THE RADIATION ONCOLOGY WORKFORCE IN NEW ZEALAND: PROJECTING SUPPLY AND DEMAND FACULTY OF RADIATION ONCOLOGY

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1 THE RADIATION ONCOLOGY WORKFORCE IN NEW ZEALAND: PROJECTING SUPPLY AND DEMAND FACULTY OF RADIATION ONCOLOGY THE ROYAL AUSTRALIAN AND NEW ZEALAND COLLEGE OF RADIOLOGISTS

2 THE FACULTY OF RADIATION ONCOLOGY, RANZCR, is the peak bi-national body advancing patient care and the specialty of Radiation Oncology through setting of quality standards, producing excellent Radiation Oncology specialists, and driving research, innovation and collaboration in the treatment of cancer. VISION To have an innovative, world class Radiation Oncology Specialty for Australia and New Zealand focused on patient needs and quality. OUR VALUES In undertaking our activities and in managing the way we interact with our Fellows, trainees, members, staff, stakeholders, the community and all others with whom we liaise, the Faculty of Radiation Oncology, RANZCR, will demonstrate the following values: Quality of Care - performing to and upholding high standards Integrity, honesty and propriety - upholding professional and ethical values Patient orientation - understanding and reflecting the views of Fellows and members and working with them to achieve the best outcomes Fiscal responsibility and efficiency - using the resources of the College prudently. OUR PROMISE TO THE PATIENTS We will advocate for the best possible care for individual patients in multidisciplinary meetings and for all patients with government. OUR PROMISE TO TRAINEES We ensure the highest standard of training in radiation oncology by combining a world-class curriculum with passionate and supportive supervisors. The voice of trainees is valued in Radiation Oncology. OUR PROMISE TO OUR FELLOWS We are a member based organisation that utilises its resources effectively and strategically to fulfil our vision, purpose and core objectives. We strive for best practice and facilitate life-long learning of our members. OUR PROMISE TO OUR PARTNERS & STAKEHOLDERS We are a transparent and collaborative organisation that strives to promote partnerships and participation of all relevant stakeholders to ensure that patients across Australia and New Zealand receive a high-quality, timely and appropriate level of care. CONTENTS 1 INTRODUCTION 5 2 METHODOLOGY 5 3 SUPPLY INDICATORS Total workforce Age distribution Gender International Medical Graduates Workforce distribution Training data Trainee attrition Graduate attrition Physical resources Services 10 4 DEMAND INDICATORS Population growth and ageing 11 Name of document and version: The Radiation Oncology Workforce in New Zealand: Projecting Supply and Demand Approved by: Faculty of Radiation Oncology Council Date of approval: 22 February 2013 (Council) ABN Copyright for this publication rests with The Royal Australian and New Zealand College of Radiologists The Royal Australian and New Zealand College of Radiologists Level 9, 51 Druitt Street Sydney NSW 2000 Australia 4.2 Cancer incidence projections Radiotherapy utilisation rates 12 5 PROJECTING SUPPLY AND DEMAND Supply Demand 14 6 DISCUSSION 15 7 ACKNOWLEDGEMENTS 16 8 REFERENCES 17 ranzcr@ranzcr.edu.au Website: Telephone: Facsimile: Disclaimer: The information provided in this document is of a general nature only and is not intended as a substitute for medical or legal advice. It is designed to support, not replace, the relationship that exists between a patient and his/her doctor.

3 1 INTRODUCTION The purpose of this report is to collate and analyse data about the New Zealand radiation oncology workforce and the factors affecting workforce supply and demand. A basic series of supply and demand projections is produced from the data, which provides a starting point for discussions within the profession, and between the Royal Australian and New Zealand College of Radiologists (RANZCR) and key stakeholders about the future of radiation oncology services in New Zealand. 2 METHODOLOGY A number of sources have been used to gather data for the discussion on supply and demand, and to inform the projections: A full data download of the RANZCR membership data was performed on 30 June The database contains basic information about age, gender, work status (part time/ full time), and qualifications. The results were analysed using Microsoft Excel. Data were compared with the results of the 2010 Faculty workforce survey, to check for any changes or major anomalies. Non-demographic data from the 2010 survey were used to inform discussion about key indicators such as workload. Data were compared where possible with other sources from the wider medical workforce. New Zealand data from the 2011 Faculty facilities survey, such as total number of services, machine type, facilities and linear accelerators. Cancer incidence and population estimates and projections were sourced from New Zealand government publications (such as the Ministry of Health and Statistics New Zealand). The demand model is adapted from the Allen Consulting Group (1) Australian workforce analysis provided to the RANZCR to inform the Tripartite Strategic Plan (2). Supply side modelling is based on assumptions made from current RANZCR data on workforce inflows and outflows, such as retirements, trainee attrition and emigration. Given the small size of the workforce and the sensitivity associated with applying a complex model to such numbers, supply calculations are made in five year cohorts to reflect the length of the radiation oncology registrar training program. 3

4 3 SUPPLY INDICATORS RANZCR data from 2010 indicated that there were nine active radiation oncologists over the age of 55. In 2012 that has increased to 12, or 25% of the workforce. 3.1 Total workforce There has been a net loss of three radiation oncologists since Demographic details from the 2010 workforce survey indicate that there were 52 Fellows and Educational Affiliates working in New Zealand, and 19 trainees. The figure from the RANZCR membership database in 2012 is 49 (39 Fellows and 10 Educational Affiliates). Four Fellows work part time, the same as in The Full Time Equivalent (FTE) in 2011 was reported to the RANZCR as being 43.8, which is below the 2011 benchmark of the NZ Ministry of Health of FTE (3). The 2010 Faculty of Radiation Oncology workforce survey (4) revealed some key data for New Zealand: Description Result Average hours worked per week 52.8 Median hours worked per week 50.0 Percentage working 50+ hours per week 45.2 Average new patients per year 252 Median new patients seen per year 250 TABLE 1: 2010 New Zealand workforce survey data The average and median hours worked are both over 50 hours per week, indicating a relatively heavy workload when compared to their Australian colleagues (4). The average and median caseload of new patients is lower than Australian radiation oncologists, and falls within the expected range. New Zealand radiation oncologists tend to spend more time per new case than their Australian counterparts (5). 3.2 Age distribution The 2012 data show that the age distribution is relatively normal, with the largest group in their early specialist career. The average age as at 30 June 2012 is 48.9 years (median 48). An ageing workforce would appear flatter in distribution across the early to mid-career age groups. This trend is occurring in the medical workforce as a whole, where it is reported that the largest age group of doctors is in the age group, steadily progressing from younger age groups in the period between 2000 and 2011 (6). According to Health Workforce New Zealand, this means that the age structure of the radiation oncology workforce is not vulnerable (7), though the small size of the workforce means that it is in fact highly vulnerable to any changes in the work intentions of a handful of people. There may be some concern about the longevity of radiation oncologists in the workforce, with no listed member over the age of 65 remaining. If the workforce is deemed to be in shortage, retention of older radiation oncologists could be an area to investigate. Health Workforce New Zealand (8) has recently completed a discussion paper on retention of older specialists. They suggest that employers and colleges work on strategies to retain specialists by: Developing exit planning strategies Increasing mentoring roles Developing measures of age related cognitive change Enabling a change in the nature of work, such as reducing workload, shifting to mentoring and training, reducing or eliminating on-call, and removing regulatory barriers to remaining in the workforce, such as insurance premiums Statistics New Zealand expects workforce participation rates among older age groups to increase, attributable to factors such as increasing flexibility in retirement age, changing attitudes to retirement, and increasing life expectancy and well-being in the older ages (9). The RANZCR can monitor whether this expectation applies to the radiation oncology workforce through its regular workforce surveys. 3.3 Gender Females currently comprise 29% of the radiation oncology workforce. Four radiation oncologists are listed with the RANZCR as working part time, and all of them are female. The proportion of females in the New Zealand medical workforce as a whole is 40% (6). A gender balanced workforce may have implications for future workforce participation and longevity. One study reported that female doctors may only have a working life that approximates 60 per cent of male doctors (10). The work practices of female radiation oncologists can be reviewed in future workforce surveys to determine whether this hypothesis holds true for the radiation oncology workforce. There may also be issues around generational attitudes towards work and work-life balance which need to be taken into account, and which may affect any conclusions drawn by observing the workforce solely by gender. 3.4 International Medical Graduates RANZCR data indicates that 15 (31%) of the 49 active radiation oncologists are international medical graduates, mainly from South Africa and the United Kingdom. The specialty does not depend on IMGs as much as the broader medical workforce, in which the proportion of IMGs is 41.5% (6), although it still attracted a moderate vulnerability rating for this indicator by Health Workforce New Zealand (7). Attracting more international medical graduates is being used as a partial solution to the problem of local graduate attrition. RANZCR data shows that only four IMGs were assessed for entry into New Zealand in the past four years. Two of these radiation oncologists have since moved to Australia, producing a net gain of two in the four year period. Figure 1: Radiation oncologist age and gender distribution in New Zealand

5 3.5 Workforce distribution Given the resource intensive nature of the specialty and the small, concentrated population in New Zealand, the workforce is concentrated in the main centres: Auckland (public and private) Hamilton Palmerston North Wellington Christchurch (public and private) Dunedin It would be useful to know whether the Ministry of Health intends to expand linear accelerator facilities to other population areas, such as Hawkes Bay or Nelson/Marlborough, in line with current population distribution and projected health service needs. For example some areas may attract more retirees than others. The new centre in the Bay of Plenty is noted. 3.6 Training data Trainee numbers in 2012 are 22, up from 19 in Males comprise 18 (82%) of the trainees. None are listed as training part time. The increase in training numbers is a welcome move, given the uncertainty over the prioritisation of the specialty in 2011, as Health Workforce New Zealand sought to create a funding model that would direct limited resources to the specialties most in need. Given the net decrease in consultant numbers observed in the period , the increase appears to be necessary, but perhaps not sufficient, to create workforce growth. 3.7 Trainee attrition Data reported by the RANZCR to the Australian Medical Council in 2012 indicated that five New Zealand registrars withdrew from the training program in the three years Supply forecasts may then assume an average trainee attrition rate of approximately 10% per annum. NZ health system approximately $1.5 million to train a medical specialist, and further money is spent on recruiting IMGs to fill the void (12). The average base salary of a public hospital specialist in New Zealand is in the region of $176,000 (13), though the Multi-Employer Collective Agreement for the Association of Salaried Medical Specialists lists a lower range salary of $149,750 (14). This level of remuneration simply cannot compete with the salaries offered in Australia, which have been reported as being at least 30-35% higher (15). 3.9 Physical resources According to the RANZCR 2011 radiation oncology facilities survey, there were 28 linear accelerators in operation in New Zealand. A 2007 Ministry of Health report indicated that by 2011, between 27 and 30 linear accelerators would be acceptable (3). If the Ministry still holds this view, then service expansion via increased numbers of linear accelerators may not be a government priority. Most of the linear accelerators are less than ten years old as the table below indicates. Age of linear accelerator Count Percent Prior to 2000 (inclusive) % From (inclusive) % From (inclusive) % Since % Age unknown 1 3.6% TOTAL % TABLE 2: Linear accelerators in New Zealand 3.10 Services Data provided to the RANZCR in 2011 indicates that 11,355 course of radiotherapy were delivered in Tables 3 and 4 provide a summary of key radiotherapy services. Of note is the reported 362 average courses delivered per linear accelerator. The Australian model (1) uses 414 courses as one of the base assumptions. 3.8 Graduate attrition Workforce planners need to be aware of the drift of recently graduated specialists to better paid work in Australia soon after graduation, and also gravitation towards centres of research excellence being built up at Liverpool Hospital in New South Wales and the Peter McCallum Cancer Centre in Victoria, and Fellowship years further abroad, mainly in Canada, the United States and United Kingdom. This attrition appears to be in the order of one or two per annum, which is significant given the small size of the training program (approx. 22 trainees, 4-5 of whom will graduate each year). To illustrate the severity of the retention problem, an analysis of RANZCR data reveals that, of 31 radiation oncology trainees who completed their training between 1997 and 2010, 10 are now based in Australia (32%). The Medical Council of NZ identifies retention as a universal problem. Their data shows that of the medical graduates that first registered in 2000, only 60% had NZ practicing certificates ten years later (6). The Association of Salaried Medical Specialists also argues that retention rates must improve (11). There is an element of the overseas experience in this early career transience, which is common amongst university graduates of all types in New Zealand. However, the financial incentives on offer elsewhere in the world are a major factor. It costs the Description of service Number reported New Course 8,887 Retreatment Courses 2,468 Attendances 170,200 Fields 873,778 Fractions 165,723 IMRT 390 Superficial 667 Orthovoltage 78 Brachytherapy HDR 184 TABLE 3: Radiation oncology services by type Description Result Number of Departments 8 Average Megavoltage Machine Per Department 4 Average Course per Megavoltage Average Fraction per Attendance 3.01 Average IMRT Course per Megavoltage 15.6 Average LDR per Brachytherapy Machine 1.0 Average HDR per Brachytherapy Machine 46.0 TABLE 4: Radiation oncology services by machine 6 7

6 4 DEMAND INDICATORS 4.3 Radiotherapy utilisation rates 4.1 Population growth and ageing Statistics New Zealand (16) predicts that the resident population will increase from the current 4.4m to 5m by the mid-2020s. The population of those aged over 65 is projected to increase from 550,000 in 2009 to 1 million in the late 2020s (1 in 5 of the projected total population). Ageing is expected to be universal in geographic distribution, though there will be variations between some cities, districts and regions (9). The Medical Training Board estimated that, of the extra money likely to be spent on health in the decade to 2012, over 78 per cent of the additional allocation of population based funding nationally will be allocated to aged New Zealanders (17). 4.2 Cancer incidence projections The NZ Ministry of Health (18) projected that cancer registrations would increase from 18,148 in 2006 to 21,942 by Assuming that the rate of increase remains constant at 1.9% per annum, the projected cancer incidence would be as follows: Year , , ,710 Projected cancer registrations TABLE 5: New Zealand Ministry of health cancer registration projections 2005 The projections above appear to have been conservative. Actual registrations increased by 2.9% in the period , and by 2.7% in the period (19). If the actual rate of increase is projected forward at 2.7% per annum, the number of registrations becomes significantly higher, as the table below demonstrates. Year 2007 actual 19, actual 20, actual 20, , , ,515 Registrations There is no comprehensive study of optimal versus actual radiotherapy utilisation rates in New Zealand. A study by Stevens et al (20) estimated that the utilisation rate for lung cancer in the Auckland area was 43%, compared with an optimal rate estimated at 76% in an Australian study for lung cancer, and 52.3% for all cancers (21). Other estimates from overseas guidelines range from 44-48% (22). This lack of data means that attempts to model supply and demand by accounting for unmet demand, manifested in the gap between optimal and actual utilisation rate) is problematic. Estimates must therefore borrow the accepted optimal measure in Australia (optimal rate of 52.3%), or rely solely on projections for population growth and cancer incidence. One might assume that the optimal utilisation rate should be universal as it is calculated on cancer type (21). According to the RANZCR facilities survey, 11,355 courses of radiotherapy were provided in If applied to estimated 2012 cancer incidence, this would indicate that the utilisation rate may be 35-40%, though there may be other factors impacting on this estimate. Recent Ministry of Health data suggests a similar utilisation rate, with variations between regions. TABLE 6: Projected cancer registrations in NZ This forecast does not acknowledge a possible acceleration of the cancer incidence rate due to population ageing, and therefore also may be conservative. Given the possibility of workforce stagnation, the current workforce size of c.50 radiation oncologists may, by 2017, be dealing with a cancer population over 14% larger than in By 2022, a workforce of perhaps may be faced with a cancer population over 30% larger than in

7 5 PROJECTING SUPPLY AND DEMAND 5.1 Supply One useful method of approaching workforce projections in a small workforce is to look at the workforce in five year cohorts. Using assumptions about the number of graduates, retirements and other entries and exits, based on current workforce characteristics, a broad assumption can be made about the likely size of the workforce in 5-10 years time. Assuming there is no further growth in the training program and that no radiation oncologist will work beyond 65 years, the NZ radiation oncology workforce could experience growth of five radiation oncologists by 2017, and nine by This approach avoids a percentage addition/ attrition rate prevalent in more complex models such as the Allen Consulting Group (1). With such small numbers, using percentages to calculate forecasts is problematic when every radiation oncologist represents approximately 2% of the workforce. Projection year Description Count Source headcount 49 RANZCR membership data Jul trainees 22 RANZCR training data Jul 2012 IMG inflow 2 RANZCR NZ Branch data Subtotal 73 Trainee attrition (7) RANZCR data Graduate migration (5) RANZCR NZ graduate data Retirement (5) All aged 60+ in 2012 workforce 2017 estimate nd trainee cohort 22 Trainees IMG inflow 2 Assumed constant Trainee attrition (7) Graduate migration (5) Retirement (7) All aged in estimate Demand The calculations used below are based on the comprehensive radiation therapy workforce projection report produced by the Allen Consulting Group (ACG) (1), as part of the Tripartite Strategic Plan in It is used with the caveat that the same assumptions may not apply to New Zealand, which will require further consideration and consultation. For example, RANZCR data indicates that the number of courses per linear accelerator in New Zealand may be 362 per annum compared with 414 in the Australian model, which was an estimate provided by the Radiation Oncology Jurisdictional Implementation Group in response to the Baume Inquiry in 2002 (23). The higher throughput figure has been retained for this model to maintain faithfulness with the ACG methodology, though the difference must be noted. Assumption Cancer registrations (19) 20,875 22,612 25,843 29,515 Retreatments 25% (24) 5,219 5,653 6,461 7,379 Non-notifiable 10% (24) 2,088 2,261 2,584 2,952 SUBTOTAL 28,181 30,526 34,888 39,845 Optimum utilisation 52.3% (21) 14,739 15,965 18,246 20,839 Linacs 414 per linac % linac unavailable loading RO required (2 per linac) % utilisation rate 12,738 13,798 15,769 18,010 Linacs % linac unavailable loading RO required (2 per linac) TABLE 8: Demand projection calculations When compared with the supply projections provided above, there is a significant disparity between the theoretical number of radiation oncologists required (in order to treat 45.2% or 52.3% of cancer cases) and the number currently and potentially available. TABLE 7: New Zealand radiation oncology workforce in 2017 and Figure 2: Supply and demand projections for New Zealand radiation oncologists

8 6 DISCUSSION The presence of a theoretical workforce shortage as defined by the data assumptions above must be distinguished from the ability or intentions of the District Health Boards to expand budgeted consultant FTE positions. Data provided to the RANZCR in 2011 indicated that there were no reported radiation oncology consultant vacancies. Using the basic calculation of 2 FTE radiation oncologists per linear accelerator, 28 operational linear accelerators should be staffed by 56 radiation oncologists; seven more than the present workforce headcount, and ten to fifteen more FTE. Using a complex model to illustrate workforce projections in such a small population must be treated with caution. The starting population of 49 means that any variation on retirement age, reduction in hours worked, an untimely death or departure overseas, from a single radiation oncologist will result in an approximate 2% difference in the model s outcome. For example, the possible emergence of a highly competitive employment market in Australia could alter the rate of graduate attrition, and also attract those currently overseas to return to New Zealand. Health Workforce Australia has indicated a reluctance to model populations of fewer than 500 practitioners, because of concerns about modelling sensitivity and undue influence of small numbers of outliers (25). There is a lack of data for the actual utilisation rate for radiotherapy treatment in New Zealand. Therefore it is difficult to make assumptions about the adequacy of the current workforce to meet service demand as there is no measure available to determine potential unmet demand (for instance in the Australian case, the difference between the 38% actual and 52% optimum rate). Given the calculations, it is unlikely that the current New Zealand workforce is able to treat 45% of cancer patients with radiotherapy. The current estimate is close to 40%, with regional variations apparent. Recent work undertaken by the Ministry of Health should provide more clarity for this key indicator. The NZ Ministry of Health took the view in 2007 that the optimum rate in excess of 50% is unlikely to be clinically indicated in the medium term (3), despite evidence to the contrary from Australia (21). Therefore, the 45% utilisation rate would appear to be a more realistic target for health service administrators in New Zealand, and equates to the mid-point of the Allen Consulting Group forecasts. Another important issue is the increased time radiation oncologists will spend on planning, as treatments get more and more sophisticated with stereotactic and Intensity Modulated Radiation Therapy (IMRT) / Volumetric Modulated Arc Therapy (VMAT) solutions. These techniques will be used increasingly often and are becoming routine now across many tumour sites. The increase in planning time can often be substantial. Palliation is also becoming more sophisticated and stereotactic treatments will become more common place over the next few years. This increase in work intensity per patient may impact on the number of new patients a radiation oncologist will be able to see each year. It would be useful to establish whether there is any planned service expansion in existing radiation oncology treatment centres through expansion in the number of bunkers or expanded service hours, and whether any more facilities are planned, in addition to the planned opening of the Bay of Plenty treatment centre. As in Australia, future service expansion may also be limited by the availability of radiation oncology medical physicists and radiation therapists, and physical resources such as linear accelerators. Data reported to the RANZCR in 2011 indicated eleven vacancies for radiotherapists and seven for radiation oncology medical physicists. The radiotherapy workforce needs to be considered and planned as a multi-disciplinary service with appropriate infrastructure. Health Workforce New Zealand (HWNZ) has indicated to the RANZCR that a cancer workforce service review is planned. It is hoped that the RANZCR can build on its existing relationship with HWNZ and provide meaningful input into the review process. There are also activities underway within the Ministry of Health to develop cancer workforce models and strategies. The RANZCR must play a central role in this work. In light of this, it is recommended that the assumptions upon which this model is based should be reviewed regularly for their applicability to radiation oncology practice in New Zealand, or used to inform other modelling work. 7 ACKNOWLEDGEMENTS To Nicholas Bradshaw for researching and writing the report. To Dr Chris Atkinson, Dr Claire Hardie, Dr Melissa James, Dr Carol Johnson, and Dr John Matthews for their invaluable input by reviewing and editing the document. 6 REFERENCES 1. Allen Consulting Group. Projecting the radiation oncology workforce: input to the tripartite strategic plan for radiation oncology in Australia. Sydney Radiation Oncology Tripartite Committee. Planning for the best: Tripartite national strategic plan for radiation oncology Sydney NZ Ministry of Health. Cancer control workfoce stocktake and needs assessment. Wellington James M, Bradshaw N, Munro P, Leung J. Faculty of Radiation Oncology 2010 workforce survey: New Zealand. Unpublished RANZCR. Report on contemporary practice: The number of new patients per year. Sydney Medical Council of New Zealand. The New Zealand medical workforce in Wellington Health Workforce New Zealand. Prioritisation of medical disciplines for funding by HWNZ. Wellington Health Workforce New Zealand. Retention of doctors in their third age. Wellington Statistics New Zealand. Demographic aspects of New Zealand s ageing population. Wellington Brooks PM, Lapsley HM, Butt DB. Medical workforce issues in Australia: tomorrow s doctors--too few, too far. Med J Aust Aug 18;179(4): Association of Salaried Medical Specialists NZ. State of the specialist workforce crisis in New Zealand s public hospitals. Wellington Association of Salaried Medical Specialists NZ. Specialist workforce alert: the growing medical specialist workforce shortage - the retention crisis. Wellington Association of Salaried Medical Specialists NZ. Senior medical and dental officer salary survey. Wellington Association of Salaried Medical Specialists NZ. New Zealand District Health Boards: Senior medical and dental officers collective agreement. Wellington

9 15. Commission on the resident medical officer workforce. Treating people well: report of the director-general of health s commission on the resident medical officer workforce. Wellington Statistics New Zealand. National population projections: 2009 (base) Wellington Medical Training Board. The future of the medical workforce: first annual report November December Wellington NZ Ministry of Health. Cancer projections: incidence to Wellington NZ Ministry of Health. Cancer registrations 2009 provisional data. Wellington Stevens G, Stevens W, et al. Radiotherapy utilisation in lung cancer in New Zealand; disparities with optimal rates explained. New Zealand Medical Journal. 2009;Nov 20(122 (1306)): Delaney G, Jacob S, Featherstone C, Barton M. The role of radiotherapy in cancer treatment: estimating optimal utilisation from a review of evidence-based clinical guidelines. Cancer. 2005;Sep 15(104 (6)): Cancer Care Ontario. Radiation treatment utilisation. Toronto [cited 2012, 3 September]; Available from: Id= Radiation Oncology Jurisdictional Implementation Group. A vision for radiotherapy: A report of the radiation oncology inquiry. Canberra CCORE. A cancer services framework for Victoria and future directions for the Peter MacCallum Cancer Institute. Sydney Health Workforce Australia. National Training Plan: Methodology paper. Adelaide

10 THE ROYAL AUSTRALIAN AND NEW ZEALAND COLLEGE OF RADIOLOGISTS