Monday, February 13, 2006

COAG: Clueless Organisation of Anacoluthic Gits

Last week I was driving home when I heard the ABC's PM show (yes, I am one of those pompous ABC listeners) summing up the recent COAG meeting.

While the news about investing in preventative health, mental illness (not that anyone has specified what changes will actually happen - will there be more acute care beds, institutional beds, community housing, CATT teams, or just bureacracy?) is essentially just feel-good news for the benefit of the media, what blew me away was firstly the ongoing failure of the Federal and State Governments to understand the workforce bottlenecks in medical training, and secondly, Peter Beattie's inane suggestions to reform the health system.

In regard to the Australian "doctor-shortage" - the Howard Goverment fails to realise that this is a problem on multiple levels created by its own attempt to reign in Medicare. On defeating the Keating Goverment in 1996 one of the early acts of the Howard Government was to restrict the availability of Provider Numbers. These numbers are how GPs and specialists are paid by Medicare every time they see a patient. The goal of this was obvious - fewer doctors who can claim money from the public purse means paying out less money, and encouraging competition for scarce funds. It also meant that the Federal Government could then place restrictions on what doctors had to do to earn the right to a Provider Number (e.g. work in the country, complete a specialist or Family Medicine training program). Many organisations spoke out against these changes, and doctors went on rallies and strikes to oppose it.

Doctors who were graduating from medical school found that they could no longer work as GPs, so what happened? They either did what the Government wanted and stuck around for training, or headed off overseas ( the so-called "brain drain" - which actually works both ways). Within a few years, the number of GPs who were able to get Provider Numbers (and thereby work in the public sector) was choked and limited by the State and Federal Government's willingness or otherwise to fund Family Medicine Training positions. Now we see the Howard Government complaining about GPs charging above the (meagre) Medicare Schedule Fees - all because there is now more demand than supply and John Howard's competitive marketplace is coming to fruition. Mind you, this is happening not only in GP-land, but in every specialty of modern medicine.

So what does COAG do? It announces that (from PM) "While for now the Federal Government won't lift the number of medical students it funds to go to university, there will be more room for full-fee paying students." Well, DUH! The Federal Government didn't need to do that... Universities could have done that all on their own. All that means is that: 1. More overseas students can come and train in our universities and hospitals so that they can then go back to where they came from and Australia gains no benefit (besides pocketing their money); and 2. More doctors will graduate and increase the backlog of doctors that can't work in the community.

Yes, you read me correctly, doctors that can't work. The people that are rubbing their hands with glee are the hospital administrators who are seeing the number of hospital resident and registrar applications increase, but only small increases in the number of registrars completing their training and becoming Specialists who can go out and serve the Australian community.

The stranglehold on Specialist Training rests with the State Governments (and in the case of GPs, the Federal Government). Specialist colleges like the Royal Australasian College of Surgeons, Royal Australasian College of Physicians, and Royal Australian College of General Practitioners merely accredit jobs as being suitable for training, and administer the courses and examinations to ensure that graduating specialists are up to scratch.

For surgeons and physicians, these are hospital posts that are funded by the State Government via each Hospital's budget, and are decided between each State Governement and Hospital. For GPs, these are via the allocation of restricted Provider Numbers by the Health Insurance Commission (and therefore, Federal Government).

So for the State and Federal Government to blame the Colleges for restricting specialist numbers is farcical. There are literally hundreds if not thousands of hospital doctors half-way through their training, waiting for a funded position to become available so that they can complete their training. Perhaps 1 in 3 of these applicants will get a position each year. The rest either become disenchanted and drop out of medicine (there are plenty of companies looking for such bright-minded people), head overseas, or fill in as locum doctors for all the gaps in the public health system. Even worse, there are those who have completed their specialist training but cannot find a hospital with enough money to employ them... so they head overseas!

At least Peter Beattie understands this part of the equation when he commented:

"…that we've got to stop thinking just about public hospitals being the provider of clinical training. The proposal that I've talked about and which I put to COAG today involves, in Queensland at least, Greenslopes Private Hospital will actually provide that training. Now, yes, there will be some follow-up that'll have to be done by the public hospital system, but we've got to stop thinking about training just being in the public system. We can do this in partnership with the private system. The whole area of health is public/private anyway, here you've got a hospital that will 60 doctors, hopefully starting – up to 60 doctors – hopefully starting this year."

Note that he actually means 60 full-fee paying medical student places, not doctors. But then, why would we quibble over that when what he is actually doing is single-handedly re-defining the whole paradigm of public/private medicine in Australia.

There are a number of reasons why doctors are not routinely rotated to private hospitals for training.
  1. Patients in a private hospital expect to be treated by their chosen doctor or specialist, not a junior doctor whom the specialist has no choice in and is only doing a 3 month rotation.
  2. Quality resident medical officers are paid handsomely by private hospitals because they are hand-picked and vetted to do a good job. This new arrangement is a cynical exercise at either cost-cutting at private hospitals (since these training-in-private doctors would presumably be paid at award rates only) and/or reduction in the quality of patient care for the sake of a 30 second soundbite.
  3. In those rare private hospitals where private surgical registrars have rotated as part of their training program (yes, they already exist), they have no input into the patient's care, and only assist during operations, without performing the crucial parts of the surgery that are the core goal of their training. This is great for the patient, but not good for the trainee.
Peter Beattie's problem (and not only his, since the same issues simmer away in every other Australian State and Territory) is that working in a (particularly Queensland) public hospital is an increasingly unpleasant and unrewarding job. The pay is paltry per-hour, overtime is routinely being refused, all the responsibility (legal liability) rests with the doctor - which means that any demarcation dispute among nurses, allied health, cleaners etc must be solved by the doctor (read "more unpaid work"), the career-progression is stymied by the lack of Government funding, and then you get screwed over to make sure you aren't another Dr Death (don't even get me started on that one...).

When doctors are appreciated and rewarded for their work, and allowed to go about their jobs without being pressured left right and centre, they will come back to the public health system. Otherwise, strap yourselves down and get ready for a ride into privatised US-style health care!

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