per cent of PGPPP participants were interns (PGY1), 47 per cent were in PGY2 and the remaining 13 per cent were in at least PGY3. Junior doctors in PGY2 and 3 undertake placements for an average of 12 weeks and can bill Medicare at the A1 rate.
At first, the program was seen as strategy to bring junior doctors to outer metropolitan, regional, rural and remote areas. Placements were available in rural and remote areas classified using the Rural, Remote and Metropolitan Areas 3–7, as well as designated urban areas, such as outer metropolitan areas and DWS. With expansion, the program now allows placements in metropolitan practices. Industry stakeholders have welcomed the reduction of location restrictions and would like to see more metropolitan practices participating in the program.
The program has expanded substantially in the past five years. In 2005–06, there were 21 doctors who provided at least one service under the PGPPP; by 2009–10 237 doctors had provided at least one service under the PGPPP. In 2005, there were 280 placements in areas where it is difficult to attract students and junior doctors from New South Wales did not participate 37 . By 2010 there were a minimum of 350 placements available in a range of locations including New South Wales, with part time placements part of the mix. The Government plans to offer 975 placements on the program by 2012.
General practice stakeholders are satisfied with, and strongly support, the continuing expansion of this program. One benefit has been the increase in capacity to integrate training between local hospitals and general practices and the opportunity to forge better links between GPET and regional training providers.
Even so, stakeholders raised some issues, which have the potential for discouraging practices and hospitals from participating in the program.
- Some hospitals are reportedly less willing to take on trainees under the program because the method for allocating the PGPPP training budget takes insufficient account of local conditions.
- Negotiating placements with individual facilities in Queensland is an issue for these facilities because the Postgraduate Medical Education Council of Queensland Health is responsible for practice accreditation.
- There is lack of transparency about planning for placements, which reportedly makes it hard for general practices and/or health services to determine how many places are available and where these are located.
- There are barriers to placing OTDs in inner metropolitan locations as they are subject to s19AB of the Act, which restricts them to working in DWS.
- The costs to general practices of training junior doctors can be high. A recent study by Laurence (2010) concluded there is a marginal net financial gain to general practices involved in prevocational and vocational training but not for those involved in undergraduate medical student training 38 .
6.4 Remote Vocational Training Scheme
The RVTS is a four year program that has been designed to deliver structured distance education and supervision to doctors while they continue to provide general medical services to a remote and/or isolated community. These doctors would otherwise have to leave their current location in order to undertake training.
The RVTS targets medical practitioners living in remote and isolated communities throughout Australia. The training provided meets the requirements for Fellowship of both ACRRM and RACGP. The program has been delivered by RVTS Ltd since 2006.
RVTS has recently allowed temporary resident OTDs, including those who are yet to attain AMC certification, to enrol on the program. The change was made to meet a need for training long-term temporary resident OTDs who are not eligible for other general practice training programs. Many of this group are well established in Australia, have provided services over many years and have made substantial investments in practices.
The program has grown over the last five years. In 2005–06 there were 10 doctors who provided at least one service, to 30 providers in 2009–10. 39 There are 52 registrars currently enrolled in the training program with around half of the participants being OTDs without AMC certification. Given the profile of doctors working in rural and remote Australia, the demand for places is expected to increase now that temporary resident OTDs are eligible.
More information is needed to understand the quantum of demand for places in the program so that appropriate funding can be provided to meet the demand for places.Top of page
6.5 Specialist College Trainee Program
This program is administered by relevant specialist medical colleges. Applications for trainees to be listed on the Register of Approved Placements for s3GA programs are processed by Medicare Australia.
The program is a mechanism for allowing registrars working in private hospitals and non-government health settings to access Medicare rebates (A2 level). It is not a funded program and is linked to, but not the same as, the Specialist Training Program managed by DoHA. 40
Specialist College Trainee placements are considered where
- trainees are in an accredited advanced training position that counts fully to training time and formal requirements
- rotations from public sector to private hospitals are part of a structured training program and placements will provide experience that is relevant to the course of training
- appropriate supervision will be provided
- the required number of training positions, and trainees in public hospitals, is maintained. The first priority is given to filling trainee positions in public hospitals.
Guidelines for this program have not been obtainable for this review. The Royal Australian and New Zealand College of Psychiatrists reported that they have been unable to ascertain adequate information about the program and as a consequence, medical practitioners are finding it difficult to understand whether a placement is eligible for the program, how to apply for provider numbers under the program, and what items can be billed against the provider numbers. The consequences to this are that improper claims could be made.
In addition, the Royal Australian and New Zealand College of Psychiatrists indicated that Group A2 Medicare item numbers are very general across in-patient settings and may not adequately recompense the skills and types of services provided by specialist registrars of their College, and pose a barrier to mental health service delivery.
Stakeholders are calling for information about the program and for its application processes to be clarified.
6.6 2010 Recommendations for section 3GA training programs
Prevocational General Practice Placement Program
GPET to ensure that all junior doctors have access to direct supervision and endeavour to place more senior trainees in remote placements.
Specialist College Trainee Program
Medicare Australia, in consultation with the specialist colleges, to prepare new guidelines about the parameters of the SCTP including who is eligible and under what circumstances rebates under the program can be claimed. The guidelines should also describe how the program relates to the Specialist Training Program managed by DoHA.
DoHA to clarify the items that can be claimed by registrars under the program and expand eligibility to item numbers to more accurately reflect the differing practices of each specialty.
DoHA to review the level of rebates (A2) that can be claimed under the program with a view to making these in line with VR (A1) items.
32 HWA Website
33 Joint Statement AMA Medical Training Summit, Sept 2010. Action on Medical Training
34 Source: RACGP
35 Source: DoHA
36 Laurence C (2010) To teach or not to teach? A cost-benefit analysis of teaching in private general practice. Medical Journal of Australia, 193(10)
37 Due to concerns about adequacy of Medical Indemnity Insurance, now addressed
38 Laurence C (2010) To teach or not to teach? A cost-benefit analysis of teaching in private general practice. Medical Journal of Australia, 193(10)
39 Discrepancy between DoHA data indicating 30 registrars accessing Medicare rebates under the program and RVTS data, 52 registrars currently involved may be explained by registrars using provider numbers under a workforce program such as RLRP through the ROMPS
40 Note that we received limited feedback about this program and there appeared to be some confusion about how the program relates to the Specialist Training Program