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10 Oct 2017

BY DR CHRIS WILSON, CO-CHAIR, COUNCIL OF DOCTORS IN TRAINING

We’re all aware of the critical disconnect between graduating medical student numbers and upstream training places.  Undoubtedly the training bottleneck has arrived and is one of the most significant challenges facing Australia’s medical workforce.  However, there’s another, more insidious assault on medical training that hasn’t garnered the same level of attention – the failure of activity-based funding (ABF) to recognise the value of teaching, training and research (TTR).

With ABF benchmarking used to decide what hospitals get paid per patient care episode, budgets and the need to drive efficiency in processes have become an increasingly important focus.  Certainly, we must look to curb the ever-growing health spend by using our resources efficiently, however teaching and training are vital components of hospital work currently left out of the ABF model.  This separation from the rest of hospital funding has led to the steady erosion of learning opportunities in preference for ‘service provision’.

The implementation of ABF models in our hospitals has pushed us to see more patients in less time, leaving doctors in training with reduced time per patient and diminished opportunity for the experiential learning afforded to our seniors in their formative years.  Emergency department four-hour rules, the rise of acute medical and surgical units and the ongoing push to drive down the length of admission have created fragmented patient journeys where it is rare for a doctor in training to see a patient from their acute presentation through to resolution and discharge, especially if their issues are complex or rare.  Front-line emergency DiTs are increasingly being used by hospitals as a triage service with the most important question being ‘destination’ rather than ‘diagnosis’.  There is little time here for deliberation and thorough investigation, and this holds true for senior doctors just as it does juniors.  Already pushed for time, hospital consultants are also asked to see more patients, increase procedural efficiency and teach the growing hordes of students, leaving little time to engage with already overburdened doctors in training in learning opportunities.

So, as we grapple with how many training places short we look to be, we must also question the quality of training we are delivering.  It is a failure of the ABF model that TTR have been left out in the cold.  Hospitals must have a budgetary incentive to strive for high-quality, integrated methods of teaching, and that incentive is missing under current block-funding arrangements.  Just as we have a responsibility to provide service to our patients, the health system has a responsibility to provide doctors in training with adequate teaching and training to allow us to deliver the outstanding level of patient care our society expects. 

Almost five years ago, the AMA convened a meeting of relevant parties including the Medical Colleges, the Medical School Deans and Health Workforce Australia to discuss how TTR could be included in ABF structures for hospitals.  That meeting identified TTR as core business for the Australian health system and argued it should be viewed as an investment in sustainable, quality health care.  Recommendations were delivered to the governing body for activity based funding, the Independent Hospital Pricing Authority (IHPA).  Reports from that meeting can be found here: https://ama.com.au/article/activity-based-funding-teaching-training-and-research

In August this year, the IHPA released a public consultation document on the ‘Development of Australian Teaching and Training Classification’ (https://www.ihpa.gov.au/sites/g/files/net636/f/development_of_the_australian_teaching_and_training_classification_-_public_consultation.pdf).  Despite the AMA highlighting the need to incorporate TTR into the core business of hospitals five years ago, there has been little action since and we’re still some way off this happening.

There is a lack of sophistication in the approach to medical training, with the current proposed classification system failing to even account for differences between prevocational and vocational trainees.  The slow pace of progress fails doctors in training, our hospitals and our health system.  The Council of Doctors in Training has written to the IHPA to highlight our concerns surrounding the proposed classifications for teaching and training. 

As we look to properly establish medical training in the ABF system, our recommendations have changed little since 2012, and we’ve again stressed that it is imperative TTR are made cornerstones of our health system, not line items short-sightedly sacrificed in the drive for cost-effective service provision. 


Published: 10 Oct 2017