SUBMISSION TO PRODUCTIVITY COMMISSION HEALTH WORKFORCE STUDY FROM THE POSTGRADUATE MEDICAL COUNCIL (PMC) OF NSW

The vision purpose and mission of the Postgraduate Medical Council (PMC) of NSW is attached at Appendix 1.

The PMC’s response to the questions raised in the original Productivity Commission Study is set out below.

1. WORKFORCE PLANNING
The lack of accurate state and national workforce data in relation to both the current available workforce and the projected future workforce means that it is difficult to undertake any formal workforce planning.

Of particular importance to the PMC are a) the projected increase in student numbers, with the opening of three new medical schools (Wollongong, Western Sydney and Notre Dame) and b) the increase in the number of International Medical Graduates (IMGs) who are sitting and passing the Australian Medical Council (AMC) clinical examinations.  

Medical workforce planning could be improved by a better understanding of the training and educational requirements of the workforce. In NSW the distribution of JMO Medical Officer Workforce is linked to the accreditation of facilities and terms and education and training of JMOs.  

Increase in the number of Medical students
In the absence of formalised data the PMC has undertaken work with local Universities, the Australian Medical Council (AMC), the Postgraduate Medical Councils in other States and Territories and the Confederation of Postgraduate Medical Education Councils (CPMEC) to help inform its planning.  

The lack of a national overview of the workforce entering the health system and the total number of positions available means that projections are likely to be a lot less predictable in the future.  In NSW we are expecting to go from 500 students looking for internship in 2006 to 800+ students by 2011 with the commencement of the three new medical schools.  As a consequence work is underway looking at ways in which this huge influx can be accommodated.

It is not clear whether other States and Territories will be able to employ the additional students graduating from new Universities in their own areas and/or if they are able to employ additional students on top.  A national co-ordinated approach to this issue is therefore needed to ensure that all graduating students will be able to enter the medical workforce for internship and that there are sufficient training positions identified so that the current workforce shortages are addressed.

1.2 International Medical Graduates
The increase in the number of IMGs sitting and passing the AMC Clinical examinations is also having an impact on the system.  IMGs undertaking their year of supervised training in NSW now represent approximately 20% of the junior medical officer (JMO) workforce as opposed to  7% in 1999.  NSW has seen an increase of 285% in the number of IMGs since 1999, as there were 33 positions in 1999 and 94 positions in 2005.

This group of doctors can be particularly resource intensive for hospitals and in the future there may be a limit as to the number of these doctors that hospitals are able to employ (this issue is covered in more detail in the next section).  Although there is some data available from the AMC as to the number of doctors who are currently in the examination process, it is unclear how many IMGs are resident in Australia who have yet to apply.  With the recent changes in the migration policy allowing IMGs to gain residency following successful registration there may be a further increase in numbers and there is no available data on this. 

Summary
There is an urgent need for accurate national and local data about:
1)	The number of new medical students who will be graduating from the new medical schools
2)	The number of available positions 
3)	The number of IMGs predicted to enter the medical workforce
and for a co-ordinated national approach to the employment of these doctors.

2. EDUCATION AND TRAINING
2.1 Generalist vs Specialist 
For a long time the PMC has supported the concept of two years of generalist medical training for the first two years post attainment of a medical degree. In recent years the changing demographics of the workforce: older graduates, graduates with previous work experience (inside and outside the health system) has placed pressure on this model with increasing numbers of graduates seeking to specialise after the completion of internship. 

This issue needs to be addressed. The value of generalist skills cannot be underestimated however it should be possible to move towards some form of specialisation while still achieving another generalist year to hone skills.  Perhaps the first year of speciality training could straddle the second year of general training. The year could be hospital/community based and would have an emphasis on the broad generic skills that transcend speciality specifics but are important to the development of an ideal doctor. The special clinical skills would be obtained later though terms could be provided that fit with the doctors area of interest. 

Work readiness
There is currently a great deal of variability in the ability of students and IMGs to perform basic procedures on day 1 of their internship/year of supervised trainormation resources, assessment and feedback, service and training requirements, supervision and safe practice.  A copy of the JMO Education and Supervision Standards can be found on the PMC website at www.pmcnsw.org.au.

Feedback from the PMC survey processes suggests hospitals feel burdened by the number of accreditation surveys they participate in currently (AMC, ACHS etc) and that although the PMC accreditation process is specialised in nature, repetition still occurs.  If a co-ordinated approach to the accreditation of hospitals in relation to education and training was developed this would provide a significant improvement to hospitals and would cut down on a great deal of administration and save time.

3. WORKFORCE PARTICIPATION
The changing profile of the workforce is beginning to have a number of impacts on the available workforce and its distribution across the system.  

As the junior workforce is older with more commitments both financial and personal, it is becoming more difficult to fill rural and regional rotations.  There is also an increase in the flexibility that is being requested by the workforce because some individuals are seeking a better work/life balance whilst others have family and other commitments.  

The PMC is currently undertaking a Flexible Working project funded by the Medical Training and Review Panel.  This will be looking at models of flexible working, which could be implemented both locally and nationally.

In NSW we have also seen a significant increase in the number of doctors working as locums.  Apart from the attractive remuneration that this provides, a number of doctors are choosing this option because it provides them with the work flexibility that they are seeking.  The associated costs to the health system for the payment of locums is significant.

In order to address the current workforce shortages which are likely to continue for some time until the additional student numbers begin to impact on the system there are a number of options that could be explored.

3.1 Job re-design
The role of the JMO in the hospital system needs to be more clearly defined and their key responsibilities outlined.  A lot of time is still spent on paperwork, which could be delegated to other member of staff thus freeing up the JMO to spend more time with patients. 

3.2 Length of time to train
As the average age of a medical graduate is older, there is pressure to finish specialist training earlier.  Consideration should therefore be given to switching to competence based rather than time based training.

The PMC’s Core Curriculum project will look at whether it is possible to adapt and then adopt the proposals in the UK Curriculum document, which aims to provide credit in the second postgraduate year towards specialist training.  This could then help to reduce total training time.

3.3	Modular Specialist Training
The development of a modular approach to specialist training would be extremely beneficial to the workforce as it would a) allow doctors to switch between specialist training a lot more easily and this in turn may assist in retention b) allow more flexibility to undertake training therefore meeting the needs of doctors with external commitments and c) assist in re-entry into the system of doctors who have left the workforce.

4. MIGRATION ISSUES
Given the increase in the number of locally trained doctors in the future, it is not clear what requirement there will be in the future for non-resident International Medical Graduates. This group are currently able to apply for residency once they gain medical registration.
 
Also, the issue of full fee paying students studying medicine at Australian Universities will need to be looked at as it is not clear what obligations or requirements there are for them to complete internship in Australia prior to returning to their home country.  A number also currently apply for and obtain Australian residency. 

5. REGIONAL, REMOTE AND INDIGENOUS ISSUES

As outlined earlier it is becoming more difficult to distribute the workforce to regional and remote areas given the change in its profile.  There is a greater pressure to place junior medical officers in rural and remote areas as part of their training program, however this can be difficult to achieve. Junior medical officers need exposure to a general education and training. However there are significant shortages of doctors in rural areas, especially of clinicians with broad competencies and so the ability of these hospitals to provide the infrastructure, supervision, and training and education for junior doctors is restricted. Rural hospitals are more likely to have one year accreditation or an increased number of provisos with respect to JMO supervision, education and training.

Specific rural workforce training packages are one way of ensuring the doctors have the skills to undertake the work in a rural area however it should be noted that many junior doctors supporting rural communities are on secondments from metropolitan hospitals. Secondments provide a way of ensuring medical workforce to rural areas in situations where enough staff cannot be located to live more permanently in the area. In this case is maybe important to first define the skills required and assess those on secondment against the skills required. 

Some options to encourage working and training in rural and remote areas may include:

a)	the use of incentives - financial enhancements, changes to the Award to pay for additional travel to visit family/friends, more flexibility in training/work hours to visit family/friends, provision of housing and additional credits towards specialist training.  
b)	financial incentives and support for the trainers
c)	Infrastructure to support education and training 
d) 	removing barriers and/or changing perceptions that accessing specialist training is difficult if you work in rural and remote areas.
e) 	improved training networks to encourage rotation to rural and remote areas and ensure that those who want to undertake training in rural and remote areas can. 
f) 	the establishment of more community/general practice terms in rural and remote areas to increase exposure to these areas.

The PMC is currently undertaking some project work in relation to options c) and d). 

Appendix 1

PMC’S VISION
To take a leadership role in the professional development of the PGY1 and PGY2 medical workforce

PURPOSE
To support the sustainable delivery of quality patient care in NSW through managing and coordinating learning, hospital accreditation, distribution and the necessary support infrastructure including policy, process, people, training, advice and advocacy related to the PGY1 and PGY 2 medical workforce.

Mission
It is the mission of the Postgraduate Medical Council to ensure that medical graduates meet agreed minimum standards of safety, clinical skill and professional confidence over the first two years of their postgraduate medical training. 

Doctors who meet these standards are then capable of undertaking vocational training in clinical specialities.

To achieve its mission, the Postgraduate Medical Council has responsibility for:
•	The accreditation of training sites and training posts
•	The rational and equitable distribution of the Junior Medical Officer workforce throughout NSW and the ACT
•	Junior Medical Officer education and training, overseen by a network of Directors of Clinical Training.

Note: The Postgraduate Medical Council of NSW will be converging with the Medical Training and Education Council to form the Institute of Medical Education and Training on 1 September 2005.