Dr Pesce, Speech to CHA National Conference

ADELAIDE

MONDAY 23 AUGUST 2010

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Supporting the medical workforce

I acknowledge the traditional owners of the land on which we are meeting today.

It is a pleasure to be in such distinguished company for this session … Chair, Professor Con Michael, Dr Flynn, and Professor Searle.

My thanks also to Martin Laverty and Catholic Health Australia for inviting me to this Conference.

The topic of the Conference – ‘10 Years From Now’ – is very appropriate given the era of health reform in which we are all operating at the moment.

We do need to plan for the future.

This session is titled ‘Medical Practitioner Registration and Training – issues for CHA facilities in 2010 and beyond’.

An important part of the future of our health system is the medical workforce.

I will concentrate on that part of the equation today.

We know that there are medical workforce pressures in the community.

The most recent estimate from the former National Health Workforce Taskforce is that Australia has a shortage of around 4500 doctors.

Despite this sobering statistic, the future outlook is more promising.

Since 2004, there has been a strategy in place to increase medical student numbers dramatically.

By 2012, there will be around 3500 medical school graduates each year, which compares to around 2100 in 2004.

This will go a long way towards addressing workforce shortages, although we know that we currently don't have enough supervisors, infrastructure, and other resources to train all these students and graduates.

The AMA has been campaigning since 2004 for more support to teach and train these students and graduates.

We need to invest in infrastructure, fund more supervisors, and utilise settings beyond public hospitals to make sure that students and graduates can get hands-on clinical experience with patients.

This can be difficult due to decisions to close wards, cut theatre time, and the like.

We know that we are fast approaching a crisis in relation to the provision of prevocational and vocational training positions in hospitals, general practice, and other community and private settings.

To illustrate the challenge, in 2009 there were 2243 intern positions across the country, which falls well short of the 3500 positions that are needed in 2013.

Already, NSW, Tasmania and Queensland are looking unable to offer intern places to all applicants.

Current allocation arrangements give overseas full fee paying medical graduates the lowest level of priority in the system and they will be first cohort to miss out on an intern place.

But as domestic graduate numbers continue to grow they too will face the same problem in a year or two.

The growth in student numbers and graduates presents enormous opportunities for not-for-profit health care facilities.

They can take a much more prominent role in the delivery of training - not just for medical students, but also for prevocational doctors and specialist trainees.

Not only can not-for-profit facilities play a part in increasing training capacity, they also provide medical students and doctors-in-training with the opportunity to see and treat conditions that you just don't see any more in the public sector.

There have been extensive reviews undertaken in this area over the last several years in relation to specialist training, including the Medical Specialist Training Taskforce and the Medical Specialist Training Steering Committee.

These demonstrated the opportunities for rich clinical experience outside of traditional teaching hospitals.

They took the view that more specialist training needed to be carried out in these areas to ensure that our junior doctors have a well-rounded training experience.

The AMA has strongly supported this direction.

We know that not-for-profit facilities like hospitals and aged care facilities are already doing this to some extent.

However, barriers such as funding arrangements have stood in the way – but this is changing.

In 2006, the Commonwealth took the first tentative steps to promote specialist training in the private sector and other community settings.

In 2008, COAG announced a $1.6 billion health workforce package that included significant funding for undergraduate clinical training and supervision.

There was a commitment to use some of this funding to support more undergraduate training in private and other community settings.

More recently, the Commonwealth - as part of national health and hospital reforms - announced that it would significantly boost prevocational medical training in community settings, as well as further expand specialist training in the private sector.

Health Workforce Australia was established as a result of the 2008 COAG agreement.

It has funding to support innovative models of undergraduate clinical training in the private sector as well as funding to train medical supervisors.

These changes provide CHA members with real opportunities to access the funding support they need to deliver more training in their facilities.

Other major policy changes will have an impact on CHA members.

From November this year, eligible midwives and nurse practitioners will be able to provide some services that are funded through the Medicare Benefits Schedule (MBS) and prescribe medications subsidised under the Pharmaceutical Benefits Scheme (PBS).

The AMA supports a team-based approach to care and advocated very strongly for collaboration with a medical practitioner to be mandated as part of the Government’s reforms.

Effective collaboration is in the best interests of patients and all members of the collaborating team.

Effective collaboration requires structured lines of reporting and well-defined roles within a team.

Every member of the team needs to know exactly what their role is and how they need to work with each other.

This will deliver high-quality patient care and avoid the fragmentation of patient care.

The AMA is anxious to see collaborative arrangements between midwives and doctors and between nurse practitioners and doctors succeed.

I am sure you do as well.

It is in the interest of your patients that they have access to a doctor and that high standards of care are maintained.

We don't want to see complaints from the nursing and midwifery lobby on 1 November that they are finding it difficult to finalise collaborative arrangements with doctors.

We will need to see three outcomes to promote collaborative care:

1. The Relevant Colleges will need to provide guidance to their respective members with a framework for collaboration;
2. Institutions will need to promote collaboration for inpatient care via their accreditation and credentialling processes; and
3. Individual practitioners will need to agree to collaborate.

One important area where CHA members will have a role to play is in the credentialling process for midwives.

Unfortunately, the Government reforms have been to some extent rushed and there is little knowledge of the changes at the hospital level.

Not a lot of thought has been given to the credentialling processes for midwives.

Understandably, doctors will be reluctant to sign up to collaborative arrangements with midwives if they are not properly credentialled to work at the local hospital.

This is something that your sector needs to address as a matter of urgency.

We must raise awareness of this new reality and make sure the processes are in place to make it work effectively.

We need a truly collaborative environment that protects our patients, does not fragment health care, and reinforces relationships with health care providers.

In terms of NRAS – the National Registration and Accreditation Scheme - the new Medical Board has commissioned work that will influence the provision of training.

The Board has asked the AMC – the Australian Medical Council - to develop a standard for the intern year.

It has also commissioned the AMC to work on a national accreditation system for prevocational training.

These will have important implications for training in not-for-profit facilities, especially how the training is structured.

CHA needs to engage in the process to ensure your views are known, and so that future arrangements can take advantage of the opportunities that your facilities offer.

One area where we think the NRAS process is proving a problem for medical training is in relation to the Australian Curriculum Framework for Junior Doctors.

The AMA has been very much engaged through our Council of Doctors in Training in the development of this document, which was first released in 2006 and then revised again in 2009.

This framework is important as it provides some structure to prevocational training.

Its rollout across the country is a work in progress, but it is currently starved of funding.

We recognise that the Medical Board has commissioned work around intern standards and prevocational medical training.

And we recognise that this may have implications for the Framework.

But our Doctors in Training are concerned that the Commonwealth Department of Health Ageing is not continuing funding for the implementation of this important work at this stage.

It is likely that the whole process will lose important momentum as a result.  This would be a major disappointment for junior doctors.

We have a world-class system of medical education in Australia.

It is built on high standards of accreditation, committed professionals, and a rich clinical environment.

We know that this is under pressure due to increased student and graduate numbers - and we need to look to the private sector to be innovative and to help fill the gap.

We know from the work of the medical specialist-training steering committee that more training in private settings can benefit patients, trainees, supervisors and facilities alike.

With the right funding and support, you can do a lot more and your facilities benefit from this.

We know CHA is very keen to treat more public patients in your private hospitals.

And we know that already there is more medical training occurring in the Catholic hospitals through Notre Dame and other medical schools.

The Catholic hospitals sector is well placed to be a pilot for how the system may evolve –’10 years from now’.

National registration

Dr Flynn has outlined the experiences of and challenges for the Medical Board with the transition to national registration.

The AMA has always supported the principle of nationally consistent registration arrangements that ensure that those doctors who are qualified and safe can work anywhere in Australia.

Throughout the consultation process conducted over the past three years, the AMA had a number of broad and specific objections to the many elements of the scheme. 

It was most important for the medical profession that the NRAS framework minimised political interference on standards for the medical profession.

We think there is now a better balance in the arrangements whereby the medical profession - through the Medical Board, the AMC and the medical colleges - is responsible for setting the standards for the medical profession.

Our efforts now are to work with the Medical Board to get the details of the registration and complaints and disciplinary processes right.

There is still quite a bit of work that the Board has to do in respect of its new requirements under the National Law.

Its consultation papers are keeping organisations like the AMA busy with submissions.

The medical profession is concerned about the potential for the mandatory reporting provisions to impact on the workplace.

We think the Board has a challenge to work out how it will handle reports that may come in from all types of health care professionals who work with doctors every day.

It will take some time before health professionals who are subject to the mandatory reporting provisions become familiar with their obligations under the National Law. 

It will be important that your organisations integrate these national requirements with your own workplace policies.

It is important that your organisations accurately identify complaints that may be brought to you by staff.

You will need to have good systems to ensure that workplace grievances are dealt with internally where appropriate, and are not automatically referred under the mandatory reporting regimen.

So I ask you as their employers to build into your staff education programs, and your staff support programs, information about the differences between a staff grievance that you as the employer will handle, and when mandatory reporting is appropriate.

In that context, I believe you have a role to ensure that complaints about health care professionals by other health care professionals, and workplace grievances, are handled through the appropriate avenues.

In closing, let me say that I believe the momentum for genuine health reform must continue.

The AMA has a role to play.  CHA has a role to play.

There must be a unity of purpose in the health sector to achieve meaningful long-term reform that benefits the patients we serve.

 

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23 August 2010

 

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