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ACCC proposes surgical college reform to help address surgeons shortage.
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The Australian Competition and Consumer Commission has proposed reform to the selectlon, training and assessment processes for surgeons and accreditation of hos conducted by the Royal Australasian College ol Surgeons'.
The reforms lnclude a greater role for governments in standard setting and implementation and improvement in the transparency of College proc8sses. .
"The need for reform is heightened by emerging evidence of a shoRage of surgeons in Australia", ACCC Chairman, Professor Allan Fek, 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-bein8 of the Australian community.
"By proposlng to grant authorisation" subject to conditions, the ACCC recognises that the Collage's trainlng and assessment processes generate important public benefits.
"The ACCC is aware that potential alternative high standard models exist - for example, dental speciallsts are trained either in universities or the dental college. This contrasts with 6urgebn~ 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 prowsses 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) recornmendatlon regarding the required number of trainee orthopaedic surgeons: that hospital training posts accredited as meeting the College's standerds exist alongside Identical pacts that are not sccredited; that the College (until recently) used penal
marking which in a key exam to limit the number of bask 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 Qnter practlce in Australia - for example, by holding multiple interviews at considerable cost to epplicants and not following or inconsistently applying assessment processes; and mgny complaints received about the College by complainants who were unwilling to 'go pubitc' for fear o! being targeted.
"The control of entry restrictions has far-reaching Con6equences for the Australian community, Such restrictions affect the avallabifity,' regional distribution, quality and price of surgeons' services. The ACCC considers that the supply of such an important professional
service 8s surgery is too important 6 community issue for the selection, training and assessment of surgeons to be lef? solely in the hands of the profession through the College and its Fellows,
"In peRlculaf, surgeons undertaking selection, assessment and accredjtation activities possess a confllct of interest. Requiring that surgical training standards, hospltat training posts and overseas-trained surgeons meet high standards generates clear community benefits, However, unreasonably high standards inappro~riately limit the size of the surgical profession thereby producing higher incomes for surgeons. More generally, the College's expertise I6 in surgical practice and techniques. It 19 therefore not well-placed to take into account broader community considerations such as access, distribution and affordability.
"The need for reform is pa~icu~arly i m ~ ~ a n t given that evidence of a surgeon shortage is now emerging. The ACCC engaged Professor Jeff Borlend of the University of Melbourne to examine whother the current supply of surgeons is sufficient. He found likely shortages of
surgeons in c f majority of surgical sub-specialties including the two largest sub-specialties - general surgery and orthopaedic surgery.
"In addltlon, 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 surgicsl 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, IO work the excessive hours many surgeons have traditional~y worked; and the i ~ ~ l e ~ e n t a t i o n of the Australian Medical Associ6tion's safe working hours policy.
"This means unwarranted entry restrictions on surgeons need to be removed and that there be Qreafet involvement of the broader health community in the refavant decisions.
"The ACCC notes that there are significant restrictions on the ~ u r n b ~ r 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 approptiate balance between the need for the College to remain 6ubstantlally involved in the setting of surgical training and assessment standards, given its
fechnlcat expenlse, while ensuring that conc&rns mentiorted before are addressed','.
The key reforms are: e key standards set by the College be independently and publicly reviewed by a committee cornprlsing 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 It3 standards have been met, These members would essentially be 'honest brokers' who
aim to ensure that standards are approprlately applied: and the College be required to publish information about its traidng and assessment proce$ses, including Information ebout the outcomes, This group of conditions seeks t0 improve the College's transparency, They seek to ensure that governments, doctors,
patients, media and the general community can easily access informatlon about the College, thereby enabling greater public scrutiny. It will clarify whether restrictions On surgeons numbers are caused by the professions or governments.
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"In proposing these conditions, the ACCC has considered a range of concerns raised by interested parties, and particularly state and territory health ministers", Professor Fe13 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 hospitol workforce. Governments, for the first time, will be consulted on the standards that hospitals need to meet before trainee s u r ~ ~ ~ ~ s can work In them. This will atlaw gQvernments input into whether a wider range of ~ospital~, and particularly rural and regional hos~itats, could accommodate tralnee surgeons wlth~ut 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 Crgining standards by proposing the conditions. Rather, it is proposing that the processes by which sutgical 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 surseons in Australia.
"The ACCC has assessed the College's application for authorisat ion a ainst the background of government workforce ptannlng arrangements. In doing fhis, inadequacies in these workforce planning arrangements became apparent. In particular: 6 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 ensurlng the ratio of surgeons to population is kept stable rather than assessing whether that ratio is approprlate in the first place would be to avoid dealing d t h the most fundame~t~l issue a workforce advisory committee would address. The ACCC consider3
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 overseas4rained surgeons should be able to practise in Australia should be redrafted to require that they be 8s competent as Australlan-trained
surgeons, rather than the ambiguous requlrernent of 'equivalency'.
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"These reforms, along with the reforms proposed by the ACCC to the Collsge's training and assessment processes, should be s06n 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 authorlsation to the more oontentious element3 of the College's applicstion
Le. 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 i6 a private association whose members comprise around 90 per cent of Australian surgeons, The College dominates all aspects of the surgical profes6ion. In eddition 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, typical\y comprising half the membership of the working parties established by AMWAC to celculate the required numbers of surgical trainees, Surgeons also sit on 'credentialling' committees which decide whether, for example, an overseas-trained surgeon should be permitted t6 practise at a
particular hospital.
The ACCC wilt now be engaging in further consultation with the College, and interested parties, including the Commonwealth, state and territory governments, before issulng 8 final decision. Interested partles can lodge a written submission and/or call R conference to inform the ACCC of their views on the potentla1 operation and effect of the draft authorisation.
The College has had interim ~ u t ~ o r i ~ ~ t i o ~ ~ * O W for it$ processes since the ACCC's consideration of its application commenced, The protection afforded by interim ~ ~ ~ o f ~ s a t i o n has been extended until the ACCC lssues a final decision.
A copy of the A ( 3 3 3 3 draft authorisation is availsble on the ACCC'S website at h t tp://www accc,gov, au -
Further l n f ~ r m ~ t i ~ n Professor Allan Fels, Chairman, (02) 9290 181 2 or pager (02) 6265 61 70 Mr Sitesh Shojeni, Commissioner, (02) 6243 1132 Ms Lln Enright, Director, Public Relations, (02) 6243 1108 MR 16/03 6 February 2003
'The College runs the only surgical training program in Australia. It decides which medlcal gradu~t~s can enter surgical training, the length of surgical training (at least six years) and its content. College Feiiows provide surgical training, which can only be conducted in hospitals whlch meet standards set by the College. The College conducts the exams that trainees must
pass to complete training successfully and become College members. In addltion, under a system agreed by Commonwealth, state and territory governments, overseas-trained surgeons who wish to practlce in Australla must first be assessed by the College to determine whether they are equivalent to Australian-trained surgeons. The College conducts advanced surgical training, and as9esses 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 ttact).
*The ACCC has the function, through the authorlsation proces6, of adjudlcating on certain anti-competitive practices that would otherwise breach the Trade Pfactices Act 1974. Authorisatlon provides Immunity from court actlon, and is granted where the ACCC is satisfied that the practice delivm offsetting public benefits. Apptications for authorisation are considered on a case by case basis and involve broad public consultation with interested
parties. The onus i6 on the applicant to demonstrete that there is a public benefit arising from !he 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, requlred to ensure that enough speclalists exist to meet community needs.
*'I* The ACCC may grant an intedm authorisation while it con$iders 8r-1 application for authorisation. Interim authorisation provides the same immunlty from court action a6 provided by authorisation proper.
