The Australian Competition and Consumer Commission has proposed reform to the selection, training and assessment processes for surgeons and accreditation of hospital training posts conducted by the Royal Australasian College of Surgeons*.
The reforms include a greater role for governments in standard setting and implementation and improvement in the transparency of College processes.
"The need for reform is heightened by emerging evidence of a shortage of surgeons in Australia", ACCC Chairman, Professor Allan Fels, said today. "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.
"By proposing to grant authorisation** subject to conditions, the ACCC recognises that the College's training and assessment processes generate important public benefits.
"The ACCC is aware that potential alternative high standard models exist – for example, dental specialists are trained either in universities or the dental college. This contrasts with surgeons whose training is controlled by the College and does not involve universities. However the ACCC accepts that Commonwealth, state and territory governments, which would have to fund any new system, consider that the College's current role should continue as long as the governments' concerns are addressed. Moreover, the ACCC recognises that the College's processes contribute significantly to the high standards of surgery in Australia.
"These processes also give the College significant influence over the number of surgeons entering the profession. In particular, the number of trainee surgeons is limited by the number of training posts in hospitals that meet College standards. Overseas-trained surgeons entering practice in Australia are, in practice, limited by the College's assessment as to whether they are 'equivalent' to an Australian-trained surgeon.
"Significant concerns emerged that College processes were used to restrict the number of surgeons. These include that the College ignored an Australian Medical Workforce Advisory Committee (AMWAC) recommendation regarding the required number of trainee orthopaedic surgeons; that hospital training posts accredited as meeting the College's standards exist alongside identical posts that are not accredited; that the College (until recently) used penal marking which in a key exam to limit the number of basic surgical trainees; that the college unnecessarily delays, and does not provide reasons for decisions, e.g. about recognition of overseas-trained surgeons or about accreditation of hospital training posts; that the College erects 'invisible barriers' (in the experience of NSW Health) to overseas-trained surgeons wishing to enter practice in Australia – for example, by holding multiple interviews at considerable cost to applicants and not following or inconsistently applying assessment processes; and many complaints received about the College by complainants who were unwilling to 'go public' for fear of being targeted.
"The control of entry restrictions has far-reaching consequences for the Australian community. Such restrictions affect the availability, regional distribution, quality and price of surgeons’ services. The ACCC considers that 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.
"In particular, surgeons undertaking selection, assessment and accreditation activities possess a conflict of interest. Requiring that surgical training standards, hospital training posts and overseas-trained surgeons meet high standards generates clear community benefits. However, unreasonably high standards inappropriately limit the size of the surgical profession thereby producing higher incomes for surgeons. More generally, the College’s expertise is in surgical practice and techniques. It is therefore not well-placed to take into account broader community considerations such as access, distribution and affordability.
"The need for reform is particularly important given that evidence of a surgeon shortage is now emerging. The ACCC engaged Professor Jeff Borland of the University of Melbourne to examine whether the current supply of surgeons is sufficient. He 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.
"This means unwarranted entry restrictions on surgeons need to be removed and that there be greater involvement of the broader health community in the relevant decisions.
"The ACCC notes that there are significant restrictions on the number of surgeons practicing imposed by governments.
"The ACCC proposes a range of reforms aimed at helping address this shortage issue. The reforms should find an appropriate balance between the need for the College to remain substantially involved in the setting of surgical training and assessment standards, given its technical expertise, while ensuring that concerns mentioned before are addressed".
The key reforms are:
- key standards set by the College be independently and publicly reviewed by a committee comprising nominees of the College, the Australian Medical Council and the Australian Health Ministers Conference. The standards accredit hospitals and hospital posts as being suitable for surgical training and the standards underpin whether overseas-trained surgeons are equivalent to Australian-trained surgeons
- government-nominated members be added to College teams assessing whether its standards have been met. These members would essentially be 'honest brokers' who aim to ensure that standards are appropriately applied and
- the College be required to publish information about its training and assessment processes, including information about the outcomes. This group of conditions seeks to improve the College's transparency. They seek to ensure that governments, doctors, patients, media and the general community can easily access information about the College, thereby enabling greater public scrutiny. It will clarify whether restrictions on surgeons numbers are caused by the professions or governments.
"In proposing these conditions, the ACCC has considered a range of concerns raised by interested parties, and particularly state and territory health ministers", Professor Fels said.
"The reforms are also intended to assist governments to address the lack of surgeons in rural and regional areas. Trainee surgeons are an important part of the hospital workforce. Governments, for the first time, will be consulted on the standards that hospitals need to meet before trainee surgeons can work in them. This will allow governments input into whether a wider range of hospitals, and particularly rural and regional hospitals, could accommodate trainee surgeons without any fall in training standards. It would also allow distribution of the new training posts to be in accordance with community needs and priorities.
"The ACCC has not sought to alter surgical training standards by proposing the conditions. Rather, it is proposing that the processes by which surgical training and assessment standards are developed and implemented be altered to allow for greater input from key stakeholders particularly state and territory governments, which are the largest employer of surgeons in Australia.
"The ACCC has assessed the College's application for authorisation against the background of government workforce planning arrangements. In doing this, inadequacies in these workforce planning arrangements became apparent. In particular:
- the methodology used by AMWAC to determine surgical training number targets needs to be improved, a view affirmed by a recent review of AMWAC. Specifically, the ACCC has expressed concerns that simply to work on the basis that projections should be aimed at ensuring the ratio of surgeons to population is kept stable rather than assessing whether that ratio is appropriate in the first place would be to avoid dealing with the most fundamental issue a workforce advisory committee would address. The ACCC considers that as a matter of priority, AMWAC should undertake a review of current adequacy of supply of surgeons
- the implementation of AMWAC targets needs reform. In particular, where such a process does not already exist, there is a need for systematic process within state and territory health departments to implement AMWAC targets. If such a process is not introduced, then questions arise about the value of having AMWAC in the first place and
- the test for determining whether overseas-trained surgeons should be able to practise in Australia should be redrafted to require that they be as competent as Australian-trained surgeons, rather than the ambiguous requirement of 'equivalency'.
"These reforms, along with the reforms proposed by the ACCC to the College's training and assessment processes, should be seen as a package aimed at ensuring that a sufficient number of surgeons are practising to meet the needs of the Australian community for high-quality surgical care into the future.
"The ACCC proposes to grant authorisation to the College's processes for selecting, training and examining trainees for six years, subject to the reforms detailed before. The ACCC proposes to grant authorisation to the more contentious elements of the College's application i.e. its processes for: assessing overseas-trained surgeons; accrediting hospitals for basic surgical training; and accrediting hospital posts for advanced surgical training for four years. These processes have attracted considerable criticism from interested parties which warrants an earlier review by the ACCC.
"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 ACCC will now be engaging in further consultation with the College, and interested parties, including the Commonwealth, state and territory governments, before issuing a final decision. Interested parties can lodge a written submission and/or call a conference to inform the ACCC of their views on the potential operation and effect of the draft authorisation.
The College has had interim authorisation**** for its processes since the ACCC's consideration of its application commenced. The protection afforded by interim authorisation has been extended until the ACCC issues a final decision.
*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).
**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.
***The Australian Medical Workforce Advisory Committee was established by Commonwealth, state and territory governments to calculate the number of trainee medical specialists, including trainee surgeons, required to ensure that enough specialists exist to meet community needs.
**** The ACCC may grant an interim authorisation while it considers an application for authorisation. Interim authorisation provides the same immunity from court action as provided by authorisation proper.