Gippsland: The Prevocational Situation

Transcription

1 Gippsland: The Prevocational Situation Gippsland Medical Workforce Partnership G i p p s l a n d M e d i c a l W o r k f o r c e P a r t n e r s h i p G u t h r i d g e P a r a d e S a l e, V i c t o r i a ( 0 3 )

2 PROJECT OFFICER CONTACT DETAILS Name: Ms Sarah Churchill Address: 155 Guthridge Parade, SALE VIC 3850 Phone: Mobile: Paper prepared by Sarah Churchill, Project Officer, Gippsland Medical Workforce Partnership Published by the Gippsland Medical Workforce Partnership, Gippsland, Victoria September

3 Acronyms and Definitions Acronyms AHPRA EFT GRIT HMO IMG PGPPP PGY PGY1 PGY2 PGY3 PMCV Australian Health Practitioner Regulation Agency Equivalent Full Time Gippsland Rural Intern Training Hospital Medical Officer International Medical Graduate Postgraduate Practice Placement Program Post Graduate Year Post Graduate Year One Post Graduate Year Two Post Graduate Year Three Postgraduate Medical Council of Victoria Definitions Core Term Domestic Student Full Fee Paying International Student General Registration Intern Doctor Intern Year International Medical Graduate Non-Core Term Prevocational Provisional Registration Vocational Standardised, compulsory training term conducted during an intern year An Australian resident studying at an Australian University An international student who is studying at an Australian University Registration granted to allow medical practitioners to practice independently in Victoria within the limits of their training and competence An intern is a practitioner, usually PGY1, who has completed a Board approved, accredited qualification in the profession, and is undertaking a period of supervised practice or internship to be eligible for general registration A one year internship, made up of four or five terms, of supervised training undertaken in health services An International Medical Graduate is someone who has gained their primary medical qualification outside of Australia or New Zealand Accredited training term conducted during an intern year Before vocational Registration granted to intern doctors for the duration of an internship year. Supervisory requirements apply Training towards a speciality medical field 3

4 Table of Contents Acronyms and Definitions... 3 The History... 5 The Current Capacity Report... 6 Intern Numbers... 7 Postgraduate Year 2 and 3 Numbers... 9 Intern and PGY2 and PGY3 Feeder Points International Medical Graduates Core Rotations and Noncore Rotations Accommodation Supervision Funding and Resources The Influencing Factors Accreditation Supervision Funding and Resources Infrastructure The Conclusion

5 The History In May 2009, the Department of Health released guidelines on the establishment of Medical Workforce Partnerships to facilitate prevocational education and training of Australian medical graduates and the assessment, up-skilling and support of international medical graduates. Chief Executive Officers and Directors of Medical Services from across a number of Gippsland health services identified the need for and the opportunity to expand and enhance the opportunities and pathways for medical training within the region. The region was successful in the receipt of a Department of Health grant and the Gippsland Medical Workforce Partnership was formed in November After the employment of a Project Officer the partnership identified the need to gain a regional perspective of what currently happens across Gippsland in relation to prevocational medical training for interns and postgraduate year 2 and 3 doctors. The partnership has recently concluded a two month consultation phase resulting in the publication of this report. 5

6 The Current Capacity Report The Current Capacity Report has been produced to provide a comprehensive overview of what currently happens across Gippsland in relation to prevocational medical training. This data has been collected through stakeholder interview sessions and questionnaires. Interview sessions were conducted from 3 May July 2010 with at least one representative from each participating organisation. Stakeholders were identified based on their current involvement in prevocational medical training across Gippsland through the placement of interns and/or postgraduate year 2 and postgraduate year 3 doctors. Furthermore stakeholders having an involvement in specialist medical training were interviewed as were organisations involved in medical student education and those involved with the accreditation and placement of junior doctors in the region. It was agreed that all Gippsland hospitals be interviewed regardless of being recipients of interns and/or postgraduate year 2 and postgraduate year 3 doctors. The organisations consulted are listed as follows: ORGANISATION Bairnsdale Regional Health Service Bairnsdale Regional Health Service Bass Coast Regional Health Central Gippsland Health Service Central Gippsland Health Service Kooweerup Regional Health Service Latrobe Regional Hospital Gippsland Southern Health Service Omeo District Health Orbost Regional Health Yarram and District Health Service West Gippsland Healthcare Group West Gippsland Healthcare Group South Gippsland Hospital Foster and Toora Medical Centre Cunningham Arm Medical Centre Trafalgar Medical Centre Heyfield Medical Centre getgp Rural Medical Workforce Australia Monash University Monash University Monash University Wonthaggi Medical Group Korumburra Medical Centre Postgraduate Practice Placement Program Postgraduate Medical Council of Victoria REPRESENTATIVE Medical Education Officer Director Medical Services Chief Executive Officer HR / HMO Manager Director Medical Services Chief Executive Officer HMO Manager Medical Education Officer Chief Executive Officer Chief Executive Officer Chief Executive Officer Chief Executive Officer Executive Assistant Chief Executive Officer Practice Manager Practice Manager Lead General Practitioner Lead General Practitioner Chief Executive Officer Gippsland Workforce Manager Dean, Gippsland Medical School Director, School of Rural Health Director, School of Rural Health Practice Manager Practice Manager Program Coordinator Accreditation Coordinator 6

7 Intern Numbers An Intern Doctor is a post graduate year one doctor. Medical graduates are required to complete a compulsory internship comprising twelve months of supervised training in order to be eligible for general registration. An intern year is made up of three core terms; At least ten weeks in Medicine; At least ten weeks in Surgery; and At least eight weeks in Emergency Medicine A further 20 weeks of non-core placement completes the intern year. All intern terms are conducted at accredited intern posts assessed and certified by the Post Graduate Medical Council of Victoria. Intern allocation is a state based process. In Victoria intern places are guaranteed to all Australian citizens and permanent residents graduating from a Victorian medical school. Intern positions in Victoria are populated by international full-fee paying graduates, Australian trained permanent residents, Australian domestic graduates and New Zealand medical school graduates, both permanent resident and international full-fee paying. Interns are placed across Gippsland in six hospitals and four general practice centres. Interns spend time completing a core rotation on a Hospital ward or a noncore rotation in either a hospital or a community setting. The total number of Equivalent Full Time (EFT) intern positions in Gippsland is 37. Table 1 illustrates where these intern positions are held. Currently a total of 164 junior doctors completing their intern program spend time in Gippsland each year. Of this number, five (5) interns are employed through the Gippsland Rural Intern Training program (GRIT) and spend the entirety of their intern year in the region. The remaining 159 intern doctors are employed by metropolitan hospitals and enter the region to complete at least one term of their intern program. These doctors spend anywhere from 5 weeks to a maximum of 22 weeks in the region. Two of the positions illustrated in Table 1 are shared between a hospital and a general practice clinic through the Post Graduate Practice Placement Program (PGPPP). These positions are a noncore hospital / general practice term at Bass Coast Regional Health and Wonthaggi Medical Group and a noncore hospital / general practice term at Gippsland Southern Health Service and Korumburra Medical Centre. Accreditation is currently being sought for a further three intern positions funded by the PGPPP to commence in Subject to accreditation approval these positions would be held at Clocktower Medical Centre and Maffra Medical group both fed from Alfred Health and Foster Medical Centre fed from Peninsula Health. 7

8 Table 1: Intern Numbers Total EFT Intern Positions Per Organisation EFT Interns Employed by Metropolitan Hospital Average Intern Rotations Per Post Total Number of Metro Interns Per Year EFT GRIT Interns Average GRIT Intern Rotations Per Post Total Number of GRIT Interns Per Post Bairnsdale Regional Health Service Bass Coast Regional Health * Central Gippsland Health Service Gippsland Southern Health Service** Kooweerup Regional Health Service Latrobe Regional Hospital Omeo District Health Orbost Regional Health South Gippsland Hospital West Gippsland Healthcare Group Yarram and District Health Service Cunningham Arm Med Clinic Heyfield Clinic Korumburra Clinic ** Trafalgar Clinic Wonthaggi Medical Group* Totals * Bass Coast Regional Health and Wonthaggi Medical Group share one intern through the PGPPP ** Gippsland Southern Health Service and Korumburra Medical Centre share one intern through the PGPPP Totals

9 Postgraduate Year 2 and 3 Numbers Post Graduate Year (PGY) 2 and 3 doctors are also known as Hospital Medical Officers (HMOs). Most PGY2&3 doctors in Gippsland are international medical graduates working towards their general registration. Rural and regional areas are often highly staffed by IMG PGY2&3s due firstly to work limitations surrounding newly arrived international medical graduates and secondly due to the trend of domestic graduates opting to move straight into specialist training programs upon commencement of their intern year and receipt of their general registration. Postgraduate Year 2 and Postgraduate Year 3 numbers are reflected in Table 2. The total number of PGY2&3 doctors that spend time across the region per year is 73. PGY2&3 s are placed in five hospitals and one general practice throughout Gippsland. These organisations are: Bairnsdale Regional Health Service Bass Coast Regional Health Central Gippsland Health Service Latrobe Regional Hospital West Gippsland Healthcare Group Cunningham Arm Medical Clinic Typically these doctors are contracted to an organisation for 12 months; however some PGY2&3s rotate from the Alfred, Eastern Health or Southern Health for a period of three months as part of their placement at these metropolitan health services. Generally a PGY2 or PGY3 doctor will not exceed 12 to 24 months in Gippsland. After this period of time many domestic graduates will return to Melbourne to pursue specialist training and international graduates will often remain only whilst pursuing their Australian medical registration. Currently the only specialist avenue available, in its entirety, to medical graduates in the region is General Practice through the getgp training program. A small number of medical graduates who spend time in Gippsland as either an intern or PGY2 or 3 doctors do access this program and continue to work in the area. Approximately 80% of getgp s training practitioners are IMGs. Some health services have PGY2&3 doctors who are completing rotations as part of an alternative vocational program (i.e. Physician training). These doctors are not included in this analysis as they are not prevocational doctors but rather specialists in training.

10 Table 2: PGY2&3 Numbers Total EFT Positions Per Organisation EFT PGY2&3 Employed by Gipps. Hospital Average Rotations Per Post Total Number Gipps. PGY2&3 Per Year EFT PGY2&3 Employed by Metro Hospital Average Rotations Per Post Total Number Metro PGY2&3 Per Year Bairnsdale Regional Health Service Bass Coast Regional Health Central Gippsland Health Service Gippsland Southern Health Service Kooweerup Regional Health Service Latrobe Regional Hospital Omeo District Health Orbost Regional Health South Gippsland Hospital West Gippsland Healthcare Group Yarram and District Health Service Cunningham Arm Med Clinic Heyfield Clinic Korumburra Clinic Trafalgar Clinic Wonthaggi Medical Group Totals Totals

11 Intern and PGY2 and PGY3 Feeder Points Upon completion of medical school a junior doctor seeks acceptance into an intern program. These programs are hosted by a Feeder Hospital where the intern is employed for a full 12 months. An intern can rotate away from this hospital to complete different terms of their program however ownership of the intern remains with the feeder hospital and typically a large portion of their training will take place at this site. Gippsland receives interns from a variety of feeder hospitals or feeder points. The feeder points for interns into the region are illustrated in Table 3. The metropolitan feeder points for Gippsland are: The Alfred Eastern Health Peninsula Health Northern Health Southern Health Along with these feeder points the Gippsland Rural Intern Training (GRIT) program employs five interns hosted by Latrobe Regional Hospital. A GRIT intern completes their core terms at Latrobe Regional Hospital, Central Gippsland Health Service and West Gippsland Health Group and noncore terms at Latrobe Regional Hospital and Heyfield Medical Centre. Feeder points for PGY2&3 doctors differ; PGY2&3 doctors are predominantly employed directly by a Gippsland hospital on a 12 month contract as a HMO. As was illustrated in Table 2 there are a total of 49 equivalent full time HMO positions across Gippsland. Aside from this number 24 PGY2&3 doctors, making up 6 equivalent full time positions, rotate into Gippsland over one year from metropolitan hospitals for periods of three months at a time. Table 4 illustrate the feeder points for these 24 rotations per year only.

12 Table 3: Intern Feeder Points GRIT Alfred Eastern Health Peninsula Health Northern Health Southern Health Feeder points Bairnsdale Regional Health Service Bass Coast Regional Health * Central Gippsland Health Service Gippsland Southern Health Service** Kooweerup Regional Health Service Latrobe Regional Hospital Omeo District Health Orbost Regional Health South Gippsland Hospital West Gippsland Healthcare Group Yarram and District Health Service Cunningham Arm Med Clinic Heyfield Clinic Korumburra Clinic ** Trafalgar Clinic Wonthaggi Medical Group* Total Percentage 13.59% 14.95% 21.74% 9.78% 1.36% 38.59% * Bass Coast Regional Health and Wonthaggi Medical Group share one intern through the PGPPP ** Gippsland Southern Health and Korumburra Medical Centre share one intern through the PGPPP Total

13 Table 4: PGY2&3 Feeder Points Alfred Eastern Peninsula Northern Southern Total Feeder points Health Health Health Health Bairnsdale Regional Health Service Bass Coast Regional Health Central Gippsland Health Service Gippsland Southern Health Service Kooweerup Regional Health Service Latrobe Regional Hospital Omeo District Health Orbost Regional Health South Gippsland Hospital West Gippsland Healthcare Group Yarram and District Health Service Cunningham Arm Med Clinic Heyfield Clinic Korumburra Clinic Trafalgar Clinic Wonthaggi Medical Group Total Percentage 16.67% 33.33% 0.00% 0.00% 50.00%

14 International Medical Graduates International Medical Graduates form a significant proportion of the prevocational trainee workforce in Victoria. A large portion of the Gippsland medical workforce is populated by IMG doctors. IMG s spend time in Gippsland as intern doctors, PGY2&3 s in hospitals and general practice clinics, vocational students and senior medical staff. International Medical Graduate Numbers are difficult to ascertain. This is due to multiple factors. Firstly, organisations do not always keep separate records for their IMGs and their Australian graduates. This is particularly true with regard to interns. As the majority of interns that enter Gippsland s health services are rotated from metropolitan Melbourne the records of the interns study and work history is held at the feeder hospital. This being so, the numbers collected from organisations on intern and PGY2&3 numbers are inclusive of some IMG s. PGY2&3 doctors in Gippsland are predominantly IMGs working towards their general registration. Often once general registration has been attained many international graduates move to metropolitan centres to enter specialty training programs. International Medical Graduates in Victoria have a number of different pathway options available in order to gain practice registration in Australia. Limited Registration is available to medical practitioners whose medical qualifications are from a medical school outside of Australia or New Zealand. These medical schools must be listed in the current online version of the International Medical Education Directory (IMED) of the Foundation for Advancement of International Medical Education and Research. Approved courses of study means that the applicant must be able to demonstrate that they have completed a medical curriculum of at least four academic years, leading to an entitlement to registration in the country issuing the degree to practice clinical medicine. There are four types of limited registration, granted for different purposes. These allow internationally qualified medical practitioners to provide medical services under supervision as set out below. The types of limited registration are: Postgraduate training or supervised practice Area of Need Public interest Teaching or research IMGs who wish to apply for initial registration for limited registration for postgraduate training or supervised practice or limited registration for area of need must provide evidence of eligibility under one of the following pathways: Competent Authority Pathway Specialist Pathway Standard Pathway

15 Whilst IMGs form an integral part of the regional medical workforce the recruitment of international graduates requires additional time and resources. Extra orientation, training and support are needed for IMG doctors as well as visa sponsorship, cultural support and sometimes up skilling and further education. 15

16 Core Rotations and Noncore Rotations Core rotations relate to the intern year. A medical student is required to complete a satisfactory intern year consisting of three core terms and up to 22 weeks of noncore terms to be eligible for general registration. The core terms an intern doctor must complete are: At least 10 weeks in medicine; At least 10 weeks in surgery; and At least 8 weeks in emergency medicine. Core term accreditation, as with noncore accreditation, is the responsibility of the Postgraduate Medical Council of Victoria. Accreditation for a core site differs from accreditation for a noncore site. An accredited core post is based on assessment of the following seven elements: Health service environment and culture in relation to intern support Orientation Education program Supervision Feedback and assessment Program evaluation Facility and amenities. Gippsland has three health service sites accredited for core terms. Table 5 illustrates core term rotations available in the region. Although all three sites, being Central Gippsland Health Service, Latrobe Regional Hospital and West Gippsland Healthcare Group, are accredited for both medicine and surgery only Latrobe Regional Hospital is an accredited core emergency medicine post. Further to the core rotations available across the region, Gippsland offers a variety of accredited noncore options for interns. Table 6 illustrates the noncore selections available. The process of accreditation is usually managed by medical administrators, like HR Managers or HMO Managers. Gippsland has only two HMO Manages located at Latrobe Regional Hospital and Central Gippsland Health Service. Accreditation is also managed by some senior administration staff. The accreditation process assesses the health service's performance in relation to HMO training against the following seven standards: 1. The health service demonstrates a commitment to the development of HMOs; 2. HMOs participate in formal orientation programs which are designed and evaluated to ensure sound learning occurs; 3. HMOs are provided with appropriate formal education opportunities; 4. HMOs are supervised at a level appropriate to their experience and responsibilities; 5. HMOs receive continuous and constructive feedback on their performance; 6. The health service formally evaluates the HMO training program in a continuous improvement framework; and 7. The health service provides a suitable physical environment and amenities that support the HMOs. The standards are assessed at both the health service level and unit/rotation level.

17 Table 5: Core Rotations Core Rotations Medical Surgical ED Bairnsdale Regional Health Service Bass Coast Regional Health Central Gippsland Health Service Gippsland Southern Health Service Kooweerup Regional Health Service Latrobe Regional Hospital Omeo District Health Orbost Regional Health South Gippsland Hospital West Gippsland Healthcare Group Yarram and District Health Service Cunningham Arm Med Clinic Heyfield Clinic Korumburra Clinic Trafalgar Clinic Wonthaggi Medical Group Total

18 Table 6: Noncore Rotations Medical Surgical ED General Practice Anaesthetics Orthopaedics General Practice / Hospital Other Rotations (Non-Core) Bairnsdale Regional Health Service Bass Coast Regional Health Central Gippsland Health Service Gippsland Southern Health Service Kooweerup Regional Health Service Latrobe Regional Hospital Omeo District Health Orbost Regional Health South Gippsland Hospital West Gippsland Healthcare Group Yarram and District Health Service Cunningham Arm Med Clinic Heyfield Clinic Korumburra Clinic Trafalgar Clinic Wonthaggi Medical Group Total

19 Accommodation Victoria have an enterprise bargaining agreement that states that clean and secure overnight accommodation will be provided to interns during rural posts. However, this is in the context of short term rotations only. Some health services may provide accommodation to interns who are appointed on a 12 months basis but this is up to the individual hospital. PGY2&3 doctors also often require accommodation. When accommodation is provided it must be close to the hospital and be fully furnished. Gippsland has an assortment of accommodation available to prevocational doctors of varying size and quality. When discussing accommodation stakeholders were asked to rank their health service or general practice in one of the following three categories: Under capacity: there is sufficient accommodation available for the current numbers with room for additional doctors At capacity: there is sufficient accommodation available for the current numbers of doctors only Over capacity: the accommodation available is not always sufficient and accommodation is an issue This information is illustrated in Table 7. The information is based on the accommodation that is currently available to a health service or general practice for interns and PGY2&3 doctors only. Table 7: Accommodation Accommodation Over capacity At capacity Under capacity Bairnsdale Regional Health Service Bass Coast Regional Health Central Gippsland Health Service Gippsland Southern Health Service Kooweerup Regional Health Service Latrobe Regional Hospital Omeo District Health Orbost Regional Health South Gippsland Hospital West Gippsland Healthcare Group Yarram and District Health Service Cunningham Arm Med Clinic Heyfield Clinic Korumburra Clinic Trafalgar Clinic Wonthaggi Medical Group Total 3 6 2

20 Supervision Adequate supervision for both interns and PGY2&3 doctors is a necessity to being able to offer prevocational positions in Gippsland. The supervision requirements for interns have a direct impact on the accreditation of core and noncore posts. Interns are supervised at a level appropriate to their experience and responsibilities. The general assessment criterion follows: Interns have designated Term Supervisors for each rotation who they know and who actively supervise them. Intern supervisors have a clear understanding of their role and responsibility in assisting interns to meet their learning objectives and demonstrate a commitment to their training. Appropriate supervision is provided at all times by suitably qualified and appropriately experienced medical practitioners. The health service has a process in place which enables an evaluation of the adequacy and effectiveness of supervision of interns annually. The supervision requirements for both core and non-core intern terms are set out by the PMCV. For a core term in either medicine or surgery an intern must be supervised by an appropriately qualified and experienced medical practitioner with full registration and a minimum of three years experience in hospitals in Australia or other countries with similar health care systems, preferably in a physician training program for medicine or a surgical training program for surgery. The supervisor must be available to supervise the intern, to perform a daily ward round with the intern and be available for some time each day to supervise the management of ward patients. The supervision requirements for an emergency medicine core term differ from general medicine and surgery. Only if the following conditions are met will an emergency medicine term be recognised as a core term: The term supervisor must be a Fellow of the Australasian College for Emergency Medicine (FACEM), or a Fellow of one of the following colleges: Anaesthetics General Practice Medicine Surgery Intensive Care Rural and Remote Medicine The term supervisor must also have completed all of the following training areas: Advanced Trauma Life Support of Emergency Management of Severe Trauma; Emergency Life Support or Advanced Cardiac Life Support; and Paediatric Advanced Life Support Course or an equivalent internationally recognised course. 20

21 Furthermore; The term supervisor must provide direct supervision 100 per cent of the time during the intern roster. Direct supervision is supervision that is on-site within the department and continuous, 24 hours a day, seven days a week. Direct supervision must be provided by a Fellow as described above or alternatively by an appropriately qualified and experienced medical practitioner with a minimum of three years experience in hospitals in Australia or other countries with similar health care systems. Supervision across Gippsland is generally provided by Visiting Medical Officers, many of whom are General Practitioners rotating from community practices, overseas trained doctors and Registrars involved in specialist training as well as a small number of resident senior medical staff. Stakeholders interviewed for The Current Capacity Report were asked to rank their health service or general practice in one of the following three categories for supervision for interns and PGY2&3s separately; Under Capacity there is more than enough supervising doctors available for the number of interns and PGY2&3 positions At Capacity there is enough supervising doctors to cater for the current number of interns and PGY2&3 positions only Over Capacity the supervision available is not always sufficient and supervision is an issue The key factors influencing each organisations ranking were identified as; not having enough suitably qualified doctors to supervise and inability to provide adequate remuneration for the additional work entailed by supervising junior staff. Table 8: Intern Supervision Intern Supervision Over capacity At capacity Under capacity Bairnsdale Regional Health Service Bass Coast Regional Health Central Gippsland Health Service Gippsland Southern Health Service Kooweerup Regional Health Service Latrobe Regional Hospital Omeo District Health Orbost Regional Health South Gippsland Hospital West Gippsland Healthcare Group Yarram and District Health Service Cunningham Arm Med Clinic Heyfield Clinic No response obtained Korumburra Clinic No response obtained Trafalgar Clinic Wonthaggi Medical Group No response obtained Total

22 Table 9: PGY2&3 Supervision Over capacity At capacity PGY2&3 Supervision Bairnsdale Regional Health Service Bass Coast Regional Health Central Gippsland Health Service Gippsland Southern Health Service Kooweerup Regional Health Service Latrobe Regional Hospital Omeo District Health Orbost Regional Health South Gippsland Hospital West Gippsland Healthcare Group Yarram and District Health Service Cunningham Arm Med Clinic Heyfield Clinic No response obtained Korumburra Clinic No response obtained Trafalgar Clinic Wonthaggi Medical Group No response obtained Total 4 3 Under capacity 22

23 Funding and Resources The Victorian Government partially funds intern and PGY2 positions. These funds are distributed by the Department of Health through the Department of Health Training and Development Fund. Based on 2009 / 10 figures, this funds approximately half of an intern or PGY2 position. Per intern health services can receive $31, and $34, for a PGY2 per annum. These funds are distributed fortnightly from the Department of Health to health services. The approximate cost to a health service for the employment, education, training and support of an intern is $100, Furthermore, the Prevocational General Practice Placement Program (PGPPP) funds postgraduate year one to three doctors to experience a variety of specialities, including General Practice. The program is administered by getgp and funded by a grant from the Commonwealth Department of Health. Whilst this Government funding supports health services to employ interns and PGY2 doctors, post graduate year 3 positions are completely not funded. The Department of Health also administer a range of Medical Scholarship and Workforce Initiative Resources including the Rural Medical Practitioners Program, Remote Vocational Training Scheme, Rural Clinical Schools Program, Relocation Grants and the Overseas Trained Doctor Rural Recruitment Scheme. Many of these programs and others have been accessed to boost the funding available for medical training across Gippsland. The availability of funding and resources for training and education was highlighted as a significant influencing factor to the regions ability to attract and retain training doctors. Of particular concern to many stakeholders was the lack of availability of capital works funding for accommodation and education resources. 23

24 The Influencing Factors The Current Capacity report illustrates where Gippsland is today. The following section aims to illustrate what factors influence the current capacity of the region. These influencing factors can be described as drivers of change. They are the things that either restrain an organisations ability to grow or, when addressed, enable it to move forward. The four key influencing factors to the current capacity of Gippsland s medical workforce having been identified through stakeholder consultation are as follows: Accreditation Supervision Funding and Resources Infrastructure Addressing these factors independently would have an influence on the medical workforce capacity, but only to a limited degree. This can be proven by the fact that prevocational medical training is interlinked strongly between the areas of accreditation, supervision and funding. For example: to gain accreditation on a ward to host intern doctors a health service needs adequate supervision and to have adequate supervision there must be appropriate funding available to attract and retain a supervisor. Furthermore, when considering infrastructure the number of prevocational doctors able to be placed in health services, even if accreditation is achieved, must be supported by adequate accommodation and education facilities. The following subsections expand on each of the influencing factors. 24

25 Accreditation The number of core and noncore accredited posts limits the number of intern places Gippsland can offer. Currently, there are only three sites accredited to offer core rotations and only one site accredited to offer a core emergency medicine rotation totalling seven accredited core posts for the region. A total of 23 accredited noncore posts exist incorporating medicine, surgery, emergency medicine, general practice, anaesthetics, orthopaedics and a shared general practice / hospital rotation. Looking at accreditation only, the key hindrance to increasing the number of accredited posts is the criteria surrounding accreditation requirements. The Postgraduate Medical Council of Victoria manages the accreditation of intern places. The criteria of the PMCV is largely centralised to metropolitan health services making the accreditation of rural posts difficult. The accreditation of an emergency medicine post is next to impossible for a rural hospital based on the current criteria. This is evidenced by the number of Gippsland health services that have been unsuccessful in gaining accreditation. A number of Gippsland hospitals have approached the PMCV regarding this. To date there has been no alterations made to the criteria. There is a large quantity of untapped general practice capacity across the region. The PGPPP has been successfully providing funding to support the growth of general practice terms for prevocational doctors. Regional general practices are favourably placed to obtain accreditation for general practice noncore posts for intern doctors. One issue with the accreditation of general practices is resistance from many medical staff to supervise and train doctors either due to lack of supervisory training, time constraints or work load. General practices that have participated in the PGPPP reported great success with the program once this resistance has been addressed through education and participation. 25

26 Supervision While the accreditation of an area allows rotations to take place, the volume of rotations is limited by the supervision that is available to be provided. Supervision was identified as a major issue with regard to medical workforce numbers. Many health services and community settings have significant problems securing enough senior medical practitioners to simply staff their organisations let alone also provide supervision to the many students and junior staff that are entering the system. With the increase of intern doctors entering programs in 2012 many Gippsland hospitals will not be in a situation to take additional places without additional supervisors. However, no health service currently has the funding to employ these additional senior staff nor is employing a senior staff member a quick or easy task. While Gippsland has many reputable senior medical officers who take great pride in the teaching and training of junior staff the responsibility for large volumes of medical students and graduates often falls on a small number of doctors. This is a result of many factors including: The number of doctors available to supervise The willingness of doctors to supervise given responsibility, time and current obligations The number of doctors with the skills to supervise Currently supervision is a larger issue for health services than for most general practices although some general practices highlighted that there is sometimes resistance from their staff to take interns and PGY2&3 doctors given their current workloads and time constraints. 26

27 Funding and Resources Funding and the availability of resources impacts on many of the influencing factors including: staffing, supervision and infrastructure. Funding is influenced by a number of factors including: The availability of funding Staff available to apply for funding Regional and rural eligibility for funding Competition with large health services Funding for prevocational training and the resources needed to deliver this service is competitive and small regional health services often find it very difficult to compete with large metropolitan hospitals. Furthermore funding applications are often long and arduous processes and not all health services have the staff available to compose strong applications. Without the adequate funding to make necessary changes the medical workforce in Gippsland will not be able to increase without grossly compromising the quality of training offered to doctors. 27

28 Infrastructure Infrastructure includes accommodation, technology and teaching and training environments and resources. Accommodation is the number one issue for many health services including our larger hospitals. The quality of accommodation across Gippsland is inconsistent and often of a poor quality. Accommodation has a big impact on the intern and PGY2&3s experience at a given site and is often noted in the rotation evaluation. The lack of funds available for accommodation redevelopment is the restraining factor. Many sites have to rent additional accommodation at a high cost to cater for the number of students, junior doctors and specialists that staff health services and community settings this proves uneconomical. When applying for capital works grants it is often difficult for a regional hospital to compete with large health services due to bed numbers and service delivery. Competition across the region and across different health disciplines is also a factor when applying for grants. 28

29 The Conclusion There is a significant prevocational workforce in Gippsland that is made up of interns and PGY2&3 doctors working in both hospital and community settings. Some prevocational positions are filled by locally employed doctors whilst others are filled by metropolitan employed doctors rotating into the region. A large proportion of the prevocational workforce is filled by IMGs and international full fee paying graduates. Whilst Gippsland is able to train a significant number of intern and PGY2&3 doctors the regions ability to offer vocational training is limited to General Practice. This results in a limit to the time a training doctor can spend in the region before having to return to metropolitan centres. There are a variety of steps available to move forward. These may include some or all of the following: Increasing the regions capacity through expanding regional training programs and utilising the untapped General Practice capacity across the region. Development of a regional model for prevocational training, education, recruitment and retention. Further mapping of the prevocational situation in Gippsland through additional consultancy and surveying. Assessment of vocational capacity and opportunities. Investigate and implement ways to improve the Gippsland experience for junior doctors. 29