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Graduate supply and public hospital funding – when will Government get this the right way around?

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BY DR RODERICK McRAE, CHAIR, AMA COUNCIL OF PUBLIC HOSPITAL DOCTORS

As I write, Victorian salaried doctors are voting on its recommended Enterprise Bargaining Agreement, and other jurisdictions are in advanced negotiations in the new industrial relations frameworks. Relevant reports will follow. 

My attendance at the sobering March 3 AMA Workforce and Training Summit convened in Melbourne, together with inspection of AMA’s 2018 Public Hospital Report Card, explains my continued exasperation at the consistent failure of Government to introduce realistic, necessary policy responses that deal with the now clearly apparent multiple medical training pipeline obstacles and poor public hospital access. Currently we have too much medical graduate supply and insufficient funding for appropriately training our junior colleagues in a manner that will meaningfully lead to reasonable public access to public hospital services. 

The Summit attitude was constructive with about 80 national stakeholders combining to produce many broadly supported actions which AMA can prosecute.  The Summit’s challenge was to consider what measures are needed further ‘downstream’ in training provision to ensure sufficient high quality training places in all medical specialties as they are needed for community benefit. While I fear the problems we now face are actually fast becoming too entrenched to solve, the Summit made it apparent that the medical profession is looking to the AMA, and within it your Council of Public Hospitals Doctors (CPHD), to lead the case for major reform.  Accordingly, CPHD will be guided by the outcome strategies of the Summit, and will press to further inform and influence our health policy makers. 

Two certain consensus points emerged from the Summit: stop opening new medical schools, and start rationalising resources towards regions and specialties where they are most needed. Government has regularly failed to fully listen to AMA’s advance warnings that there is real structural constraint to training capacity and that substantial ongoing investment is necessary to maintain training standards. Additionally, we need to urgently find sustainable, equitable paths to tackle the maldistribution of doctors (particularly across rural settings) and the shortages or bottlenecks arising in some craft areas. 

I observe that it was AMA advocacy that achieved for most medical school graduates (and including many International Medical Graduates) guaranteed internship after graduation when, incredibly, Government had not actually originally factored this in to its expansion decision. Just another Federal/State divide. And, let’s not forget, the massive increase of new graduates doesn’t actually have true tsunami characteristics of quick destruction by ingress then receding as fast as it came, enabling an early, planned, rebuild. Instead, there is actually a permanent rising of the water table, overwhelming teaching infrastructure capacity, which means patients in public hospital beds. 

The point is, we are graduating medical students in numbers far in excess of the OECD average without ensuring the adequate provision of the essential training places, both prevocational and specialist. This is at the same time that Commonwealth funding investment is not keeping pace with population growth.  Any economist would reel. 

In my December 2017 Australian Medicine piece, I discussed the ‘doing more with less’ implications of the Commonwealth financially penalising public hospitals who report acquired conditions, sentinel events and avoidable readmissions, otherwise known as possible healthcare outcomes (as if we are exercising choice to not provide optimum care now!). Added to that is the idea of penalising ‘low value care’ based on what are imposed and unsophisticated definitions, all with the aim of minimising financing, and a country mile from favourable health outcomes. This Commonwealth approach is in conjunction with them not offering any additional long term hospital funding via its 2020 State Agreement. 

So, we have no additional funding despite AMA’s 2018 Public Hospital Report Card establishing there has been a 3.3 percent year-on-year average increase in separations (that’s called increased productivity), that one third of urgent emergency department patients are not seen within the recommended 30 minutes and that most States’ urgent elective surgery is not performed within the 90 day clinically indicated timeframe (that’s called increased demand). Don’t get me started on the sometimes years of a patient waiting to be seen in outpatients before actually being counted on an elective waiting list! And they want to claw back already insufficient funding when a complication happens. That economic management is called madness. If only health care really was like slapping a motor vehicle together on a production line; but it just is not. 

The Summit’s Report will help us work together to develop initiatives to build a sustainable, well-trained, well-qualified and accessible medical workforce. The AMA’s Report Card is true evidence-based advocacy about hospital performance and the need for Government funding support to improve public access. Both suggest the public health climate is ominous with Government offering less funding but at the same time pressing for improved outcomes and offering more graduates but with no clear, coordinated, training pipeline management. Government must listen to us because of the implications for the community’s fair access to appropriate public hospital services, and for the career aspirations of our best and brightest. 

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