Review of Australian Government Health Workforce Programs

3.2 Health education and training

Page last updated: 24 May 2013

The training of the health workforce occurs in both the vocational education (VET) and tertiary sectors. While many health professionals, including medical practitioners, registered nurses and allied health professionals, are educated within the university sector, other important categories of health workers such as personal care assistants, enrolled nurses, allied health assistants and Aboriginal and Torres Strait Islander health practitioners gain their qualifications through VET courses, ranging from certificate to diploma level (from a few months to a year or more in duration).

Responsibility for, and influence over, health education and training is shared across a range of players, including Commonwealth and state/territory governments, universities and other tertiary education providers, registration and accreditation boards, and professional colleges.

The Commonwealth provides funding for university-delivered health education though the provision of Commonwealth Supported Places (CSP), administered by the Department of Industry, Innovation, Climate Change, Science, Research and Tertiary Education (DIICCSRTE). The Commonwealth, through DIICCSRTE, also contributes funding to the VET sector, although the allocation of funding is the responsibility of state and territory governments.

As mentioned earlier, prior to 1 January 2012, the Commonwealth set targets for the number of undergraduate places a university could offer. The Commonwealth has now moved to a demand-driven system, allowing universities to determine how many undergraduate students it wishes to enrol, and in what course of study. The only exceptions to the new arrangements are that the number of medical places and postgraduate places will remain capped. The impact this change will have on the future supply and mix of health professionals is not yet known.

Further information on the history of the Commonwealth’s involvement in the education and training of the health professions is provided in Appendices iii to v.

Clinical training

A clinical training component is a significant part of the education and training requirements of health professionals. While all university-based health qualifications include an undergraduate clinical training component, some disciplines also require postgraduate clinical training as a condition of registration, most notably medicine.

Requirements for clinical training are set by the accreditation authorities operating under the National Boards. The accreditation authorities for some disciplines, for example nursing and midwifery, specify minimum numbers of hours for clinical training as a requirement for accreditation.

Through the National Partnership Agreement on Hospital and Health Workforce Reform, the responsibility for funding undergraduate clinical training is now shared between the Commonwealth and the states and territories, where it was previously left to states and territories to fund indirectly through public hospitals. Since 2006, states and territories have committed to providing clinical training for both Commonwealth-funded medical students and interns.

Most undergraduate clinical training and medical internships have traditionally been delivered within the public hospital sector, although delivery within other settings has become more common in recent years. It is the responsibility of the training provider to arrange clinical training opportunities for their students/trainees.

In the past, there has been no cost accruing to universities for the clinical training provided through public hospitals. The clinical training of professional entry health students has long been viewed by health professionals as part of their professional responsibilities in growing the future professional workforce. Health students, to varying degrees, also contribute to providing health care within the hospital or other health service setting.

The National Health Reform Agreement 2011 requires that the Independent Hospital Pricing Authority (IHPA) provide advice to the SCoH on the feasibility of transitioning funding for teaching, training and research (TTR) to an activity based funding system by 30 June 2018. IHPA has convened an advisory body consisting of jurisdictional, clinical and academic representatives – the Teaching, Training and Research Working Group (TTRWG). The TTRWG will assist IHPA with developing a work program on approaches to the classification and costing of TTR activities undertaken within public hospitals. It is expected that significant progress will be made on identifying the types of TTR that need to be funded in public hospitals, the cost drivers of this activity and the methods for counting and costing these items.

This has the potential for a dramatic impact on the relationship between the Commonwealth and state and territory jurisdictions with regard to the funding of clinical training, with corresponding implications for the training institutions, notably the universities.

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Capacity constraints

Concerns about the capacity of the health sector to support the clinical training needs of an increasing number of undergraduate health students have been expressed over a number of years, and were consistently raised by stakeholders during the course of this review. There are now over 16,000 medical students studying in Australian medical schools, with 3,770 commencing in 2011. This is over double the numbers of a decade ago.40 Pressure on clinical training capacity is not limited to medicine, but also applies to the nursing, dental and allied health disciplines; in 2011, there were 16,338 students who commenced courses that led to qualification for initial registration as nurses or midwives, compared to 10,950 students in 2005.41

The pressure on clinical training extends beyond university-based clinical training required for entry into health professions, and impacts clinical training provided as part of internships and graduate entry positions and programs. For medicine especially, the training pathway is long and involves a number of distinct phases. It typically takes around 12 to 17 years to train a medical specialist in Australia, assuming no gaps in training. Any increases in the undergraduate medical student population therefore can take most of two decades to work its way through the system, with consequent difficulties for planning.42

The pressure on clinical training for health students other than medicine is likely to continue under the demand-driven system of funding higher education, as from 2012 providers have been able to enrol as many eligible undergraduate students as they wish. There is a clear tension between higher education reforms to expand participation, and the ability of the health system to provide high quality clinical training for increasing numbers of health students, especially when such clinical training capacity is already under significant pressure.

Stakeholders consulted during this review also noted that the current increase in demand for clinical training is coming at a time when state and territory Governments are seeking to make savings, and indeed, to maximise the extent to which budgetary burdens are borne by the Commonwealth. This has implications for the capacity of public hospitals to offer additional clinical placements to meet demand.

The complexity and diversity of the arrangements for clinical training adds to the challenge of meeting the increasing clinical training burden. Requirements, such as the length of training, differ between professions and between individual universities. Clinical training is delivered across a range of settings; hospitals may have relationships with multiple universities (and universities with multiple hospitals or other health care settings), and clinical supervision may be provided by a university employee or an employee of the service provider. There are also multiple streams of funding for clinical training, and a mix of costing models and payment arrangements, from pro bono provision through (increasingly) to paid placements.

Health Workforce Australia’s clinical training program

Clinical training capacity has been the subject of considerable COAG reform activity. Under the 2009 National Partnership Agreement on Hospital and Health Workforce Reform, the Commonwealth and states agreed to share the responsibility for funding undergraduate clinical training, which was previously left to states and territories to fund indirectly through public hospitals. Commonwealth funding for this purpose is held and administered by HWA.

HWA’s Clinical Training Funding program provides funding to increase capacity across the health system to expand the number of training places, with special emphasis on new and underserviced areas, for example, rural and remote areas, primary care, mental health, aged care, dental and private sector settings.

This is a key component of HWA’s work, comprising 70% of HWA’s total funding allocation ($547 million over four years). Through this funding stream HWA is:

  • Supporting growth in clinical training places with a focus on improving access to clinical training for rural students and increased training opportunities in rural settings;
  • Expanding training capacity by investing in the use of simulated learning technologies for use, where appropriate, within health professional curricula;
  • Improving the management and coordination of clinical training placements across training providers; and the public, private, non-government and education sectors through the establishment of Integrated Regional Clinical Training Networks; and
  • Supporting and recognising the role of clinical supervisors through the delivery of a Clinical Supervision Support Program.

In a number of cases, organisations funded by DoHA through its health education programs are also receiving grant funding through HWA. Under current arrangements there is no requirement for funding support between HWA and DoHA to be standardised and in some cases DoHA expresses the view that there is a lack of visibility, as a result of the reporting requirements under HWA’s governance structure, about exactly what has been funded through HWA’s clinical training reform stream.

There has also been concern expressed that the HWA funding of additional clinical training places has escalated the already existing pressure for service providers to charge for the provision of clinical placements, where previously no such fee was imposed. While this was already an emerging trend, as one stakeholder bluntly put it, a market has now been created and there may be a reduction in the availability of public sector clinical placements in favour of those funded by HWA. These concerns have also been expressed within the context of the 2011 Higher Education Base Funding Review43, which noted that this could have a significant impact on clinical costs for universities.

A recently published study has sought to quantify the economic value of this component of clinical training. Oates and Goulston (2012) conducted an analysis of the total costs of medical education at Sydney University, incorporating the teaching by government-employed health providers and honorary teachers along with that provided by university-employed staff. The study found that in 2010, 38% of the total cost of medical education (or $38,326 per student per year) was not paid for directly by the university.44 While this study represents a single medical school, the principle of including the cost of face-to-face teaching for which a university does not pay would apply to many other medical schools. The future consequences for universities, and for students, of a direct cost recovery model by all parties involved, are likely to be reasonably dramatic.

Work by the IHPA may or may not substantiate the current market prices set for clinical training in the public sector, lately influenced by HWA’s clinical training program. Responsibility for funding costs over and above the IHPA costing (if activity based funding is found to be feasible for TTR) will be a question for future exploration, beyond the scope of this review. Nevertheless, clinical training costs do not merely impact on education provision at the tertiary level. Pressures from large numbers of graduating medical students needing to complete internships (primarily a clinical training year with minimal unsupervised service delivery) have required the Commonwealth to contribute funding in 2013, to cover the shortfall in places (see Box 3.1 below).

While the move to a demand-driven system of university places (outside medicine) will assist in responding to Australia’s future health workforce needs, its impact on the clinical training system will require close monitoring, given the extensive clinical placements required as part of a health professional’s training. It is likely that expanded use of simulated learning environments will need to be part of the solution in meeting future demand for clinical training.

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Intern training

In the decade to 2010, the number of commencing medical students increased by 109%,45 with graduate numbers also expected to double from 1,608 students (international and domestic) in 2005 to 3,935 projected to graduate in 2015.46 The dramatic increase in medical students in recent years had raised concerns that the states and territories would be unable to build internship training capacity at a rate sufficient to match and that, at some stage, there would be too many graduates and not enough internships.

This has been further complicated by increasing levels of international student enrolments, with many universities keen to continue increasing their overseas student cohort. It has been well publicised that this is placing stress on the demand for clinical training and internship availability. As domestic students cannot be charged full fees for a medical degree (under current policy settings), the market for overseas full-fee paying students, whose numbers are uncapped, has become important for many Australian medical schools, keen to ensure their viability. In 2011, 15.4% of students enrolled in Australian medical schools (2,535 of 16,491) were from overseas.47 In 2010, students from Canada, Singapore and Malaysia comprised 64.7% of all commencing overseas medical students.48

There has been a substantial increase in the overall number of intern training positions, from around 1,500 in 2004 to 2,753 in 2011.49 Despite this growth, current accreditation requirements have been raised as a barrier to the implementation of more innovative solutions to expanding intern capacity, particularly in the rural and private sectors (discussed below).

The Australian Medical Council is in the process of implementing new national standards for the accreditation of intern positions. This is likely to improve the consistency between jurisdictions in the accreditation of new intern places in the medium term. In addition, stakeholder discussions are ongoing in relation to the adoption of a new national process for intern selection. These two changes have the potential to streamline current arrangements.

In terms of supply, state, territory and Commonwealth governments have committed to supporting the development of additional intern places and have undertaken to provide an intern place for all Commonwealth-supported students. Some jurisdictions have accredited internship positions in non-traditional settings (such as GP practices and private hospitals) which are based on the premise that the key learning objectives can be achieved in other settings. It is likely that the number of such positions will need to expand to help cope with the increasing demand for internship places. There has even been consideration of Australian internships being conducted overseas.

This issue is still developing and the short to medium term outcomes for supply and distribution are still unclear. Before the supply of interns can increase (via additional medical students) accredited internship places must be available for them. The complexities of maintaining educational quality while accrediting sufficient numbers of new intern positions to meet projected needs has been raised as a major challenge both during this review and in other forums.

The situation as 2014 draws near is unclear. As yet unpublished data indicates that an additional 191 domestic and 46 international medical students will graduate in 2013 than did last year. It is too early to determine the exact number of additional internship places which will be required nationally but it is likely to be more than states and territories will bring online this year and the issue of an internship shortage is once again likely to be raised in the community.

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Box 3.1: Additional Medical Internships 2013

Due to the increase in medical graduates in 2012, the Australian Government proposed a shared solution to work with the states and territories as well as private hospitals to ensure that all eligible medical graduates would be offered an accredited internship commencing in 2013. The Australian Government offered to fund up to 100 internships in private settings (and to provide accreditation funding) providing states and territories fund the remaining positions that might be required.

Subsequently, agreement was reached with the governments of Western Australia, Queensland, New South Wales, the Australian Capital Territory and Northern Territory, in late October and early November 2012. This became known as the Additional Medical Internships 2013 initiative (AMI 2013).

As a result of this collaboration, there are an extra 60 doctors working in Australian hospitals in 2013, of whom 19 are employed in private hospitals in Mackay (noting some public sector rotations in Mackay), Brisbane, Sydney and Perth. This reflects the willingness to participate and flexibility displayed by private sector hospitals, several of which have benefited through achieving accreditation for intern training which will allow them to utilise a future intern workforce to provide services to the Australian community.

[end of box]

A major issue last year was the inability of jurisdictions to specify how many internships were required at any given time to place all potential applicants. The SCoH and Australian Health Ministers' Advisory Council have continued to address this by considering issues such as a national application and allocation system, data standardisation and sharing, a unique student identification number and national agreement of internship priority. However, recent discussions between jurisdictions indicate that no system will be fully in place in time to resolve all outstanding issues for the intern application and allocation system for 2014.

The issue is made more complex as some jurisdictions alter their internship allocation priority, with some states and territories prioritising overseas nationals graduating from in-state universities over domestic students from out-of-state universities. The ultimate effect of these changes will not be clear until 2014.

Current data would suggest that this problem will recur over time until the number of graduates plateaus. Information on projected graduate numbers from 2013 to 2016 shows only a constant increase with no firm peak established. However, while the overall demand for clinical training/internships will remain high, the demand for creation of new positions will reduce after 2015.

Table 3.1: Projected medical graduate numbers
Year 2013 2014 2015 2016

Source: MTRP Fifteenth Report, Table 2.21

Expected total number of graduates
3,623
3,762
3,935
3,970
Expected difference in graduate numbers between years
111
139
173
35

These developments in the public health sector will inevitably mean a renewed focus on the provision of intern places in the private sector and community or general practice.

Engaging the private health sector

The role of the private sector in delivering clinical training was discussed with stakeholders as part of the consultation process for this review.

Private hospitals accounted for 40% of admissions to Australian hospitals in 2010-11.50 Of all elective admissions involving surgery in 2010-11, about two-thirds occurred in private hospitals.51 This indicates that not only is the delivery of acute health care a shared responsibility amongst public and private service providers, but that the development of a well-qualified and highly skilled workforce is critical for both the public and private sectors.

As noted above, a large proportion of clinical training has historically been provided pro bono or through in-kind arrangements. However, private sector stakeholders expressed concerns that this has led to significant variation between jurisdictions and education providers, such that it is disadvantaging the service providers.

Private sector stakeholders also identified a perceived bias towards public sector providers within the HWA Clinical Training Funding program, with the implication that the private sector is unable to provide the same quality of training. The private sector decries this view, noting a long tradition of clinical training for nursing, midwifery and allied health students, and the growing role of the private sector in providing clinical training for undergraduate medical students, junior doctors and medical specialists.

Much like their public sector compatriots, private sector health care providers expressed some concerns about the administration of clinical training for undergraduate health students. In recent years, private hospitals say they have been asked to accept greater numbers of students although there is not always a commensurate increase in the level of supervisory support provided by the universities. This is commonly accompanied by allegations of a lack of clarity on the part of some educational institutions about the level of support required by students, which will vary significantly according to the education level achieved by the individual.

Some stakeholders perceive the development of formal contractual arrangements with universities and vocational education and training providers as a mechanism to more clearly define the roles and responsibilities of all parties, thereby providing students with more appropriate professional experience.

The private health care providers consulted as part of this review agreed that there is a significant level of untapped capacity in their sector for the clinical training of all health professions. A key to accessing this potential is to recognise the high quality care provided by some private sector medical facilities, and that this reflects the provision of high quality, meaningful and supported professional experiences for students at all points in the health education pipeline. However, unlike the public sector, private health care providers are not funded to support education and training for undergraduate students, a cost that would need to be considered in any proposal to utilise these settings.

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Prevocational training

Prevocational training is the period of clinical education and practice in which doctors and other health professionals develop competencies, usually after (or in the final stages of) completion of their basic academic qualification. Prevocational training is a requirement for medicine and many of the allied health professions including psychology, pharmacy, optometry and radiation oncology. While there is significant investment by the Government in prevocational medical education and training, other specialised areas of the health workforce are supported in ways which best fit their traditional models of training.

The Australian Government’s major contribution to prevocational medical training to date has been its support for the Prevocational General Practice Placements Program (PGPPP)which is designed for individuals in any postgraduate year who are not enrolled in a specialist training program. The program offers general practice placements for 10 to 13 weeks at a time with a view to encouraging participants to take up a general practice career and to improve junior doctors’ knowledge of general practice. The aim is to ensure that once they are vocationally qualified, doctors will be better informed about the role of general practice and its integration with other specialties and the broader health system.

Box 3.2: Background to broader general practice education and training arrangements

Up until the late 1990s, GP training, with Commonwealth funding, was solely managed by the Royal Australian College of General Practitioners (RACGP) through 21 regional providers. At the same time, a growing awareness arose of the need to consider the future of the GP education system as a whole, and to ensure that the system was capable of meeting the needs of the Australian community, especially in rural areas.

Following a Ministerial Review of General Practice Training in 1998, the Minister for Health announced a package of reforms involving significant changes to the structure and delivery of general practice vocational training in June 2000, including:

  • establishing a government-owned company which would hold the funds for all postgraduate general practice vocational training; and
  • the regionalisation of the management and delivery of training, with encouragement for a wider range of training providers to participate under a contestable GP training model.

General Practice Education and Training Limited (GPET) was founded as a company under the Commonwealth Authorities and Companies Act 1997 in March 2001 to implement the regionalised and contestable GP vocational training program known as the Australian General Practice Training Program (AGPT).

The Department is the sole funder of the AGPT, which is a national three to four year general practice vocational training program with a regionalised focus. The program supports individuals to obtain fellowship from either the RACGP or the Australian College of Rural and Remote Medicine (ACRRM), noting that both colleges are represented on the GPET Board.

While registrars are training they are also providing primary care services to individuals and communities.

In January 2002, GP training under the regionalised training program commenced. GPET has subsequently reduced the number of regional training providers (RTPs) from 21 to 17 and in 2010 took over the management of the PGPPP from RACGP and ACRRM.

GPET sub-contracts with the 17 RTPs, who are themselves independent entities, who manage the distribution of places at the local level and coordinate educational delivery to registrars amongst general practices in their region.

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The PGPPP offers additional general practice training to that offered in the standard internship program. In particular, the opportunity exists for students to experience general practice in a variety of non-standard settings, such as Aboriginal medical services, drug and alcohol services and community-based facilities. Placements can also occur in outer metropolitan, regional, rural and remote areas. There is a requirement that at least 50% of placements must occur in regional, rural or remote locations.52

PGPPP was originally designed to influence the distribution and supply of general practitioners by improving understanding of the role of general practice and encouraging individuals to take up this career rather than another specialty or a hospital career. While the value of providing interns with primary care training experiences is strongly supported by stakeholders, there has been debate as to whether PGPPP, in its current form, is the most appropriate strategy for the Australian Government to invest in building intern training capacity.

PGPPP was introduced at a time when uptake of vocational training places on the AGPT was low. It was reasoned that the greater exposure a junior doctor could have early on in his or her training to general practice, the more likely he or she would be ultimately to pursue a career as a GP (see Figure 3.1 below).

Figure 3.1 General practice training funding arrangements

Figure 3.1 General practice training funding arrangements D

PGPPP has also been utilised as one of the solutions to building prevocational training capacity. Moving interns out of hospital settings, even for a short period, is a way of freeing up additional placements in settings which provide necessary training experiences for interns to obtain registration. However, GPET reports that reluctance of jurisdictions to release trainees, even with backfilling costs met, was one of the reasons GPET did not meet its PGPPP targets in 2011.

In the current environment, demand for vocational training places is increasing (see data under specialist training below). The impact of higher numbers of students, it has been argued, is an opportunity to rethink the purpose of the PGPPP – insofar as the original aim of the scheme was to provide an early pathway for recruitment into GP training in an era when GP training was undersubscribed. In 2011, 1,427 doctors applied for the 1,000 entry training places on the AGPT for 2012. This surpassed the previous record of 1,235 applicants for the 2011 training year.53

While demand for AGPT places is high, there are indications that undertaking PGPPP placements has not necessarily articulated into graduates choosing to enter general practice training. It appears that only 25% of doctors (171 of the 692 in 2012) who had undertaken a PGPPP placement later accepted a place in the AGPT program.

GPET has recently engaged consultants to review the costs and funding model of the PGPPP. This project is currently underway with the aim of assessing costs of and developing a new standardised funding model, taking account of regional variations. Additionally, GPET aims to ensure that there is an equitable distribution of funds across their RTPs with the view to reducing costs over time.

The consultants are reviewing the details of funding of samples of PGPPP places from each RTP. This includes assessing actual costs of, for example, backfilling funding to hospitals, payments to practices, placement costs, regional differences, supervisor costs, etc. The intent is to identify similar costs borne by all RTPs, along with any regional variations. GPET expects that the new model will apply a standard base cost with regional weightings, similar to the AGPT funding model.

The present cost of PGPPP places (at an average cost of $54,500 per three month rotation or $218,000 per year) does not compare well with other investments in the training pipelines, such as the AGPT with an annual cost per participant of $60,000 or the Specialist Training Program (STP), which provides an annual salary contribution of $120,000 per registrar (including a rural loading). While a secondary benefit of the program involves freeing up intern places in hospitals, the current levels of funding for placements could create more than the current 240 (approximately) internship places funded. In fact given the raw cost of intern salaries and/or maximum on-costs (superannuation, indemnity etc.) a conservative estimate would allow the number of intern places to double if funding models were reshaped.

While this possibility is clearly attractive, there are also risks. One identified risk would be the potential loss of financial and human capital to the practices currently hosting junior doctors. There are various payments made to the practice during the 10 to 13 week rotation, the PGPPP also permits a relationship between the student and supervisors to develop, which may assist in future recruitment as a registrar and ultimately practice partner.

The current challenge is to develop a system that maintains the benefits of prevocational training in private general practice and community settings while establishing a more cost-effective and sustainable funding base for this activity. One element of such a proposal in the form of a new rural training pathway is outlined in Chapter 4. The Commonwealth has already set a precedent in funding intern positions in 2013, mostly in private settings, to address the unmet demand from Australian trained graduates (as described earlier in Box 3.1). An imperative of any expansion in clinical training capacity must include funding only for genuinely new positions.

If any such proposal were implemented, it would produce understandable concern about the potential loss of funding for metropolitan intern placements. Accreditation and supervision arrangements which are already in place should be retained and may be better supported as part of longer term placements for junior doctors integrated with the AGPT (see Box 3.3 below). Approximately 50% of PGPPP placements (up to 488 from 2012 onwards) may be located in metropolitan areas. Conservatively, this could provide at least 100 better integrated, well-structured internship positions, with priority given to students who wish to undertake later specialist training as a GP.

As part of this process, it would also be timely to investigate the consolidation of all Commonwealth investments in prevocational medical training into a single coordinated funding platform. Such an arrangement could incorporate historical funding agreements such as that between the Department of Veterans’ Affairs and Ramsay (Greenslopes and Hollywood Private Hospitals) for clinical training positions. Given that approximately 110 junior medical officer positions (some of which may be interns) are funded under this arrangement, this represents a strong potential to develop better networked arrangements for prevocational training in the private and community sectors.

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Box 3.3: Case study of the community-based intern education project

Background

There have been significant increases in the number of medical graduates entering the hospital system to undertake intern training in recent years. This has resulted in pressure on service delivery capacity due to increasing costs, supervision and training load.

Aim

The aim of the project is to determine the feasibility of offering medical graduates who have expressed an interest in a career in general practice an alternative pathway to a hospital-based internship. This will be achieved by piloting an intern program that is community-based and provides a pathway into general practice vocational training through the Australian General Practice Training program.

Program Model

The pilot project will involve up to 24 community-based internships, which will be provided in an agreed mix of supervised training undertaken by junior doctors in their first postgraduate year. The training will be based primarily in accredited general practices, and provide experience in the local, regional or rural hospital settings and relevant community health services.

The pilot will be run by GPET in conjunction with a small group of RTPs. It will be delivered to meet the requirements of the relevant boards and authorities, including the Australian Medical Council, the Medical Board of Australia, the postgraduate medical education councils, the colleges and other key stakeholders. This will ensure that interns meet the mandatory requirements to enable the granting of unconditional registration at the completion of the internship.

University of Melbourne Commercial tendered successfully to deliver the pilot program. In 2013, the university will undertake a community-based intern training feasibility study. This will involve a scoping and feasibility study; consultation, model design and selection of training providers; and finalisation of the pilot program and preparation for full implementation. Subject to the findings of the feasibility study and the decision of the GPET board, the pilot intern placements will commence in the first half of 2014.

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Vocational training

Once an intern has achieved general medical registration they have the option of training to become a specialist (including a GP). The Government supports several training initiatives to influence the supply and, especially, the distribution of specialists and GPs.

General practice training

During the past 30 years GP shortages, particularly in rural and remote areas, have been a regular subject of media reports and action by Governments. Several major measures have been taken in recent years to increase GP numbers and encourage doctors to pursue a rural career, thereby alleviating the main issue of access.

At the risk of labouring the point, while there is some concern over the absolute numbers in Australia, of greater immediate concern is the distribution of doctors throughout the country and the relatively low level of services provided in rural and remote areas.

In the case of GPs, in 2006-07 there were 97 per 100,000 people in urban areas in Australia. This figure dropped through regional and rural areas until in remote areas, the figure was 68.2 per 100,000 of population and 47.1 per 100,000 people in very remote areas.54 Significant government resources are directed towards countering this imbalance.

The recent expansion in training places has also coincided with substantial increases in applicants indicating that there is strong demand and interest in general practice as a career, notwithstanding the rural/regional training requirements. With the increases in training places made by the government (almost doubling to 1,200 places per year by 2014), and the requirement that at least 50% of this training must occur in ASGC-RA 2–5 locations, the AGPT is a key element in improving the distribution of GPs in rural and regional areas.

Stakeholders have advocated for an increase in the overall number of placements on the AGPT on top of current growth, with a suggested expansion of up to 600 additional places to a total of 1,700 per annum.55 While the current training capacity seems to be leading towards a shortage of vocational training places (see Table 3.2 below), it is important to acknowledge that the Government’s focus has been filling places on, what was until recently, an undersubscribed training program.

While the potential to expand vocational training, including funding limitations, is addressed further under the specialist training section of this chapter, it is important to note at this point that the Commonwealth’s control of GP training places represents an important mechanism to influence the future mix of the medical workforce.

Stakeholders have presented strong arguments during this review that increasing the number of GPs and “generalists” needs to be a key priority in workforce planning and future funding for vocational medical training. This is supported by the findings of HWA’s HW2025 Volume 3 report, which identified both an insufficient number of “generalists” and that the general practice workforce is highly reliant on overseas trained doctors, which may not be sustainable.56

There are instances where regional training providers are working well with other regional medical education providers, such as universities delivering the Rural Clinical Training and Support (RCTS) program, to deliver vertically integrated training with good prospects of developing sustainable teaching practice environments.

A case study of this type of arrangement is contained in the 2008 Urbis evaluation of the Rural Clinical Schools (RCS) and University Departments of Rural Health (UDRH) programs. It describes an innovative partnership between the Australian National University Rural Clinical School and the Coast City Country GP Training consortia in delivering both university medical education and GP training, sharing teaching resources and access to primary care settings under a formal partnership.57 Clearly these sorts of arrangements can be established if goodwill and flexibility exists on both sides.

However, feedback from some stakeholders suggests that these types of arrangements are not being consistently adopted nationally, are not always maintained, and that there are competitive pressures between GP training providers and other institutions, with little incentive for GP registrars to become involved in teaching. Promoting vertically integrated training is part of GPET’s charter and this is an area that requires further work in some cases to ensure training is delivered with maximum effectiveness in primary care settings. As noted earlier, the RTPs themselves are independent entities, with local boards and obligations under the Corporations Act 2001, who may be organisationally resistant to direction from GPET and (it is alleged by local stakeholders) may be more strongly motivated by the need to comply with corporate governance requirements than the desire to collaborate with other regional institutions.

The AGPT, and the PGPPP, have been successful in placing doctors in training in rural and regional areas. For the AGPT, this has had the added benefit that all registrars provide Medicare eligible services while they train. There is also some evidence that more GPs who have trained in rural areas are now staying on where they train, or in other rural areas. The regionalised model of delivering the AGPT has been a key element in ensuring that GP registrars have been well distributed across Australia.

However, there was some criticism of regional training providers not being open to allow registrars to train in new practices. In particular, some larger corporate practices believe that they are being shut out of the AGPT by particular regional training providers, which preferred to direct registrars to practices that had an established involvement in the AGPT program.

Ongoing educational support for GPs is available through the General Practice Procedural Training Support Program (GPPTSP) whichprovides funding and locum access to allow medical practitioners to attend further training and upskilling while not disrupting the provision of medical services in the area where they are posted.

Under GPPTSP, 25 obstetrics scholarships and 15 anaesthetics scholarships have been awarded to rural and remote GPs for the 2012 training year. Scholarship recipients commenced training from 1 January 2012. For the 2013 training year, 35 obstetric scholarships and 15 anaesthetic scholarships will be awarded to rural and remote GPs. This targeted program shows evidence of providing a valuable boost to service provision at locations where participants are based.

There has been high demand for this program as shown by the numbers of GPs applying for the scholarships, which are oversubscribed. With the growing focus on rural generalism, and training GPs to have a range of procedural skills, demand for this program is likely to increase. A relatively small investment in a program like this may result in substantial gains in service delivery in rural and regional Australia.

Some GPs participating in the program have experienced difficulty in gaining training posts, especially when they are competing against specialist trainees on the relevant college training program. As the administration of the program is managed by the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) and the Australian College of Rural and Remote Medicine (ACRRM), it may be necessary for colleges to play a greater role in assisting successful applicants to access appropriate positions in order to participate. Some colleges already provide such a service as part of their fellowship programs and for registrars participating in the STP.

During the course of this review there have been some suggestions that further administrative reform of the management of the AGPT should be considered by the Government, including proposals for the possible incorporation of GPET functions within the Department of Health and Ageing (DoHA), with the replacement of GPET with an advisory board. The advantages and costs of such proposals need to be carefully considered in the context of the major reforms to GP training over the last decade or more. GP colleges, the AMA and other stakeholder groups are likely to view any such proposal as a backward step.

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Specialist training

Predominantly, the supply of new specialists comes from within the Australian training pathway. In 2010, of the 1,538 doctors (except general practitioners) who became fellows of their respective colleges, only 411 were international medical graduates.58

The distribution of specialists tends to group around urban areas, particularly capital cities. In 2005, urban areas supported 122 specialists per 100,000 of population and this figure dropped to 16 specialists per 100,000 people in very remote areas.59 Specialists located in regional and rural areas often need to travel to undertake continuing professional development because the education they need will often not be available in their local area. Also, many types of specialists are reluctant to work rurally as there may not be a sufficient population base to support their specialty in private practice.

The admittance of doctors into specialist training programs is controlled by each individual professional college. From time to time allegations are made that some professional colleges limit entry to training programs for effectively industrial reasons, such as the protection of income levels or maintenance of prestige. Colleges have generally countered that the number of training places that they can offer is limited by the number of accredited training positions that are being funded by the state or territory governments.

The table below includes demands based projections from HW2025 for specialist training places (including GP training) in the coming decade.

Table 3.2: Community demand scenario – demand for advanced training places versus available places60
Year20092012201620202025
First year advanced training positions available
2,589
3,169
3,416
3,497
3,559
Doctors seeking first year advanced training positions
2,589
2,444
3,820
4,344
4,824
Difference between available first year advanced training positions and demand for positions
0
725
-404
-848
-1,265

The major concern in ongoing implementation of vocational training programs is that there are no clear linkages between the different initiatives investing Australian Government funding in medical education, particularly that which is rurally based. There is no requirement for universities, regional training providers involved in GP training or specialist colleges managing the Specialist Training Program or emergency medicine places to collaborate to ensure that career pathways are transparent for either students or graduates participating in these initiatives.

The impact of this lack of connection is that organisations tend to focus primarily on educational quality and student welfare at specific points of the training pipeline, without focussing on the end point in terms of workforce goals. While this focus on educational quality should in no way be diminished, an additional emphasis towards supporting vertically integrated rural positions and building partnerships between organisations at different levels of the training spectrum to assist with achieving distribution outcomes needs to become embedded within these programs.

The SCoH has recently acted to address this lack of coordination in the medical training system through the introduction of a National Medical Training Advisory Network (NMTAN), which was agreed in November 2012. HWA has been tasked with developing the network and released a discussion paper on its potential operation in February 2013.61 Members of the network are expected to include governments, representative organisations of the medical profession, registration and accreditation bodies, medical colleges and universities, and consumer representative groups. It is proposed that the NMTAN will produce five-year rolling medical training plans across the whole medical training pipeline from university training through to vocational training. These will be informed by analysis of information and quality data sources to identify future workforce supply, and will consider employment demand.

The NMTAN has strong potential to improve the interconnectedness of the various stages of the medical training pipeline and the capacity to make evidence-based decisions. However it is likely to be a number of years before it is fully operational and the benefits can be felt.

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Specialist Training Program (STP)

The STP provides support to enable medical specialist trainees to rotate through an expanded range of settings beyond traditional public teaching hospitals. It is the only source of Commonwealth grants support for specialist training initiatives and could be considered to have both supply and distribution outcomes for specialists. In addition to establishing specialist training posts, the program also provides funds for a range of support activities, including clinical supervision and training infrastructure for private sector participants and developing support projects aimed at Specialist International Medical Graduates. The program will support 900 specialist training positions by 2014.

The STP has been highly successful in extending vocational training into new settings, particularly in the rural and private sectors. It has also demonstrated that specialist colleges can take a flexible approach to accrediting new positions and to supporting networked training arrangements involving multiple health care settings, sometimes in different regions. However, the program has been consistently oversubscribed during its national application rounds for new positions.

The following table shows the difference between STP applications and available places.

Table 3.3: Applications for the Specialist Training Program
Year 2011 2012 2013

Source: DoHA administrative data, unpublished

New places available
464
82
150
Applications received
902
520
542

There is clearly high demand for new specialist training positions across the different disciplines, perhaps reflecting that jurisdictions have not traditionally supported significant growth in specialist training outside the traditional metropolitan teaching hospitals.

Although widely regarded as a successful initiative, as discussed above there is no clear pathway for graduates interested in working in the type of settings supported by STP (i.e. rural and private) to enable them to plan to undertake placements in this program. This problem persists beyond STP and the lack of structured pathways into vocational training outside general practice is often cited as an issue by junior doctor representative groups.

Specialist registrar recruitment and selection is ad hoc and there is very strong potential that prospective graduates interested in training in non-traditional settings will miss out on the limited places offered by STP. The program has also generally only supported one year placements for registrars and, under its current structure, has somewhat limited potential to provide a genuine solution to the need to construct clear and coordinated training pathways for graduates interested in pursuing rural careers. While health care settings that successfully apply for an STP place gain a registrar, the impact on long-term workforce recruitment of trainees has not yet been demonstrated and is likely to be reduced by the relatively short-term nature of most STP posts.

The ability of the STP to provide higher numbers of longer term rural specialist training positions should be examined, subject to available funds and the maintenance of training standards. This would be based on the concept of trainees rotating back to metropolitan sites for advanced skill rotations, unlike the more traditional system through which metropolitan trainees rotate out for rural terms. Ideally, these positions should be linked with rural internships to provide a seamless, vertically integrated transition through the different levels of training.

It is important that the STP policy of only supporting new training posts is maintained to avoid the potential for cost shifting and that the allocation of new training places is linked to both geographic areas and those specialties predicted to be in shortage by HWA’s HW2025 Volume 3 report. This situation would also apply to any extension of the STP model into prevocational training.

The major challenge in pursuing this approach is that by 2014, current funding for the STP will be fully committed. While there is the potential that a review analysing existing STP positions may free up some capacity, it will be difficult for the program to continue to extend specialist training into new settings without further resources. Regardless, it is recommended that a full evaluation of the STP should be carried out to inform its future direction and to ensure existing posts are meeting the objectives of the program. Indexation of funding should also be applied for future posts.

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Supporting emergency medicine

Funding from the 2011-12 Budget measure, Building emergency department workforce capacity is being used to support an additional 22 emergency medicine specialist trainees each year over four years; and a minimum of ten new private sector clinical supervisor/staff specialist training coordination positions nationally.

The Australasian College for Emergency Medicine (ACEM) is administering a number of critical elements of the program including:

  • Delivery of 22 emergency medicine specialist training places each year for four years, reaching a total of 110 annually in 2015. Funding covers salary support of $100,000 per post, plus a rural loading of up to $20,000;
  • Increasing the capacity for ACEM fellows to participate in structured training and supervision activities in public sector emergency departments nationally through the Emergency Medicine Education and Training (EMET) Program;
  • Providing a more structured training and upskilling environment for overseas trained doctors working in Australian hospital emergency departments to access training that is not available at their normal workplace; and
  • Providing support for GPs and other doctors to become better skilled in emergency medicine through the development of the ACEM Certificate and Diploma of Emergency Medicine qualifications.

Support for private sector training is delivered through the Emergency Department Private Sector Clinical Supervisor (EDPSCS) program. The EDPSCS aims to expand and enhance the postgraduate training capacity of private emergency departments by establishing and supporting new emergency medicine clinical training coordinator positions.

ACEM has established 30 agreements with public sector hospital networks, covering around 190 hospitals across Australia. Stakeholders are positive about this activity and would likely welcome an increase in its funding and scope. College reporting demonstrates high demand for public sector training support as well as benefits from the delivery of training services. However, the potential for cost shifting onto the Commonwealth needs careful consideration.

Other components of the program, such as supporting clinical supervision to build training capacity in the public and private sectors have yet to operate for sufficient periods to demonstrate their effectiveness. There have been some initial difficulties in recruiting key clinical supervisors and/or gaining accreditation for private sector hospitals to train emergency medicine specialists. This is a risk as there is limited capacity for other private operators to replace these hospitals.

Support for the specialist training of the radiation oncology workforce

The delivery of a course of radiotherapy is highly technical and involves a team of health professionals including radiation oncologists, radiation therapists (radiographers) and radiation physicists.

The Commonwealth’s Radiation Oncology Workforce Training measure aims to address the shortage of specialist radiation oncology staff. Component activities include contribution towards two types of training positions and associated clinical support:

  • Professional year placements for radiation therapists;
  • Three and a half year training placements for radiation oncology medical physics registrars; and
  • Clinical preceptors (tutors) to support these registrars.

Annual funding rounds called cohorts usually commence prior to the end of the academic year. Allocation of funding is via a targeted non-competitive Expression of Interest process as only accredited facilities are able to take on trainee positions. Accredited facilities include both public (State and Territory Health) and private providers.

The program has generally met the targets for the radiation therapist placements, with a lower rate for the medical physics registrars. Participants have indicated that this has been largely due to the unavailability of senior staff to provide the clinical support required. However, numbers of senior staff will evidently not be bolstered in the long term without sufficient supply of junior practitioners to replace/increase the workforce.

HWA are developing a National Cancer Workforce Strategy (NCWS) that offers a course of action to address workforce issues for the cancer control sector. The Strategy will identify key reforms with potential national application, and HWA will provide funding for activities that support innovative cancer workforce models arising from the finalised NCWS. There may be value in examining the aims and operation of the Radiation Oncology Workforce Training measure within the context of the NCWS, once it is finalised.

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Inter-professional learning

Inter-professional learning (IPL) is a stated aim of most institutions which deliver health education. However, the degree to which it is implemented is not well known. What is clearer is that, where health education occurs in a rural setting, inter-professional learning is more prevalent, as much out of necessity as design.

Where students who need to be exposed to the same clinical training do so in a rural setting, resource limitations often mean that medical students will attend a lecture or a practical clinic with nursing students and in some cases with allied health students as well, such as physiotherapy or pharmacy students. The move towards IPL therefore presents opportunities for efficiencies in how training is delivered which could be applied in a broader range of settings.

Some institutions which coordinate clinical placements for health students in rural areas – particularly universities delivering the RCTS and UDRH initiatives – are happy to facilitate a greater degree of IPL by choice, perhaps reflecting a greater openness to team-based service delivery in rural and regional health care settings in which they operate. The university departments, particularly, promote IPL as they deal with a range of health students from the same location.

Placements in small communities, particularly in Aboriginal and Torres Strait Islander communities, also involve levels of IPL by necessity. For example, when established rural health professionals gather for an education session – perhaps from a travelling expert or through a satellite educational broadcast – that gathering will most likely be an inter-professional one.

There has been significant academic debate about what should be the ideal model of IPL. These issues are then often linked with discussions about common assessment processes under competency based frameworks. There has been a degree of professional resistance to this concept, on the basis that it could lead to a break down in the recognition of different professional roles, e.g. between doctors, nurses and other health professionals.

Notwithstanding these issues, inter-professional education (IPE) in rural areas reflects the reality of health service provision in rural areas where the relative scarcity of health professionals can tend to break down the demarcation of roles which may be able to perpetuate in urban areas. However, with large urban universities and hospitals reporting increasing pressure on resources, inter-professional learning may become more of a reality across all settings and the benefits of this approach should be considered as part of the implementation of Commonwealth health education training programs.

Over the past number of years, with the dialogue for enhancing collaborative inter-professional practice between health professionals in service delivery, the education sector has also seen an emergence of IPE, albeit with no national consistency. HWA engaged a consultant to provide an overview of the current status of inter-professional programs in undergraduate university programs. The report, entitled Interprofessional Education: a National Audit was published in early 2013. The report provides a detailed profile and analysis of current activity and achievement in IPE in health across all relevant Australian universities, describes best practice in inter-professional education in Australian practice contexts, and identifies gaps, opportunities and recommendations for future development and deployment of IPE models in health nationally.

Informal indications are that although many universities have introduced inter-professional learning as part of the core curriculum, the mode of delivery is varied. Some institutions e.g. Curtin University commence IPE in first year student curriculum, whilst other institutions include IPE components only with clinical placements in later years. Edith Cowan University utilises the simulated learning environment in the early years to introduce inter-professional practice.

There is a divergence of opinion and little evidence nationally or internationally to the best approach – some believing that it is important to establish the ‘discipline entity’ in the initial years, whilst others believe that the concept of inter-professional practice should commence early in studies to ensure it becomes core to clinical practice. Evaluation of inter-professional programs is often limited to surveys of student experience and often IPE is driven by and dependent on a local champion, with sustainability an issue in some IPE programs. Additionally, there are expressed fears that inter-professional learning will lead to professional creep and that introducing inter-professional education into core curriculum will impact on the quality (and quantity) of discipline training and skill development.

The National Audit study listed seven recommendations for development and national capacity building. Key areas which impact on the quality and capacity of the health workforce include adoption of inter-professional practice (IPP)/IPE requirements in the accreditation standards of all Australian health professions and adoption of IPP/IPE in the continuing professional development requirements for ongoing registration. The remaining recommendations relate mostly to curriculum development and harmonisation of core competencies and information sharing. This review recommends that the benefits of IPL should continue to be explored within existing programs, particularly those funded under HWA’s clinical training stream.

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Recommendations
Recommendation number Recommendation Affected programs Timeframe
Recommendation 3.4 The Commonwealth should continue to invest in clinical training initiatives to help ensure the future health workforce has the right training to meet community needs. This should include ongoing investments in the clinical aspects of undergraduate health education across disciplines, as well as targeted funding for vocational medical training. There are pressures on training capacity and it is critical that government investment is cost-effective and sufficiently flexible to allow resources to be directed towards identified priority areas. HWA, AGPT, STP, PGPPP, RHMT Short term –ongoing.
Recommendation 3.5 A new focus on collaboration between organisations involved in health education programs needs to be mandated as part of core program delivery. Specific requirements should be incorporated into funding arrangements, with effective collaboration included as a key performance indicator for each initiative. AGPT, STP, RHMT (inc RCTS, JFPP, UDRH and DTERP) PGPPP, RVTS Medium term – as agreements expire.
Recommendation 3.6 The Commonwealth (as well as Health Workforce Australia (HWA)) should engage more closely with the private health sector in developing and implementing health education training initiatives. This engagement should be planned and regular and occur at a senior level. This approach should help to enhance the potential for private sector training capacity to be utilised more fully and in a more structured and consistent way. DoHA and HWA Health education programs. Short term and ongoing – to commence post-Review.
Recommendation 3.7 The Commonwealth, in close consultation with General Practice Education and Training Limited (GPET) and other key stakeholders, should investigate reforms to the way in which support for intern training placements is delivered in general practice and community settings. While maintaining the focus on intern training in primary care is crucial, there may be an opportunity to work with GPET to invest a portion of the funds currently dedicated to the Prevocational General Practice Placements Program (PGPPP) in new models discussed in this review. PGPPP Medium term
Recommendation 3.8 Reforms to the Commonwealth’s investment in junior doctor training will need to be targeted towards building a more integrated training pathway for new graduates, with a proportionate emphasis on rural training. This pathway should continue to provide structured opportunities for junior medical officers to experience general practice. PGPPP Medium term
Recommendation 3.9 The Specialist Training Program (STP) should provide indexed funding for its training posts. STP, Specialist training component of the More Doctors and Nurses for Emergency Departments program. Short term – indexation to commence as agreements with specialist colleges are extended.
Recommendation 3.10 While STP has been a well-received and apparently successful program, it is important that a full evaluation of the program should be carried out to verify that settings such as the mix of positions are optimal, and to inform the future development of the scheme. In addition, existing STP posts should be reviewed by colleges (in discussion with the Department and other program stakeholders) to ensure they are meeting the objectives of the program. This may provide the opportunity to redirect funds to new training posts that may better meet emerging workforce priorities. STP, Specialist training component of the More Doctors and Nurses for Emergency Departments program Short term – review to commence by the end of 2013.

40 Medical Training Review Panel (MTRP), Fifteen Report, Commonwealth of Australia, 2012, p. iii

41 Department of Industry, Innovation, Science, Research and Tertiary Education (DIISRTE) Higher Education Statistics Data Cube (uCube), 2012

42 It should be noted, in passing, that many countries are seeking to grapple with the extended length of current medical education models and in some cases are looking for ways to compress at least undergraduate medical education.

43 Higher Education Base Funding Review, Final Report, October 2011, accessed at www.innovation.gov.au/HigherEducation/Policy/BaseFundingReview/Documents/HigherEd_FundingReviewReport.pdf

44 R. Kim Oates and Kerry J. Goulston, “The hidden cost of medical student education: an exploratory study”, Aust. Health Review, 2012. accessed at http://www.publish.csiro.au/paper/AH12151.htm

45 MTRP Fifteenth Report, Table D1, p. 183

46 ibid., Table 2.21, p. 37

47 ibid., Table 2.15 p. 31

48 ibid., Table 2.9, p. 26

49 Higher Education Base Funding Review, Final Report

50 AIHW, Australian hospitals 2010-11 at a glance. Health services series no. 44. Cat. No. HSE 118. Canberra: AIHW, 2012

51 AIHW, Australian hospital statistics 2010-11. Health services series no. 43. Cat. No. HSE 117. Canberra: AIHW, 2012

52 Defined as RA 2 to 5 locations under the Australian Standard Geographical Classification – Remoteness Area (ASGC-RA) system. Further discussion of ASGC-RA is included in Chapter 4.

53 General Practice Education and Training Ltd, Annual Report to 30 June 2012, Canberra

54 Department of Health and Ageing, Report on the audit of health workforce in rural and regional Australia, Commonwealth of Australia, 2008

55 A. Bracey, “Plea for more GP training”. Medical Observer, 26 March 2013.

56 HWA, HW2025 – Medical Specialties – Vol 3

57 Urbis Pty Ltd, Evaluation of the University Departments of Rural Health Program and the Rural Clinical Schools Program, Commonwealth of Australia, 2008

58 MTRP, Fifteenth Report, Table 4.39

59 Department of Health and Ageing, Report on the audit of health workforce in rural and regional Australia, 2008

60 HWA, HW2025 Vol 1

61 National Medical Training Advisory Network Discussion Paper (http://www.hwaconnect.net.au/nmtan/files/HWA-NMTAN-discussion-paper-a.pdf), accessed 1 April 2013.