ACCC requires reform of surgeons' training program

Major reforms to the program that trains and selects surgeons in Australia have been required by the Australian Competition and Consumer Commission in an authorisation* decision issued today.

"The 'closed-shop' arrangements and culture, represented by the Royal Australasian College of Surgeons, which unduly influence the selection, training and assessment of Australian surgeons and the accreditation of hospitals – must be overcome", ACCC Chairman, Professor Allan Fels, said today.

The key reforms are:

• an independent and public review of the standards used by the College to assess whether hospital posts are suitable for surgical training
• government nominated members to be added to College assessment teams for hospitals and the College to assess all Health ministers' nominations of any hospitals for which Ministers seek College accreditation for surgical training
• an independent and public review of the test used to assess overseas-trained surgeons for Australian registration. There will be time limits on assessment decisions. Those overseas trained doctors previously not recognised will be able to apply under the reformed system
• selection processes for basic and advanced surgical training to conform with the "Brennan principles" which include that training post limits be openly declared; interviews be objective and free of bias; decisions be documented and appealable; and applicants receive greater feedback. The College allow Health Ministers to have input into decisions to limit the number or distribution of basic surgical training posts
• government-nominated members be added to College teams selecting applicants. These members would essentially be 'honest brokers' who aim to ensure that standards are appropriately applied
• the College to form formal agreements with sub-speciality societies involved in advanced surgical training to ensure the College's obligations to meet Australian Medical Workforce Advisory Committee (AMWAC) and Australian Health Ministers Conference (AHMC) decisions on training numbers are fulfilled
• changes to the College's appeals committee to provide for a majority of external members with a minority of College Fellows
• improved appeals processes, including expanded grounds for appeal, time limits for appeals, appropriate representation and allowing sponsoring hospitals to appeal on behalf of overseas trained surgeons
• the College be required to publish information about its training and assessment processes, including information about the outcomes. This group of conditions seeks to ensure that governments, doctors, patients, media and the general community can easily access information about the College, thereby enabling greater public scrutiny
• formal consultative arrangements be established between the College, Health Ministers/departments and between College and consumer groups.

"The supply of such an important professional service as surgery is too important a community issue for the selection, training and assessment of surgeons to be left solely in the hands of the profession through the College and its Fellows. There is a serious risk of conflict of interest.

"The College recently published the Birrell Report which claimed that government is the sole source of restrictions on entry to the surgical profession. The ACCC disagrees.

"While acknowledging that government medical workforce planning is a major source of restrictions on entry into the surgical profession, the ACCC also considers that the College plays a significant role. However, the ACCC recognises that if community concerns about the College subside as a result of the reforms, the spotlight will fall squarely on government if shortages of surgeons continue.

"The ACCC has imposed important conditions on the authorisation to address the potential of the College's training and assessment processes being used to inappropriately restrict entry into the surgical profession.

"The ACCC considers setting standards without input from key stakeholders – e.g. health departments, which are the biggest employer of surgeons in Australia and in whose hospitals training largely takes place – is inappropriate. In particular, a review will allow governments input into whether surgical training could take place in a wider range of hospitals, and particularly rural and regional hospitals.

"More training in rural and regional areas should help address the rural shortage of surgeons, as many surgeons prefer to work in the area in which they trained, and because trainee surgeons are in themselves important members of hospital workforces. Ensuring that enough competent surgeons are available in rural, regional and metropolitan Australia to meet patients' needs is crucial to the ongoing health and well-being of the Australian community.

"The ACCC notes an important new initiative which may help address this shortage. The Hunter Area Health Service, in conjunction with the University of Newcastle, proposes to establish a new medical specialist training program based in the Hunter Valley. The proposed program could be implemented in partnership with the College or not.

"The reforms aim to appropriately balance the need for the College to remain substantially involved in the setting of surgical training and assessment standards, given its technical expertise, while ensuring competition concerns are addressed.

"Requiring that surgical training standards, hospital training posts and overseas-trained surgeons meet high standards generates clear community benefits. But standards that exceed those needed to ensure that surgeons are competent inappropriately limits the number of surgeons, affecting access, distribution and affordability.

"Significant concerns came to light during the authorisation inquiry about whether the College solely focuses on maintaining appropriate surgical standards.

"The concerns include that the College:

• ignored an AMWAC recommendation about increased trainee orthopaedic surgeons positions
• that it erects 'invisible barriers' (in the experience of NSW Health) to overseas-trained surgeons wanting to practice in Australia (for example, by holding multiple interviews at considerable cost to applicants and not following or inconsistently applying assessment processes)
• many complaints received about the College by complainants who were unwilling to 'go public' for fear of being targeted.

"Significantly, the College's responses to the draft decision issued in February display a broader inability to accept that its processes impact on competition in the surgical profession.

"In particular, the College disputes that it influences the number of surgeons entering surgical practice. However, this is self-evidently what entry standards do. The benefit to the public will outweigh the detriment if standards are set at an appropriate level – if not, the public will be disadvantaged by an unjustified reduction in the affordability and availability of surgery.

"Consequently, while acknowledging that the College has worked co-operatively with health departments and the ACCC to refine the conditions proposed in the draft determination, the ACCC is concerned about the longer-term commitment of the College to ensuring that its processes do not inappropriately impact on competition. Unless the concerns about the College have subsided, the ACCC is likely to carefully consider whether granting a further authorisation is appropriate".

Authorisation for the College's role in accrediting surgical training posts and overseas-trained surgeons is granted for four years.

Authorisation for the remaining College processes is granted for six years.

*The ACCC has the function, through the authorisation process, of adjudicating on certain anti-competitive practices that would otherwise breach the Trade Practices Act 1974. Authorisation provides immunity from court action, and is granted where the ACCC is satisfied that the practice delivers offsetting public benefits. Applications for authorisation are considered on a case by case basis and involve broad public consultation with interested parties. The onus is on the applicant to demonstrate that there is a public benefit arising from the conduct and that the public benefit outweighs any public detriment.

Background

Shortage of surgeons

The need for reform is particularly important given that evidence of a surgeon shortage is now emerging. A report to the ACCC by Professor Jeff Borland of the University of Melbourne found likely shortages of surgeons in a majority of surgical sub-specialties including the two largest sub-specialties – general surgery and orthopaedic surgery. In addition, a number of factors suggest that there could be a severe shortage of surgeons in the coming years.

These include: the ageing Australian population; the ageing Australian surgical profession, including the possibility that many surgeons are considering retiring early; increased demand for Australian surgeons overseas; the reluctance of younger surgeons, and particularly female surgeons, to work the excessive hours many surgeons have traditionally worked; and the implementation of the Australian Medical Association's safe working hours policy. The College has now recognised this shortage in the just-released Birrell Report.

Government restrictions on entry into the surgical profession Australian Medical Workforce Advisory Committee (AMWAC) The ACCC has assessed the College's application for authorisation against the background of government workforce planning arrangements. Under these arrangements, health ministers, acting on AMWAC advice, set target numbers for the number of trainees in each speciality in order to ensure that patient demands are met into the future. During the course of the authorisation, inadequacies in these workforce planning arrangements became apparent.

In particular the ACCC became concerned about the methodology used by AMWAC to determine surgical training number targets. While the ACCC's concerns about some of the earlier reviews of surgical specialties remain, it welcomes the fact that the AMWAC methodology has been improved and that the ACCC's views to the 2002 review of AMWAC have been taken into account. It further welcomes the fact that AMWAC will be re-examining key surgical sub-specialties as part of its 2003-04 work program.

The College

The College is a private association whose members comprise around 90 per cent of Australian surgeons. The College dominates all aspects of the surgical profession. In addition to being the sole body training surgeons in Australia and assessing overseas-trained surgeons, the College is heavily involved in all other processes affecting entry to the surgical profession. For example, surgeons are heavily involved in AMWAC, typically comprising half the membership of the working parties established by AMWAC to calculate the required numbers of surgical trainees. Surgeons also sit on 'credentialling' committees which decide whether, for example, an overseas-trained surgeon should be permitted to practise at a particular hospital.

The College runs the only surgical training program in Australia. It decides which medical graduates can enter surgical training, the length of surgical training (at least six years) and its content.

College Fellows provide surgical training, which can only be conducted in hospitals which meet standards set by the College. The College conducts the exams that trainees must pass to complete training successfully and become College members. In addition, under a system agreed by Commonwealth, state and territory governments, overseas-trained surgeons who wish to practice in Australia must first be assessed by the College to determine whether they are equivalent to Australian-trained surgeons. The College conducts advanced surgical training, and assesses overseas-trained surgeons, in the following specialities: cardiothoracic surgery (heart and chest), general surgery, neurosurgery (nervous system, including brain), orthopaedic surgery (skeletal system), paediatric surgery, plastic and reconstructive surgery, otolaryngology (ear, nose and throat), vascular surgery (blood vessels) and urology (urological tract).

Proposal for new medical specialist training program in Hunter Valley There is a shortage of medical specialists in rural and regional Australia, including in the Hunter Valley in NSW. To address this, the Hunter Area Health Service in conjunction with the University of Newcastle proposes to establish a new medical specialist training program based in the Hunter Valley. The proposed program could be implemented in partnership with the College or not. No government funding would be needed. This proposal potentially represents a major turning point in the history of medical specialist training in Australia. It potentially signals the end of the training monopoly held by the specialist medical colleges. The ACCC will be liaising closely with Hunter Health and the University of Newcastle as they seek to establish their new training program, as well as actively monitoring the situation generally. The ACCC will vigorously investigate all complaints that the development or ongoing operation of the new training program is being impeded by anti-competitive activity.