|Implemented in this survey?|
Since 2003 Australian governments have implemented a range of expansionary policies regarding the medical workforce. More university places, more medical schools and more funding for training. Yet despite these efforts, an audit of the rural health workforce released in 2008 concluded that the supply of the medical workforce in rural and regional areas was too low. This led to a Rural Health Workforce Strategy. This survey will report on the background and key elements of this strategy.
It has been widely accepted that regional and rural parts of Australia have, for considerable time, suffered shortages in the medical workforce. However, by the late 1990 and early 2000 there were increasing concerns that these shortages were also present in some outer metropolitan areas. The shortages were reported to be particularly grave in the area of general practice but also for some specialty areas.
The Government responded by increasing the number of medical student places. Prior to 2003 this number had been restricted to approximately 1250 per year. However, by 2008 this had increased to 2544 and is expected to increase further in the future. The government has also committed to increasing the numbers of clinical training places. However, the results of these changes will take a number of years to filter through to workforce numbers due to the long and complex processes involved.
Initially, the aim of the policy was to address emerging issues about shortages of medical professionals, particularly in outer-metropolitan and rural and regional areas.
A package of measures was announced in the 2003 federal budget to train more doctors and ensure that they are working in areas of most need. Students who take up these new medical places would be 'bonded' to areas of workforce shortages for a minimum of six years.
Subsequent announcements also expanded the number of medical schools and places in rural and outer metropolitan areas, as well as further expansion of university places more generally.
With the election of a new government in 2007 the emphasis of the expansionary workforce program changed. Firstly, it shifted emphasis to training (rather than education). For example, it announced Aus $60 million funding for new vocational training places for the health care workforce (broader than just doctors). It also announced greater funding for training positions for junior doctors to become general practitioners as well as new training positions for pathologists and the diagnostic imaging workforce.
In 2008, the Government announced the Rural Health Workforce Strategy. The major focus of this initiative included a Aus $134.4 million package to improve rural and remote workforce shortages and better target existing incentives through the provision of additional financial and non-financial support for rural doctors.
The Rural Health Workforce Strategy builds on a number of existing programs that have been implemented over the years. A summary of these existing and new initiatives are:
|Degree of Innovation||traditional||innovative|
|Degree of Controversy||consensual||highly controversial|
|Structural or Systemic Impact||marginal||fundamental|
|Public Visibility||very low||very high|
Overall, there is widespread consensus on the problem and the policies contained in the new strategy. This new strategy is really a continuation and expansion of a general package of policies aimed at curbing workforce shortages in the regions. The major political parties in Australia have supported the initiatives contained in the new strategy.
The range of initiatives contained in the new strategy can be implemented elsewhere but does require a joint health and education approach.
The change in the perception that Australia had an oversupply (albeit a maldistributed) in its medical workforce coincided with a general increase in the out-of-pocket costs for health care services and persistently long waiting times for some elective surgery procedures. These two factors mean that there was a problem which needed to be solved politically. One of the political responses has been to blame a workforce shortage and therefore the answer is to increase the numbers.
The issue of waiting times and out-of-pocket costs go beyond that of workforce numbers. The interaction between public and private provision of health care, tight budgetary controls on public hospital funding and Medicare benefits as well as an increase in the demand for services are likely to have contributed to these problems.
In reality, these perceptions of shortage have never been well researched. By international standards, Australia has fewer doctors per head of capita than the OECD average but is ahead of countries such as the UK, Canada and the US. But international comparisions such as these do not take into account the health care needs of the population and the geography of the land.
|Implemented in this survey?|
Several papers and reports were published in the 1990s and early 2000s questioned Australia's health workforce capacity. A recent paper by the Australian Parliamentary Library summarises the origins of how the problems came into the public debate and how this transplated into policy action. It states that:
Numerous government reports and commission have commented on the maldistribution of Australia's medical workforce. The conclusions of these reports have been echoed by the various medical colleges, patient groups and the Australian Medical Association who have, at times, applied pressure on political parties via the media.
Whilst there has been no formal response from student bodies such as the National Union of Students (NUS), these initiatives are in agreement with some of their previous lobbying efforts. In particular, greater access to university places for rural and regional students is an issue that the NUS has been very vocal on in the past.
|Prime minister||very supportive||strongly opposed|
|Minister for Health||very supportive||strongly opposed|
|Specialist colleges||very supportive||strongly opposed|
|General practitioners||very supportive||strongly opposed|
|Australian Medical Association||very supportive||strongly opposed|
|Students||very supportive||strongly opposed|
|Prime minister||very strong||none|
|Minister for Health||very strong||none|
|Specialist colleges||very strong||none|
|General practitioners||very strong||none|
|Australian Medical Association||very strong||none|
The new package of initiatives are fairly easily implemented because they build on existing programs and are within the responsibilities of the Australian Government.
Where the federal governement is likely to erncounter greater difficulty is in the area of training. This is because specialist training, aside from general practice, falls largely outside of its control.
As reported in the Australian Parliamentary Library Background Note (2009), twelve major specialist medical colleges in Australia determine the standards of education and training and, in most cases, also determine the number of training places. Once trainees have been accepted into a specialist training program, they are required to apply for hospital registrar positions which have been accredited by a relevant college. These positions are generally in public hospitals. Thus the federal government relies on the colleges to offer training places and on state and territory government to support such places in their public hospitals. There have been suggestions for a number of years that various colleges deliberately restrict entry. These types of allegations led the Australian Competition and Consumer Commission (ACCC) to consider if the trainee selection practices of one college, the Royal Australian College of Surgeons (RACS), were in breach of the Trade Practices Act 1974 Cth. After some investigations, in 2003, the ACCC was reportedly aghast at the mean-spirited way surgeons limited people entering the profession. However, the regulator granted the college an exemption from prosecution because its selection practices were deemed ultimately to be in the public interest. These issues have arisen from time to time and may require governments to develop new policies on medical training by encouraging university medical schools to provide alternative options for specialists training.
Several publications have been released which have reviewed certain aspects of the government's workforce policies (see for example www.health.gov.au/internet/main/publishing.nsf/Content/work-res).
An audit of the health workforce in rural and regional Australia found that Australians living in regional and remote areas continue to be disadvantaged in their access to health professionals compared to their urban counterparts. There continues to be a maldistribution of health professionals relative to population in all major health professions except perhaps for nursing. Despite some success, the growth in the supply of medical practitioners has not kept pace with the growth in the general population. The gains in distribution in rural and remote areas over recent years have been in a large part due to the increased numbers of overseas trained doctors working in these areas.
It will take considerable time for these policies to filter through and impact on workforce shortages in the regions. This is due to the long time lag between education and qualification as a medical provider.
Not surprisingly, the initiative that has had the most immediate impact on the regional workforce has been to encourage overseas trained doctors to practise in areas of high need. Overall, one third of doctors in Australia have been trained overseas but in rural areas this percentage is over 40 percent. It is anticipated that the supply of medical practitioners will continue to rely upon the recruitment of overseas trained professionals in the immediate and medium term future.
The more recent announcements build on existing incentives to attract newly educated and trained doctors to the regions. In particular, the new incentives entice new practitioners to areas of greatest need. Whilst these initiatives are likely to have some impact on workforce numbers in the long term, they may also raise future issues around quality and safety. This is because rural and regional areas are likely to have a greater concentration of young and inexperienced doctors with fewer available resources for professional development and mentoring.
Furthermore, aside from the overseas trained doctor initiatives, these policies do little to address short term problems - although the General Practice Rural Incentives Program may create some financial incentives for doctors to stay in the regions or move to areas where there are shortages.
|Quality of Health Care Services||marginal||fundamental|
|Level of Equity||system less equitable||system more equitable|
|Cost Efficiency||very low||very high|
A greater reliance of overseas trained doctors in rural and remote areas has let to some concerns over the lack of support for overseas trained doctors in terms of training and orientation to the Australian health system and culture. Should the policies be succesful in reducing the workforce shortage in rural and remote areas, the health care system will be more equitable.
There is considerable doubt around the cost-effectiveness of some measures. Firstly, there is little evidence that some of these initiatives will work in terms of redistributing the workforce to areas of undersupply. Secondly, some of the incentives on offer will go to doctors who are already in areas of under-supply. This means that a large proportion of allocated funding will go to existing rural providers, without necessarily increasing rural doctor supply. Finally, these arrangements need to be placed in the context of a broader rural health care plan. There is a need to examine how health care services can be delivered more equitably and efficiently in rural and remote areas. This may entail different care models for regions compared to metropolitan areas. Such alternative models can then become the basis of a more comprehensive workforce strategy.
Report on the Audit of Health Workforce in Rural and Regional Australia available at www.health.gov.au/internet/main/publishing.nsf/Content/work-res-ruraud
Details on the new rural health workforce strategy available at www.doctorconnect.gov.au/internet/otd/publishing.nsf/Content/program-mrbs
Details of previous government commitments available in various budget papers at www.health.gov.au/internet/budget/publishing.nsf/Content/2009-2010_Health_PBS
A background note from the Australian Parliamentary Library on medical education and training, and is available at www.aph.gov.au/library/pubs/BN/sp/MedicalPractitioner.htm
van Gool, Kees