basic physician training

Basic Physician Training

Pilot Consortia Model

Final Report

Published by the Victorian Government Department of Human Services

Melbourne, Victoria

© Copyright State of Victoria 2005

This publication is copyright, no part may be reproduced by any process except in accordance with the provisions of the Copyright Act 1968.

This document may also be downloaded from the Department of Human Services web site at:

www.dhs.vic.gov.au/workforce

Authorised by the State Government of Victoria, 555 Collins Street Melbourne.

Table of Contents 1 Introduction 1

2 Context for Change 3

3 Planning for Medical Training in Victoria 5 3.1 Statewide Planning 5 3.2 Consortia Based Training 6

4 Basic Physician Training Consortia Pilot 8 4.1 Current Basic Physician Training 8 4.2 Training Consortia Configuration 9 4.3 Specialist Hospitals 14

5 Consortia Operations 16 5.1 The Role of the Training Consortia 16 5.2 Statewide Management 16 5.3 Consortium Management 17 5.4 Funding 18 5.5 Trainee Recruitment Principles 19 5.6 Quality of Training 23 5.7 Pilot Timelines 26

6 APPENDIX 1: RACP accredited teaching hospitals 27

7 APPENDIX 2: Sites consulted 28

8 APPENDIX 3: Current metropolitan intra-health service rotations. 29

9 APPENDIX 4: University Links 30

10 End Notes 31

Basic Physician Training: Consortia Pilot

1 Introduction

The health sector in Victoria is facing increasing challenges in seeking to provide Victorians with access to safe and high quality health services. In order to achieve an optimal level of health service, a skilled and competent workforce is required which is equitably distributed across the State.

The training of medical specialists has developed over the years into a complex set of interwoven processes and relationships, sometimes in competition, between the specialist colleges responsible for training, and hospitals requiring staff to meet service needs. There are overlapping roles, responsibilities and markedly differing practices between specialist colleges regarding selection, training programs and requirements for rotations.

Overlaying this is the relationship between training and service delivery. Medical trainees comprise a significant proportion of the hospital workforce. Hospitals rely on junior medical staff and registrars to meet service delivery requirements. Thus, whilst from a purely training perspective, market forces could dictate training locations (based on infrastructure and available resources), the intrinsic association between training and service delivery dictates the need for some intervention to ensure that there is an appropriate number, mix and distribution of registrars.

In order to address these demands, the Department of Human Services established a Medical Workforce & Training Advisory Committee (MWTAC) in February 2004 to canvass the opinions of a wide range of stakeholders in medical vocational education in the public health sector and to put forward potential solutions to the issues that had been raised. Initial issues for the Advisory Committee involve:

♦ Strategies to support adequate supply and equitable distribution of the medical specialist workforce across Victoria.

♦ Strategies to ensure Victoria meets its Australian Medical Workforce Advisory Committee (AMWAC) targets and any specific Victorian requirements on the numbers and location of pre vocational and vocational training places.

♦ Strategies to address workforce shortages in identified specialties and locations.

♦ Training and support needs of junior doctors, vocational trainees and international medical graduates.

This paper is the first product of this process. It sets out to examine the current situation in regard to medical education and training and proposes the development of training consortia as a model through which the current training milieu could be organised to respond to emerging and competing priorities. The MWTAC has proposed that the consortia model be piloted for basic physician training for a two-year period from 2006.

Consortia Consultation Process

In December 2004, the Department of Human Services released a discussion paper outlining a model for consortium-based training of the Basic Physician Trainee workforce. This model seeks to address concerns with both the distribution of BPTs across accredited training sites and the provision of training to BPTs at these sites. The release of the discussion was supplemented by a series of consultations with health services with RACP accreditation for basic physician training.

A team from the Department of Human Services1 consulted with 24 health services over December 2004 and January 2005 (for a detailed list of sites see Appendix 1), in addition to meetings with the AMA, Victorian RACP Training Committee, BPTs, the RACP Federal Office, the RACP Victorian State Committee, The University of Melbourne and Monash University. During the course of the consultations, the team met with more than 312 individuals over a 2-month period.

1 The DHS consultation team comprised Peter Carver, Director Service & Workforce Planning, Lise Pittman, Manager Workforce Policy & Programs, Professor Ken Hardy, Senior Medical Advisor, Dr Peter Trye, Senior Medical Advisor, Rural & Regional Health & Aged Care Services, Praveen Sharma, Senior Policy Officer and Courtney Holt, Policy Officer.

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Specific consultation meetings were organised with: ♦ Hospital Chief Executive Officers, ♦ Hospital Administrators (HMO-managers or those responsible for rostering BPTs, Directors of

Medical Services (DMSs), Directors of Physician Training (DPTs), Directors of Clinical Training (DCTs), Medical Education Officers (MEOs), and any others who have a role in the administration of BPTs and training in hospitals),

♦ Hospital Senior Medical Staff (including academics, clinicians, staff specialists, visiting medical officers (VMOs) and others involved in senior clinical positions who may have an interest of involvement with the pilot),

♦ Hospital Junior medical staff (including interns, HMOs and medical registrars) ♦ University Deans ♦ Other representatives with an active interest in the consortia model and/or physician training.

The consultation meetings confirmed widespread dissatisfaction with the current system, and found encouragement for a system-wide overhaul in terms of training delivery, capacity and distribution. Hospitals advised of in principal support for the consortia model to address issues relating to the training and distribution of junior medical workforce in Victoria. There was also widespread acceptance of the role of the Department in setting priorities for the education and training of junior medical staff. A significant number of stakeholders were of the view that the current system was inefficient and ineffective. This view was most evident amongst hospital administrators, clinicians and College representatives.

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2 Context for Change

One of the principal challenges faced by the health sector is the increasing medical workforce demand, and the need to balance supply and distribution. Undergraduate medical places are the responsibility of the Australian Government, which has not yet responded to Victoria’s request to increase its number of places by a minimum of 80. Efforts are already underway to increase the labour pool with initiatives such as increasing medical undergraduate places, use of international medical graduates (IMGs), role redesign and changes to health practitioner legislation to explore greater scope of practice (as a strategy to reduce pressures on some occupations). However, in the short to medium term at least, the projected demand for medical practitioners appears likely to continue to exceed supply. This suggests that a market based approach to determining workforce numbers, distribution and skills alone cannot ensure that the health sector has access to the workforce it requires.

A major component of the medical workforce in public hospitals is made up of doctors in specialist training programs. Given that the public health sector largely relies on these medical registrars in vocational training programs for service delivery, there is a need to ensure that the system of allocation of medical registrars enables public hospitals to access a well trained and skilled registrar workforce to meet service delivery outcomes.

It is becoming increasingly apparent that the current training system is facing difficulty in coping with the challenges facing medical workforce supply and demand. Increased (State, Hospital and Specialist College) investment in training has resulted in additional vocational training places in most major specialities but has not kept up with increased demand for services. The corollary of this overall shortage is both geographical and speciality maldistribution. This is reflected in a number of ways:

♦ Hospitals are competing for staff in a tight market and there is no coordinated approach to facilitate an appropriate distribution of vocational training posts to meet current and future need. Specialist colleges, through their Fellows, negotiate with individual hospitals to establish vocational training posts. This is largely undertaken in isolation from national or state priorities and broader health service requirements.

♦ There is limited interaction between parent and rotation hospitals in planning for the number and distribution of training places. The majority of relationships are based on historical linkages and personal contacts with no formal agreements underpinning these relationships. In an environment of overall workforce shortage, the lack of formal agreements between parent and rotation hospitals often results in rotations being curtailed or ceased due to workforce pressures at the parent hospitals.

♦ Training requirements compete with service delivery requirements – the same workforce that comprises the prevocational, vocational trainee and international medical graduates is responsible for service delivery in hospitals. Hospitals rely on registrars to meet their current service delivery requirements, which may be in conflict with future workforce supply and distribution requirements.

♦ Rotation hospitals often face a lack of clarity about the overall training program they are to provide. This has resulted in concerns that rotations are not of high quality nor focused on meeting the training needs of the program.

♦ Training infrastructure across hospitals is varied. This results in some hospitals being unable to meet specialist college accreditation requirements, thus hindering their ability to expand or maintain the registrar workforce to meet service delivery requirements. A lack of training facilities and equipment including library facilities, tele/video-conferencing etc can disadvantage a hospital. At present, there is no coordinated process of identifying and funding training infrastructure needs for hospitals.

♦ Specialist College education programs are conducted primarily in metropolitan Melbourne. This places trainees in rotation hospitals situated in rural and outer metropolitan locations at a significant disadvantage. Whilst efforts are being made to better utilise tele/video conferencing, this is not consistent across all vocational training programs. There is a perception that rural and outer metropolitan rotations reduce access to specialist college fellows who are perceived as being instrumental in progressing the careers of specialist trainees. This has resulted in trainees often being unwilling to relocate outside of their parent

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hospital, especially in the latter years of their basic training.

♦ The increased focus on sub-specialisation by a number of specialist colleges has also had an effect on the ability of rural and outer metropolitan hospitals to access registrars. These hospitals are less likely to be able to provide training in the range of sub speciality areas due to the nature of their services.

♦ The maldistribution of trainees not only affects immediate service delivery capacity, but has longer term repercussions for rural hospitals and the retention of the rural specialist workforce. Research has demonstrated that the location of training is a key determinant on future practice.

♦ The increased reliance on international medical graduates (IMGs) to meet service requirements is impacting on hospitals, often through increased supervision costs.

♦ Given the difficulty that the outer metropolitan and rural hospitals have in recruiting Australian educated vocational trainees, there is danger of a perception developing that the medical workforce composition is defined by the location of the health service.

The planning of the medical workforce for Victoria must focus on appropriate training and equitable distribution to meet the health needs of all Victorians. Given the nexus between training and service delivery, to enable Victorians to access quality and safe health services it is necessary to develop a more coordinated and managed approach to vocational training in public health services.

To do so, requires the establishment of a more formal system for determining the number, mix and distribution of training places that:

♦ Is stable – to avoid scenarios where withdrawal of rotations can occur without prior consultation and agreement between the parent and rotation hospital.

♦ Allows statewide prioritisation of specialities and location of training places based on AMWAC targets, client needs and identified priorities.

♦ Facilitates and markets the advantages of training in a diverse range of sites including outer metropolitan and rural sites to trainees.

♦ Supports hospitals to have adequate levels of training infrastructure eg access to library, computers, tele/video conferencing etc. Ideally, hospitals could have appropriate training facilities and equipment that can be used by all disciplines.

♦ Provides a process through which to facilitate management support for training – some hospitals have faced difficulties filling posts in the past, due to the quality of training support provided.

♦ Engages with Specialist Medical Colleges with regards to curricula, accreditation of training sites, selection of trainees, access to college training programs and support for rural specialists.

♦ Takes into account the training needs of IMGs.

♦ Is able to transcend speciality specific boundaries to encompass training and allocation issues across the spectrum of prevocational and basic training.

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3 Planning for Medical Training in Victoria

3.1 Statewide Planning

To provide a strategic direction for medical education in Victoria and develop a system that enables all health services more equitable access to the medical workforce in training, there is a need to develop a statewide plan that guides the investment in and the amount and distribution of medical training across the state. Such a Statewide Plan would seek to identify shortages or oversupply in the medical workforce, map current workforce education and training capacity and provide mechanisms for addressing changes in the medical workforce. The Statewide Plan would need to take into account localities of projected growth, pressures on the current workforce, service gaps and strategic planning priorities. This would include prioritisation of specialities and geographical locations for training posts, based on current and projected service and workforce requirements.

The inherent linkages between training and service delivery dictate that training requirements need to be aligned with service delivery priorities. Determining service delivery priorities as a guide to immediate medical workforce requirements is a vital element for the Statewide Plan. Health service input is crucial to determining such needs and would be an inherent part of the planning process. A cooperative partnership with specialist colleges in determining the number and distribution of proposed training positions, and the shape of training programs is critical to the development of such a plan.

It is not envisaged that the Plan will supersede the staffing strategies of individual health services. Instead, the Statewide Plan will articulate those localities and specialisations that are a priority for the purposes of state investment. Hospitals will maintain their ability to establish additional positions outside of the Statewide Plan. However, the Department will negotiate with the Royal Australasian College of Physicians (RACP) to facilitate a process whereby positions identified as priorities in the statewide plan are filled ahead of other posts.

The delivery of the statewide plan is dependent on:

♦ Aligning the training and selection processes of the RACP with the workforce priorities and requirements identified in the plan.

♦ Local area based plans that articulate individual health service needs and inform the statewide plan.

The initial focus of the Statewide Plan for the purposes of this pilot will be to determine a set of priority areas for state investment (relevant to the pilot), including considerations around:

♦ Service requirements and viability, particularly in rural, regional and outer metropolitan locations.

♦ Population growth areas.

♦ Demographic change (for example population ageing).

♦ Existing workforce and change projections (e.g. ageing, feminisation, work/life balance, safe working hours).

♦ Victoria’s national obligations (e.g. Australian Health Ministers Conference (AHMC)/Australian Health Workforce Officials Committee (AHWOC) directives/ AMWAC targets).

The Plan will detail priority areas and specialisations to be addressed. It will include:

♦ Targets for the number of trainees in priority sub-specialties (relevant to the pilot).

♦ Targets for distribution of trainees to priority localities.

Targets will be reassessed annually against emerging priorities and performance to date and will be redeveloped where necessary.

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Data Sources

Data to be utilised in development of the plan will include:

♦ Victorian Admitted Episodes Data.

♦ Burden of Disease study.

♦ Demographic data & projections (Australian Bureau of Statistics (ABS) & Department of Innovation, Industry and Regional Development (DIIRD)).

♦ WIES modelling (Weighted Inlier Equivalent Separations).

♦ DRGs (Diagnosis Related Groups).

♦ Victorian Estimated Resident Population datasets.

♦ Local area based plans on health service workforce needs.

♦ Government/Department priorities.

♦ AMWAC targets.

♦ Other variables (i.e. infrastructure development).

Other data sources will be identified as appropriate.

3.2 Consortia Based Training

Whilst a Statewide Plan can articulate targets for the number of basic trainees, trainees in priority sub-specialties and the distribution of these trainees to priority localities, more localised mechanisms need to be put in place to address the mismatch between service needs and workforce supply and the maldistribution of the medical workforce. A training model that operates within and across a consortia of health services is likely to be the best way to ensure a more equitable distribution of trainees, thereby assisting service delivery needs, as well as better meeting the training needs of junior doctors. Achieving this requires linking hospitals in a more formal way and developing mechanisms that enable collective capacity across hospitals in training and workforce planning.

The establishment of training consortia to oversee the distribution of trainees, training delivery and outcomes could achieve these linkages. A training consortia model aims to link parent teaching hospitals with rotation teaching hospitals under a set of governance arrangements for the purposes of medical training. It is expected that each consortium will be self sufficient through the mix of hospitals contained within it and largely able to provide all aspects of registrar training.

Linking metropolitan, outer metropolitan and rural hospitals together provides opportunities to influence the geographical distribution of the medical workforce. A consortia model would facilitate this by enabling equitable access to the registrar workforce - as its distribution is coordinated by the consortium working on behalf of all of its constituent hospitals (as opposed to one hospital), the model provides stability and an opportunity to ensure that the allocation matches the service needs of all training sites within the consortium.

A consortia model provides trainees with a diverse range of training experiences and provides mechanisms through which the delivery of training and the maintenance of training standards can be monitored and improved. The model also provides an opportunity to review the availability of training resources and infrastructure at the various sites and ensure that adequate resources are allocated to enable smaller hospitals to manage their workloads and their training requirements.

The formation of consortia will provide diversity in hospital experiences for junior medical staff and registrars across a range of settings. A consortia approach also provides a vehicle for supporting hospital service needs through the grouping together of facilities where an individual facility may not have the volume or mix of work to support registrar education.

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To facilitate the implementation of the statewide plan within the Pilot, further work will be required with regard to:

♦ Consultation with the RACP to enable posts identified as state priorities to be filled ahead of others

♦ Alignment of hospital workforce requirements with State workforce priorities

For the purposes of the consortia, the statewide plan will articulate targets for the number of basic physician training places and the mix of advanced physician training places required to meet Victoria’s workforce commitments. The targets will guide the allocation of basic physician trainees (BPTs) across consortia. Data provided will also be used to inform negotiations with the RACP regarding the implementation of state priorities. The following diagram illustrates the respective processes relating to the development and the implementation of the statewide plan.

Statewide Plan

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Consultation Outcomes

The concept of a statewide plan received widespread support from hospital administrators. There was a common view that the collection and analysis of data was critical to determining optimum workforce numbers. There was also consensus that an evidence base was necessary to guide discussions with specialist colleges regarding the accreditation of training sites and the allocation of trainees. It was acknowledged that the statewide plan will also assist in national negotiations regarding undergraduate and vocational medical training places. To ensure that the statewide plan reflects Health Service needs and capacity, the first phase of this project will identify the numbers of vocational training places in Victoria and projected numbers required by health services for 2006 and 2007. A medical vocational training survey has been developed and issued for completion by all accredited training sites.

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4 Basic Physician Training Consortia Pilot

In August 2004, the Medical Workforce & Training Advisory Committee recommended that the Department explore the piloting of a consortia approach for basic physician training. The rationale for this recommendation is that the distribution of basic physician and basic surgical trainees is one of the greatest concerns to outer metropolitan and rural hospitals. However, the Royal Australasian College of Physicians has had more exposure to a State led distribution process than other Colleges, due to the establishment of NSW training networks.

It is envisaged that this Pilot will provide a framework to better support basic physician training across Victoria. Trainees have expressed concerns regarding the quality of training at some sites and that service delivery needs have tended to override training requirements. This Pilot should also support the development of new training sites. At present, where new training sites for secondment purposes are accredited, there is no coordinated mechanism though which rotation arrangements for new sites can be negotiated.

The Pilot should also address the current inequitable distribution of responsibility for external rotations. Data provided by the RACP indicates that there is no consistency in the rotation responsibilities of level 3 teaching sites. Whilst some level 3 physician teaching hospitals rotate up to 25% of their trainees externally, others rotate 10% or less. In addition, trainees have discretion in regard to the teaching hospital at which they undertake their training. Rural rotations appear not popular with a significant proportion of trainees and it appears that some resign their posts to take up positions in other metropolitan hospitals to avoid rural rotations.

The Pilot should commence in 2006 for a two-year period. Pending the outcome of the pilot, there is potential to expand the model to other basic and pre-vocational training programs.

4.1 Current Basic Physician Training

Victoria has a number of hospitals1 that are involved in physician training. These are divided according to the RACP classifications of Level 1, 2, 3 or secondment hospitals.

A Level 1 hospital can provide up to 12 months of basic physician training; a Level 2 hospital can provide up to 24 months of the 36 month basic physician training and a Level 3 hospital can provide up to 33 months of training. Training in a secondment hospital is on rotation from a Level 3 hospital and is restricted to 6 months for basic physician training. Victoria has 9 hospitals designated as level 3 teaching sites.

In 2004, 431 trainees were registered as basic physician trainees in Victoria. These trainees were employed in the 9 RACP designated level 3 teaching hospitals. The following table illustrates the employing hospital and the year of training of basic physician trainees in 2004.

2004 Basic Physician Training numbers 2

Level 3 Teaching Hospital Year 1 Year 2 Year 3 Total BPTs Bayside Health - The Alfred 24 19 18 61 Melbourne Health - Royal Melbourne Hospital 21 17 18 56 Eastern Health - Box Hill Hospital 7 10 10 27 Austin Health – Austin Hospital 29 25.5 24 78.5 Southern Health - Monash Medical Centre, Clayton Campus

22 18 21 61

Western Health - Western Hospital 0 14 20 34 St Vincent’s Health – St Vincent’s Hospital (Melbourne) Ltd 29 20 20 69 Barwon Health – Geelong Hospital 8 8 8 24 Peninsula Health – Frankston Hospital 9 0 12 21 Total 149 131.5 151 431.5

Current Rotation Relationships

The following table illustrates the current rotational arrangements for basic physician trainees. A number of hospitals receive rotations from more than one level 3 teaching hospital. In addition, whilst some hospitals rotate a number of candidates externally, others are responsible primarily for their health service.

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Level 3 teaching hospitals St Vincent’s Health – St Vincent’s Hospital (Melbourne) Ltd

Bayside Health - The Alfred

Melbourne Health - Royal Melbourne Hospital

Austin Health - The Austin

Eastern Health – Box Hill Hospital

Barwon Health - Geelong Hospital

Southern Health - Monash Medical Centre, Clayton Campus

Western Health – Western Hospital

Peninsula Health -Frankston Hospital

Level 2 teaching hospital Northern

Health - Northern Hospital

Level 1 teaching hospital Warrnambool Hospital

Ballarat Hospital

Northern Health - Bundoora Extended Care

Ballarat Hospital

Secondment hospitals Barwon Health -Geelong Hospital

Mildura Hospital

Wangaratta Base Hospital

Bendigo Hospital

Wodonga Regional Health Service (from 2005)3

Western District Health Service - Hamilton Hospital

Southern Health - Dandenong Hospital

Western Health - Sunshine Hospital

Eastern Health - Maroondah Hospital

Goulburn Valley Health

Western Health - Western Hospital

Royal Children’s Hospital


Warragul Hospital

Western Health - Williamstown Hospital

Central Gippsland Health Service (Sale),


Wodonga Hospital (2004)3

Eastern Health - Peter James Centre

Calvary Healthcare, Bethlehem

Goulburn Valley health (Shepparton)

Eastern Health - Angliss Hospital

Latrobe Regional Hospital, Traralgon

4.2 Training Consortia Configuration

Options for the number of training consortia is restricted to 5 to ensure equity in the distribution of trainees, provide a diverse range of training experiences, minimise infrastructure costs and enable effective use of training resources. Any less than 5 would make a consortia too large to provide the approaite training focus and any more than 5 would make consortia too small to offer the diverse range of rotations required for the model to function effectively.

In accordance with RACP guidelines, each consortium needs to include a Level 3 physician teaching site. Given that there are 9 Level 3 teaching hospitals, some consortia will inevitably have more than one Level 3 teaching site. To ensure consistency in rural rotation responsibilities there should not be more than two level 3 teaching sites in any one consortium. Consortia need to include a mix of metropolitan and rural hospitals with each consortium having a minimum of three rural teaching sites for secondment purposes.

Option One – consortia based on existing linkages with a mix of inner metro, outer metro and rural teaching hospitals

This option has been developed from the premise that, in the long term, the membership of consortia needs to be diverse enough to enable the model to be applied to other basic specialist training beyond BPT. As a result, this option proposes consortia based on a mix of inner metro (A1), outer metro (A2) and rural hospitals. Linking the range of inner metropolitan hospitals with

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outer metropolitan and rural hospitals ensures that each consortium has the ability to offer training across the breadth of specialties. A1 hospitals have the capacity to offer training opportunities in all sub-specialties which enables the consortium to offer a diverse range of training experiences to retain its pool of junior doctors across the continuum of training from PGY 1 to the end of basic training. Thus, on completion of this pilot for BPT, the same consortia could be expanded to other specialties for the purposes of basic training.

This option maintains current links between metropolitan and rural hospitals with regard to basic physician training. It takes into account existing rotation relationships of rural training sites and seeks to maintain this where possible. Outer metropolitan hospitals have been linked with inner metropolitan hospitals on the basis of current rotation arrangements, clinical training relationships (eg undergraduate clinical teaching) and patient referral patterns.

Consortia A Consortia B Consortia C Consortia D Consortia E

BPTs 4 87 88 90 78.5 5 73 PGY 1s 71 83 86 67 66 PGY 2s 78 126 119 119 120

Barwon Health Bairnsdale

Regional Health Ballarat Health Service

Austin Health The Austin Heidelberg Repatriation Hospital Royal Talbot Rehabilitation Centre

Southern Health Monash Medical Centre- Clayton campus Monash Medical Centre - Moorabbin campus, Dandenong Hospital Kingston Centre Casey Hospital

Central Gippsland (Sale)

Bayside Health Caulfield General Medical Centre Sandringham & District Memorial Hospital The Alfred

Melbourne Health Melbourne Extended Care & Rehabilitation Service Royal Melbourne Hospital

Bendigo Healthcare Group

Peninsula Health – Frankston Hospital Mount Eliza Centre Rosebud Hospital

Mercy Hospital for Women (Werribee campus)

Eastern Health Angliss Hospital Box Hill Hospital Healesville Hospital Maroondah Hospital Peter James Centre

Wangaratta Hospital

Echuca Health Service

Latrobe Regional Hospital (Traralgon)

St Vincent’s Health Caritas Christi Hospice Ltd St George’s Health Service St Vincent’s Hospital

Goulburn Valley Health

Western Health Sunshine Hospital Western Hospital Williamstown Hospital

Northern Health Broadmeadows Health Service Bundoora Extended Care Centre The Northern Hospital

West Gippsland Health Service (Warragul)

South West Healthcare (Warrnambool)

Mildura Base Hospital

Wodonga Regional Health Service

Wimmera Health Service (Horsham)

Swan Hill and District

Western District (Hamilton)


Benefits

♦ This option links all major teaching sites into consortia. Each consortium has a mix of rural, outer metro and inner metro hospitals. This ensures that each consortium is relatively similar in size and scope of practice.

♦ It enables longer-term sustainability. The membership of consortia can remain the same for a number of specialities. Collectively, the constituent hospitals within each consortium have the

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capacity to provide basic training across the physician and surgical specialties in the first instance. There is also scope for each consortium to be able to provide training beyond the physician and surgical specialties to other specialities.

♦ It complies with College guidelines regarding training and rotations as each consortium includes level 3 teaching sites as well as secondment sites.

♦ The proposed consortia are similar in terms of membership and all consortia have similar levels of external rotations across them.

♦ The inclusion of a mix of inner metro, outer metro and rural hospitals in consortia, ensures that each consortium is similar in terms of its ability to market a diverse training experience whilst providing adequate metropolitan exposure and not giving one consortium an advantage over other consortia in terms of the attractiveness of the training program. This is particularly pertinent given that trainees express a preference for metropolitan rotations in the latter part of their training - especially near exam times. Whilst efforts have been made to enable access to College tutorials/training programs via telemedicine, this has not reduced the preference for metropolitan rotations.

♦ Each consortium is relatively similar in terms of its size and the diversity of training experiences it can provide.

Risks

♦ The main disadvantage of this model is that it proposes some new links and reduces duplication of current training relationships, which may cause some disruption and require some level of commitment or incentives to implement changes. Whilst health services in the proposed consortia have links to each other, individual hospitals within each health service have different arrangements with regard to training. A consequence of reducing duplication has resulted in some current relationships being terminated.

♦ Wimmera Healthcare Group (a newly accredited site) has been placed in consortia D to ensure an equitable distribution of rural rotation sites (minimum of 3 rural rotations). Wimmera Healthcare Group currently has limited links with the hospitals in its proposed consortia.

Option Two - Consortia based on existing linkages but refined for improved geographic alignment

This option maintains the hospital membership as proposed in Option One for Consortia A, C and D. It proposes the following changes to Consortia B and E:

♦ Eastern Health to be allocated to Consortia E.

♦ Peninsula Health to be allocated to Consortia B.

♦ Swan Hill and District and Calvary Health care, Bethlehem to be linked with Consortia B (under consortia E in Option One).

♦ Bairnsdale Regional Health to move to Consortia E.

The above changes are to geographically align the inner metro, outer metro and rural hospitals within consortia B and E. The geographical fit of Eastern Health and Southern Health is considered more relevant given the further development of Knox Hospital as the geographic centre of Eastern Health. The movement of Bairnsdale Health is consistent with the move of Eastern Health given the links between these health services. Swan Hill and District Health Service is considered better geographically aligned with Consortia B that also includes Mildura Hospital.

The table below illustrates the proposed allocation of hospitals within each consortium:

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BPTs6 87 73 90 78.57 88 PGY 1s 71 66 86 67 73 PGY 2s 78 104 119 119 114.5

Barwon Health

Geelong Hospital Bayside Health Caulfield General Medical Centre Sandringham & District Memorial Hospital The Alfred

Ballarat Health Service


Bairnsdale Regional Health

Central Gippsland (Sale)


Melbourne Health Melbourne Extended Care and Rehabilitation Service Royal Melbourne Hospital

Bendigo Healthcare Group



Goulburn Valley Health (Shepparton)

Wangaratta Hospital

Echuca Health Service Latrobe Regional Hospital (Traralgon)







Peninsula Health Frankston Hospital Mount Eliza Centre Rosebud Hospital






Benefits

♦ Allows for a more even distribution of BPTs across Consortia B and E.

♦ Eastern Health and Southern Health are considered better aligned geographically.

♦ Maintains Eastern Health rotations to Bairnsdale Regional Health Service.

♦ Swan Hill and District Health Service is better geographically aligned with Mildura.

♦ Bayside Health has existing rotation relationships with Peninsula Health.

Risks

♦ If geographical alignment is the key driver, Southern Health and Peninsula Health are better aligned geographically than Eastern and Southern Health and Peninsula Health and Bayside Health.

♦ Potential to disrupt undergraduate clinical training, as The Alfred and Box Hill Hospital form part of the same Monash University clinical school. This may require reallocation of University teaching staff, which will need to be negotiated with Monash University.

♦ Although Calvary Healthcare, Bethlehem receives intern rotations from Bayside Health, it has a rotational relationship with Southern Health for basic physician training.

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Option Three - Consortia based on existing linkages but refined for different geographic alignment

This option proposes changes to the consortia model proposed in Option One. In this option, Ballarat Health Services has been allocated to Consortia A and Central Gippsland Health Service (Sale) has been moved to Consortia C. Consortia B, D and E remain the same as in Option One.

This option is designed to geographically align hospitals in Consortia A to create a South West consortia. The allocation of Central Gippsland Health Service (Sale) has been substituted with Ballarat Health Services to facilitate this.


BPTs2 87 88 90 78.53 73 PGY 1s 83 67 66 PGY 2s 126 119 120

Ballarat Health

Service Bairnsdale Regional Health

Central Gippsland Health Service (Sale)



Barwon Health Bayside Health Caulfield General Medical Centre Sandringham & District Memorial Hospital The Alfred

Melbourne Health Melbourne Extended Care and Rehabilitation Service Royal Melbourne Hospital


Peninsula Health – Frankston Hospital Mount Eliza Centre Rosebud Hospital



Wangaratta Hospital Bendigo Healthcare Group

Latrobe Regional Hospital (Traralgon)


Goulburn Valley Health (Shepparton)


Echuca Health Service









Benefits

♦ Enables Consortia A to be geographically aligned as the South West Victorian Consortia.

Risks

♦ There are limited linkages between Royal Melbourne Hospital and Western Health (Level 3 teaching sites in Consortia C) with Central Gippsland Health Service. It is understood that Melbourne Health and Ballarat Health Services have a long-standing relationship with regard to patient referrals and clinical training. It is further understood that Central Gippsland Health

2 Based on level 3 teaching hospital figures provided by the RACP for 2004 3 Does not include BPTs which may be directly recruited by the other constituent hospitals

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Service and St Vincent’s Hospital have similar clinical and training linkages. Thus, these health services may not be agreeable to this change given the effect on their existing patient referral and clinical links.

4.3 Specialist Hospitals

To enable trainee access to specialist teaching hospitals8 specialist hospitals would not be allocated to specific consortia. This will allow each consortium access to specialist hospitals for training purposes. For the purposes of the pilot, current rotations to specialist hospitals would remain unchanged under Options One, Two and Three. Thus the following rotations of BPTs would continue:

♦ St Vincent’s Hospital (Consortia A) rotations to Peter MacCallum Cancer Institute.

♦ The Austin Hospital (Consortia D) rotations to Royal Children’s Hospital.

This, however, does not preclude other consortia that wish to develop relations with specialist hospitals for basic physician training purposes from making specific arrangements with these hospitals.


Widespread in principle support was received for consortia arrangements from each stakeholder sector. The institutionalisation of links between hospitals wais supported for its ability to allow the provision of a range of training experience for trainees within a formal training program. Rural sites strongly supported the improved security in rotational relationships the consortia model offered.

Membership options were of greatest concern to CEOs, physicians and administrators, whose priorities included the maintenance of current links and referral patterns, alignment according to culture and geography, and furthering the particular health service’s strategic outlook. For the most part, the views of these sectors were aligned. BPTs were concerned that the overall quality of training in each consortium would be comparable, and of an acceptable standard.

The majority of stakeholders expressed a preference for option 2. During the consultation process, other concerns were raised about option 2. These are detailed below:

Size of Consortium E Southern Health and Eastern Health are large health services in themselves, both involving several intra-health service rotations in addition to external rotations. As such, some hospitals have expressed concerns that this consortium will be significantly larger than others and may become unwieldy. Concerns were also raised that due to intra-health service rotations, there is a danger that BPTs in this consortium may have significantly less time at the level 3 teaching site when compared to the experience of other consortia. Southern Health has approximately 4 intra-health service rotations and Eastern Health has 3 intra-health service rotations, bringing the total number of rotation sites for Consortium E to 9 (including 2 rural rotation sites4).

Adequate exposure to medical specialties There is an RACP requirement that of the 24 months of core training required, 12 months must be spent in medical specialty rotations. The consortia will be guided by the RACP accreditation for the adequacy of medical specialty exposure at accredited level 3 teaching sites.

University clinical school links The membership model will result in a crossing of university undergraduate links. Consortia A, B and D will involve sites from both The University of Melbourne and Monash University (See Appendix 3 for breakdown of university links). Monash University’s Central and Eastern Clinical School will be divided by Option 2, in which The Alfred is allocated to Consortium B and Box Hill to Consortium E. This was not considered to be a setback, as medical educators consulted at the Box Hill Hospital advised that they would provide a stand-alone clinical school for Monash University undergraduate medical students within the next 5 years. Such a crossing of links did

4 Consortia E rural rotations include Traralgon and Warragul. Although Bairnsdale is part of Consortium E, it is not an accredited training site.

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not alarm universities, who suggested that this is not contrary to current practice and may provide an avenue through which cross-institutional links may be fostered.

Number of rural rotations within consortia There is inequality in the number of EFT rural rotations across consortia. Consortium C has 8 EFT rotations, Consortium A has 6, Consortium D has 5 and Consortia B and E have 4. However this is not perceived to be a critical issue, as it may go some way toward remedying the intra-health service rotations which burden Consortia B and E more heavily.

Recommendations:

Option 2 be adopted for the 2006 pilot.

Governance and training concerns should be addressed through the establishment of a Consortia Governance Subcommittee of the MWTAC.

The impact on the size of consortium E and the effect on University clinical school links be monitored over the 2006/2007 period.

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5 Consortia Operations

5.1 The Role of the Training Consortia

The Training Consortia will have responsibility for overseeing the medical education and training of basic physician trainees. Specifically, the Training Consortia will:

♦ Implement the Statewide plan with regard to the priorities for basic physician training.

♦ Coordinate and prioritise basic physician training across its constituent hospitals. In doing so, a consortium will ensure that it represents the needs of all hospitals within the consortium on an equitable basis.

♦ Oversee the education and training experience of basic physician trainees within their constituent hospitals.

♦ Determine a method of distributing basic physician trainee workforce through the Consortium’s constituent hospitals in order to provide a positive training experience and provide staffing numbers to meet service delivery imperatives.

In consultation with their constituent hospitals, and with the input of the supervisors of the RACP BPT training program, Consortia may need to establish a broadly defined set of education outcomes to be met for each year of training. This will ensure the delivery of basic physician training in a co-ordinated manner. To facilitate this, the education and training plans of consortia would ideally include the following:

♦ Plan, supervise (administer) and monitor rotations of basic physician trainees.

♦ Allocation of education outcomes to each rotation to ensure that hospitals know what is expected of them and trainees know of the rotations and the aspect of training to be provided at the rotation hospital.

♦ Establish and monitor standards/quality for basic physician training, oversee their placement and provide personal and professional support.

♦ Establish and monitor appropriate supervisory systems.

♦ Develop rotation plans that ensure that constituent hospitals receive basic physician trainees in line with their service requirements.

♦ Establish a system of monitoring the educational achievement of basic physician trainees in the Consortium.

♦ Report in line with contracts (i.e. monitoring, reporting to the Department).

The Training Consortia would be responsible for the training and education outcomes across their constituent hospitals. They would be responsible for reporting on areas such as:

♦ Achievement against the Statewide Plan with respect to priorities for basic physician training.

♦ Numbers and rotations of trainees.

♦ Trainee assessment of training experience.

♦ Assessment of consortia against constituent hospital workforce requirements.

♦ Trainee well being & support.

For the consortia model to work effectively, the consortia needs to be separate from but working on behalf of its constituent hospitals. This is to ensure that the interest of each constituent hospital is advocated for in an equitable basis and avoids perceptions (real or otherwise) of bias.

5.2 Statewide Management

It is proposed that the Medical Workforce & Training Advisory Committee (MWTAC) will assist the Department in the overall implementation of the BPT consortia pilot. The role of MWTAC would be to provide a forum through which issues relating to the Consortia could be progressed.

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This would include assisting in the following:

♦ Distribution of BPTs within consortia via a centralised allocation process.

♦ Development of funding models for consortia-based training targets.

♦ Reviewing consortium training plans in the context of the Statewide plan.

♦ Assist in monitoring consortia activity against specified deliverables.

♦ Facilitate an appeals process to address grievances including arbitration.

♦ Addressing any policy issues that affect the operation of consortia.

♦ Reviewing the number of BPTs per consortium and the impact of increased numbers in one consortium on other consortia.

MWTAC

Statewidemanagement

Constituenthospitals

Constituenthospitals

Consortia Mgt Committee






Most stakeholder sectors throughout the consultation process made calls for the MWTAC to be extremely vigilant in its responsibility to oversee the consortia. The preferred model for consortia governance involves a subcommittee of the MWTAC, including representatives of each consortium and BPTs.

Key tasks for the statewide management involved in the oversight of the consortia will be to ensure that there is avoidance of a silo-effect between consortia, that all consortia have comparable educational standards set, to provide an avenue for arbitration and dispute resolution, and critically, that all consortia comply with consortia governance guidelines.

In the absence of any well-defined governance structures and mechanisms presented in the discussion paper taken to consultation, all stakeholder sectors invariably insisted on a need for the statewide and consortium governance structures to be robust, vigilant and active. There is a need for the governance arrangements have the capacity to maintain standards and to enforce guidelines. Many questioned the ability of this model to enforce its guidelines, and suggested that if guidelines cannot be, or are not enforced, the model will fail.

Recommendation

The MWTAC establish a Consortia Governance Committee, to have responsibility for the oversight and implementation of the pilot. Representation to include consortia, hospitals, RACP and BPTs.

5.3 Consortium Management

To enable the consortia process to function effectively, the establishment of a Management Committee for each consortium is proposed. Given that the consortia is working on behalf of its constituent hospitals, the Committee would need to include representatives of all its constituent hospitals as well as basic physician trainee representatives.

The success of the consortia model relies on each constituent hospital meeting its responsibilities with regard to training in return for guaranteed access to trainees. The Consortium Management Committee(s) will be key to monitoring the performance of constituent hospitals against the overall training plans. In addition to monitoring the education and training deliverables of its

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constituent hospitals, the Consortium Management Committee would also be responsible for addressing specific management issues within each consortium such as:

♦ Recruitment of consortia staff.

♦ Recruitment and allocation of trainees.

♦ Administration of the consortium.

♦ Quality assurance (including maintaining standards of education, supervision and training and rostered hours on duty and on call).

♦ Reporting requirements against key performance indicators to ensure accountability to DHS, hospitals within consortium, trainees and the RACP.

♦ Conflict of interest.

♦ Transparency of funding processes.

♦ Confidentiality.

♦ Dispute resolution and grievance handling.

♦ Legislative compliance.

♦ Maintaining a Code of Conduct within the consortium.


There are significant levels of distrust within some groupings of hospitals. These concerns include:

♦ Outer metropolitan hospitals expressing a concern that they may be dominated by A1 hospitals;

♦ Rural hospitals are apprehensive of the degree of change in attitudes which will be possible, and are concerned they will be subjugated by metropolitan hospitals; and

♦ Inner metropolitan hospitals have concerns that they may be out-voted by rural and outer metropolitan hospitals, resulting with them being forced to bare significant levels of vacancies and hold limited influence, despite providing the bulk of teaching and employing the majority of BPTs.

While the notion of equality in representation is maintained as the ideal mechanism for consortium governance, there are clear concerns which will need to be addressed in particular consortia to allay apprehension from all parties. These will need to be addressed on an individual basis, but may be supported by guidelines and the Statewide Governance Committee.

Recommendation

Each consortium will need to establish a management committee with membership from constituent hospitals, trainees and DPTs to deal with these issues.

Management committee voting rights will be based on the principle of one health service – one vote.

5.4 Funding

For the consortia model to work, additional funding support will be required. This support could be in the form of dedicated staff to administer and implement the BPT pilot on behalf of constituent hospitals. Ideally, each consortium would recruit a Director of Physician Training (DPT) who would head the consortium. In addition to the DPT, each consortium would be allocated additional funding to employ additional staff, assist in meeting infrastructure requirements or provide incentives to trainees to undertake rural rotations.


The consultation process identified that there are concerns that if adequate funding is not provided, the consortia model will be unsuccessful.

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It was proposed during the consultation process that the consortia position leading the consortia should be a Director of Clinical Training (DCT) as opposed to a DPT. A DCT is preferred because a number of hospitals advised that they would prefer to maintain the current responsibilities of their hospital DPTs in terms of monitoring training deliverables. Hospital-based DPTs have a far more extensive knowledge of the training capacity and delivery in their sites, and are better able to implement change from within their respective hospitals. It was suggested that a single consortium DPT would have difficulty overseeing a training program across the cluster of hospitals at the required level of detail. Thus a consortium DCT would have a coordinating and monitoring role, while the delivery and reporting of training programs will be the responsibility of hospitals DPTs.

It was also proposed that small rural hospitals should be provided support to facilitate the recruitment of a DPT to oversee training at each rural secondment site. As such, each training site will be required to have a dedicated DPT responsible for the delivery of training.

Recommendation

Each consortium should be led by a Director of Clinical Training or equivalent.

Each training site should have dedicated staff responsible for basic physician training. This position(s) will have the responsibility for the education and training of BPTs.

5.5 Trainee Recruitment Principles

Application

The following two options for the selection of trainees to consortia are proposed:

♦ The recruitment of BPTs could be undertaken centrally. This system could be similar to the Postgraduate Medical Council of Victoria (PMCV) computer match (or the national selection processes of most Specialist Colleges) where candidates express their preference for consortia based on their merit ranking and are allocated to consortia accordingly.

♦ Alternatively, trainees could apply in open competition to a hospital for employment purposes. Pending their recruitment to a base hospital, trainees would be allocated to the consortia based on the membership of their employing hospital.

Trainees will need to identify a base hospital within the consortium. The base hospital will be responsible for the trainee’s employment, including issues such as coordinating leave entitlements. Selection to base hospital positions could be undertaken simultaneously with consortia interviews through the inclusion of constituent hospital representatives on the interview panel. Thus, in addition to nominating a preferred consortium, trainees would also identify their preferred base hospital within their preferred consortia. During the interview process, the nominated base hospital could also make a decision regarding whether they wish to recruit the trainee to their hospital.


During the consultation program, the first option was viewed by trainees, administrators and physicians as overly complex and burdensome, due to the two-tiered nature of selecting a consortium and then a base hospital. This option found limited, qualified support from these sectors of the consultation, because it provided a capacity to manage consortium vacancies, and avoid the situation that emerged in NSW in which trainees were reassigned post signing of contracts due to high vacancy levels in one network. That experience was viewed universally as one that was critical to avoid.

The consultation process revealed limited support for the second option particularly from some administrators and some trainees. Administrators favouring this model did so because they have not had positive experiences with the PMCV computer matching system, or because they felt that competition offered them greater control over their recruitment, due to the direct recruitment of BPTs to hospitals, rather than consortia, offered in this option. Trainees favoured it because they felt it offered them greater flexibility and freedom of choice in employer, again due to the direct recruitment to hospitals, not consortia.

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Over the course of the consultation a third alternative for a method of recruitment was developed, in which a centralised matching system would allocate trainees to hospitals (rather than consortia, as in the first option above). Under this option, BPTs would nominate their preferred hospitals to a matching process, which then allocates to hospitals similar to the PMCV match. The allocation to consortia would be by default to the consortium in which their nominated hospital has membership. Among those who received that suggestion, it was the most popular option.

This model addressed concerns about the complexity and lack of freedom in choice of employer that were noted in the two-tiered system by matching only to hospitals. It also addressed concerns about the capacity to manage vacancies prior to contracts being offered.

There will need to be contingencies established to manage instances in which a hospital receives insufficient preferences during the matching process, resulting in the hospital being unable to meet its workforce needs. A potential method to address this concern would be to require BPTs to rank all hospitals in their list of preferences to allow distribution across all sites.

Recommendation

A central allocation process should be established utilising a matching process. The Consortia Implementation Subcommittee should develop guidelines for the recruitment and computer match process and determine the system for conducting interviews and allocating rosters.

Filling of Positions

It is proposed that trainee positions within each consortium will be filled on the basis of the following principles:

♦ The number of available positions in each consortium will be finalised by the Consortia Management Committee in consultation with the Department.

♦ If a vacancy arises within a consortium, vacancies must be filled in the following order - rural health services, outer metropolitan health services and inner metropolitan hospitals.

♦ Any changes to the number of rural positions within each consortium will need to be negotiated with the Department.

Appointments will ideally be for 2 years to align with the length of the training program. As far as possible, the allocation of rotations will be made available to trainees when they commence their training. This will allow trainees, hospital administrators and Directors of Physician Training (DPTs) greater flexibility in planning rotations to ensure balance of terms over the 2 years and enable trainees to plan their personal and family lives to accommodate rotations. However, provision will need to be made within the contracting arrangements to allow for changes to rotation, at short notice, to fill gaps within the consortium, where necessary.

It is recommended that BPTs commence medical registrar roles in PGY3 or later, by which time they are expected to be registered with the RACP as basic trainees. Where trainees commence basic physician training in PGY2, they will remain under the auspices of the PMCV. For the consortia model to work, all medical registrar positions (i.e. PGY3 and above) suitable for basic physician training must be recruited via the consortia.


Trainees have raised concerns about the order of filling of positions; the Victorian Training Committee of the RACP suggested that there should be no distinction between inner metropolitan and outer metropolitan hospitals, rather distinction should be in accordance with RACP accreditation. A number of metropolitan hospitals have also expressed that a distinction needs only to be at a metropolitan and rural level.

Most trainees considered that rosters were best completed by the administrations at their own hospitals, due to the ability of these administrators to tailor a roster that is appropriate for the personal needs and interests of individual BPTs. Concerns about the intricacies of rostering also involved suggestions from physicians, administrators and trainees that certain rotations that are appropriate only for more experienced medical registrars, in particular some rural rotations.

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Currently, administrators arrange rosters to address such personal and professional concerns, and all stakeholder sectors suggest that this should continue under the consortia pilot.

Administrators held concerns in that they may cede control of rostering their staff to meet consortium needs, and competing pressures from the consortium as well as from BPTs might compound the difficulty of their task. During the consultation process, there were calls for clarification of the logistics involved with the rostering to ease these concerns.

The ability to provide an accurate 24-month roster was questioned by administrators, physicians and trainees, due to the cumulative effect over 2 years of unanticipated vacancies that will impact several rosters, making these arrangements almost impossible to implement. There was little confidence in the accuracy of a potential 24-month roster and as such, it was rejected by most stakeholder sectors.

There are also concerns about how BPTs who fail the RACP Part 1 exam, but have met clinical requirements, part-time BPTs, and others for whom a 24 month contract is inappropriate will fit into a system with such contracts, given these groups will have commitments which cannot fit that term.

Trainees have concerns that they may miss out on subspecialty rotations which they feel are critical for their exam preparation, due to filling rural vacancies. To address these concerns the RACP training committee suggested that vacancies that occur at very short notice should be filled by several BPTs for a term of 3-weeks each, to ensure their access to subspecialty rotations and fill rural vacancies.

Recommendations

The distinction between outer metropolitan and inner metropolitan hospitals should be removed for the purposes of vacancy management and filling of positions.

The Consortia Implementation Subcommittee should develop guidelines for contract and roster management.

Trainee Movement Between Consortia

To reduce the number of instances where trainees are asked to fill rural posts because of last minute resignations, two options are proposed:

♦ Any trainee requests to move between consortia are restricted to an annual basis, in line with hospital recruitment processes. Movements outside this period could result in the trainee being allocated to a non-accredited position resulting in the term of service (outside the annual recruitment cycle) not being accredited towards basic physician training. Under this option any requests for movement between consortia will need to be approved by the Statewide Management Committee. This will enable the documentation and monitoring of trainee movements between consortia. It will also allow the Statewide Management Committee to address any concerns that are resulting in trainees leaving particular consortia.

♦ Alternatively, consortia DPTs could develop an agreement with each consortium not to recruit outside of the contractual period of 2 years.


Hospital administrators and some physicians have suggested that at present, some trainees resign their posts to take up positions in other metropolitan hospitals to avoid rural rotations, which destabilises the hospital workforce and makes planning difficult. It also requires these vacancies to be filled with very little notice for the BPT who is assigned to fill that position, which is an unsustainable system.

Many administrators welcomed these options as a positive step toward ensuring staff availability and stability in rostering. However, this point provided a source of alarm for trainees, who felt that this potentially posed a threat to their work-life flexibility and could compel them to remain in jobs that may be unsatisfactory in meeting their career or personal needs. This contributed to trainee opposition to a 24-month contract, with many considering annual recruitment and re-application to positions as necessary to guarantee their freedom of choice in employer.

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Administrators and physicians rejected the second option that involved an agreement not to recruit to training positions outside the 24-month contract period, due to the potential for workforce shortages to lead to the undermining of this agreement. Trainees held concerns that this option would limit their career options and as such, it was strongly rejected.

To ensure flexibility for BPTs, the capacity to re-enter the allocation process and switch employing hospital at the annual recruitment cycle was accepted as an acceptable measure for flexibility, while a 24-month contract would otherwise provide stability and minimise the administrative burden. BPTs sought guarantees that the decision of a BPT to re-enter the allocation process would not lead to prejudice in their future career options.

Recommendations

Annual movement between consortia should be allowed at designated recruitment times: trainees who wish to resign from their current position will have an opportunity to re-enter the allocation system and apply to another hospital at the designated time.

Vacancy Management

In an environment of workforce shortage, vacancies will be inevitable. To avoid scenarios where a single consortium may be faced with a significant number of vacancies, efforts will be made to ensure that all consortia have a similar level of vacancies. The allocation of vacancies can be undertaken via the central trainee allocation system. This is considered necessary to avoid situations where one or two hospitals have to bear the burden of vacancies.

This paper proposes that such vacancies be borne by the major metropolitan hospitals. The rationale for this is two-fold:

♦ Metropolitan hospitals are in a better position to absorb vacancies than smaller rural centres given the size of their workforce. A rural hospital has less capacity to cover the vacancy. Given the smaller rural workforce, there is also a potential impact on other junior doctors requiring supervision (eg interns requiring supervision from registrars), which could produce a domino effect of classifying the rural training site as a “bad rotation”.

♦ Where vacancies in training positions occur, hospitals have to rely on alternative mechanisms of recruitment. Primary amongst this is the engagement of the IMG workforce. It can be argued that the IMG workforce in a number of scenarios may require more support than an Australian trained registrar (who is on a rotation and within an established training program). This support is more likely to be available in a metropolitan setting.

In the event of an oversupply, the Statewide Plan will guide the distribution of the additional workforce.


There was a concern amongst BPTs that vacancy management measures were “punitive measures” to force compliance with the consortium, and that trainees who declined to be sent to rural sites with no notice would face recriminations.

BPTs felt that they may be disadvantaged, regardless of their behaviour, under the vacancy management section, and as such demanded some easing of this section. Administrators and physicians were sympathetic to their dilemma. BPTs suggested that there should be standard notice periods for changes to the roster from both hospital administration and trainees. If either did not provide sufficient notice, measures for recompense may be considered.

The RACP training committee has made specific recommendations for addressing this issue. These include a requirement that for situations in which a trainee is required to fill a rural post at short notice, this be restricted to 3 weeks only.

Recommendation

The Consortia Implementation Subcommittee to further develop guidelines to address the issues raised regarding vacancy management at short notice.

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Duration of Rotations

This model proposes that each rural rotation be of a minimum period of 3 months. Whilst extended rotations are considered more beneficial to trainees and hospitals, it is acknowledged that not all trainees are able to consider extended rural rotations. As a result, it is proposed that rural rotations remain for a minimum of 3 months, with options to continue that period to 6 or 12 months (depending on the accreditation status of the training site).


There was consensus from administrators, physicians and trainees that a 3-month rural rotation was an acceptable term. Trainees agreed to the potential for one rural rotation in 12 months. The AMA HMO Certified Agreement 2002-2005 allows no more than one third of the contract period to be worked outside the employing health service without prior negotiation, which enables a 3-month rotation plus a period of short-term cover to be acceptable under that agreement. It is expected that there will be no need for any BPT to fill more than 2 rural rotations in the 24-month period of consortium employment, indeed, working from current numbers, approximately 17% of BPTs will have to fill their compulsory rural clinical term in their PGY 2 year to meet RACP clinical requirements.

Recommendation

The maximum duration of a rural rotation should be capped at 4 months. Trainees should not be rostered to undertake more than one rural term in 12 months. Trainees who wish to undertake additional rural terms in a clinical year should be encouraged. The Consortia Implementation Subcommittee should suggest incentives to encourage trainees to undertake additional rural terms.

5.6 Quality of Training


Provision of Training

Quality of training at particular sites was a key issue raised by administrators, physicians and trainees throughout the consultation process. It was widely commented that there is a great variety in the experience offered by working in rural sites. It was suggested that some rural sites provide excellent training exposure, a number of rural sites offer no formal teaching opportunity. It was also suggested that in some centres, some consultants had little or no interest in the provision of formal teaching. There is a marked lack of communication between trainees, consultants, hospitals and the RACP regarding the level of teaching that is expected in accredited training sites. The role of RACP in monitoring the delivery of training at accredited sites needs to be clarified, in terms of continued accreditation of sites that have been reportedly failing to deliver training. Trainees were sceptical of the ability of the DHS and the MWTAC to institutionalise adequate changes to address attitudes toward training prior to the commencement of the pilot in 2006.

Some sites have suggested that a boost in infrastructure would greatly assist their ability to provide training, however, some trainees do not believe that this is sufficient, because they suggest that for them, the quality of a secondment site is shaped largely by their relationship with, and the attitudes of, physicians. This is demonstrated by the fact that some physicians have claimed that they provide good teaching, and a successful training experience, but among trainees these rotations are not viewed positively. In other situations, busier and more challenging rotations are preferred due to the enthusiasm of physicians, which ensures that the rotation is a beneficial training experience.

In some situations, the provision of ‘train-the-trainer’ programs could be beneficial, and have been strongly supported by physicians and trainees, however changing attitudes and the alleviation of personality conflicts will be difficult. To help with the ability of rural physicians to

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provide effective and up-to-date training, it was suggested that the initiation of a program involving seconding physicians from tertiary teaching sites to rural secondment sites, for one day a month, to mentor and provide some training to BPTs and to foster ties with consultants. Similarly, to maintain access to continued professional development, and awareness of emerging developments in clinical practice, it has been suggested that rural physicians be supported through the consortia to attend conferences and spend time in tertiary teaching hospitals. This may foster collegiality and support for rural physicians that has been lacking in some places, and address junior doctor concerns about quality of teaching.

There are concerns from trainees, administrators and physicians around the capacity of rural physicians to introduce an extensive training program. These concerns are due to the current workload of rural physicians which have to date been such that additional demands on their time will make their position particularly unattractive due to excessive hours. Many trainees suggested that while consultants were affable, it was difficult to arrange time with them because they were so busy. Similarly physicians and administrators believe that the introduction of compulsory training programs will further limit their ability to meet service demands in their region.

There is a significant disconnect between trainees and physicians about the nature of physician training. Trainees overwhelmingly understand training to be conveyed through formal teaching, however, many physicians, especially rural physicians, understand training to be better delivered through an “apprenticeship model” in which essential elements of training are best delivered through practice. This is compounded by the RACP exam process, which is understood universally to be an extremely stressful experience for trainees, and is suggested to be heavily academically oriented. This is an issue raised by trainees and physicians who are each having difficulty reconciling the priorities of training and service delivery.

Access to training programs

There is difficulty involved with the provision of training in rural sites and the ability of hospitals to provide cover to enable BPTs to attend such training. At sites where teaching is provided, an additional barrier to BPTs accessing that teaching is their service load requirements and differential hospital arrangements to cover BPTs for tutorials and other training. The lack of designated training time limits access to RACP telemedicine lectures and in-house teaching, as some BPTs are reluctant to leave their wards unmanned. This has lead to frustration in some sites due to poor attendance at formal training occasions, and the termination of such programs. Some sites have arrangements in which consultants hold the pager of BPTs for the period of formal teaching opportunities to ensure that BPTs are able to avail themselves of that service. In other sites, there is an agreement that BPTs will be paged in that time period only in emergency situations. At other sites BPTs are forced to share between themselves the service load and teaching in alternate weeks, in order to maintain medical cover across the wards or hospital. There will need to be measures included in the governance mechanisms to ensure that there will be some form of cover arrangement to span the time of training deliverables.

BPTs and rural hospitals have suggested that there is a need to set minimum educational and training standards for each site. This would assist with the setting of boundaries and expectations for rural sites and may contribute to a change in attitudes toward training in rural sites across the system. The RACP may be able to provide suggestions regarding the type of requirements that are essential for BPT training and supervision. It has been acknowledged that certain concessions are essential to enable BPTs’ education and training needs to be addressed within a consortia model. These include specific guidelines will be necessary to ensure that each constituent hospital delivers on a set of training deliverables. Through the consultation, some suggested training deliverables include a minimum number (determined by the number of BPTs at the site) of the following to be delivered weekly:

♦ Grand rounds with a specific basic physician training focus

♦ Tutorials

♦ Guaranteed time free from service requirements to attend telemedicine lectures

♦ Journal clubs

♦ Protected time with consultants

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♦ Assistance with study groups, including the involvement of advanced trainees and senior

registrars

♦ Minimum numbers of ward rounds with consultants

♦ Case presentations involving consultants.

Training needs of IMGs

Concern was also raised by metropolitan hospitals regarding a potential influx of IMGs into metropolitan hospitals. IMGs will require higher levels of supervision and assistance, and there is general opposition to the relocation of IMGs into metropolitan hospitals as jobs are filled in rural sites. While many accept the increased need to support IMGs, there is little support from BPTs to give up their inner metropolitan rotations to IMGs, given the competition for subspecialty rotations. Metropolitan hospitals also indicated that the increased pressure placed on them by carrying higher levels of vacancies and the added needs of IMGs will serve to lengthen patient stays, and jeopardise their 12-hour stays and waiting periods.

Recommendations:

The Consortia Implementation Subcommittee with membership from trainees, RACP, hospitals and the Department develop education and training guidelines as minimum standards for consortia. Guidelines to consider the following: ♦ Access to metropolitan hospitals at examination times ♦ Cover for rural hospitals during exam periods ♦ Maximum on call arrangements ♦ Training deliverables for each accredited site ♦ Mechanisms through which to enable compliance

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5.7 Pilot Timelines

It is proposed that the BPT consortia model be piloted in 2006. Pending the implementation of the pilot, changes to the guidelines and membership of consortia may be considered based on the experiences of trainees, constituent hospitals and the Department.

A consultation process is underway with all hospitals and trainees affected by the pilot to ensure that their issues and concerns are incorporated in the model. It is proposed that members of the MWTAC participate in this consultation process with the Department.

The time frame proposed for the BPT pilot is as follows:

December – January 05 Consultation process with hospitals

Jan - March 05 Development of Statewide Plan

March 05 Finalisation of Statewide Plan

April/May 05 Establishment of training consortia

May 05 Allocation of training places based on priorities for state investment

May 05 Establishment of recruitment process

May - August 05 Recruitment of BPTs to consortia and hospital selection processes

January 2006 Commencement of consortia training programs

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6 APPENDIX 1: RACP accredited teaching hospitals

Level 3 Teaching Hospitals Austin Health - Austin Hospital Barwon Health - Geelong Hospital Bayside Health - The Alfred Eastern Health - Box Hill Hospital Melbourne Health - Royal Melbourne Hospital St Vincent’s Health - St Vincent’s Hospital Southern Health - Monash Medical Centre – Clayton campus Western Health - Western Hospital Peninsula Health - Frankston Hospital

Level 2 Teaching Hospitals

Northern Health - Northern Hospital

Level 1 Teaching Hospitals

Ballarat Health Service – Ballarat Hospital Bendigo Healthcare Group - Bendigo Hospital Southwest Health Care -Warrnambool Hospital

Secondment Hospitals

Barwon Health - Grace McKellar Centre Bayside Health - Caulfield General Medical Centre Bendigo Hospital Epworth Hospital Northern Health - Bundoora Extended Care Centre (for geriatric medicine) Northern Health - Northern Hospital Royal Children’s Hospital Wimmera Healthcare Group – Horsham Hospital Eastern Health - Angliss Hospital Eastern Health - Maroondah Hospital Eastern Health - Peter James Centre Gippsland Hospital Goulburn Valley Health, Shepparton Wangaratta District Base Hospital Western District Health Service - Hamilton Hospital Latrobe Regional Hospital, Traralgon Melbourne Health - Melbourne Extended Care & Rehabilitation Service Southern Health - Casey Hospital Southern Health - Monash Medical Centre - Moorabbin Peter MacCallum Cancer Institute (for medical oncology and haematology Western Health - Sunshine Hospital Warragul Hospital Mildura Hospital

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7 APPENDIX 2: Sites consulted

Alfred Hospital Austin and Repatriation Centre Box Hill Hospital Geelong Hospital Frankston Hospital Monash Medical Centre Royal Melbourne Hospital St Vincent’s Hospital Western Hospital The Northern Hospital Ballarat Base Hospital Bendigo Base Hospital Warrnambool Hospital Wimmera Base Hospital Bendigo Health Care Group Royal Children’s Hospital Traralgon Hospital Warragul Hospital Peter MacCallum Cancer Institute Wangaratta District Base Hospital (by teleconference) Gippsland Hospital Goulburn Valley Hospital Hamilton Hospital RACP Training committee (by videoconference and in person) RACP Victoria RACP national University Deans AMA Doctors in Training

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8 APPENDIX 3: Current metropolitan intra-health service rotations.

♦ Austin Health - The Austin Hospital - Heidelberg Repatriation Hospital - Royal Talbot Repatriation Centre

♦ Barwon Health - Geelong Hospital

♦ Bayside Health - Caulfield General Medical Centre - Sandringham & District Memorial Hospital - The Alfred

♦ Eastern Health ♦ Angliss Hospital

- Box Hill Hospital - Healesville Hospital - Maroondah Hospital - Peter James Centre

♦ Melbourne Health - Melbourne Extended Care & Rehabilitation Service - Royal Melbourne Hospital

♦ Northern Health - Broadmeadows Health Service - Bundoora Extended Care Centre - The Northern Hospital

♦ Peninsula Health - Frankston Hospital

♦ Southern Health - Monash Medical Centre – Clayton Campus - Monash Medical Centre – Moorabbin Campus - Dandenong Hospital - Kingston Centre - Casey Hospital

♦ St Vincent’s Health - Caritas Christi Hospice Ltd. - St George’s Health Service - St Vincent’s Hospital

♦ Western Health - Sunshine Hospital - Western Hospital - Williamstown Hospital

Other sites: ♦ Peter Mac ♦ Epworth Hospital

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9 APPENDIX 4: University Links

The University of Melbourne Monash University

Austin Health and Northern Health Royal Melbourne Hospital and Western Health Clinical School Rural Clinical School Ballarat Shepparton Wangaratta St Vincent’s Hospital and Geelong Hospital Clinical School Royal Women’s Hospital Mercy Hospital for Women

Central and Eastern Clinical School Box Hill Hospital Alfred Hospital Southern Clinical School Monash Medical Centre School of Rural Health Mildura Bendigo Gippsland

- East Gippsland (Sale and Bairnsdale)

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10 End Notes

1 Appendix A contains the list of Victorian hospitals accredited for basic physician training in accordance with RACP designations.

2 Source – RACP Vic State Committee 2004 survey of BPTs; Barwon Health data provided by Dr Rodney Fawcett, Director of Clinical Training (HMO), Director Medical Resource Unit, Barwon Health

3 Subject to recruitment of additional BPTs 4 Based on level 3 teaching hospital figures provided by the RACP for 2004 5 Does not include BPTs which may be directly recruited by the other constituent hospitals

6 Based on level 3 teaching hospital figures provided by the RACP for 2004

7 Does not include BPTs which may be directly recruited by the other constituent hospitals

8 Specialist Teaching Hospitals include Dental Health Services Victoria, Mercy Hospital for Women (East Melbourne Campus), Peter MacCallum Cancer Institute, Royal Children’s Hospital, Royal Women’s Hospital and the Royal Victorian Eye & Ear Hospital.

basic physician training

Documents

medical training

training programs

training locations

provision of training

accredited training

vocational training

current training milieu

consortiumbased training