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Expansion of Medical Education - Report of Committee on Medical Schools to Australian Universities Commission, July 1973


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THE PARLIAMENT OF THE COMMONWEALTH OF AUSTRALIA

1973— Parliamentary Paper No. 110

EXPANSION OF MEDICAL EDUCATION

R eport of the Com m ittee on M edical S ch ools to the A ustralian U niversities C om m ission

JULY 1973

Presented by Command 23 August 1973 Ordered to be printed 11 September 1973

THE GOVERNMENT PRINTER OF AUSTRALIA CANBERRA 1973

© Commonwealth o f Australia 1973

Brow n P rio r A nderson P ty L td 5 E vans Street Burwood 3125

AUSTRALIAN UNIVERSITIES COMMISSION

Reserve Bank Building, London Circuit, Canberra City A.C.T. 2601 31 July 1973

Dear Minister,

On 22 June 1972 the then Minister for Education and Science (the Honourable Malcolm Fraser, M.P.) appointed, under section 17 of the Australian Universities Commission Act 1959-1971, a Committee to advise the Commission on the need for new or expanded medical schools in the light of likely trends in the delivery of health care in Australia over the next twenty years.

The Committee has now completed its Report, which it conveyed to the Com­ mission by letter dated 23 July 1973. The Commission considered the Committee’s recommendations at its meeting on 30 July and expressed its support for them.

The Commission wishes to place on record its thanks to the members of the Com­ mittee for the work undertaken by them in the preparation of the Report.

Yours sincerely, Peter Karmel Chairman

The Hon. Kim E. Beazley, M.P., Minister for Education, Parliament House, Canberra A.C.T. 2600

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COMMITTEE ON MEDICAL SCHOOLS

Reserve Bank Building, London Circuit, Canberra City A.C.T. 23 July 1973

Dear Chairman,

On 22 June 1972 the then Minister for Education and Science (the Honourable Malcolm Fraser, M.P.) appointed us, under section 17 of the Australian Universities Commission Act 1959-1971, as a Committee to advise the Commission on the need for new or expanded medical schools in the light of likely trends in the delivery of health care in Australia over the next twenty years.

We have now completed our task and we have the honour to submit to the Commission the full and unanimous report of the Committee.

We wish to place on record the very great assistance that we have received from the universities, health and hospital authorities and the various professional groups of medical practitioners. We are also much indebted to the Commonwealth Bureau of Census and Statistics for valuable statistical help and to the Commonwealth Department of Health for its ready co-operation.

Finally, we wish to express our gratitude, for their work on the Committee’s behalf, to the two members of the Secretariat of the Commission who have acted as secretary of the Committee, Miss Astrid Norgard and Mrs Carol Procter, and to the Chairman’s secretary, Mrs Anne Freebody.

Yours sincerely, Peter Karmel, Chairman H. R. Beer L. W. Cox F. B. Horner Selwyn Nelson J. A. Sewell Sydney Sunderland

Chairman, Australian Universities Commission, P.O. Box 250, Canberra City A.C.T. 2601

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Contents

Chapter 1. Introduction Terms of Reference . . . . . . . . . . . 1

Procedure . . . . . . . . . . . . . 2

Conclusions . . . . . . . . . . . . 3

Recommendations . . . . . . . . . . . 4

Chapter 2. Medical Schools in Australia Existing Medical Schools . . . . . . . . . . 6

Student Enrolments . . . . . . . . . . . 7

Teaching Hospitals . . . . . . . . . . . 12

Academic Staff . . . . . . . . . . . 1 4

Costs of Training Medical Graduates . . . . . . . . 14

Undergraduate Medical Course . . . . . . . . . 17

Vocational Training for Specialists . . . . . . . . . 19

Chapter 3. Current Position of Medical Manpower Total Number of Doctors in Australia . . . . . . . . 21

Doctors in Each State . . . . . . . . . . . 25

Doctors in Metropolitan and Country Areas . . . . . . . 25

Types of Doctors . . . . . . . . . . . 28

Sex Distribution of Doctors . . . . . . . . . . 35

Age Distribution of Doctors . . . . . . . . . . 36

Workload of Doctors . . . . . . . . . . . 37

Group Practices . . . . . . . . . . . . 40

Sources of Doctors . . . . . . . . . . . 42

Retirement of Doctors and Withdrawal from Medicine . . . . . 47

Conclusions on Current Position . . . . . . . . . 49

Chapter 4. Trends in the Demand for Medical Services Demographic Trends . . . . . . . . . . . 52

Morbidity Trends . . . . . . . . . . . 54

Technological Advances . . . . . . . . . . 55

Preventive Medicine . . . . . . . . . . . 56

Economic Trends . . . . . . . . . . . . 56

Social T r e n d s ...................................................................................................... 57

Institutional C h a n g e s ............................................................................................. 58

Chapter 5. Trends in the Productivity of Doctors Organisational Changes . . . . . . . . · . 6 1

Advances in Medical Knowledge and Technology . . . . . . 66

Conditions of Work . . . . . . . . . . . 67

Age and Sex Distribution of Doctors . . . . . . . . 68

Net Effect of Demand and Productivity Trends on Manpower Needs . . . 70

Chapter 6. Supply of Doctors up to 1991 According to Approved Plans

Chapter 7. Future Requirements for Doctors Criteria for Adequacy of Future Supply of Doctors . . . . . . 77

Conclusions on Future R e q u ir e m e n ts ................................................................85

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Chapter 8. New and Expanded Medical Schools—Recommendations Conditions for Expansion . . . . . . . . . . 88

Size of Medical Schools . . . . . . . . . . 94

Existing Versus New Schools . . . . . . . . . . 95

Possibilities for E x p a n s io n ................................................................................ 97

R e c o m m e n d a tio n s ............................................................................................... 117

Effects of Recommendations on Medical Manpower Projections. . . . 119

Chapter 9. Some Related Problems in Medical Education Undergraduate Curricula . ........................................................................ 124

Postgraduate Medical Education . . . . . . . . . 128

Teaching Hospitals and Medical S c h o o l s ........................................................... 131

Selection of Medical Students...................................................................................... 133

Physician A s s i s t a n ts ............................................................................................... 135

Financing of Medical S c h o o l s ............................................................................. 136

Paramedical E d u c a t i o n ...................................................................................... 137

Research into Health A d m in is tra tio n .................................................................... 138

Conclusions .........................................................................................................139

Appendixes A. Form of advertisment inviting submissions . . . . . . 142

B. Organisations and individuals who made written submissions to the Com­ mittee . . . . . . . . . . . . 143

C. List of organisations and individuals who appeared before the Committee 146 D. Statistical Appendix . . . . . . . . . . 149

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Tables

CHAPTER 2

2.1 Number of M.B., B.S. Degrees Conferred, Australian Universities, 1939 to 1972 6 2.2 Enrolment Quotas, Australian Medical Schools, 1973 ....................................7

2.3 Female New Enrolments as a Proportion of Total New Enrolments, Australian Medical Schools, 1950 to 1973 ........................................................................9

2.4 M.B., B.S. Degrees Conferred on Females as a Proportion of Total M.B., B.S. Degrees Conferred, Australian Universities, 1939 to 1972 . . . . 10 2.5 Annual Rate of Growth in Total Enrolments by Sex, Australian Medical Schools, 1962 to 1973 ................................................................................. 11

2.6 Overseas Students as a Proportion of Total Students, Australian Medical Schools, 1968 to 1972 ................................................................................ 11

2.7 Overseas Students as a Proportion of Total Students in Sixth Year Medicine, Australian Medical Schools, 1968 and 1970 ...................................................... 12

2.8 Teaching Hospitals at Australian Universities Which Have Received Building Grants from the Australian Universities Commission . . . . . 13

2.9 Students, Staff and Student-Staff Ratios, Australian Medical Schools, 1973 15 2.10 Comparison of Average Costs in Teaching and Non-Teaching Hospitals, New South Wales, Victoria and Queensland, 1971-72 .................................... 17

2.11 General Plan of Australian Medical Courses . . . . . . 18

CHAPTER 3

3.1 Doctor-Population Ratios in Australia and Other Countries. . . . 22

3.2 Standard Doctor-Population Ratios Suggested or Implied as Adequate for Current Australian Needs . . . . . . . . . . 23

3.3 Growth of Doctor-Population Ratios, Australian Censuses, 1933 to 1972 . 24 3.4 Doctor-Population Ratios Suggested as Adequate for Other Countries’ Current Needs . . . . . . . . . . . . 24

3.5 Doctor-Population Ratios, Australian Census, June 1971 . . . . 25

3.6 Doctors in Metropolitan and Country Areas in Relation to Population, Aust­ ralian Censuses 1961, 1966 and 1971 . . . . . . . . 26

3.7 Distribution of Doctors in Country Areas, by Number of Doctors per Town, Australia 1947 to 1971 . . . . . . . . . . 26

3.8 Distribution of Doctors in Pensioner Medical Service by Doctor-Population Ratios of Local Government Areas, Sydney Statistical Division, 1968 and 1972 27 3.9 Estimates of Active Medical Practitioners by Prime Activity and Employment Status, Australia 30 June 1972 . . . . . . . . . 28

3.10 Doctor-Population Ratios by Prime Activity and Employment Status, Australia, 30 June 1972 .................................................................................................. 28

3.11 Doctor-Population Ratios for Types of Doctor, Switzerland and Northern Ireland 1969, New Zealand 1967-68, Australia 1972 .................................... 29

3.12 Approximate Number of General Practitioners, Australia 1965 to 1972 . . 30

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3.13 Approximate General Practitioner-Population Ratios, by State, Australia 1965 to 1972 ............................................................................................................ 31

3.14 Approximate Number of Specialists, Australia 1965 to 1972 . . . . 31 3.15 Approximate Specialist-Population Ratios, by State, Australia 1965 to 1972 . 32 3.16 Proportion of Doctors in Private Practice and Salaried Employment, Australia 1933 to 1972 32

3.17 Doctors in Private Practice and in Other ‘Industries’, Australian Censuses 1947 to 1 9 7 1 ....................................................................................................................33

3.18 Full-time Salaried Medical Officers Employed by Hospitals, by Type of Employ­ ment, Australia, June 1972 34

3.19 Proportion of Salaried Medical Officers Employed by Hospitals, Australia 1961, 1965 and 1972 .................................................................................................. 34

3.20 Female Doctors as a Proportion of All Doctors, Australia, 1933 to 1971 . . 35 3.21 Distribution of Male and Female Doctors by Type of Work, Australia, June 1972 36

3.22 Number of Doctors by Age, Australian Censuses, 1933 to 1971 . . . 36 3.23 Medical Services per General Practitioner, Various Estimates, Australia, 1962-63 to 1971-72 37

3.24 Mean Working Time, Victorian Survey of General Practice, 1967 . . . 39 3.25 Average Hours Worked per Week, Australian Medical Association Surveys, Including Hours O n Call’, 1971 and 1972 . . . . . . . 40

3.26 Doctors in Group Practice, Australia, 1970 to 1973 . . . . . 40

3.27 Group Practice in New South Wales, 1972 41

3.28 Medical Practitioners, by Type of Practice, Victoria, 1970 . . . . 41

3.29 Active Medical Practitioners Resident in Australia at 30 June 1972, by Country of First Graduation . . . . . . . . . . 42

3.30 Sources of Doctors, Australia, 1962 to 1972 ............................................. 42

3.31 Components of Net Immigration of Doctors, Australia, 1962 to 1972 . . 43 3.32 Arrivals of Doctors as Settlers, by Country of Birth, and Net Arrivals of Settlers, Australia, 1962 to 1972 ....................................................................... 43

3.33 Net Departures of Doctors Resident in Australia, Permanent (Other than Former Settlers) and Long-Term, 1962 to 1972 . . . . . . 44

3.34 Doctors from Australia Entering the United States and Canada as Immigrants, 1962 to 1972 .................................................................................................. 44

3.35 Long-term Movement of Doctors Resident in Australia, 1962 to 1972 . . 45 3.36 Female Doctors, Graduations and Net Permanent and Long-term Arrivals, 1962 to 1972 46

3.37 Age Distribution of Graduations from Four Medical Schools in Recent Years 47 3.38 Components of Net Immigration of Doctors by Age-group, mid-1966 to mid-1 9 7 1 .................................................................................................................. 47

3.39 Estimated Retirements and Withdrawals of Doctors from Medicine, Australia, 1961-66 and 1966-71 ........................................................................ 48

3.40 Apparent Retirements and Withdrawals from Medicine, by Sex and Age-group, 1961-1966 and 1966-1971, Unadjusted Census D a t a ............................................ 49

3.41 Estimated Rates of Retirement and Withdrawal of Doctors under 65 Years of Age, by Sex, 1961-66 and 1966-71 . . . . . . . . 49

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CHAPTER 4

4.1 Effect of Changing Age Structure of Population on Demand for Medical Services, Australia, 1933 to 1 9 9 1 . .......................................................................52

4.2 Proportion of Population Aged 0 years and 1 to 4 years, Australia, 1933 to 1971 and Projected 1 9 9 1 ..................................................................................................53

4.3 Doctors Engaged in Public Administration, Teaching and Research, Australia, 1961 to 1 9 7 1 .......................................................................................................... 58

4.4 Doctors who Reported Hospitals as their Industry of Employment, Australia, 1947 to 1 9 7 1 .......................................................................................................... 59

CHAPTER 5

5.1 Medical Graduates of Australian Universities, Distributed by Weekly Hours of Medical Work, by Year of Graduation and Sex, 1972 .................................... 69

CHAPTER 6

6.1 Second Year Enrolments and Degrees Conferred, Australian Medical Schools, Actual 1972 and Estimated 1973 to 1991, on Basis of Approved Plans of Existing Medical Schools . . . . . . . . . . . 74

6.2 Projections of Number of Doctors, 1971 to 1991, on Basis of Approved Plans of Existing Medical Schools Compared with Period 1961 to 1971 . . . 75

CHAPTER 7

7.1 Projected Doctor-Population Ratios Representing Future ‘Needs’ Published in Reports of Enquiries . . . . . . . . . . 79

7.2 Desirable Doctor-Population Ratios in Australia in Various Future Years from Submissions to the Committee and Other Studies . . . . . . 81

CHAPTER 8

8.1 Numbers Admitted to Medicine as a Percentage of Qualified First Preference Applicants, Australian Medical Schools with First Year Quotas, 1970 to 1973 89 8.2 Second Year Medical Students per 1,000 of Population Aged 19 years, 1967 to 1973 90

8.3 Second Year Enrolments and Degrees Conferred, Australian Medical Schools, Actual 1972, and Estimated 1973 to 1991, on Basis of the Committee’s Re­ commendations . . . . . . . . . . . 1 2 0

8.4 Projections of Number of Doctors, 1976 to 1991 on Basis of Approved Plans of Existing Medical Schools Compared with Period 1933 to 1971. . . . 121 8.5 Projections of Number of Doctors, 1976 to 1991 on Basis of Expansion up to 1991 in Existing Schools Recommended by Committee. . . . . 1 2 1

8.6 Projections of Number of Doctors, 1976 to 1991 on Basis of Expansion up to 1991 in Existing Schools and New Schools Recommended by the Committee . 121 8.7 Second Year Medical Enrolments per Thousand of Population Aged 19 Years, on Basis of Committee’s Recommendations, Australia 1971 to 1986. . . 122

8.8 M.B., B.S. Degrees Conferred per Million of State Populations on Basis of Committee’s Recommendations, Australia 1971 to 1991. . . . . 1 2 3

B

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APPENDIX D

D . 1 Derivation of Registered, Resident, Active Medical Practitioners in Australia from Total Registrations, June 1972 . . . . . . . . 150

D .2 Monash University Survey of Medical Graduates 1972, Contact and Response Rates, by year of Graduation and S e x ..................................................... 152

D.3 1965 Graduates, Australian Medical Schools, 1972 Survey . . . . 1 5 3 D.4 Distribution of Doctors in Pensioner Medical Service, by Doctor-Population Ratios in Local Government Areas, 1968 to 1972. . . . . . 153

D.5 Distribution of Full-time Doctors Mainly in Private Practice Outside Metro­ politan Area, by size of Doctor-Population Ratio of the Area, Victoria, 1964 and 1970 .................................................................................................. 154

D.6 Distribution of Medical Practitioners Recorded in Censuses of 1961, 1966 and 1971 Outside Metropolitan Statistical Divisions, Australia, by size of Doctor- Population Ratio of the Area, all States except Victoria. . . . . 1 5 4

D.7 Full-time Salaried Medical Officers Employed in Hospitals, Australia, June 1972 ........................................................................................................... 155

D.8 Number of Doctors at Censuses, 1933 to 1971, by Sex . . . . . 155

Note Any discrepancies between totals and the sum of components in tables are due to rounding.

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CHAPTER 1

Introduction TERMS OF REFERENCE

1.1 On 23 May 1972, the then Minister for Education and Science (the Honourable Malcolm Fraser, M.P.) and the then Minister for Health (Senator the Honourable Sir Kenneth Anderson) announced that the Commonwealth had decided, with the agreement of the States, to appoint a committee of the Australian Universities

Commission with the following terms of reference:

to enquire into and make recommendations to the Australian Universities Com­ mission on the need for new or expanded medical schools in the light of likely trends in the delivery of health care in Australia over the next 20 years.

1.2 The Committee was set up in response to proposals made by several universities, in their submissions to the Australian Universities Commission for the 1973-75 triennium, for the establishment of new medical schools. It was felt that, in view of developments in the fields of medicine and patient care, a decision to establish

additional facilities for training doctors should not be made without a full enquiry by an expert committee.

1.3 The Committee was formally appointed on 22 June 1972, in accordance with section 17 of the Australian Universities Commission Act 1959-71, with the following membership: Emeritus Professor P. H. Karmel, C.B.E., Chairman of the Australian Univers­

ities Commission Chairman Mr H. R. Beer, M.C., Chief Executive Officer, Sydney Hospital Professor L. W. Cox, Professor of Obstetrics and Gynaecology, University of Adelaide

Dr F. B. Horner, Deputy Commonwealth Statistician Dr Selwyn Nelson, Physician, Sydney Mr J. A. Sewell, I.S.O., State Auditor-General, Queensland Professor Sir Sydney Sunderland, C.M.G., member of the Australian Universities

Commission and Professor of Experimental Neurology, University of Melbourne.

1.4 The terms of reference made it clear that the central task of the Committee related to medical manpower requirements; the Committee has limited its recom­ mendations strictly to these matters. However, since the Committee was enjoined to take account of likely trends in the delivery of health care, it has necessarily received

submissions dealing with wider questions and has had discussions with organisations and individuals on matters relating to health organisation, the medical curriculum and the training of paramedical workers. The Committee has made no recommenda­ tions on these matters but, as it has received a great deal of information on them and

has had to form views about them in order to reach its conclusions on medical

1

manpower matters, it has thought it proper to set out its observations on a number of issues which it believes are of critical importance for Australian health services in the next two decades. These observations have been brought together in Chapter 9.

1.5 The Committee’s terms of reference refer to the next twenty years. Since the most recent Census information is at June 1971, the Committee decided to fix the end of its period of review at 1991. This means that it has taken into account the effects on medical manpower of new graduates who will have completed their university work in 1990. In terms of new (first year) medical students, it has considered the period up to and including the year 1985 (1986 for the University of Sydney which has now adopted a five year course). Since a decision to create a new medical school must be made some four or five years in advance of the first intake of first year students, the period under review for decisions about new schools extends only to the early 1980s. Thus, where the Committee has decided not to support proposals for new schools within the period under review, it has committed itself only until the early 1980s.

PROCEDURE

1.6 The Committee held its first meeting on 27 June 1972. It has met on 19 separate occasions for a total of 28 days. Meetings were held in each capital city and in New­ castle, Wollongong and Townsville. The Chairman made certain enquiries on behalf of the Committee while in the United Kingdom in July, 1973, and Sir Sydney Sunderland made more extensive enquiries while in the United States and the United Kingdom in 1972 and 1973.

1.7 Submissions were invited generally through advertisements appearing in the press throughout Australia on 5 and 8 July 1972. The form of advertisement is set out in Appendix A. In addition, the Committee issued written invitations to 42 organisa­ tions (including the State Governments and the universities) which it regarded as having a special and direct interest in medical manpower problems. Submissions were received from 107 organisations and persons. These are listed in Appendix B.

1.8 In its press advertisement calling for submissions, the Committee indicated that notice of intention to make a submission, together with a brief summary of matters to be covered, should be communicated by 30 July 1972. This enabled the Committee to clarify, where necessary, the extent to which the matters intended for inclusion in the submission were relevant to the Committee’s enquiry. Many of those intending to make submissions indicated that they would be discussing in some detail the desired content and structure of the medical curriculum. In these cases it was pointed out that the Committee’s terms of reference directed its central concern to requirements for medical manpower as relating to the possible need for new or expanded medical

schools. Consequently, its formal concern with curricular questions could relate only to the extent to which changes in curriculum might affect medical manpower require­ ments.

1.9 During 1973 the Committee made a series of visits to the cities referred to in paragraph 1.6 above. Members of the Committee inspected hospitals at Canberra, Newcastle, Wollongong and Townsville, and community health centres at Glebe in New South Wales, Melba in the Australian Capital Territory, and South Yarra and Caulfield in Victoria. During the visits, and at meetings in Canberra, discussions

2

were held with representatives from State Governments, universities and various medical and allied groups. Persons with knowledge of particular relevance to the Committee’s enquiry were also invited to attend meetings for discussion with the Committee. A list of all persons with whom the Committee had discussions, and the

organisations which they represented, is set out in Appendix C.

1.10 The Committee’s main sources of material were submissions made to it, information supplied by State Governments, hospital authorities and universities and data made available by the Commonwealth Bureau of Census and Statistics and the Commonwealth Department of Health. Other sources of material were learned journals, reports of official enquiries, monographs, etc. . .

1.11 The Committee has set out in Chapter 2, by way of background, information about medical education in Australia. Chapter 3 contains a statistical analysis of the current state of medical manpower in Australia and includes a considerable amount of information which has not previously been available. It contains the most accurate

estimates that the Committee could obtain of the total number of doctors in Australia and the way in which they are distributed, both geographically and functionally. It also includes an assessment as to whether or not there is a current shortage of medical manpower. In Chapter 4 the factors which can be expected to influence

likely trends in the demand for medical services up to 1991 are canvassed, and in Chapter 5 expected movements in the productivity of doctors are discussed. In Chapter 6, estimates of the supply of doctors up to 1991, based on the present known and approved plans of medical schools, are set out. Chapter 7 gives an analysis of the

likely requirements for medical manpower by 1991 and in Chapter 8 recommendations are made for expansion in existing medical schools and the creation of new ones in order to meet those requirements. Chapter 9 contains the Committee’s observations on a number of issues, which although not strictly within the Committee’s terms of

reference, are relevant to them.

CO NCLUSIO NS

1.12 Investigation of the current supply of medical manpower suggests that in relation to current demand and currently accepted standards, there is no gross overall deficiency in medical manpower in Australia. There are, however, serious problems of distribution. In some country regions and in certain parts of some metropolitan

areas there are clearly shortages of doctors. Moreover, there is a general tendency for a greater proportion of the profession to enter the specialties or to be involved in hospital work rather than to go into general practice. Overall, at 30 June 1972, the doctor-population ratio was 1 to 721. This represents a considerable and steady improvement over the past 40 years (in 1933 the ratio was 1 to 1,360); it also

represents a ratio well within the range of those obtaining in comparable countries.

1.13 The Committee has little doubt that the demand for medical services relative to the population will continue to rise steadily over the next 20 years as a result of increasing affluence and rising educational standards, changes in the structure and organisation of the delivery of health care, advances in medical research and tech­

nology and social trends. On the other hand, while the development of new forms of health care and the more efficient use of paramedical personnel may contribute to improvements in the productivity of doctors, the tendency for doctors to reduce their

3

hours of work both in order to enjoy more leisure and in order to maintain their professional standing by continuing education will probably operate to reduce the output of medical services per doctor. The Commonwealth Department of Health has estimated that all these factors taken together may raise the requirement for doctors relative to the population by about 22 per cent by 1991.

1.14 The recommendations of the Australian Universities Commission in its Fifth Report imply certain enrolments in medical schools. These will produce a rising number of graduates for some years to come; the output of graduates is expected to rise from 878 in 1972 to 1,247 in 1991 and the Committee estimates that by 1991 the

output of existing schools on their presently approved plans together with appropriate allowances for international movements of doctors, will produce a doctor-population ratio of 1 to 567—an improvement of 27 per cent on the 1972 ratio. In looking forward to 1991, the Committee believes that it would be imprudent to aim for an improvement of much less than one-third in the doctor-population ratio; it is more serious to err on the side of producing too few doctors than producing too many. It is also necessary to ensure that the doctor-population ratio has the capacity to improve further beyond

1991.

1.15 Accordingly, the Committee recommends some expansion of existing schools together with the establishment of new schools at the University of Newcastle and the James Cook University of North Queensland. The Committee also proposes that a decision on the establishment of a medical school at the Australian National Univ­ ersity should be deferred for three years. The expansion of existing medical schools will increase the number of graduates in 1991 to 1,433 and the establishment of new schools at Newcastle and Townsville will increase it to 1,560 in the same year. The resulting additional output of graduates should raise the doctor-population ratio to about 1 to 543 by 1991, and the enlarged capacity should permit a continued growth in the doctor-population ratio for a further ten years or so without additional inputs into medical schools; it should also provide a base for further growth. The projected

ratio of 1 to 543 is high by standards proposed for English-speaking countries.

RECOMMENDATIONS

1.16 A complete list of the Committee’s recommendations is set out below. These recommendations relate strictly to numbers of medical students. The Committee’s views on wider issues are contained in Chapter 9.

1. (a) The University o f Sydney should increase its second year enrolment to 330 in 1978, to make fu ll use o f its existing clinical schools and the development o f Westmead Hospital.

(b) The University o f New South Wales should maintain its projected output of 200 graduates per year.

(c) The University o f Newcastle should establish a medical school to take its first students in 1977, maintaining a second year enrolment o f 60 until 1983 when it should be increased to 100.

(d) Proposals fo r new medical schools at Macquarie University and Wollongong University College should not be supported within the period under review.

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2. (a) The University o f Melbourne should proceed to its projected second year enrol­ ment o f 240 by 1977.

(b) Monash University should increase its second year enrolment to 200 in 1979.

(c) A medical school should not be established at La Trobe University within the period under review.

3. (a) The James Cook University o f North Queensland should establish a medical school to take its first students in 1980 maintaining a second year enrolment o f 50 (ultimately increasing to 100 with the growth o f the Townsville area), subject to the clinical facilities at the Townsville General Hospital being appropriately expanded and

upgraded.

(b) In the event o f this condition not being met, the University o f Queensland should increase its second year enrolment to 280 by 1981.

(c) The proposal for a new medical school at Griffith University should not be supported within the period under review.

4. (a) The University o f Adelaide should increase its second year enrolment to 150 in 1979.

(b) The Flinders University o f South Australia should progressively increase the enrolment in second year to 80 by the mid-19805, the timing to depend on the development o f hospital facilities at the Flinders Medical Centre.

5. (a) The University o f Western Australia should increase its second year enrolment to 120 in 1977 and to 150 in 1983.

(b) The proposal for a new medical school at Murdoch University should not be supported within the period under review.

6. The University o f Tasmania should not increase the intake to the medical school during the period under review.

7. A decision on the proposed medical school at the Australian National University should be deferred for three years, pending consideration o f the effects o f the new National Health Insurance Scheme and o f community health centres on medical practice in the Australian Capital Territory.

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CHAPTER 2

Medical Schools in Australia EXISTING MEDICAL SCHOOLS 2.1 At present there are eight medical schools in Australia and a ninth, at the Flinders University of South Australia, will take its first students in 1974. The existing medical

schools and the years in which they first enrolled students are as follows : University of Melbourne . . . . . 1862

University of Sydney . . . . . . 1883

University of Adelaide . . . . . . 1885

University of Queensland . . . . . 1936

University of Western Australia . . . . 1957

University of New South Wales . . . . 1 9 6 1

Monash University . . . . . . 1961

University of Tasmania . . . . . 1965

2.2 In 1972, the medical schools produced 878 graduates. The output of medical graduates has fluctuated markedly over the years, as is shown in Table 2.1. There was a noticeable peak in 1952 with the graduation of those who studied medicine under the Commonwealth Reconstruction Training Scheme after the Second World War. This peak was followed by a decline until 1959, since when the output of medical graduates has increased fairly steadily, subject only to minor fluctuations. Table 2.1 shows the number of M.B., B.S. degrees conferred at Australian universities from 1939 to 1972. Over this period the number of degrees conferred has almost trebled.

TABLE 2.1

NUMBER OF M.B.. B.S. DEGREES CONFERRED AUSTRALIAN UNIVERSITIES, 1939 to 1972

Sydney New South Wales Melbourne Monash Queensland Adelaide Western

Australia Tasmania Total

1939(a) 210 — 83 — _ 25 _ _ 318

1940 118 — 106 — 21 19 — — 264

1941 138 — 134 — 27 29 — — 328

1942 155 — 111 — 43 56 — — 365

1943 149 — 90 — 30 21 1 — 291

1944 134 — 89 — 38 32 1 — 294

1945 151 — 87 — 27 15 — — 280

1946 152 — 90 — 32 39 — — 313

1947 179 — 103 — 20 47 1 — 350

1948 131 — 93 — 34 38 — — 296

1949 2(e) — 123 — 53 51 — — 229

1950 152 — 147 — 60 22 3 — 384

1951 229 — 175 — 84 75 — — 563

1952 310 — 163 — 77 85 — — 635

1953 306 — 155 — 48 101 — — 610

(a) 1939-1960: Degrees conferred for year ended 31 December. (e) There was no medical graduation ceremony at the University o f Sydney in 1949. Degrees normally conferred that year were conferred at ceremonies in December 1948 or January 1950.

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Table 2 .1 —continued

NUM BER OF M.B., B.S. DEGREES CONFERRED AUSTRALIAN UNIVERSITIES, 1939 to 1972

Sydney New South Wales Melbourne Monash Queensland Adelaide Western

Australia Tasmania Total

1954 255 148 76 85 _ 564

1955 198 — 145 — 65 70 — 478

1956 195 — 148 — 67 77 — — 487

1967 148 — 159 — 62 71 — — 440

1958 161 — 131 — 64 66 — — 422

1959 193 — 87 — 43 58 13 — 394

1960 192 — 128 — 67 48 3 — 438

1961(b) 198 — 6 — 5 62 15 — 286

1962(c) 199 — 149 — 67 62 28 — 505

1963 197 — 150 — 103 79 34 — 563

1964 246 — 151 — 93 68 44 — 602

1965 278 — 144 — 93 85 40 — 640

1966 308 — 164 — 122 77 39 — 710

1967 288 25 147 32 116 100 36 — 744

1968(d) 266 35 148 59 119 84 36 — 747

1969 230 59 145 99 153 110 46 — 842

1970 217 80 158 102 139 107 48 — 851

1971 256 69 153 128 117 99 51 20 893

1972 235 91 131 141 114 102 49 15 878

(b) 1961 : Degrees conferred for seven months ended 31 July. (c) 1962-1967: Degrees conferred for year ended 31 July. (d) 1968- : Degrees conferred for year ended 30 June. Source: Commonwealth Bureau of Census and Statistics, University Statistics.

STU D EN T EN RO LM EN TS

2.3 Limitations (quotas) on the number of enrolments are applied in all Australian medical schools at either the first or second year level of the course. The years in which quotas were first imposed and their current level are shown in Table 2.2.

TABLE 2.2

ENROLMENT QUOTAS AUSTRALIAN MEDICAL SCHOOLS 1973

University Year a Quota -

First Imposed

Current Quota

First Year Second Year

Sydney New South

1962 250 —

Wales 1961 235 —

Melbourne 1952 220 —

Mon ash 1963 160 —

Adelaide 1962 135 —

Flinders — 64(b) —

Queensland

Western

1972 185 Not including

repeats and later year entrants.

Australia 1958 190 90 72 reserved for

students entering from 1st year.

Tasmania 1968(a) 48 N ot including

repeats.

(a) A second year quota has been imposed only in 1968 and 1972, (b) 1974. Source: Universities.

7

2.4 In all universities, students applying for entry to the medical course are selected according to academic merit. If selection is for entry to the first year of the course, it is based on results gained in the preceding matriculation examination, usually according to an aggregate of the marks gained in the best four or five subjects. In the case of Queensland, Western Australia and Tasmania, where the limitation on enrolments takes place at the second year level, selection is based on results gained in certain science subjects studied during the first year. In these universities a student is enrolled in ‘Medicine Γ knowing that there is no guarantee of his continuing in the second year of the course. At no medical school is there any entry restriction based on the sex of the applicants.

2.5 Because of the policy of the Australian Government regarding the training of foreign students, all Australian medical schools allow for a small intake of overseas students, mostly from Singapore, Malaysia and Hong Kong. About one-half of these students are on government scholarships, the remainder being privately sponsored from overseas.

2.6 There is no requirement on universities to admit overseas students and, in medical faculties, an upper limit is set to the intake, but not a lower limit. If no over­ seas students qualify for entry on the competitive basis, no special places are provided for them. However, it is generally agreed that those overseas students accepted into the medical course are of extremely high ability and that those rejected when the overseas sub-quota has been filled are often of higher standard than many of the Australian students accepted into the general quota. The upper limits on the annual intake of overseas students to medical faculties in 1973 were as follows:

2.7 It has been suggested to the Committee that special sub-quotas should exist for underprivileged students or educationally disadvantaged students, for example, those from some country areas. At present such sub-quotas do not exist in any Australian medical school and none has expressed any intention to introduce them. However, at the Universities of Queensland, Western Australia and Tasmania where the restriction on entry to the medical course operates at the second year level, it has been felt that the imposition of the quota at this level helps to improve the chances

of selection for educationally disadvantaged students through the equalising experience of the common first year at university. On the other hand, the imposition of a quota at the second year level is likely to mean that some students who have enrolled for medicine are unable to continue their course even though they have successfully passed their first year and the universities concerned are now moving towards the imposition of first year quotas.

2.8 In most universities, admission is based on performance in the matriculation level examination of the State in which the university is located; in some cases admission is restricted to permanent residents of the State. Such provisions clearly

Number o f Students

University o f Sydney University o f New South Wales University of Melbourne Monash University University o f Adelaide University o f Queensland University of Western Australia University of Tasmania

6 6

10 24 6 7

6 4

8

limit the opportunity for interstate movement of students seeking entrance to medical courses and can mean that standards of entry to Australian medical schools may differ considerably. This situation may change, however, following the agreement between the Australian Government and the State Governments that the financing of tertiary education should become the responsibility of the Australian Government from 1974.

2.9 Sex Distribution o f Graduates. Over the last five years there has been a marked increase in the proportion of females entering medical schools. In 1967, females constituted about 19 per cent of total new enrolments for the M.B., B.S. degrees; by 1973, the proportion had reached 30.5 per cent. The variation between individual

universities is wide, ranging from 36.6 per cent at the University of Tasmania to 21.7 per cent at the University of Western Australia in 1973. Table 2.3 shows the proportion of female new enrolments to total new enrolments in medical schools from 1950 to 1973.

TABLE 2.3

FEMALE NEW ENROLMENTS AS A PROPORTION OF TOTAL NEW ENROLMENTS AUSTRALIAN MEDICAL SCHOOLS 1950 to 1973

Year Sydney New South Wales Melbourne Monash Queensland Adelaide Tasmania Western

Australia Australia

per per per per per per per per per

cent cent cent cent cent cent cent cent cen

1950 16.7 — 12.0 — 10.8 12.6 — 5.0 13.7

1951 16.8 — 11.9 — 8.3 18.4 — — 13.8

1952 17.3 — 13.1 — 20.6 11.3 — 17.6 15.9

1953 18.5 — 12.6 — 12.5 15.1 — 10.0 15.6

1954 24.8 — 11.6 — 11.4 10.5 — — 15.6

1955 17.1 — 17.9 — 9 .4 8.8 — 12.5 14.8

1956 19.3 — 12.2 — 11.6 21.5 — 9.8 16.1

1957 21.5 — 18.0 — 11.3 14.9 ----- - 7.5 17.1

1958 20.3 — 14.3 — 16.8 19.8 — 8.5 17.5

1959 18.0 — 20.1 — 15.1 15.6 — 10.3 17.1

1960 18.5 — 14.8 — 13.3 20.8 — 8.5 16.1

1961 20.9 18.4 17.0 9.9 22.2 20.6 — 17.2 19.1

1962 23.0 11.8 21.3 10.8 21.3 17.1 — 17.1 19.1

1963 23.9 15.5 14.4 17.9 22.4 18.3 — 10.5 18.9

1964 26.7 18.4 18.3 11.0 25.2 15.7 — 22.4 20.9

1965 27.9 12.8 12.4 19.5 17.0 16.5 12.5 15.4 18.6

1966 24.1 19.5 21.7 15.6 18.1 13.7 20.0 24.6 19.8

1967 16.0 8.3 16.5 17.6 26.7 14.8 36.4 22.1 19.1

1968 24.5 12.2 23.6 15.4 25.1 24.2 40.9 21.9 20.7

1969 28.0 20.7 21.0 23.1 27.0 20.5 28.6 15.5 23.1

1970 29.4 30.9 25.6 19.9 26.9 19.6 23.7 24.2 25.6

1971 36.2 28.4 24.4 26.7 31.6 30.1 25.5 28.5 29.5

1972 34.0 31.8 22.0 22.8 30.1 25.8 19.0 24.7 27.6

1973 33.6 30.7 27.1 30.2 35.4 27.8 36.6 21.7 30.5

Source: Commonwealth Bureau o f Census and Statistics, University Statistics.

2.10 The proportion of females among those graduating is currently slightly more than 19 per cent, which is similar to the proportion which females represented of new enrolments when those currently graduating commenced their course. Table 2.4 shows the number of M.B., B.S. degrees conferred and the proportion of female medical graduates at Australian universities from 1939 to 1972.

9

M.B., B.S. DEGREES CONFERRED ON FEMALES AS A PRO­ PORTION OF TOTAL M.B., B.S. DEGREES CONFERRED AUSTRALIAN UNIVERSITIES, 1939 TO 1972

TABLE 2.4

Year Degrees

Conferred

M.B.,B.S. Degrees Conferred on Females

M .B., B.S. Degrees Conferred on Females as Proportion of Total M.B.,B.S.

Degrees Conferred

1939 318 41

per cent 12.9

1940 264 29 11.0

1941 328 35 10.7

1942 365 44 12.1

1943 291 40 13.7

1944 294 44 15.0

1945 280 39 13.9

1946 313 62 19.8

1947 350 53 15.1

1948 296 48 16.2

1949 229 35 15.3

1950 384 64 16.7

1951 563 61 10.8

1952 635 66 10.4

1953 610 76 12.5

1954 564 70 12.4

1955 478 65 13.6

1956 487 68 14.0

1957 440 60 13.6

1958 422 65 15.4

1959 394 60 15.2

1960 438 63 14.4

1961 286 37 12.9

1962 505 83 16.4

1963 563 70 12.4

1964 602 80 13.3

1965 640 94 14.7

1966 710 107 15.1

1967 744 123 16.5

1968 747 144 19.3

1969 842 166 19.7

1970 851 152 17.9

1971 893 155 17.4

1972 878 168 19.1

Source: Commonwealth Bureau o f Census and Statistics, University Statistics, and Universities.

2.11 The annual rates of growth for female enrolments compared with male enrol­ ments for the years 1962 to 1973 are shown in Table 2.5. Whereas male enrolments increased by 1.9 per cent in 1973, female enrolments increased by 11.2 per cent. Over the ten year period from 1963 to 1973 female medical school enrolments increased by 126.3 per cent while male medical school enrolments increased by only 28.0 per cent. There is no reason to believe that this trend will not continue.

2.12 Overseas Students and Graduates. As pointed out in paragraphs 2.5 and 2.6, places are provided in all Australian medical schools for overseas students. Overseas students comprised about six per cent of total students in medical schools in 1973, a figure which is similar to the proportion which overseas students represented of total full-time students in universities. The University of New South Wales had the highest proportion with 10.5 per cent and the University of Sydney the lowest with 2.8 per cent. Monash University also had a relatively high proportion of overseas enrolments,

10

AN N U A L RATE OF GROWTH IN TOTAL ENROLMENTS BY SEX, AUSTRALIAN MED­ ICAL SCHOOLS, 1962 TO 1973

TABLE 2.5

Year Male Enrolments Female Enrolments

1962

per cent 0.4

per cent 0.5

1963 2.4 8.4

1964 2.6 10.2

1965 4.1 4 .6

1966 —0.2 4.0

1967 2.9 2.7

1968 5.0 7.8

1969 3.8 7.8

1970 0.2 11.0

1971 2.3 16.3

1972 2.7 10.0

1973 1.9 11.2

Source: Commonwealth Bureau of Census and Statistics, University Statistics.

the figure for 1973 being 9.7 per cent. The proportion of overseas students has been declining, and at some universities the reduction has been quite marked. In 1973, overseas students in the University of New South Wales medical school comprised 10.5 per cent of the total, compared with almost 25 per cent in 1968. The overall

reduction in the proportion between 1968 and 1973 was 2.5 percentage points for Australia as a whole. Table 2.6 sets out the relevant information for 1968 to 1973.

TABLE 2.6

OVERSEAS STUDENTS AS A PROPORTION OF TOTAL STUDENTS AUSTRALIAN MEDICAL SCHOOLS 1968 TO 1973

University 1968 1969 1970 1971 1972 1973

per per per per per per

cent cent cent cent cent cent

Sydney 4.3 3.7 2.8 2.9 3.1 2.8

New South Wales 24.8 20.1 18.6 16.3 13.1 10.5

Melbourne 4.3 4 .0 4.6 4.9 4 .7 4.3

Monash 13.1 12.3 12.4 13.0 12.7 9.7

Queensland 6.4 5.0 4.5 4.4 4.0 3.8

Adelaide 5.3 5.0 4.9 3.8 3.9 3.7

Western Australia 5.5 5.4 5.5 4.4 4.5 4 .2

Tasmania 1.0 3.7 5.6 8.0 7.5 6.9

Total 8.2 7.6 7.3 7.2 6.6 5.7

Source: Universities

2.13 Information on the number of overseas students who graduate is not available. However data on the ratio of overseas students to total students in the final year of the medical course are available. In 1970, 6.6 per cent of final year medical students were from overseas, a reduction from 9.3 per cent in 1968. Table 2.7 shows the

proportion of overseas students in the final year of medicine in 1968 and 1970.

11

OVERSEAS STUDENTS AS A PROPORTION OF TOTAL STUDENTS IN SIXTH YEAR MEDICINE AUSTRALIAN MEDICAL SCHOOLS 1968

A N D 1970

TABLE 2.7

University 1968 1970

Sydney . . .

per cent 6.1

per cent 2.9

New South Wales . 38.2 25.0

Melbourne . . 4.7 2.6

Monash . . . 15.8 8.5

Queensland . . 6.3 4.9

Adelaide . . . 6.0 8.3

Western Australia . 2.1 7.5

Tasmania . . — —

Total . . . 9.3 6.6

Source: Universities

TEACHING HOSPITALS

2.14 At present a medical student’s training in the final three years of his course takes place mainly in teaching hospitals. This involves daily attendance in hospital wards and out-patient departments where the student receives clinical instruction in

diagnosis, treatment and patient care. During this period he may be attached to a number of teaching hospitals, including short periods of residence. At the same time, the student continues to receive formal lectures and tutorials. A teaching hospital accordingly has two main functions. On the one hand it must provide first class medical care for the community and on the other, it must provide the environment in which clinical training of the highest standard can be given. In addition, as an essential part of both these functions, the teaching hospital provides facilities for clinical research.

2.15 The teaching hospitals associated with a university medical school are often situated at considerable distances from the university campus. To facilitate the provision of teaching services, the university establishes professorial clinical units at the larger teaching hospitals. Clinical instruction in the hospitals is shared by these

university staff and the full-time and visiting staff of the hospital. A large part of clinicial teaching, involving bedside instruction, falls on the visiting staff. The visiting staff, together with the full-time staff of the hospital and of the university clinical school, are responsible for the patient care and training programmes in the hospital.

2.16 The association between a university and a teaching hospital may be the subject of a formal agreement between the two bodies although this is not always the case. Generally speaking, the university is represented on the board of the hospital and

on the committees concerned with medical staff appointments. The provision of teaching services in the hospital is supervised by special boards or committees on which there is full representation from the university and the hospital.

2.17 The teaching hospitals affiliated with medical schools in Australia which have received building grants from the Australian Universities Commission are listed in Table 2.8. They may be divided into two groups, general teaching hospitals which also provide teaching in a wide range of specialties and special teaching hospitals,

12

which are usually smaller and confined to specialties such as obstetrics and gynae­ cology, paediatrics and psychiatry. The main general teaching hospitals are usually large central metropolitan public hospitals, but a number of medical schools makes use of smaller peripheral community or district hospitals in suburban or urban

provincial locations. Small numbers of students are rostered by some medical schools to hospitals other than those listed in Table 2.8.

TABLE 2.8

TEACHING HOSPITALS AT AUSTRALIAN UNIVERSITIES WHICH HAVE RECEIVED BUILDING GRANTS FROM THE AUSTRALIAN UNIVERSITIES COMMISSION

University of Sydney

University of New South Wales

University of Melbourne

Monash University

University of Queensland

University of Adelaide

University of Western Australia

University of Tasmania

Royal Prince Alfred Sydney Royal North Shore Repatriation General Concord Royal Alexandra for Children Women’s (Crown Street)

Mater Misericordiae Broughton Hall St. Margaret’s for Women

North Ryde Psychiatric Centre Prince of Wales Prince Henry St. Vincent’s

St. George Royal Hospital for Women Eastern Suburbs Lewisham Sutherland Bankstown St. Vincent’s Austin Royal Women’s

Royal Children’s Royal Victorian Eye and Ear Peter MacCallum

Mercy Fairfield Royal Melbourne Royal Park Psychiatric Larundel Psychiatric

Alfred Prince Henry’s Queen Victoria Memorial

Fairfield Royal Park Psychiatric Larundel Psychiatric Royal Brisbane

Princess Alexandra Royal Brisbane Women’s Mater Misericordiae Royal Brisbane Children’s Chermside Royal Adelaide Queen Elizabeth Queen Victoria Maternity Adelaide Children’s

Royal Perth Princess Margaret Fremantle King Edward Sir Charles Gairdner

Royal Hobart

13

ACADEMIC STAFF

2.18 Medical training may be divided into three parts. Pre-clinical departments are concerned with the teaching of basic medical sciences, an understanding of which is necessary before commencement of the study of patients and disease. Broadly they embrace the normal structure, function and chemistry of the human body. Para- clinical departments have both a science basis and an applied aspect; they relate to the cause and progress of disease in the body. Their study should begin before clinical studies and be continued in parallel with them. Clinical departments are directly concerned with the cause, diagnosis and treatment of medical disorders, and the effect of those disorders on the patient.

2.19 The numbers of students and staff and the student-staff ratios applying in pre-clinical, para-clinical and clinical departments in Australian medical schools in 1973 are set out in Table 2.9. The figures shown in the table are not restricted to the teaching of medical students. Some pre-clinical and even para-clinical departments teach non-medical students; in some universities pre-clinical departments such as biochemistry, physiology and pharmacology are located in other faculties. Since it is not possible to identify separately the staffing of these departments in terms of medical and non-medical teaching responsibilities, the full staffing and student load of such departments has been included in Table 2.9.

2.20 Student-staff ratios in Australian medical schools vary considerably from one university to another. It is clear however that, in general, pre-clinical departments have more students per staff number (i.e. higher student-staff ratios) than para- clinical departments which in turn have significantly higher ratios than clinical departments. It will also be seen that, in general, smaller schools tend to have more favourable ratios than larger schools.

2.21 Table 2.9 shows student-staff ratios for full-time staff and for full-time equiv­ alent staff. A comparison between the numbers of full-time and full-time equivalent staff shows the extent of dependence on part-time teaching. It is noticeable that the newer institutions such as New South Wales, Monash, Western Australia and Tasmania have less dependence on part-time teaching than the older schools. In the case of clinical departments, the major component of bedside instruction in the older schools is carried out by visiting staff and full-time hospital staff; this is less common

in the newer schools.

COSTS OF TRAINING MEDICAL GRADUATES 2.22 University Costs. On the basis of information available to it on the costs of university departments involved in teaching medical students, the Australian Universities Commission was able to give the Committee some broad estimates of the cost to a university of producing an M.B., B.S. graduate. These estimates included an allowance for the portion of general university overheads (central administration, library, maintenance, etc.) which might be attributable to medical training and also took into account the costs involved for those students who failed to complete the course. The estimates suggest that, for schools with an intake of more than 100, the average cost to the university of producing a graduate in medicine was approximately

$20,000 at 1973 salary and cost levels. The cost of training a medical graduate at the

14

TABLE 2.9

STUDENTS, STAFF, A N D STUDENT— STAFF RATIOS, AUSTRALIAN MEDICAL SCHOOLS, 1973

Pre-Clinical Departments Para-Clinical Departments

University Students per Students per

Equivalent

Full-time

S ta ff

S ta ff Member

Equivalent

• Full-time

S ta ff

S ta ff Member

Full-time Full-time Full-time Full-time

Studentsia) Full-time Full-time Students(a) Full-time Full-time

Equivalentib) Equivalent Equivalent(b) Equivalent

Clinical Departments

Equivalent S ta ff

Students per

S ta ff Member

Full-time

Students(a) Full-time Full-time

Equivalent(b) Equivalent

Sydney New South 1,091 67.0 80.8 16.3

Wales 564 52.0 58.1 10.9

Melbourne 818 69.5 79.2 11.8

M onash 788 75.0 81.2 10.5

Queensland 794 58.5 67.7 13.6

Adelaide Western

524 36.0 52.0 14.6

Australia 386 34.7 39.3 11.1

Tasmania 105 17.0 17.4 6 .2

13.5 238 13.5 18.6 17.6 12.8

9 .7 267 19.0 21.9 14.1 12.2

10.3 262 31.9 39.8 8 .2 6 .6

9 .7 262 25.7 29.9 10.2 8.8

11.7 261 2 4 .0 2 8 .4 10.9 9 .2

10.1 119 16.0 17.8 7 .4 6 .7

9 .8 127 14.2 17.0 8 .9 7 .5

6 .0 16 4 .0 4 .0 4.1 4 .0

659 42.5 79.6 15.5 8 .3

520 4 3 .0 5 9 .0 12.1 8 .8

676 7 0 .4 120.3 9 .6 5 .6

327 4 1 .4 60.0 7 .9 5 .5

492 61.5 80.0 8 .0 6 .2

460 36.0 64.6 12.8 7.1

214 33.2 44.3 6 .4 4 .8

56 11.5 12.4 4 .9 4 .5

(a) Equivalent full-time students are calculated by weighting each subject on the basis o f the proportion it represents of a year’s work by a full-time student. Full-time, part-time and external higher degree students receive weights o f 2, 1 and £ respectively. (See paragraphs 6.2 to 6.5 of the Australian Universities Commission Fifth Report, May, 1972.) (b) Full-time equivalent staff are calculated by equating 700 hours o f tutoring or demonstrating and 250 hours of lecturing by part-time staff to a full-time staff member Source: Universities.

two universities with intakes of less than 100 into their medical school was from 40 per cent to 160 per cent greater than the average for the larger schools.

2.23 In addition to these recurrent costs, the training of a medical graduate requires an investment in buildings and equipment. Information on this component is not easy to obtain. However some indication of the costs involved may be gained from the estimated cost of the new medical school at Flinders University. For the 1973-75 triennium the Australian Universities Commission has recommended grants of $3.46 million for pre-clinical facilities and $2.17 million for three-fifths of the clinical facilities which it is estimated will be required for an eventual output of 90 to 100 graduates. In addition $400,000 has been provided for equipment. Thus, an investment of approximately $7f million will be required for a school of this size. It should be remembered however, that a portion of the investment in pre-clinical facilities will be used by non-medical students.

2.24 Hospital Costs. Training in the final three years of the medical course takes place mainly in teaching hospitals and the activities of university clinical schools are therefore closely integrated with the activities of the hospital in which they are located (see paragraphs 2.14 to 2.17). As explained in paragraph 2.17, teaching hospitals fall into two groups: general teaching hospitals and special teaching hospitals. The Committee has examined the average costs of selected general teaching hospitals in three States and compared them with costs in selected metropolitan and country non-teaching hospitals. It will be seen from Table 2.10 that the average costs in teaching hospitals exceeded significantly those in non-teaching hospitals although the extent of the excess differed in the three States. In New South Wales and Victoria where the comparison covered a number of hospitals in each category, teaching hospitals were from 28 per cent to 38 per cent more expensive than metropolitan non-teaching hospitals and from 38 per cent to 46 per cent more expensive than country hospitals. The reason for the difference between the figures for New South Wales and Victoria seems to be that the average costs of non-teaching hospitals in Victoria are significantly higher than those for non-teaching hospitals in New South Wales. This would appear to be due to better staffing provisions in non-teaching

hospitals in Victoria. It is important to realise that the additional cost of a teaching hospital compared with a non-teaching hospital is not only due to its role in medical education. Special medical units and highly developed medical and nursing facilities would be required in a small number of hospitals in the major population centres of each State whether or not those hospitals were required to carry out teaching functions. In the same way, as is shown in Table 2.10, major metropolitan non­ teaching hospitals are more expensive than country non-teaching hospitals due to differences in the range of specialist services provided.

2.25 The costs incurred by a teaching hospital as a result of the training of medical students are of two kinds. First, there are the costs of operating the areas used solely by university staff and students. These direct costs cover such items as cleaning, power, administration and library expenditure. Grants are currently made to universities from which payments are made to hospitals as a contribution towards these costs. Secondly, there are additional costs incurred in the provision of many of the normal hospital services such as pathology, anaesthetics, radiology, clinical photography and nursing and medical staff, as a result of medical teaching. It is

16

COMPARISON OF AVERAGE COSTS IN TEACHING A N D NON-TEACHING HOSPITALS, NEW SOUTH WALES, VICTORIA A N D QUEENSLAND, 1971-72

TABLE 2.10

Average Cost (a) Excess o f Teaching

Hospital Costs Over Non-Teaching Hospital Costs General Teaching Hospitals

Non-Teaching Hospitals

Metropolitan Country Metropolitan Country

New South

$ $ $ per cent per cent

Wales 47.00(b) 29.13(c) 25.50(d) 38.0 45.7

Victoria 47.44(e) 34.02(f) 29.43(g) 28.3 38.0

Queensland 27.41(h) 19.11(i) 17.28Q) 30.3 37.0

(a) Average occupied bed cost per day. (b) Prince Henry, Prince of Wales, Royal Prince Alfred, Royal North Shore, St. Vincent’s and Sydney Hospitals. (c) Bankstown, Sutherland and Hornsby District Hospitals. (d) Wollongong, Albury, Cessnock, Maitland, Tamworth, Lismore and Wagga Wagga Base Hospitals. (e) Alfred, Prince Henry’s, Royal Melbourne, St. Vincent’s and the Austin Hospitals. (f) Box Hill, Preston and Northcote, Footscray and Dandenong District Hospitals.

(g) Ballarat, Bendigo, Geelong and Mildura Base Hospitals. (h) Royal Brisbane Hospital. (i) Redcliffe, Nambour and Southport Hospitals. (j) Ipswich, Toowoomba, Maryborough, Rockhampton and Townsville Base Hospitals. Source: Annual Reports of State Hospital Authorities and individual hospitals.

difficult to isolate these indirect costs of teaching medical students since teaching functions are closely integrated with the other functions of the hospital. An attempt to determine the extent of these indirect costs was made in the First and Second Reports of the Committee on Teaching Costs of Medical Hospitals.1 In its First

Report, the Committee set out estimates of the proportion of certain hospital costs which might be attributable to undergraduate medical education. The Second Report indicated that in general, hospitals agreed that these proportions were reasonable. If these proportions are applied to the costs of one teaching hospital in New South

Wales with a strong commitment to medical education and an allowance is made for the direct costs referred to above, approximately 4 per cent of the hospital’s expend­ iture would appear to be applicable to undergraduate medical education. It might be expected that the proportion for hospitals with less commitment to teaching would be

less than this figure. It is not possible to draw any firm conclusions on the basis of this evidence without a detailed analysis of the impact of medical education on the costs of teaching hospitals. This would be difficult in view of the present lack of uniform data on hospital costs. However, the evidence available suggests that the teaching of

medical students itself does not constitute a major part of the additional costs of running a teaching hospital, these additional costs being principally associated with the provision of specialist services by highly qualified staff who engage in research and post-graduate training in addition to their responsibilities for patient care, and

with the level of other services required by these activities.

U N D E R G R A D U A T E M ED ICA L COURSE 2.26 Courses in Australian medical schools have been modelled on the English tradition. This is not surprising, since recognition by the General Medical Council

1 Committee on Teaching Costs o f Medical Hospitals (Australian Universities Commission); First Report,

October 1961, pages 4 and 19 and Second Report, May 1965, pages 3 to 14.

17

required universities to follow certain guidelines. Although the General Medical Council has recently adopted a more flexible attitude with a view to allowing univer­ sities to introduce innovations, the number of innovations actually achieved in Australia has not yet been great. There are several reasons for this, the most important probably being that course alterations take place only with expenditure of more time by academic staff, and generally speaking Australian universities are not well off in this respect. Those North American schools which have innovatory curricula have student-staff ratios much more favourable than any school in Australia.

2.27 The general plan of medical courses is shown in Table 2.11. These are of six years duration. However, in 1974 the University of Sydney will reduce the length of its course to five years. In all States (but only recently in Victoria) there is a compulsory pre-registration year of hospital residence.

TABLE 2.11

GENERAL PLAN OF AUSTRALIAN MEDICAL COURSES

1st Year Pre-Medical 2nd Year 3rd Year

4th, 5th and 6th Years

Physics Anatomy Anatomy Medicine

Chemistry Physiology Physiology Surgery

Biology Pharmacology Pharmacology Pathology

Fourth subject such as Biochemistry Biochemstry Microbiology

Medical Studies* Behavioural Science* Pathology Pharmacology

Behavioural Science* Community Medicine* Microbiology Psychiatry Optional Arts or Behavioural Science* Paediatrics

Science subject Medical Psychology* Obstetrics and

Human Biology* Clinical Science* Gynaecology

Cellular Biology* Introductory Medicine* Social or Community

Genetics* Medicine

* Subjects introduced into revised or new courses in recent years.

2.28 At present, although most Australian schools include the various disciplines in similar proportions, the methods of integration and management of teaching vary considerably. Revised courses have diminished barriers between subjects, and altered the emphasis in some areas, to allow the introduction of new work. Behavioural science has been introduced to most first and second year courses as a major subject, while community medicine is taught to some extent in all schools, but the most important innovation is its introduction to the early (formerly entirely scientific) years of some courses. Integration of subjects in pre-clinical, para-clinical and clinical studies has been achieved in some schools.

2.29 Innovations in the medical curriculum may be brought about by altering the whole course, or by introducing new disciplines or methods into existing courses. Behavioural science, clinical pharmacology and community medicine are examples of new disciplines. Behavioural science is usually introduced relatively easily, because existing departments of psychology and psychiatry can be augmented to take up the added teaching load. Clinical pharmacology should be in a similar situation, since existing departments of pharmacology and medicine should be able to combine on such a project even if a new department is not set up. But community medicine is often almost unrepresented in any way in existing departments as its teaching requires facilities and an organisation outside the medical school and hospitals (see paragraphs 9.7 to 9.15).

18

2.30 Another feature of curricular revision has been the shortening of formal teaching time. At the University of Adelaide, the present formal tuition is completed in five years, the sixth year being entirely an “apprenticeship” or practical year. The new course at the University of Sydney and the proposed one at the University of New

South Wales have the same object, except that the M.B., B.S. degrees will be awarded at the end of the fifth year. The University of Sydney will require only one pre­ registration year.

VOCATIONAL TRAINING FOR SPECIALISTS 2.31 The new M.B., B.S. graduate is in no sense a fully fledged practitioner. Before registration, he normally serves an intern year with a hospital, followed by a further one to two years as a resident medical officer in a hospital. At present approximately one-third of medical graduates then commence general practice, perhaps one-half continuing their training with the aim of becoming specialists (see Appendix D, Table D.3).

2.32 This specialist training is, in the main, carried out during service in resident medical officer and, later, registrar posts in hospitals. During his senior resident appointment the resident may take additional training in the basic medical sciences. The clinical content of his senior residency is influenced by the specialty for which he is training. For example, the trainee physician is expected to include a significant

content of internal medicine in his training so that in his intern and two senior resident years he will have covered at least 24 months in medical wards; the trainee surgeon is expected to hold appointments which would ensure familiarity with basic surgical principles. During the latter part of this senior residency period, each of the colleges, the Royal Australasian College of Physicians, the Royal Australasian College of

Surgeons and the Royal College of Obstetricians and Gynaecologists conducts exam­ inations, success in which is necessary before the trainee is accepted for the advanced training phase.

2.33 This final phase involves appointments in approved registrar posts, the approval or accreditation being made by the appropriate college. During this time it is expected that service and educational activities will be appropriately balanced. The minimum requirement for the three Colleges is a period of three years in an accredited registrar

post although a longer period may be required in the case of many sub-specialties, e.g. neurosurgery, thoracic surgery, cardiac surgery, neurology, cardiology and other specialist fields. In these fields specialist skills are expected to be superimposed on

more general training. The training programmes are to some extent flexible and need not be taken in the one institution.

2.34 As a result of recent changes the Royal Australasian College of Physicians does not intend to hold an examination at the end of the advanced training period but will depend on the design of the registrar attachment and the reports of supervisors. The Royal College of Obstetricians and Gynaecologists, however, will hold exam­ inations prior to and after the completion of the registrar training programme and

will expect the trainee to serve a further period after successfully passing the examination. The Royal Australasian College of Surgeons will hold a final examination at the end of the advanced training period.

19

2.35 The Royal Australian College of General Practitioners has requirements for admission to membership which follow a similar pattern to those of the other colleges described above. The College expects trainees in their senior residency period to cover appointments in medicine, paediatrics, obstetrics, psychological medicine and geriatrics as well as a period spent in general practice. The advanced training phase

will extend over a further two years and will normally be spent as an associate or registrar in an accredited practice, at the end of which there will be an examination for membership of the College.

2.36 There are other modes of training for specialists. Several universities offer vocational diplomas in such subjects as ophthalmology, dermatological medicine, diagnostic radiology, radiotherapy, clinical pathology and otorhinolaryngology. These university diplomas have a pattern of internship and senior resident posts and examinations similar to those which are required by the colleges. Since the intro­ duction of these diplomas by universities, colleges have been established in these specialties and they have evolved their own system of requirements for admission to membership or fellowship. While there is now a tendency for university diplomas to be phased out in favour of an appropriate college qualification as requirement for entry to these specialties, candidates have found these courses to be useful as sources of training.

2.37 Although vocational training through the professional colleges is not a university postgraduate activity (as contrasted with study and research for higher diplomas and degrees), medical schools are inevitably involved in such training because academic staff alone may be qualified to give advanced instruction in the medical sciences and because university clinical departments are embedded in teaching hospitals. Strictly speaking, academic staff have no formal responsibility for vocational training, but as the number of full-time academic staff has increased in recent years so has the

expectation, on the part of hospital authorities, the professional colleges and the profession generally, that they will involve themselves with postgraduate training in the widest sense and with the continuing education of doctors.

20

CHAPTER 3

Current Position of Medical Manpower TOTAL NUMBER OF DOCTORS IN AUSTRALIA 3.1 The likely future demand for medical services in Australia cannot be estimated without data on the number of medical practitioners currently active in Australia and

an assessment of the adequacy of that number. There is a widespread belief that there is a shortage of doctors at present. If this is the case, it will be necessary to plan the output of medical schools in such a way as to remove the shortage as well as to meet longer-term requirements.

3.2 The estimated number of medical practitioners active in Australia at 30 June 1972 is 17,972. The source of this estimate is a random five per cent sample enquiry conducted by the Commonwealth Department of Health. Although the estimate was based on a sample enquiry1, there was a thorough follow-up procedure to ensure a

very high response, and the results are believed to be reasonably free of bias from this source. They agree very closely with estimates for the same date derived from the 1971 Census (adjusted for understatement and temporary absence from Australia and

updated one year) and from the Permail2 lists (adjusted for unlisted doctors). This can be seen from the following comparison of the three sources.

(1) Commonwealth Department of Health sample survey, active medical practitioners resident in Australia, 30 June 1972 .................................................................... 17,972

(2) Population Census, 30 June 1971, number of medical practitioners in work force . . . . . 16,107

plus estimated understatement —defence . . . . . . . 85

—universities . . . . . . . 351

plus estimated number of Australian doctors overseas, on visits intended to be less than a year . . 700

Adjusted Census figures, 30 June 1971 . . . 17,243

plus increase in Permail figures, 9 August 1971 to 22 June 1972 .................................................................... 789

Estimated number of medical practitioners in work force, adjusted Census basis, 30 June 1972 . . . . 18,032

(3) Permail, number of doctors on lists 22 June 1972. . 17,309 plus number of doctors known to the company who declined to be listed (September 1972, 500-600) . 550 17,859 1 The standard error was 385. 2 Commercial mailing service operated by Permail Pty. Ltd. See Appendix D for description of main

statistical sources used in this Chapter.

21

Thus the three sources yield much the same result: a figure of about 17,900 to 18,000 doctors at 30 June 1972.

3.3 In relation to population, 17,972 doctors amounts to one doctor to 721 persons, or 1,387 doctors per million of population. This doctor-population ratio is close to the corresponding ratios in countries with similar social and economic structure, as Table 3.1 shows. The question arises whether this ratio is adequate for current Australian needs. Some ratios proposed as suitable standards in submissions received by the Committee or in references consulted by it are set out in Table 3.2.

TABLE 3.1

DOCTOR-POPULATION RATIOS IN AUSTRALIA AN D OTHER COUNTRIES

Country Doctor-Population

Ratio in 1969

Annual Rate o f Increase 1963 to 1969

1 to per cent

Australia 721(a) 1.8(b)

England and Wales 830 0.3

United States 650 1.1

Canada 710 3.6(c)

New Zealand 863(d) -0.2(e)

France 770 2.1

Germany F.R. 590 1.6

Italy 560 1.1(f)

Netherlands 820 1.1

Belgium 640 1.3

Sweden 770 3.8

Norway 710 3.4(g)

Denmark 690 1.6

Finland 1,050 4.9

Switzerland 720 0.7

U.S.S.R. 430 2.8

Germany D.R. 660 not available

Czechoslovakia 500 2.3

Poland 690 4-1

Hungary 520 3.9

Yugoslavia 1,050 3.5

Israel 410 0.9

(a) 1972 (b) 1966-1972 (adjusted Census figures). See paragraph 3.2 and Table 3.39, Footnote (b) (c) 1962-63 to 1969 (d) 1970 (e) 1961-1970 (f) 1961-69 (g) 1962-69 Sources: Australia, Table 3.3. New Zealand, Annual Report, Department

of Health. Other countries, WHO World Health Statistics Annual, 1962 and 1969, Vol. III. (Note on definition: Physicians are among the health personnel in the World Health Statistics Annual called ‘fully qualified personnel in the profession’, who are described as ‘persons with a diploma or higher educational qualification exercising a leading health profession’. The statistics of physicians do not include auxiliary personnel in the pro­ fession, under such titles as ‘medical assistant, health official, health assistant, senior auxiliary health workers, medical aides, dispensers, limited physicians, apothecaries, feldsher, behdar, hakeem etc.’)

3.4 As can be seen from Table 3.3, the doctor-population ratio in Australia has been rapidly improving in recent years, in comparison with the period from the mid­ fifties to the mid-sixties.

22

STANDARD DOCTOR-POPULATION RATIOS SUGGESTED OR IMPLIED AS ADEQUATE FOR CURRENT AUSTRALIAN NEEDS(a)

TABLE 3.2

Source State Year

Doctor-population Ratio

Remarks

Scotton(b) Australia 1964-65 1 : 823 ‘By world standards

Australia is adequately supplied with doctors.’

Western Australian Committee on Medical

Manpower Needs

Western Australia

1972-87 1 : 800 ‘Adequate for next

fifteen years.’

Monash University

Australia 1971 1 : 791 Estimate of actual

in 1971. ‘Australian manpower is in a reasonably good state o f health.’

Llewellyn- D a vies et al (c)

Australian Capital Territory

1972 1 :710 From studies of

desirable levels of manpower in the A.C.T.

Government o f New South Wales

New South Wales 1972-92 1 : 640 Sum of figures for

private generalists, private specialists and others.

Godfrey Scott(d)

New South Wales 1972 1 : 699 General practitioner

ratios of 1 to 1,750 in Sydney and 1 to 2,000 in the rest of the State, others at

1972 actual rates.

Commonwealth Department of Health

Australia 1972 1 : 741 ± 5 per cent

‘Selected as meeting current Australian requirements.’

(a) It should be noted that some of these ratios are implied standards in that they are current estimates of an actual manpower situation which is claimed to be adequate. Some of these ratios are on slightly different statistical bases from the 1972 estimate quoted in paragraph 3 .2 because they are based on unad­ justed Census data. (b) R. B. Scotton, Medical Manpower in Australia, Medical Journal of Australia

1967, 1 : 984. (c) Quoted in Commonwealth Department o f Health submission. (d) A Study o f Medical Manpower in New South Wales, University of Sydney, 1972.

3.5 The annual rate of growth in the six years to 1972 exceeded that in any previous intercensal period shown in this comparison except that of the early post-war period 1947 to 1954. The rate of growth of about 1.8 per cent per annum is faster than that of England and Wales and that of the United States, but not as fast as those of

Canada and some Scandinavian countries (see Table 3.1).

3.6 Apart from these actual ratios for other countries, standards have been put forward for other countries, with which the Australian doctor-population ratio may be compared. Those shown in Table 3.4 are quoted from references available to the Committee.

23

GROWTH OF DOCTOR-POPULATION RATIOS AUSTRALIAN CENSUSES 1933 TO 1972

TABLE 3.3

Adjusted Census

June June June June Basis (a)

1933 1947 1954 1961 June June June

1961 1966 1972

1 to 1 to 1 to 1 to 1 to 1 to 1 to

Doctor-population ratio 1,360 1,141 979 886 856 803 721

Rate o f increase per cent per annum since not not

previous Census available 1.3 2.2 1.4 available 1.3(b) 1.8(b)

(a) See paragraph 3.2 (b) Includes effect of adjustment for female doctors 65 and over in 1966. See Table 3.39, footnote(b)

TABLE 3.4

DOCTOR-POPULATION RATIOS SUGGESTED AS ADEQUATE FOR OTHER COUNTRIES’ CURRENT NEEDS

Doctor-

Source Country Year population Remarks

Ratio

1 to

Todd Report (1968)(a) Great Britain

1975 722 Recommended improvement from actual 1 to 847 in 1965, to remove current shortage.

Carnegie Report (1970)(b) United States

of America

1972 650 Improvement from actual I to

681 in 1967, based on ‘an attainable and desirable estimate of the annual increase in the number of

medical school places.’

Canada, Royal Commission on Health Services (1964)

Canada 1971 848 ‘To maintain the 1961

population-physician ratio.’

S. Judek: Medical Manpower in Canada, p. 268

Canada 1971 787 To maintain the 1951-61 rate

of improvement in the doctor- population ratio.

Joint Committee on Medical New Zealand

1968 738 To remove current shortage (actual 1968, 1 to 866).

Graduate Needs in New Zea and(c)

(a) Royal Commission on Medical Education 1965-68, Cmnd. 3569. (b) Higher Education and the Nation’s Health, Carnegie Commission on Higher Education, October 1970. (Includes osteopaths). (c) Report on Medical Graduate Needs in New Zealand fo r the Years 1968-2000,

Wellington, 1970.

3.7 From a comparison of overall figures with the past, or with similar countries, or with various standards that have been put forward for Australia or for other countries, it seems difficult to find any statistical evidence either of a general shortage of doctors in Australia or of a tendency to a shortage through a failure to sustain

24

growth. To decide whether there are particular shortages of doctors in certain States, or in country areas, or in particular parts of Australia, or in certain branches of medical activity, more detailed evidence must be examined.

D O CTO RS IN EA CH STATE

3.8 The doctor-population ratios shown by the Census figures for June 1971 for States and Territories are set out in Table 3.5. Among the States, Victoria and South Australia in 1971 were near the national average, New South Wales above it, Queens­ land and Western Australia furthest below and Tasmania between these and the

national average. The State ratios for 1971 were much closer together than those for 1933, which ranged from 1 to 1,239 for Victoria to 1 to 1,751 for Tasmania.

TABLE 3.5

DOCTOR-POPULATION RATIOS AUSTRALIAN CENSUS, JUNE 1971 (UNADJUSTED FIGURES(a))

Doctor- Annual Rate o f Increase in Population Ratios

Ratio 1966-1971 1933-1971

1 to per cent per cent

New South Wales 751 0.9 1.5

Victoria 785 1.6 1.2

Queensland 886 1.7 1.5

South Australia 787 3.2 1.6

Western Australia 885 0.8 1.4

Tasmania 849 1.2 1.9

Northern Territory 1,028 2.8 not

available

Australian Capital Territory 554 5.1 1.0

Australia 792(b) 1.3(b) 1.5(b)

(a) See paragraph 3.2. (b) Using adjusted Census data available for Australia only, the ratio in 1971 was 1 : 740. Annual rates o f increase in the ratios for Australia calculated on the same basis were 1.7 per cent per

annum for 1966-71 and 1.6 per cent per annum for 1933-71.

3.9 Since 1933 Tasmania has improved its ratio faster than the other States, Victoria more slowly. The rest have improved their ratios at about the same rate as the Aust­ ralian average, that is, around per cent per annum. At some periods, certain States lagged or went ahead of others to a marked extent. Tasmania did not show the

general rapid post-war recovery in the period 1947 to 1954, but increased its ratio very rapidly in the period 1961 to 1966. Queensland, South Australia and Western Australia had a period of rapid growth from 1954 to 1961, but lagged between 1961 and 1966. South Australia had the biggest increase in ratios in the five years 1966 to

1971, while New South Wales and Western Australia lagged.

D O CTO RS IN M ETR O PO LIT A N A N D C O U N TRY AREAS 3.10 The doctor-population ratios in metropolitan and country areas are shown in Table 3.6. While still less than one-half that in the metropolitan areas, the country ratio has been improving at a faster rate than the metropolitan ratio in the decade up to 1971.

25

DOCTORS IN METROPOLITAN AN D COUNTRY AREAS IN RELATION TO POPULATION AUSTRALIAN CENSUSES 1961, 1966 AN D 1971

TABLE 3.6

Number o f Doctors(a) Doctor-Population Ratio Annual Rate o f Increase in Ratio

1961 1966 1971 1961 1966 1971 1961-66 1966-71

1 to 1 to 1 to per cent per cent

Metropolitan 8778 10269 12198 672 654 628 0.5 0.8

Country 3126 3428 3909 1488 1425 1304 0.9(b) 1.8

Total 11904 13697 16107 886 847 792 0.9(b) 1.3

(a) Census, unadjusted. (b) Apparent anomaly probably due to metropolitan boundary changes.

3.11 The rapid improvement in the country ratio conceals some deterioration in certain areas, especially in smaller towns. An analysis carried out by the Australian Medical Association on the distribution of country doctors at Census dates since 1947 is set out in Table 3 .7. This shows that the number of doctors in country areas in which the towns have few doctors (2 or less, 3 to 5, or 6 to 10 doctors) has not

kept pace in general with the growth of population in those areas since 1961, even though the population growth in these areas has tended to be less than in other country areas. As a result, doctor-population ratios in the small-town areas have declined since 1961. The improvement in areas where the major towns have doctors numbering eleven or more has been sufficient to raise the doctor-population ratio for country areas in general.

TABLE 3.7

DISTRIBUTION OF DOCTORS IN COUNTRY(a) AREAS, BY NUMBER OF DOCTORS PER TOWN, AUSTRALIA 1947 TO 1971

Percentage of— Doctor-Population Ratios Annual Rate of Increase in Ratios

Population 1971 Doctors 1971 1947 1961 1966 1971 1947-61 1961-66 1966-71

Areas in which major town or towns had doctors numbering—·

per cent per cent 1 to 1 to 1 to 1 to per cent per cent per cent

2 or less 11.0 7.1 1,974 2,016 2,160 2,285 - 0 . 1 - 1 . 3 - 1 . 1

3 to 5 . 24.1 18.5 2,046 1,900 1,858 1,924 + 0 .6 + 0.5 - 0 . 7

6 to 10 . 24.3 20.8 1,922 1,661 1,689 1,723 + 1.0 - 0 . 3 - 0 . 4

11 to 16 . 16.0 17.3 1,873 1,548 1,421 1,370 + 1.4 + 1.7 + 0 .7

Major centres (b) 24.6 36.3 1,470 1,253 1,125 999 + 1.1 + 2 .2 + 2 .4

All country areas . 100.0 100.0 1,817 1,605 1,533 1,476 + 0 .9 + 0.9 + 0 .8

(a) Excludes Newcastle, Wollongong, Geelong. (b) With full-time specialists and salaried hospital doctors; these centres usually have 18 or more doctors.

Source: Australian Medical Association (unpublished). Figures prior to 1971 supplied to Association by Commonwealth Statistician. Numbers of doctors in 1971 are from Association surveys.

26

3.12 Further light on the distribution of doctors in country areas is provided in Table D.4 to Table D.6, Appendix D. These tables show the results of analyses of the distribution of doctors in country areas of Australia, ranging from areas with one doctor to less than 1,200 population to areas with one doctor to 3,600 or more. Comparisons are given for the years 1964 and 1970 for Victoria, for doctors mainly in private practice, and for the census years 1961, 1966 and 1971 for the other States for

all doctors. The results of a special analysis by Dr. Godfrey Scott1 of New South Wales doctors in the Pensioner Medical Service in 1968 and 1972 are also shown in Appendix D.

3.13 The figures indicate some increases in the number of areas with doctor- population ratios of 1 to 2,800 or more in New South Wales, South Australia and Western Australia, and in the number of doctors in those areas. In these States the number of such areas increased from 18 areas in 1961 with 31 doctors, to 41 areas in

1971 with 66 doctors. However, there was a fall in the number of such areas in the other three States, with an almost corresponding fall in the number of doctors in such areas. There are some limitations on the conclusiveness of these analyses: low ratios in certain areas close to a metropolitan or State border may be misleading; the census

figures record doctors according to their whereabouts on census night, not according to usual residence or practice; and additional medical services in remote areas of some States are provided by the Flying Doctor Services.

3.14 Analysis of the distribution of doctors within metropolitan areas requires the doctors to be classified by area of practice, not residence, and this cannot be done from census data. The special analysis by Dr. Godfrey Scott of doctors in the Pensioner Medical Service by location of practice showed that in the Sydney Statistical Division

in 1972 there were seven local government areas with doctor-population ratios of 1 to 2,400 or more. These were Fairfield (1 to 2,454), Canterbury (1 to 2,556), Campbelltown (1 to 2,631), Liverpool (1 to 2,938), Penrith (1 to 3,140), Botany (1 to 3,182) and Blacktown (1 to 3,332). There were six local government areas with doctor-population ratios of 1 to 1,200 or less. These were Woollahra (1 to 762),

Mosman (1 to 1,008), North Sydney (1 to 1,103), Manly (1 to 1,154), Waverley (1 to 1,164) and Marrickville (1 to 1,191). The changes between October 1968 and February 1972 in the distribution of doctors are shown in Table 3.8.

TABLE 3.8

DISTRIBUTION OF DOCTORS IN PENSIONER MEDICAL SERVICE BY DOCTOR-POPULATION RATIOS OF LOCAL GOVERNMENT AREAS, SYDNEY STATISTICAL DIVISION, 1968 AN D 1972

October 1968 February 1972

In Local Government Areas with Doctor-Population Ratio o f 1 to

Under 1,200­ 1,200 1,599 1,600­ 2,399

2,400 +

Under 1,200­ 1,200 1,599 1 ,6 0 0 - 2,400 2,399 +

Number of Doctors 267 461 632 131 292 360 680 222

Per cent 17.9 30.9 42.4 8.8 18.8 23.2 43.8 14.3

Source: Appendix D, Table D .4.

1 Department of Social and Preventive Medicine, University of Sydney.

27

3.15 These statistics of doctors in the Pensioner Medical Service were used by Scott as an approximation to the number of general practitioners. Scott points out that the adequacy of medical services in particular areas depends not only on the doctor-population ratio but also on the frequency of consultation, which varies with the age structure, proximity to public hospitals, proportion of non-insured patients, educational and socio-economic status of the population, and the type and range of procedures offered by the general practitioner. From these considerations Scott concludes that with a few exceptions the distribution of general practitioner- population ratios in the Sydney Statistical Division conforms with what might have been expected.

TYPES OF DOCTORS

3.16 The best estimates available to the Committee of the various types of doctors are those based on the Commonwealth Department of Health Survey for June 1972. These are set out in Table 3.9. The doctor-population ratios corresponding to these types of doctor are set out in Table 3.10. The ratio corresponding to these for general practitioners in metropolitan statistical divisions was 1 to 1,607 and for the rest of Australia 1 to 2,121.

TABLE 3.9

ESTIMATES OF ACTIVE MEDICAL PRACTITIONERS BY PRIME ACTIVITY A N D EMPLOYMENT STATUS, AUSTRALIA, 30 JUNE 1972

Private Practice Salaried Total Private

Practice Salaried Total

General Practitioners 7,155 7,155

per cent

39.8

per cent per cent

39.8

Specialists 3,677 1,426 5,103 20.5 7.9 28.4

Other — 5,714 5,714 — 31.8 31.8

Total 10,832 7,140 17,972 60.3 39.7 100.0

Source: Commonwealth Department o f Health, Sample Survey.

TABLE 3.10

DOCTOR-POPULATION RATIOS BY PRIME ACTIVITY A N D EMPLOYMENT STATUS OF DOCTOR, AUSTRALIA, 30 JUNE 1972

Private Practice Salaried Total

1 to 1 to 1 to

General Practitioners 1,811 — 1,811

Specialists 3,524 9,088 2,540

Other — 2,268 2,268

All Doctors 1,196 1,815 721

Source: Table 3.9.

3.17 To judge whether these figures provide evidence of shortages, it would be desirable to compare them with similar figures from other countries, with whatever standards may be quoted from various authorities, and with other Australian figures that are available on a continuous basis, from which trends can be derived. A general

28

comparison with other countries such as that in Table 3.1 for all doctors is not possible for types of doctors. Tables in the WHO World Health Statistics Annual 1969, Vol. Ill, give figures for “general medicine” and particular specialties for a large number of countries, but the figures for general medicine for most countries do not distinguish general practitioners from consultants and in many cases the figure includes all doctors whose field of activity is not specified. Two countries for which figures of general practitioners, specialists and other doctors appear to be available are Switzerland and Northern Ireland, although even these present problems of comparison of the specialists. Both these countries have an overall doctor- population ratio similar to Australia’s. Some figures are also available for New Zealand. Table 3.11 gives the ratios for types of doctor in these countries for the years indicated.

TABLE 3.11

DOCTOR-POPULATION RATIOS FOR TYPES OF DOCTOR SWITZERLAND A N D NORTHERN IRELAND 1969, NEW ZEALAND 1967-68, AUSTRALIA 1972

Switzerland Northern Ireland(b) New Zealand Australia

General

1 to 1 to 1 to 1 to

Practitioners 3,536 1,891(c) 2.042(e) 1,811

Specialists 1,932(a) 2.202(d) 1,502 2,540

Other 1,957 3,063 (approx.) 2,268

All doctors 723 764 866(f) 721

(a) In private practice. (b) In National Health Service, which includes all except 4 doctors. (c) In general medical services (family doctors). (d) Consultants, specialists and clinical assistants. (e) 1967. (f) 1968.

Source: Switzerland and Northern Ireland, WHO World Health Statistics Annual 1969, Vol. Ill; New Zealand, Report on Medical Graduate Needs in New Zealand 1968-2000 (Welling­ ton 1970); Australia, Table 3.10.

3.18 A standard doctor-population ratio for general practitioners frequently quoted to the Committee was 1 to 1,750 for urban areas and 1 to 2,000 for non-urban areas. This standard was suggested for New Zealand in A. W. Thompson, Where Should I Practise? (Wellington, 1970), and was adopted by Scott in assessing the distribution of

general practitioners in New South Wales. In England and Wales the average number of patients per general medical practitioner (“unrestricted principal”) in 1970 was 2,460 (2,263 rural, 2,521 urban and 2,448 mixed). The average size in practices classed as “restricted” (that is, considered to have sufficient doctors) was 1,884 (1,874 rural,

1,914 urban and 1,843 mixed).1 The Australian Medical Association in its submission suggested a standard of 1 to 2,000. The New South Wales Government suggested 1 to 1,600 for private generalists, 1 to 2,300 for private specialists and 1 to 2,000 for other categories. In an attachment to the submission of the Illawarra Region Health

Committee, a standard of 1 to 1,600 was suggested for local government areas in the Sydney metropolitan area, 1 to 1,800 for rural local government areas above 18,000 population and 1 to 2,000 for other rural local government areas. Other ratios quoted

1 Department of Health and Social Security, Digest o f Health Statistics, 1971, p. 39.

29

to the Committee as desirable tended to relate to some future period in which tech­ nology and health care delivery systems would have changed, and therefore are not relevant to the question whether the current number of general practitioners is adequate. This is true of the ratio of 1 to 1,500 suggested as desirable in the first

report of the Australian Medical Association Study Group on Medical Planning.1

3.19 General Practitioners. For the study of trends in general practitioner-population ratios two series are available which are approximations to the number of general practitioners. Doctors on the Permail lists at June 1972 recorded as general practi­ tioners numbered 6,953 (not adjusted for those declining to be listed). There were 6,817 doctors participating in the Pensioner Medical Service at June 1972, and these may be presumed to be almost entirely general practitioners. Comments on these sources of statistics are included in Appendix D. These figures compare with the 7,155 general practitioners in the Commonwealth Department of Health Sample Survey.

3.20 Table 3.12 shows the numbers of general practitioners and general practitioner- population ratios from 1965 to 1972. In relation to population, the number of general practitioners has tended to be fairly stable in recent years. This is shown by both the Permail and the Pensioner Medical Service series; the sharp fall in the former series since June 1971 is believed to be mainly due to reclassification of doctors by the Permail organisation following the change in the provisions of the National Health Scheme relating to specialists’ fees.

TABLE 3.12

APPROXIMATE NUMBER OF GENERAL PRACTITIONERS, AUSTRALIA 1965 TO 1972

A t 30 Pensioner

Doctor-Population Ratios

June Permail Medical Pensioner

(approx.) Service Permail Medical

Service

1965 6.497(a) 5,896

1 to 1,753

1 to 1,931

1966 6,800 6,034 1,706 1,922

1967 7,072 6,175 1,668 1,911

1968 7,072 6,333 1,698 1,896

1969 7,133 6,417 1,719 1,911

1970 7,392 6,451 1,692 1,939

1971 7,376 6,617 1,729 1,928

1972 6,953 6,817 1,864 1,901

(a) At 12 November.

3.21 General practitioner-population ratios by State are set out in Table 3.13. The figures for the Pensioner Medical Service appear to provide some evidence of improve­ ment since 1965 in the ratio of general practitioners to population in the four smaller States, but not in New South Wales or Victoria. In the latter State both series suggest a deterioration since 1965, which is confirmed to some extent by the Victorian Statist’s survey of 1964 and 1970.2

1 General Practice and Us Future in Australia, First Report of the Australian Medical Association Study Group on Medical Planning, Sydney, 1972. 1 Victoria, Survey of Medical Practitioners 1970, Office o f the Government Statist and Actuary, Melbourne March 1971.

30

APPROXIMATE GENERAL PRACTITIONER-POPULATION RATIOS, BY STATE, AUSTRALIA 1965 TO 1972

TABLE 3.13

Permail Pensioner Medical

Service

Nov. 1965

June 1971 1972 1965

June 1971

June 1972

New South Wales 1 to 1 to 1 to 1 to 1 to 1 to

and A.C.T. . . 1,568 1,547 1,684 1,822 1,895 1,843

Victoria . . . 1,773 1,757 1,926 1,930 1,983 2,040

Queensland . South Australia . 2,222 2,023 2,112 2,144 1,923 1,860

and N.T. . . 1,739 1,767 1,807 2,021 1,930 1,895

Western Australia 1,830 1,993 2,190 1,929 1,937 1,874

Tasmania . . 2,343 2,145 2,241 2,216 1,842 1,767

Australia . . . 1,753 1,729 1,864 1,931 1,928 1,901

3.22 Specialists. The number of specialists in Australia in June 1972, according to the Commonwealth Department of Health’s estimate, was 5,103. This figure is likely to be closer to the number of active qualified specialists than the Permail figure which was 5,908 but which probably includes some doctors not qualified as specialists. It is

also likely to be a better estimate of the number of active qualified specialists than the number of specialists and consultant physicians recognised for purposes of the National Health Act, which was 6,227 in June 1972. This figure, though confined to qualified specialists and consultant physicians, is known to include a number of

duplications (through separate State listings), retired doctors, overseas residents, and part-time specialists whose main activity is general practice.

3.23 The Permail and National Health Scheme figures can probably be used to illustrate the trend in the number of specialists in recent years, which has shown a rapid increase, both in total and in relation to population. These are shown in Table 3.14. Part of the large increase in the Permail figures since 1971 is probably due to the

reclassification already mentioned. Specialist-population ratios by States are given in Table 3.15. The rate of increase in the specialist-population ratio between 1966 and 1971, according to the Permail figures, was 3.9 per cent per annum.

TABLE 3.14

APPROXIMATE NUMBER OF SPECIALISTS AUSTRALIA 1965 TO 1972

At 30 June {approx.) Permail

National Health Scheme

Specialist-Population Ratios

Permail National

Health Scheme

1 to 1 to

1965 3,725(a) n.a. 3.057(a) n.a.

1966 3,790 n.a. 3,061 n.a.

1967 3,926 n.a. 3,005 n.a.

1968 3,998 n.a. 3,004 n.a.

1969 4,358 n.a. 2,814 n.a.

1970 4,655 n.a. 2,687 n.a.

1971 5,007 5,572 2,548 2,289

1972 5,908 6,227 2,193 2,081

(a) At 12 November.

C

31

APPROXIMATE SPECIALIST-POPULATION RATIOS, BY STATE, AUSTRALIA 1965 TO 1972

TABLE 3.15

Permail National

Health Scheme

Nov. 1965

June 1971

June 1972

June 1971

June 1972

New South Wales

1 to 1 to 1 to 1 to 1 to

and A.C.T. . . 2,935 2,464 2,104 2,016 1,835

Victoria . . . 2,815 2,453 2,104 2,538 2,289

Queensland . South Australia . 3,679 2,798 2,409 2,284 2,134

and N.T. . . 3,451 2,471 2,281 2,250 1,977

Western Australia . 3,237 3,040 2,588 3,113 2,831

Tasmania . . . 3,040 2,585 2,086 2,656 2,498

Australia . . .. 3,057 2,548 2,193 2,289 2,081

3.24 Private Practice and Salaried Employment. The Census provides a dissection between doctors in private practice and salaried doctors broadly comparable to that given in the Commonwealth Department of Health’s sample survey of June 1972, which showed that 40 per cent of doctors were salaried. Corresponding proportions for Census dates since 1933 are set out in Table 3.16.

TABLE 3.16

PROPORTION OF DOCTORS IN PRIVATE PRACTICE AN D SALARIED EMPLOYMENT 1933 TO 1972

June 1933(a)

June 1947(d)

June 1954(a)

June 1961(b)

June 1966(b)

June 1971(b)

June 1972(c)

per per per per per per per

Private

cent cent cent cent cent cent cent

practice .

Salaried

. 85.4 73.3 71.5 68.5 63.7 59.7 60.3

employment(d) . 14.6 26.7 28.5 31.5 36.3 40.3 39.7

Total . . 100.0 100.0 100.0 100.0 100.0 100.0 100.0

(a) Scotton, op. cit., from Census. (b) Census adjusted (see para. 3.2). (c) Commonwealth Department of Health Sample Survey. (d) The word ‘salaried’ has been applied to the Census figures of doctors employed in ‘in­

dustries’ other than ‘medicine, private practice’. Not all of them were, in fact, employees. In 1971, 104 doctors not in private practice described themselves as employers or self- employed persons, mainly in industries classified for Census purposes as ‘hospitals’ and ‘health services not elsewhere counted’. In the same Census 1,711 doctors in private practice described themselves as employees, presumably being members of an incorpor­ ated practice.

In relation to population, the number of doctors in private practice showed no increase between 1966 and 1971, while those in salaried employment increased at 3.5 per cent per annum. If there was no growth in the numbers of private practitioners or general practitioners in relation to population, it would appear that most of the growth in the specialists referred to in paragraph 3.23 must have occurred among salaried specialists. This is borne out to some extent by the Victorian Statist’s surveys (see paragraph D .ll, Appendix D), which showed that the number of specialists

32

mainly in private practice in Victoria increased in relation to the population by only 0.2 per cent a year between 1964 and 1970.

3.25 The bulk of the increase in salaried employment has occurred in hospitals, which, in the Department of Health’s survey of June 1972, employed 32 per cent of all doctors. The growth in hospital employment is shown in the Census figures of doctors employed according to their ‘industry’, set out in Table 3.17. The figures

since 1961 have been adjusted for understatement of doctors in the defence services and universities, but not for doctors temporarily absent overseas.

TABLE 3.17

DOCTORS IN PRIVATE PRACTICE AN D IN OTHER ‘INDUSTRIES’, AUSTRALIAN CENSUSES 1947 TO 1971

Census Industry June

1947 1961 1966 1971

Medicine, private practice . .

Number of Doctors

4,867 8,301 8,975 9,880

Hospitals (other than mental) . . 867 2,322 3,171 4,267

Mental hospitals . 82 245 343 446

Other, health . . 295 355 456 546

Sub-total, health 6,111 11,223 12,945 15,139

Universities n.a. 236(a) 448(a) 552(a)

Public authorities . and defence . . 343 434(a) 453(a) 517(a)

Other industries 190(b) i n 239 335

Total 6,644 12.120(a) 14.085(a) 16.543(a)

(Including doctors temporarily absent overseas and, in 1966, female doctors 65

and over). . . (12,320) (14,440) (17,243)

Proportion of Total per per per per

cent cent cent cent

Medicine, private practice . . 73.3 68.5 63.7 59.7

Hospitals (other than mental) . . 13.0 19.2 22.5 25.8

Mental hospitals . 1.2 2 .0 2.4 2.7

Other, health 4 .4 2.9 3.2 3.3

Sub-total, health 92.0 92.6 91.9 91.5

Universities . . n.a. 1.9 3.2 3.3

Public authorities and defence . . 5.2 3.6 3.2 3.1

Other industries . 2.9(b) 1.9 1.7 2.0

Total . . . 100.0 100.0 100.0 100.0

(a) Adjusted for understatement (see paragraph 3.2). (b) Includes universities.

Table 3.17 throws much light on the complexities of assessing the adequacy of the supply of doctors. Hospitals in 1971 employed five times as many doctors as in 1947. Their share in the total more than doubled. In relation to population, the number of doctors employed by hospitals increased at 4.1 per cent per annum between 1966 and

1971. The Department of Health’s sample figures for June 1972 show even higher

33

hospital employment of doctors, namely, 5,738 compared with 4,713 at June 1971 in the Census. (There are no obvious reasons for the difference between these figures; it appears to be too great to be explained by the time difference.) It is clear that in the period since the war, radical changes in medical technology, in health care delivery and in specialist training have led to the emergence of a new pattern of medical manpower which makes it hard to assess the adequacy of the supply of doctors by standards of an earlier period.

3.26 Most of the doctors employed by hospitals are in in-service training posts, as interns, resident medical officers or registrars. The results of a special survey of salaried medical officers employed by hospitals, carried out at June 1972 by the

Commonwealth Statistician, are shown in Table D .7 of Appendix D. From this table, the numbers of doctors in in-service training and other posts are summarised in Table 3.18. The number of doctors in first-year (intern) training posts was 933, corresponding broadly with the number emerging from the most recent graduations.

However, the total number of doctors in all in-service training posts was 3,276, indicating the extent to which hospital posts are being used for higher medical education (see paragraph 2.32). One-half of the doctors in in-service training posts were in third year or higher years. In New South Wales and Victoria, for which more detailed information is available, about 25 per cent were in fifth-year or higher years. Certain specialist units in these States contribute towards this high proportion. Much of the relative growth of numbers in higher training posts seems to have occurred in recent years, judging by broadly corresponding proportions derived from figures for 1961 and 1965 made available by Dr. Scotton (from collections made by him for use in his thesis).1 These are set out in Table 3.19.

TABLE 3.18

FULL-TIME SALARIED MEDICAL OFFICERS EMPLOYED BY HOSPITALS, BY TYPE OF EMPLOYMENT AUSTRALIA, JUNE 1972

Number Per cent

In in-service training posts: First year (interns) . 933 19.4

Second year . . 697 14.5

Third year or higher . 1,646 34.3

Total . . . 3,276 68.3

In administrative posts . 318 6.6

Specialists(a) . . . 786 16.4

Other . . . . 420 8. 8

4,800 100.0

Source: Special survey, Commonwealth Statistician (see Table D . 7, Appendix D). (a) The corresponding figure in the Health Depart­ ment’s sample survey, June 1972, was 1,174

(standard error 160). A substantial amount of the difference would be due to the omission of many specialists in Victoria, where hospital specialists other than radiologists and patho­ logists tend to be included in hospital records among ‘other’ doctors.

1 R. B. Scotton, Medical Care and Health Insurance in Australia, unpublished thesis, University of Melbourne, 1970.

34

PROPORTION OF SALARIED MEDICAL OFFICERS EMPLOYED BY HOSPITALS, AUSTRALIA, 1961, 1965 A N D 1972

TABLE 3.19

1961 1965 1972

In in-service training posts: per cent per cent per cent

First year (interns) — 28.9 30.1 19.4

Second year or higher . 38.1 35.6 48.8

Total . . . 67.0 65.7 68.3

In administrative posts . 6.8 6.2 6.6

Specialists and others . 26.2 28.1 25.2

100.0 100.0 100.0

Source: 1961 and 1965, Scotton (see paragraph 3.26); 1972, Table D.7, Appendix D.

SEX D ISTR IB U TIO N O F DOCTORS 3.27 Many submissions to the Committee referred to the relative growth in the number of female doctors as an aspect of doctor shortages, because of the reputedly shorter working life, or working day, of female doctors. The proportion of women in the workforce of doctors has indeed increased a good deal in recent years as can be seen from Table 3.20. In 1972, 19.1 per cent of M.B., B.S. degrees were conferred

on women. In the following year 25.9 per cent of medical school enrolments were of women and 30.5 per cent of new enrolments. These figures suggest the proportion of female doctors will continue to rise.

TABLE 3.20

FEMALE DOCTORS AS A PROPORTION OF ALL DOCTORS .AUSTRALIA 1933 TO 1971

Year Number per cent

1933 . . 300 6.2

1947 . . 579 8.7

1954 . . 880 9.6

1961 . . 1,309 11.0

1966 . . 1,488 10.9

1971 . . 2,104 13.1

Source: 1933-1971, Census figures, unadjusted. Addition o f the estimated number of female doctors aged 65 and over in 1966 would raise the number in that year to 1,583 and the percentage to 11.5. (See Table 3.39, footnote (b))

3.28 From the Department of Health’s survey, it appears that the proportion of female doctors in general practice was almost the same as the proportion of male doctors in general practice, but rather less in specialist work. Approximately one- half were in salaried positions. The distribution of male and female doctors by type

of work is shown in Table 3.21.

3.29 Whether female doctors have a greater tendency than men to leave medicine, either temporarily or permanently, is a question examined further below. Certainly, by virtue of the design of the census questionnaire, the female doctors recorded at the

35

DISTRIBUTION OF MALE A N D FEMALE DOCTORS BY TYPE OF WORK, AUSTRALIA, JUNE 1972

TABLE 3.21

Male Doctors

Female Doctors

All

Doctors

per cent per cent per cent

General practitioners Specialists: . 40.2 37.8 39.8

private practice . . 21.7 13.2 20.5

salaried . . . 7.6 10.0 7.9

Other salaried . . . 30.5 39.0 31.8

100.0 100.0 100.0

Census and in the Department of Health survey were still active in medicine, though they were not necessarily working full-time. However, it seems unlikely that the increase in the proportion of female doctors could have been a significant cause of a shortage of doctors in recent years. Assuming that the workload of female doctors had been 65 per cent1 of that of men, the increase of slightly over 2 percentage points in the proportion of female doctors between 1961 and 1971 would have reduced the effective supply of medical manpower by less than 1 per cent. The future, however, may be different; the effect of the expected more rapid increase in the proportion of women among doctors will be examined later in this report (see paragraph 5.44).

A G E D ISTR IB U TIO N O F DOCTORS 3.30 The age distribution of doctors shows “bulges” in two five-year age groups, which can be followed through from those aged 30-39 years in 1961 to those aged 40-49 years in 1971. These are probably due to the heavy output of graduates from the medical schools in the early 1950s. They can be seen in Table 3.22. It was suggested

TABLE 3.22

NUMBER OF DOCTORS BY AGE, AUSTRALIAN CENSUSES, 1933 TO 1971

Number Proportion of Total

Age-group ------------------------------------------------------------------------------------------------------------—

1933 1947 1961(a) 1966(a) 1971(a) 1933 1947 1961 1966 1971

per per per per per

cent cent cent cent cent

20-24 . 102 396 343 508 705 2.2 6.0 2.9 3.7 4.4

25-29 . 446 929 1,374 1,795 2,434 9.2 14.0 11.5 13.1 15.1

30-34 . 967 986 2,137 1,600 2,053 19.8 14.8 18.0 11.7 12.7

35-39 . 853 676 2,174 2,409 2,001 17.5 10.2 18.3 17.6 12.4

40-44 . 644 668 1,628 2,257 2,498 13.2 10.1 13.7 16.5 15.5

45-49 . 533 1,022 1,234 1,667 2,279 10.9 15.4 10.4 12.2 14.1

50-54 . 392 723 769 1,200 1,578 8.0 10.9 6.5 8.8 9.8

55-59 . 309 524 717 737 1,079 6.3 7.9 6.0 5.4 6.7

60-64 . 277 345 795 623 570 5.7 5.2 6.7 4.5 3.5

65-69 . 180 183 429 502 424 3.7 2.8 3.6 3.7 2.6

70 & over . 159 170 304 399 486 3.3 2.6 2.6 2.9 3.0

Not stated . 12 22 — — — 0.2 0.3 — — —

Total . 4,874 6,644 11,904 13,697 16,107 100.0 100.0 100.0 100.0 100.0

(a) Unadjusted Census figures. See paragraph 3.2. Addition of the estimated number of female doctors aged 65 and over in 1966 would raise the numbers 65-69 and 70 and over in that year to 567 and 429 respectively, and the proportions correspondingly. (See Table 3.39, footnote (b)).

1 This is the ratio o f median medical hours worked by female doctors to those of men doctors from a survey by Mrs lone Fett, Monash University (see Table 5.1).

36

to the Committee that this age distribution would cause future problems, when doctors in these age groups reached retirement age. The “bulges” appear to have become less marked during the decade. In the country areas of some States, however, a high proportion of the doctors are in these age groups, ranging from 34 per cent in Tas­ mania to 51 per cent in South Australia (1966 Census, ages 35-44), compared with the 25 per cent that might be expected if the distribution were even throughout working life.

WORKLOAD OF DOCTORS

3.31 Important evidence of a shortage of doctors in Australia would be statistics showing that doctors were examining more patients, in surgery, home or hospital, or were working longer hours. Figures of patients treated per doctor, or hours worked per doctor, cannot offer a conclusive answer to this question, because the productivity

of doctors and the types of services provided are relevant to their interpretation. For example, there has been a decline in the number of operative procedures and obstetric services performed by general practitioners. Nevertheless, such figures are a starting point.

3.32 Estimates of the number of services per general practitioner are available from surveys and from statistics recorded by the Commonwealth Department of Health of services provided under medical benefits schemes, pensioner medical services and repatriation services, adjusted for the incomplete coverage of benefit schemes. The

available statistics are set out in Table 3.23.

TABLE 3.23

MEDICAL SERVICES PER GENERAL PRACTITIONER, VARIOUS ESTIMATES, AUSTRALIA, 1962-63 TO 1971-72

Year

From Surveys From Commonwealth Depart- ment o f Health Data

Number per annum Number per Number per annum

Number per week

1962-63 . 6,577 134(a)

1965-66 . 5,270 101

Nov. 1967 9,114(a) 186

(Vic.) 1969-70 . 7.252(a) 148 6,261 120(a)(b)

1971-72 . 6,396 123

(a) Assuming 49 weeks worked per annum. (b) December quarter, 1969 Sources: Surveys 1962-63 and 1969-70, results quoted in report of Dr. C. Bridges-Webb to Research Committee of Royal Australian College

of General Practitioners. 1962-63 Survey: Report on a National Morbidity Survey Part 1, National Health and Medical Research Council (Canberra 1966). 1969-70 Survey: Morbidity Survey, Pharmaceutical Research

Services of Australia. November 1967 Survey: R. B. Scotton and A. D. Grounds, Survey of General Practice in Victoria, Medical Journal of Australia, Supplement 1969, Vol. 1, No. 1, (18 Jan.).

Department of Health data. Number of general practitioner services under medical benefits schemes, pensioner medical scheme and Repatriation, divided by estimated covered population, multi­ plied by total population. Result divided by number of general

practitioners on Permail lists.

37

3.33 The survey results quoted in Table 3.23 may be affected by the fact that the doctors in the samples used in the morbidity surveys were volunteers and not randomly selected, and that the sample used in the survey by Scotton and Grounds expectedly met with appreciable non-response. The latter survey intentionally excluded some doctors considered to be part-time, while the estimates based on Department of Health data reflect the work of part-time as well as full-time general practitioners. The latter estimates are approximate only, especially the estimates of the covered population. If coverage factors recommended by Scotton1 had been used instead, the number of services per general practitioner would probably have been between 2 and

3 per cent higher. On the other hand, the number of general practitioners in the Permail lists, as already mentioned, was below the Department of Health’s best estimate in June 1972 and this would tend to overstate the number of services per general practitioner estimated from this source.

3.34 Of the possible changes in the nature of services underlying these estimates, the most significant is probably a fall in the proportion of home visits. Scotton believes that this fall has been considerable: “Data from a voluntary insurance fund indicate that home visits in New South Wales comprised 30 per cent of insured general practi­ tioner attendances in 1957, compared with Deeble and Section’s (1968) finding of

13.8 per cent in 1965-66”.2 Home visits as a proportion of all pensioner medical services fell from 38 per cent in 1965-66 to 27 per cent in 1971-723.

3.35 The workload indicated by these estimates may be compared with a standard of 7,500 services per annum suggested by the New Zealand Council of the Royal College of General Practitioners4, this being the level around which the New Zealand figure had tended to fluctuate between 1962 and 1970. This figure is also cited by Thompson5,

and is consistent with a workload of about 30 patients a day suggested by a number of doctors in discussions with the Committee as being a “comfortable” workload for a general practitioner in Australian conditions. Dr. Godfrey Scott considered that a general practitioner could “comfortably” see 25 to 30 patients a day. Dr. Andersen of the Royal Australian College of General Practitioners told the Committee that 150 consultations per week would be a reasonable workload, although if the general practitioner had no other commitment he could probably take more. Some United States figures quoted to the Committee6 were :

American Medical Association Periodic Survey (1966)7 131 attendances per doctor week U.S.A., N.D.T.I. (Pennsylvania) (1966)8 6,100-8,700 general practitioner visits a year

(depending on age of doctor) 5,700-8,000 general practitioner visits a year (depending on city size)

1 R. B. Scotton, Membership of Voluntary Health Insurance, Economic Record, Vol. 45, No. 109, March 1969. 2 Scotton and Grounds, op. cit. 3 Commonwealth Department of Health, Quarterly Review o f Health Statistics, December, 1972. 4 N.Z. Joint Committee on Medical Graduate Needs, Report May 1970. 5 A. M. Thompson, Where Should I Practise ? (Wellington, 1970). 6 Ulawarra Region Health Committee submission, Attachment III. ’ C. N. Theodore and G. E. Subtler, A Report on the First Periodic Survey of Physicians, Journal of the

American Medical Association, Vol. 202, No. 6, 6 November 1967. 8 Patient Visits to the General Practitioner, National Disease and Therapeutic Index. Lea Associates, Ambler, Pa., 1966.

38

3.36 From the figures quoted above for Australia, it appears that the average work­ load of general practitioners in terms of services provided per week or year has been increasing, but it is still at a level considered acceptable by practitioner groups which gave evidence to the Committee. It is also close to the figures quoted in source material

as acceptable. Some at least of the increase has probably been due to the effects of reduced home visiting in increasing the productivity of general practitioners.

3.37 With regard to the hours worked by doctors, Mrs. Fett’s 1972 survey of all graduates of Australian medical schools shows median time worked by all male doctors of 61.8 hours and by all females of 39.9 hours1. The median for all doctors would be about 59 hours. The survey included Australian graduates whether working in Australia or abroad. The hours worked were reported in response to the question:

“ How many hours of medical work are you doing per week?” . The median tended to decline with years since graduation, the male median ranging from 65.9 hours for those who graduated in the period 1965-69, to 55.9 hours for 1930-44 graduations and 41.7 hours for 1920-29 graduations. For females the corresponding medians were 43.9 hours, 40.3 hours and 28.2 hours. The distribution of hours worked, by

sex and period since graduation, is shown later in Table 5.1.

3.38 Scotton and Grounds’ survey of general practice in Victoria in 1967 shows an average time of 57.5 hours a week, of which 53.4 hours were clinical time. The working times in different types of practice, and in metropolitan and country practices, are set out in Table 3.24.

TABLE 3.24

MEAN WORKING TIME,(a) VICTORIAN SURVEY OF GENERAL PRACTICE 1967 (HOURS PER WEEK)

Solo Practice Group Practice 2-4 5 +

Metro­ politan

Country All

Doctors

Clinical Time . 53.3 52.3 56.5 52.2 55.7 53.4

Other working time . 6.0 3.2 2.9 4 .4 3.5 4.1

59.3 55.5 59.4 56.6 59.2 57.5

(a) Does not include ‘stand-by’ time. Source: R. B. Scotton and A. D. Grounds, Survey of General Practice in Victoria, Medical Journal and Australia Supplement, 1969, Vol. 1, No. 1 (18 Jan.)

3.39 The Australian Medical Association has conducted surveys of hours worked; these include hours spent officially ‘on call’. Data from these surveys are summarised in Table 3.25. For general practitioners, despite the difficulty of ensuring comp­ arability, these figures do not suggest any critical building-up of working hours in recent years.

3.40 The hours of resident medical officers in hospitals, however, present problems of another kind. A survey of weekly hours worked by first and second year resident medical officers in New South Wales2 in a six-week period in 1972 showed average

1 See Table 5.1. 2 Survey conducted by a Committee appointed by the Hospitals Commission of New South Wales.

39

hours (actual work and ‘on call’ combined) of 105 hours (working one week-end in two), of which 79 hours were actual work. For doctors working one week-end in three the hours were 97 and 73 respectively. Recent changes in awards in all States have the effect of imposing considerable penalty payments for hours worked in excess of certain limits. Although these changes may at first tend to raise the salaries of resident medical officers rather than to reduce their hours, it seems likely that they will eventually give rise to some increase in the establishment of hospital posts. Some States have a working week limit of 56 hours. As many hospital posts have been filled in recent years by graduates from overseas, especially India and Pakistan, and since the inflow of these graduates will be greatly curbed following recent changes in registration laws (see paragraph 3.46), it appears that additional graduates from Australian medical schools will be required to fill hospital posts.

TABLE 3.25

AVERAGE HOURS WORKED PER WEEK, AUSTRALIAN MEDICAL ASSOCIATION SURVEYS, INCLUDING HOURS O N CALL’, 1971 AND 1972

1971 1972

General Practitioners(a) . . 63 63.5

Physicians . . . . 56 56

Surgeons . . . . 61 63

Obstetricians . . . 64 65

Neurosurgeons . . . 78 79

All specialists . . . 58.5 59

(a) The Association added that it has been claimed by general practitioners that hours spent actually attending patients, writing notes etc., are about 50 a week. In Doctors Fees, 1973 (Australian Medical

Association) it is stated that ‘an A.M.A. Survey last year showed that the average general practitioner works a 49.2 hour week’ and that for specialists ‘an overall average of 64.3 hours was worked in the week surveyed’. Source: Australian Medical Association submission.

Unpublished survey.

G R O U P PRACTICES

3.41 The development of group practices has been described to the Committee as a means of relieving the pressure of solo clinical work, and at the same time of organising the available medical manpower in more effective ways. The number of doctors practising in groups is given in Table 3.26. In association with the census and Depart-

TABLE 3.26

DOCTORS IN GROUP PRACTICE, AUSTRALIA 1970 TO 1973

June 1970 . . 2,041

August 1971 . . 3,280

June 1972 . . 3,746

May 1973 . . 3,761

Source: Permail Pty. Ltd.

ment of Health survey figures, these figures suggest that about one-third of all doctors in private practice in 1971 and 1972 were in group practices. Information on the

40

structure of group practices in New South Wales and Victoria is given in Table 3.27 and Table 3.28. Dr. Scott commented on Table 3.27 as follows:

TABLE 3.27

GROU P PRACTICE IN NEW SOUTH WALES, 1972

Number o f General Practices with Group Number o f Proportion

Area Size of: General Practitioners(a) Total in Solo

2 3 4 5 6 Group Solo

U rban Sydney (Including Richmond- W indsor and Glenbrook— Faulconbridge) . . 92 52 21 11 3 497 1,057 1,554

per cent

68

Newcastle (Gosford-Maitland including Raymond Terrace) . . . 13 13 7 5 118 74 192 39

Wollongong (Helensburg to Shellharbour) . . 4 7 2 39 44 83 53

Country (Remainder of State) . 44 17 9 7 1 216 397 613 65

Total . . . . 153 89 37 25 4 870 1,572 2,442 64

(a) Includes assistants. Source: Godfrey Scott, A Study o f Medical Manpower in N.S.W .

The table is based upon the list of participants in the Pensioner Medical Service as at February 1972 . . . There does . . . appear to be a clear association between the formation of large group practices and areas in which rapid population growth is occurring; for example, of the 14 Sydney metropolitan practices with 5 or more

members, 8 are situated in the southern, outer-western and northern seaside suburbs which have experienced high intercensal population growth rates, and of the 8 group practices of similar size in country areas, 6 are situated in large rural municipalities which have intercensal (1966-71) population growth rates exceeding

14 per cent. In general, the solo practitioner is more likely to be located in the middle and upper socio-economic class areas which exhibit stable population trends.

TABLE 3.28

M EDICAL PRACTITIONERS BY TYPE O F PRACTICE, VICTORIA, 1970

Type o f Practiced)

Within Melbourne Metropolitan Outside Melbourne Metropolitan Victoria

General

tioners

Specialists Both General tioners Specialists Both

General Practi­ tioners Specialists Both

Solo . . 315 571 59 129 61 17 444 632 76

Partnership . 614 127 111 218 44 78 832 171 189

. 11 19 6 8 2 8 19 21 14

Association . 3 7 1 1 — 4 8

N ot Stated . 42 40 6 18 2 — 60 42 6

Total . . 985 764 182 374 110 103 1,359 874 285

(a) Description o f the practice as given by doctors on the return form. Within the Melbourne metropolitan area 24 doctors described their practice as ‘assistant’ and 26 as ‘locum’. Outside the Melbourne metropolitan area the relevant numbers were 4 ‘assistant’ and 4 ‘locum’. With the exception of one ‘assistant’ practising outside the Melbourne metropolitan area as both a general practitioner and specialist, all of these doctors were general practitioners.

Source: Victorian Statist, 1970 survey results.

41

SOURCES OF DOCTORS

3.42 Of the doctors active in Australia in June 1972, three-quarters had received their basic medical training in Australia. About 14 per cent had been trained in the United Kingdom, Ireland or New Zealand, and about 7 per cent in Asia. This is shown in Table 3.29.

TABLE 3.29

ACTIVE MEDICAL PRACTITIONERS RESIDENT IN AUSTRALIA AT 30 JUNE 1972, BY COUNTRY OF FIRST GRADUATION

Country o f First Graduation Number Proportion per cent

Australia . . . 13.586 75.6

United Kingdom . . 2,013 11.2

Ireland, New Zealand . 467 2.6

Asia . . . . . 1,204 6.7

Other . . . . 702 3. 9

Total 17,972 100.0

Source: Commonwealth Department of Health Sample Survey.

3.43 Recent trends in graduations and in overseas arrivals and departures of doctors show that the net contribution of all overseas arrivals and departures (apart from temporary movements for less than one year), although increasing in recent years, is a smaller proportion of the total than it was ten years earlier. This contribution is called “ net immigration” in Table 3.30.

TABLE 3.30

SOURCES OF DOCTORS, AUSTRALIA, 1962 TO 1972

1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972

Graduations in Australia (a) . 505 563 602 640

Numbers

710 744 747 842 851 893 878

Net immigration(b) 126 159 173 101 104 5 86 162 151 195 179

Total . . 631 722 775 741 814 749 833 1.004 1,002 1,088 1,057

per per per per

Proportions of Total per per per per per per per

cent cent cent cent cent cent cent cent cent cent cent

Graduations in Australia(a) . 80.0 78.0 77.7 86.4 87.2 99.3 89.7 83.9 84.9 82.1 83.1

Net immigration(b) 20.0 22.0 22.3 13.6 12.8 0.7 10.3 16.1 15.1 17.9 16.9

Total . . 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0

(a) Year ended July. Other figures are calendar years. (b) Net excess of arrivals over departures, permanent and long-term. ‘Long-term’ implies a stay of one year or more, intended in the case of residents departing or visitors arriving, actual in the case o f residents returning or visitors departing. (Net short-term movement o f doctors, which involves a stay o f less than

one year, has been found negligible in recent years; in 1972 residents going and coming short-term numbered about 4,300, visitors about 5,300. The modal age o f the two combined was 40-44.)

3.44 Immigration of doctors as settlers has become more important as a source of doctors during the decade, even when former settlers departing have been deducted. However, there have been increasing numbers of doctors departing, permanently or for long-term visits, who were not former settlers and these have not been offset by those returning from long-term visits. This can be seen from Table 3.31.

42

TABLE 3.31

COMPONENTS OF NET IMMIGRATION OF DOCTORS, AUSTRALIA, 1962 TO 1972

1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972

Net arrivals of settlers . .

Net arrivals of

172 199 227 182 207 165 172 256 249 294 365

overseas visitors, long-term . . 9 24 16 26 20 22 15 61 50 51

Net departures, Australian residents(a) - 5 5 - 6 4 - 7 0 - 1 0 7 -1 2 3 -1 8 2 -1 0 1 -1 5 5 - 1 4 8 - 1 5 0 - 1 8 6

Net immigration . 126 159 173 101 104 5 86 162 151 195 179

(a) Permanent (other than former settlers) and long-term. Note: Minus sign denotes departures or excess o f departures over arrivals.

3.45 Net arrivals of settlers from the British Isles have fallen since the mid-sixties, and the number of former settlers from there departing permanently has increased. Arrivals from the remaining countries separately shown in the statistics (grouped together in the table as “New Zealand, Canada, South Africa, Malta, United States,

Germany, Greece, Italy, Yugoslavia”) have been maintained in recent years but the number of former settlers from these countries departing has been increasing. As a result, the predominant source of the increased inflow of doctors as settlers in recent years has been the “Other countries” in Table 3.32, believed to be mainly India.1 Net

immigration of settlers from these “other countries” amounted to 27.4 per cent of the 1972 supply of doctors (from graduations and net immigration), compared with only 6.8 per cent in 1962. By contrast, the British Isles, which had contributed 16.3 per cent in 1962, had fallen to 4.7 per cent by 1972.

TABLE 3.32

ARRIVALS OF DOCTORS AS SETTLERS, BY COUNTRY OF BIRTH, A N D NET ARRIVALS OF SETTLERS, AUSTRALIA, 1962 TO 1972

1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972

Settlers arriving, born in: British Isles . . . 111 132 151 148 152 120 98 111 83 81 81

New Zealand, Canada, South Africa, Malta, United States, Germany, Greece, Italy, Yugoslavia . . 12 24 24 19 27 25 40 39 38 35 41

Australia . . . . 14 17 21 11 1 — 3 7 1 1 7 2

Other countries . . . 57 44 55 53 67 64 96 153 160 246 308

Total settlers arriving . . 194 217 251 231 247 209 237 310 292 369 432

Less former settlers departing . . . . - 2 2 - 1 8 - 2 4 - 4 9 - 4 0 - 4 4 - 6 5 - 5 4 - 4 3 - 7 5 - 6 7

Net arrivals of settlers . 172 199 227 182 207 165 172 256 249 294 365

3.46 The heavy immigration of Indian doctors is likely to fall away during 1973. Amendments to registration acts in New South Wales, South Australia and Tasmania

1 Use of medical register statistics for information on the countries of origin of immigrant doctors can be misleading. For example, registrations in New South Wales in 1971 included 261 from graduates of uni­ versities in India, Hong Kong, Malaysia and Singapore. Of these, according to the 1971 report of the N.S.W. Medical Board, ‘164 indicated an overseas address. It is assumed they do not intend to practise in New South

Wales’. It is believed that these doctors were predominantly Hong Kong graduates.

43

have removed a large number of Asian universities and medical schools from the lists of institutions whose graduates are entitled to automatic registration in those States. These institutions had not been on the lists for the other States. In future, the experience of graduates from those universities will be examined. They may be required to undertake twelve months supervised hospital service in Australia, and may have to sit for a qualifying examination before practising in Australia.

3.47 The other element in the immigration figures which has changed significantly, the net departure of Australian residents other than former settlers, has three components, shown in Table 3.33. The main increase has been in the third component: Australian residents going overseas for a year or more, in excess of those returning after a year or more, which is shown in Table 3.33 as “net long-term departures, Australian residents” .

TABLE 3.33

NET DEPARTURES OF DOCTORS RESIDENT IN AUSTRALIA, PERMANENT (OTHER THAN FORMER SETTLERS) A N D LONG-TERM, 1962 TO 1972

1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972

Permanent departures of Australian residents (non-settlers): Australian born .

Other . . j ~ 3?

- 1 9 - 3 0 - 2 4 - 3 8

1 - 2 0

J - 1 7

- 1 8 - 2 6

- 2 5 - 2 2

- 3 3 - 2 4

- 3 2 - 3 4

- 3 7 - 1 8

Net long-term departures, Australian residents(a) . . - 1 8 - 4 5 - 4 0 - 8 3 - 8 5 - 1 4 5 - 5 7 -1 0 8 - 9 1 - 8 4 -1 3 1

Total . . . - 5 5 - 6 4 - 7 0 - 1 0 7 -1 2 3 - 1 8 2 -1 0 1 -1 5 5 - 1 4 8 - 1 5 0 - 1 8 6

(a) Excess o f departures o f Australian residents for a year or more over arrivals o f Australian residents from overseas visits o f a year or more. Note: Minus sign denotes departures or excess o f departures over arrivals.

3.48 The first component, Australian-born residents departing permanently, numbered 37 in 1972 and has increased in recent years. The statistics do not record the countries of destination, but some light is thrown on this by some statistics obtained from the United States and Canada. These statistics, which are quoted in Table 3.34,

TABLE 3.34

DOCTORS FROM AUSTRALIA ENTERING THE UNITED STATES A N D CANADA AS IMMIGRANTS (a), 1962 TO 1972

1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972

United States . . 6 4 8 9 21 19 19 14 19 19 43

Canada . . . 4 10 3 5 13 19 32 24 35 37 n.a.

Total of above . . 10 14 11 14 34 38 51 38 54 56 n.a.

Total permanent departures from Australia(b) . . 59 37 54 73 78 81 109 101 100 141 122

(a) ‘Immigrants’ excludes those undertaking study or internships for limited periods. (b) From Australian statistics. Includes former settlers departing. Sources: United States, Immigration and Naturalisation Service, Department o f Justice. Canada, Immigration Statistics, Canada Manpower and Immigration.

44

relate to arrivals of doctors from Australia as immigrants and would presumably therefore correspond to permanent departures of all kinds in the Australian statistics, including former settlers and other non-Australian-born, as well as Australian-born,

although in the nature of immigration statistics this correspondence is not certain.

3.49 No similar figures are available for the United Kingdom, but an impression of the numbers of Australian and New Zealand male doctors working in Great Britain in 1966 can be formed from the Sample Census 1966. This shows that there were 1,350 males born in Australia and New Zealand working in ‘medical and dental services’ in Great Britain in April 1966, of whom 690 were in ‘hospital and con­

sultant services’. The figure of 1,350 can presumably be taken as an upper limit to the number of Australian-born male doctors working in Great Britain at the time, including of course those who had left Australia as ‘long-term departures’ as well as those who had left permanently. The corresponding figures for females would be less useful for this purpose, as they would presumably include a large number of nurses.

3.50 The second component of the net departures of doctors resident in Australia in Table 3.33 consists of permanent departures of doctors resident in Australia but not Australian-born, who were not classified as former settlers. Some of these may actually be former settlers who have not recorded themselves as such, or visitors who have identified themselves wrongly because they regarded themselves as residents at time of departure. Foreign-born graduates of Australian universities returning to

their home countries may presumably be either in this component or in long-term visitors returning.

3.51 The third component of Table 3.33, ‘net long-term departures of Australian residents’, would include the net effect of Australian doctors going overseas for a year or more for study or experience. The increase in this component appears to be due to an expansion in the numbers going and coming, perhaps partly also to an extension from about two to about three years in the average length of stay overseas on the part of those returning in the last four years. This seems to be borne out when the departure and arrival figures are shown separately, as in Table 3.35.

TABLE 3.35

LONG-TERM MOVEMENT OF DOCTORS RESIDENT IN AUSTRALIA, 1962 TO 1972

1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972

Departures, Australian residents long-term(a) . - 2 1 2 - 2 3 0 - 2 5 7 - 2 9 2 -3 3 1 - 4 3 0 -3 7 3 -4 7 1 -4 8 1 - 4 6 2 -5 8 9

Australian residents returning from long-term visits(a) . . 194 185 217 209 246 285 316 363 390 378 458

Net movement . - 1 8 - 4 5 - 4 0 - 8 3 - 8 5 - 1 4 5 - 5 7 -1 0 8 - 9 1 - 8 4 -1 3 1

(a) For one year or more. Note: Minus sign denotes departures or an excess of departures over arrivals.

45

3.52 On the adequacy of the current supply of doctors, the immigration statistics as a whole appear to offer mixed evidence. The heavy immigration of Indian doctors has been represented to the Committee as evidence of a shortage, in the sense of a lack of Australian-trained doctors to fill the positions occupied by the Indian doctors. The statistics of arrivals and departures show that doctors have been moving fairly freely across international boundaries, and while Indian doctors have no doubt filled increasing numbers of Australian hospital posts, Australian doctors appear to have filled increasing numbers of British, American and Canadian posts. From enquiries of the Committee, the influx of Indian doctors was not in response to major recruitment campaigns on the part of Australian hospital authorities, but was due to a rise in the number of immigration enquiries made by Indian graduates, which were followed by the issue of entry permits because the qualifications were acceptable and the occupation was one for which the Commonwealth Department of Labour certified a continuing demand. If the expected falling off of immigration by Indian doctors is followed by a rise in hospital vacancies in Australia, a shortage will obviously exist, but from the Committee’s studies of the overall supply position it will probably be due to the distribution of doctors rather than any inadequacy of total

supply.

3.53 Sources o f Doctors by Sex and Age. Table 3.36 shows that in both graduations and net immigration female doctors have been forming an increasing proportion of the total in recent years.

TABLE 3.36

FEMALE DOCTORS, GRADUATIONS A N D NET PERMANENT A N D LONG-TERM ARRIVALS, 1962 TO 1972

1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972

Graduations in Australia . 83 70 80

Number of Female Doctors 94 107 123 144 166 152 155 168

Net permanent and long-term arrivals . . 26 17 5 - 6 - 6 - 1 7 10 41 30 59 28

Total . . . . 109 87 85 88 101 106 154 207 182 214 196

per per per

Proportion of Total Doctors per per per per per per per per

cent cent cent cent cent cent cent cent cent cent cent

Graduations in Australia . 16.4 12.4 13.3 14.7 15.1 16.5 19.3 19.7 17.9 17.4 19.1

Net permanent and long-term arrivals . . 20.6 10.7 2.9 (a) (a) (a) 11.6 25.3 19.9 25.4 15.6

Total . . . . 17.3 12.1 11.0 11.9 12.4 14.2 18.5 20.6 18.2 19.7 18.5

(a) Net departure of females. Source: Commonwealth Statistician.

3.54 The age structure of graduations and immigration (permanent and long-term) shows that while the graduates are mainly in the 20-24 year age group, and to a lesser extent the 25-29 year age group (see Table 3.37), the settlers tend to spread over the 25-39 year groups. However, when the departure of Australian residents for a year or more and their subsequent return are taken into account, the net total of permanent and long-term arrivals tends to spread over the 30-39 year age groups. This is shown in Table 3.38.

46

AGE DISTRIBUTION OF GRADUATIONS FROM FOUR MEDICAL SCHOOLS(a) IN RECENT YEARS

TABLE 3.37

Age Proportion

per cent

20 —

21 —

22 4.6

23 31.0

24 31.1

20-24 66.7

25 16.6

26 6.4

27 3.0

28 2.3

29 1.6

25-29 29.9

30-34 2.1

35-39 1.0

40 and over 0.2

Total 100.0

(a) Universities o f Sydney (1972), New South Wales (1971 to 1973), Queensland (1971 to 1973), and Monash University (1969 to 1972).

TABLE 3.38

COMPONENTS OF NET IMMIGRATION OF DOCTORS BY AGE-GROUP, M ID-1966 TO MID-1971

Settlers arriving . . .

20-24 51

25-29 313

Australian residents departing long-term . . - 1 6 4 -1 ,0 3 8

Australian residents returning from long-term visits . . . . . 28 358

Former settlers departing . - 1 0 - 4 6

Other permanent departures . - 7 - 1 2 5

Net arrivals, long-term visitors . . . . 25 98

30-34 35-39 40-44 45-49

50 &

Over

344 243 171 110 141

-5 5 2 -1 3 4 - 1 2 4 - 7 4 -1 0 8

724 243 124 79 108

- 4 7 - 2 3 - 1 4 - 1 5 - 1 1

- 6 3 - 4 2 - 4 2 - 2 2 - 3 8

46 6 - 5 - 5 1

Net permanent and long-term arrivals . . —77 —440 452 293 110 73 93

R E T IR E M E N T O F D O CTO RS A N D W ITH D R A W A L FR O M M ED IC IN E

3.55 The Census figures, in association with immigration statistics, graduations and estimates of deaths, enable estimates to be made of the loss of doctors between Census years owing to retirement and withdrawal into other activities. In Table 3.39

47

deaths of doctors have been estimated from life tables and are therefore approximate. When the actual intercensal increase in the number of doctors is deducted from the net addition due to graduations, immigration and deaths in the intercensal period, the residual obtained must be attributed, apart from errors and omissions, to retire­ ments and withdrawal of active doctors from the profession.

TABLE 3.39

ESTIMATED RETIREMENTS A N D WITHDRAWALS OF DOCTORS FROM MEDICINE AUSTRALIA 1961-66 AN D 1966-71

1961— 66(b) 1966-71

Graduations . .

Net immigration . .

Mates 2,586 582

Females 434 25

Persons 3,020 607

Males 3,337 403

Females 740 101

Persons 4.077 504

3,168 459 3,627 3,740 841 4,581

Less deaths . . . - 5 7 7 - 3 3 - 6 1 0 -6 3 3 - 2 5 -6 5 8

2,591 426 3,017 3,107 81 3,923

Actual intercensal increase (a) (adjusted) . . . 1,795 (325) (2,120) 2,209 (594) (2,803)

Apparent loss due to retirement and withdrawal . . . 796 (101) (897) 898 (222) (1,120)

Annual rate, per cent (b) . . 1.3 1.3 1.3 1.3 2.1 1.4

(a) See paragraph 3.2. (b) The 1966 Census figures would appear to have been edited before publication to show no female doctors aged 65 years or more, although there were 42 in the 1961 Census results and 77 in the 1971 results. The figures in this Table and in Table 3.40 and Table 6 .2 have been adjusted to include an estimate of 95

female doctors aged 65 years or more in 1966; the figures affected by this adjustment are shown in brackets.

3.56 From Table 3.39 it appears that retirements and withdrawals from the profession amounted to about 897 in the 1961-66 period and about 1,120 in the 1966-71 period. This is 179 per year in the earlier period and 224 per year in the later, or, expressed as annual rates in proportion to the mean number of doctors in the period, 1.3 per

cent and 1.4 per cent respectively.

3.57 In order to calculate the age distribution of the estimated retirements and withdrawals it is necessary to adjust the Census data of the number of doctors in each age group for the understatements mentioned in paragraph 3.2, as well as that mentioned in the footnotes to Table3.39. This age distribution is shown in Table 3.40. When expressed as a proportion of the numbers in each age group, the losses due to retirement and withdrawal show proportions increasing with age, as might be expected, but also a heavy concentration of withdrawals in the 25-29 age-group for both sexes. The method used for distributing the graduations, immigration and deaths among the Census age-groups in these calculations does not enable very precise results to be obtained, but there are clearly some relatively heavy losses for both sexes in the younger age groups.1

1 These losses are unlikely to be explained by short-term departures of doctors overseas. These tend to be matched fairly closely by arrivals of doctors returning from short-term overseas visits, and there is no concentration of departures in the 25-29 age group, (See Table 3.30, footnote (b)).

48

APPARENT RETIREMENTS A N D WITHDRAWALS FROM MEDICINE, BY SEX A N D AG E- GROUP, 1961-66 A N D 1966-71, UNADJUSTED CENSUS DATA

TABLE 3.40

20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70 and over All ages

1961-66 Male doctors . — 411 48 — 41 10 32 17 28 103 106 796

Female doctors — 116 33 — 17 - 1 0 - 3 0 - 6 - 1 0 8 (13) (4) (101)

1966-71 Male doctors . — 361 — 24 28 90 88 (94) 213 898

Female doctors — 127 46 - 1 0 - 1 4 - 3 6 18 19 25 (17) (30) (222)

As proportion of the projected number o f doctors(a) at end of period (per cent) 1961-66 Male doctors . — 20 2 — 2 1 3 2 5 16 20 6

Female doctors — 32 14 —6 - 4 - 1 7 - 5 - 1 4 13 (16) (14) (6)

1966-71 Male doctors . — 14 — 1 2 8 14 18 31 6

Female doctors — 20 15 1

“ 't 1

- 1 3 9 14 33 (33) (38) (9)

(a) Number from the previous Census advanced 5 years in age plus graduations and net immigration, less deaths, all by age group, adjusted to match corresponding Census age-group as closely as possible. For explanation of figures in brackets see Table 3.39, footnote (b).

The occurrence of a minus sign means that for the particular age group, the number of doctors projected from the previous Census falls short of the actual number shown at the Census at the end of the period. This may result from a lack of precision in adjusting graduations, net immigration and deaths in each age group to match

Census age groups; or it may reflect to some extent the return of female doctors from temporary retirement.

3.58 The withdrawals and retirements of doctors aged less than 65 years are sum­ marised in Table 3.41. The annual rate was about 1 per cent of all doctors in the decade, and was rather higher for women than men in the second half.

TABLE 3.41

ESTIMATED RATES OF RETIREMENT A N D WITHDRAWAL OF DOCTORS UNDER 65 YEARS OF AGE, BY SEX, 1961-66 AN D 1966-71

1961-66 1966-71

Males Females Persons Males Females Persons

Total estimated retirements and withdrawals under 65(a) . . . 587 84 671 591 175 766

Number per year . . 117 17 134 118 35 153

Annual rate, per cent(b) . . . 1.0 1.1 1.1 0.7 1.8 1.0

(a) From Table 3.40. (b) Number as percentage of the number of doctors under 65 (mean of adjusted figures for the period), expressed as an annual rate.

CO NCLUSIO NS O N C U R R E N T PO SITIO N 3.59 The conclusions to be drawn on the current position of medical manpower in Australia may be stated by summarising what has emerged from the statistics exam­ ined. There is no reason to believe that Australia is badly supplied with doctors in

general, in relation to either the past or other countries, or by reference to various

49

standards that have been suggested. Distribution among the States shows no obvious deficiencies, and although some country areas have low doctor-population ratios and the number of such areas has increased in some States, in other States the number has decreased. Some of the outer suburban areas of Sydney have relatively few general practitioners in relation to population and the number of these areas has increased between 1968 and 1972. Corresponding figures for other capitals are not available, but the situation in some of their outer suburbs is believed to be similar.

3.60 General practitioners in Australia appear to have just kept pace in numbers with population over the last seven years. In Victoria, there may have been a slight deterioration and in the four smaller States a slight improvement. On the average, the general practitioner-population ratio seems to be not greatly below some commonly quoted standards.

3.61 Most of the increased supply of doctors in recent years has gone into specialist activity. In relation to population the number of specialists has increased at about 3.9 per cent per annum in the five years to 1971. Perhaps partly to meet the training needs posed by this expansion, the number of hospital doctors in general has increased in relation to population at 4.1 per cent per annum in the same five years.

3.62 As with general practitioners, the number of doctors in private practice grew no faster than the population in the five years to 1971, but doctors in salaried employ­ ment increased in relation to population at 3.5 per cent per annum. The rapid growth in the number of doctors who are specialists and of those who are salaried, especially those who are employed by hospitals, partly explains the paradox of the apparent scarcity of doctors in a time of almost unprecedented expansion in medical manpower, with the number of doctors growing in relation to population at 1.8 per cent per annum. The doctors whose numbers have not grown faster than population are those visible to the public: those in private practice and in particular the general practi­ tioners.

3.63 The average workload of general practitioners in terms of items of service appears to have increased in the last ten years; but with changes in the range and variety of services provided, including the decline in the frequency of home visiting and the growth of deputising services, the change is difficult to interpret. Certainly the average does not appear to have exceeded widely recommended standards, and there is no evidence of a critical building-up of working hours. In hospitals, however, newly introduced restrictions on working hours may lead to reduced hours of work and increased establishments of resident medical officers. With the recent heavy inflow

of Indian doctors curbed by changes in registration laws, it could temporarily become harder to fill hospital posts.

3.64 Australian doctors in the five years to 1971 left the country to take hospital posts or practise overseas, in numbers equal to nearly three-fifths of graduations. About 3 per cent departed for good; the rest for a year or more and these appeared to return on the average about three years later. Doctors not born in Australia, including former settlers departing, left the country in numbers equal to a further 9 per cent of graduations, making the permanent loss each year equal to about 12 per cent of graduations. As the temporary movement itself was increasing there was a further annual loss equal to about 13 per cent of graduations due to the excess of the

50

temporary departures over those who returned during the year. As a result of this temporary and permanent loss the contribution of immigration to the total annual additional numbers of doctors was cut from the 30 per cent provided by new settlers (mostly Indian in recent years) to about 11 per cent.

3.65 Further losses occur through doctors leaving the profession or retiring early. Losses through withdrawal from medicine or retirement at less than 65 years of age are estimated at about 153 a year in the five years to 1971 and 134 in the five years before that. They amounted each year to about 1 per cent of the total number of doctors

under 65 in the ten-year period, and were rather higher for women than for men in the second half of the period.

3.66 Women as a proportion of all doctors have increased only by about 2 per­ centage points in the ten years to 1971, when they reached 13 per cent of the total, but they have increased their share of new enrolments in medical schools, which was 30.5 per cent in 1973. Their proportion of total manpower will therefore increase

more rapidly in future. Women’s share in net immigration of doctors has also been increasing.

3.67 A general conclusion to this chapter is that currently the particular shortages of medical manpower that exist or are threatened are due to the distribution of doctors rather than the total supply. The question to be answered concerns the desirable future rate of expansion in the number of doctors in relation to the future population

and expected changes in medical knowledge and technology and in health care delivery. This question is examined in Chapters 4, 5 and 7.

51

CH A PTER 4

Trends in the Demand for Medical Services 4.1 The past trends in medical manpower in Australia outlined in the previous chapter suggest that far-reaching changes in the nature and volume of the demand for medical services have been taking place. This chapter isolates and examines the more important of those changes, especially those of a continuing nature, in order to judge their likely effect on the demand for medical services in the next two decades.

D E M O G R A PH IC TR EN D S

4.2 Population increase per se is not a change necessitating a detailed discussion as this is taken into account when manpower figures are expressed in terms of population. However, demographic factors, such as the age and sex distribution of population, and the trend towards urbanisation, are of interest and relevance to the questions being considered by the Committee.

4.3 Different age groups may be weighted according to their demand for medical services. The weights used for this purpose in the Todd Report ranged from 0.6 for those under 40 to 2.4 for those 80 and over, relative to an average of 1.0 for the whole population.1 Applying these weights to the period reviewed in the last chapter and to the projected population over the next two decades on the basis of an annual net immigration of 40,000 and the latest projections of mortality and fertility, it can be concluded from Table 4.1 that over the period 1933 to 1971 the demand for medical

TABLE 4.1

EFFECT OF CHANGING AGE STRUCTURE OF POPULATION ON DEM AND FOR MEDICAL SERVICES, AUSTRALIA 1933 TO 1991

Weights

Age-Group (Todd Report) Age Distribution Weighted Age Distribution

1933 1954 1971 1991 1933 1954 1971 1991

per per per per per pe per per

cent cent cent cen cent cent cent cent

0-39 0.6 68.0 64.6 65.5 66.6 40.8 38.8 39.3 40.0

40-49 0.8 13.0 13.1 12.3 12.1 10.4 10.5 9.8 9.7

50-59 1.2 9.0 9.8 9.9 8.4 10.8 11.8 11.9 10.1

60-69 1.6 6.2 7.6 7.0 7.2 9.9 12.2 11.2 11.5

70-79 2 .0 3.1 3.8 3.9 4.2 6.2 7.6 7.8 8.4

80 and over 2.4 0.7 1.2 1.5 1.5 1.7 2.9 3.6 3.6

100.0 100.0 100.0 100.0 79.8 83.8 83.6 83.3

services increased about 4 \ per cent because of the change in age structure (all of it occurring prior to 1954), but will not increase at all for this reason between 1971 and 1991.

1 op. cit., Appendix 13, Table 1, p. 289.

52

The reason for this is apparent from the table: the bulk of the increase in the propor­ tion of persons aged 70 years and over occurred prior to 1954, and, while the proportion of this age group will continue to increase up to 1991, its effect on demand for medical services is offset by the growth in the share of the under 40 years age

group, at the expense of those aged between 40 and 60 years.

4.4 Demographic effects are sometimes assessed by use of attendance rates, by sex and age, derived from morbidity surveys of general practice. These allow weights more detailed than those of the Todd Report to be used. Such surveys for Australia show, for example, that attendance rates for children under one year may be about

30 per cent above the average for all ages, while attendance rates for females over 15 years may be one and one-half times to twice the corresponding male rates. How­ ever, the application of such rates to the 1991 population projections results in only minimal variations compared with Table 4.1. Although babies and children under five years increased their share of the total population between 1933 and 1954, this

has since declined slightly and is expected to be about the same in 1991 as in 1971, as Table 4.2 shows. Thus, the demands of persons of these ages for medical services are unlikely to change greatly in volume in the period under review.1

TABLE 4.2

PROPORTION OF POPULATION AGED 0 YEARS AN D 1 TO 4 YEARS, AUSTRALIA, 1933 TO 1971 A N D PROJECTED 1991

Aged 1933 1954 1971 1991

per cent per cent per cent per cent

0 1.6 2.2 2.0 2.0

1-4 7.0 8.6 7.6 7.8

0-4 8.6 10.8 9.6 9.8

4.5 Much the same is true of those aged 70 years and over, whose share is expected to increase only slightly, as Table 4.1 shows. However, this does not mean that the “chronically ill” will not absorb an increasing share of medical resources. Their claims on medical services are only partly a question of numbers; these tend to

increase also with the development of techniques for relieving their condition. Contrary to popular conception, the increase in the proportion of old people in the population owes little to the effects of advances in medicine in “keeping them alive longer” . If it did, one would expect the average expectation of life of people aged,

say, 60 or 70 years to have increased. In fact the expectation of life of males at these ages has fallen by a few months since 1933, and that of females has risen by 1.8 years at age 60 years and 1.3 years at age 70. Changes in the proportion of old people in the population are due principally to changes in the numbers of births occurring

60 or 70 years before, modified mainly by the effect of wars on the generation concerned.

This expectation is based on the Commonwealth Statistician’s projection (assuming 40,000 net immigration per annum). This projection was based on the assumption that 1971 female age-specific birth rates con­ tinued to operate (both for migrants and Australian-born) but with a decline of 2 per cent per year in the rates for those aged 30 years and over. This assumption was adopted after an analysis of the current position and recent trends in female age-specific birth rates.

53

4.6 Urbanisation is another demographic change of significance for the demand for medical services. The proportion of the population living in metropolitan areas increased from 46.9 per cent in 1933 to 60.0 per cent in 1971, and the trend is likely to continue. This trend might be expected to increase the demand for medical services. Whether city people use the doctor’s services more than country people because of necessity or because of propinquity, they appear to use him more, and there is plenty of evidence that urban life contributes to the incidence of certain types of illness. A disturbing feature of recent infant mortality statistics are the high rates shown in inner suburban and some outer suburban areas in Sydney and Melbourne. In some recent years the rates in these areas have been up to twice those in some other suburbs.

MORBIDITY TRENDS

4.7 A number of influences other than demographic has affected the pattern of morbidity underlying the demand for medical services. Some of these are the result of changes in our way of life, such as motor vehicle accidents and changes in the incidence of drug addiction, abortions and venereal disease. Others are the direct result of changes in medical techniques.

4.8 The rising death and injury rate from motor vehicle accidents in Australia is serious in itself, but is also of concern for its effect on medical manpower—both directly by the heavy demands it poses, and indirectly by the effect it has on the pattern of hospital cases available for teaching purposes. Deaths from motor vehicle trauma exceeded deaths from all infectious diseases in 1954, and are now more than four times as numerous. The deaths from road accidents appear to have reached a

peak of 3,798 in 1970 but were still 3,423 in 1972, and the number of injuries had declined only to 89,815 in 1972 from its 1970 peak of 91,554. This means that each year about one person in 139 in the population may be expected to be injured or killed in road accidents. For those aged 17 to 20 years the expectation is increased to one in 40 and for males aged 17 to 20 years it is one in 29. Cases of ‘accidents, poisonings and violence’, the majority of them probably motor vehicle accident victims, accounted for 15 per cent of the patients and 16 per cent of the public bed- days in Victorian public hospitals in 1968. Serious accidents require specialised care; medium grade accident cases occupy hospital beds for some time, and minor accidents overburden the casualty service regularly on Friday and Saturday nights. The demand for medical services for the treatment of road accident victims seems likely to increase further, even if the incidence of accidents can be controlled. Better treatment facilities will require more doctors: for example, if mobile teams for resuscitation and roadside emergency treatment included a doctor. Professor J. S. Robertson1 has estimated that 12.6 per cent of fatalities occurring in country areas would probably have survived, given some system of earlier detection, communication and rescue. The indirect effect of road accidents on medical manpower is their effect on teaching facilities: by and large, road accidents cause injuries which are not very productive for medical tuition, and by pre-empting bed space, particularly in the large central teaching hospitals, they reduce the effective volume of cases which are useful for clinical teaching purposes.

1 The Management o f Road Traffic Casualties. Seminar of the Royal Australasian College of Surgeons, Melbourne, October 1969.

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4.9 The social pressures which have led to legislative change regarding abortion increase the volume of medical work. There is no doubt that abortion legalised by enactment or case law has led to additional requests, many of which have been

granted. The prevention of unwanted pregnancy by medically prescribed contra­ ceptive methods creates even more work for doctors than does legal abortion. In the last twelve years, probably between one-third and one-half the women of child­ bearing age in Australia have consulted doctors regarding family planning. Most

methods medically prescribed require continuing supervision. For example, oral contraceptives should be prescribed at not more than six-monthly intervals, and intra-uterine devices should be checked at one or two yearly intervals. Changing social opinions have led to permanent methods of contraception, by tubal ligation or

vasectomy.

4.10 Social problems such as the rising incidence of venereal disease may produce additional medical work by diagnostic, therapeutic and follow-up case-finding methods. Part of this can be done by paramedical workers, but doctors are always involved in the diagnosis and treatment.

4.11 Drug dependence, both physical and psychological, is creating additional medical work. Therapy (including prevention) is developing only in special care centres. While the results of these centres are encouraging, as compared with treat­ ment by individual practitioners, the benefit is largely achieved by time and effort

spent by doctors and paramedical personnel. If drug abuse increases, the effect on medical services may become pronounced.

4.12 Increasing demands on medical services are likely to be made by persons suffering from minor mental illnesses such as neurosis. Statistical data on the incidence of these are not available, but there seems to be increasing awareness of the part that medical treatment can play in relieving or curing such conditions, treatment which, of course, tends to be time-consuming and labour intensive.

TECHNOLOGICAL ADVANCES

4.13 The introduction of new medical techniques usually demands additional medical manpower. This is true of transplantation surgery which has been established as a regular procedure in Australia in the last decade. At present this is confined to transplantation of vital organs and is almost entirely restricted to the kidney. The cost

(in terms of medical manpower) is high: assessment and preparation of the patient usually takes some weeks or months, the technical procedures of tissue typing, donor selection and surgical transplant are time-consuming, and finally the follow-up management to maintain health and prevent rejection of the transplanted organ

requires permanent supervision by the specialised medical team.

4.14 Micro-surgery has advanced beyond the research and development phase, and will be used with increasing frequency in the future. Preservation of severed limbs and their junction and repair require meticulous and painstaking surgery, often carried out under the low-power microscope. Successful salvage of the limb must be followed

by continuing supervision of recovering muscle function as nerve re-growth takes place over months and even years.

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4.15 Intensive care units are another example of heavy demand on medical services. Continuous monitoring of seriously ill patients with heart, lung, metabolic, and traumatic illness and of patients recovering from operations, has proved one of the most important advances in reducing mortality. But these units must be staffed on a twenty-four hour basis, and senior members of staff must always be available at short notice.

4.16 These highly successful techniques are particular examples which have captured public interest. Many other specialties employ new techniques equally time-consuming and these are likely to become regular features of medical practice in main centres of population. Although such techniques must be restricted to special teams in a limited number of hospitals, the number of doctors involved is not small, when these methods are considered on a nation-wide basis.

PREVENTIVE MEDICINE

4.17 Campaigns for detection of disease at the symptomless stage have received public attention. The most effective of these has been the detection of uterine cancer, by vaginal cytology. Others attempted on a smaller scale, or proposed, have been screening for diabetes, glaucoma and hypertension. In the case of uterine cancer the effect on medical work was a net increase. As the success of this campaign depends on contact of the patient with a doctor, it results in consultations at intervals of one, two or three years and therefore requires continuing services by practitioners or specialists. The laboratory specimens are processed mainly by technologists, but pathologists supervise the large laboratories, and gynaecologists and radiotherapists become involved in therapy when diagnosis is positive.

4.18 The introduction of a screening technique produces an immediate apparent incidence of new disease, since the normal incidence of symptom-producing disease at advanced stage in the community is augmented by the symptomless newly detected cases, which probably would have progressed to symptoms in the course of the next few years. There is thus a sudden increase in medical work, followed by the con­ tinuing maintenance of the detection procedures. As yet, the number of diseases suitable for detection screening methods is small, but there is little doubt that these will increase. The cost in terms of medical manpower is an increase in demand, which may more than offset reductions in the morbidity and mortality which would have

otherwise taken place.

ECONOMIC TRENDS

4.19 Economic studies have shown that, with rising per capita income, the demand for medical services tends to rise faster than population. Much of the increased demand underlying the improving doctor-population ratios has no doubt been due to

the rise in average incomes (and perhaps changes in the distribution of income) during the period. This has been due directly to increasing affluence, but also indirectly to the consequent expectations of a higher level of physical and mental health.

4.20 Because most medical services are labour-intensive, one would expect a rising trend of costs of medical services in relation to the prices of other goods and services not so labour-intensive. This has occurred; however, the submission of the Com-56

monwealth Department of Health showed that, despite a rise in the cost of medical services in the six years to 1971-72, changes in the benefit scheme meant that the cost per service to the member was almost unchanged.1

4.21 Although these figures illustrate the effects of a particular change in the govern­ ment health scheme, their implication is more general. While medical services are accepted by the Australian Government as part of its general responsibility for health, increases in their cost to the consumer which might otherwise be expected to

be more rapid than those of other goods and services, are likely to be cushioned by the effect of changes in government policy. Even without changes in government schemes, the insurance principle in health benefit schemes probably operates to make consumer demand less responsive to price increases than it would otherwise be. Thus,

for both reasons, rising demand due to increasing affluence is less likely to be dis­ couraged by rising prices to the consumer than in the case of goods and services in general.

SOCIAL TRENDS

4.22 Over the last few decades the rise in the standard of education and in the proportion of the population reaching at least a minimal educational level have had their effect on the demand for medical services. In addition to the tendency for children to stay at school longer and the increased opportunities for tertiary education,

a shift in curricular emphasis from classical to scientific studies and a concurrent cultural emphasis on the importance of scientific and medical advance have led to greater public knowledge of medical matters. The resulting heightened awareness of

personal health has contributed to the increasing demand for doctors’ services, often in a preventive rather than curative sense, and has also probably led to an increase in requested referrals to specialists.

4.23 Improved communications have probably increased the demand for medical services, especially in distant and sparsely populated parts of the country. The difficulty experienced by many small country towns in attracting and retaining the services of a medical practitioner is discussed elsewhere (see paragraphs 3.10 to 3.13).

The problem is mitigated somewhat by increasingly efficient road and air transport, telecommunications and special services such as those provided by the flying doctor services. These allow a person requiring medical treatment either to travel to a doctor in a provincial centre, or, if he is immobilised or critically ill, to receive home care

from a doctor. In some circumstances, the doctor can radio instructions for interim treatment to someone at the scene. Regular visiting clinics involving medical con­ sultants of various kinds are becoming more commonplace. Diagnostic facilities are

made more readily available by air transport services.

4.24 Even in the urban environment improved communications have affected the demand for medical services. The Committee was told often of the increasing use being made of a service involving mobile doctors in radio-controlled cars. These doctors are used mainly as an after-hours service by local practitioners. The mobile

doctor works in a particular area making home visits at short notice in response to radio messages relayed to him from a central office which receives after-hours calls

1 If fund benefits are included as part of the cost to the insured member, it rose by not much more than half the rise in the total cost per service.

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for medical treatment. A recent electronic innovation is the transmission of electro­ cardiograms over ordinary telephone lines between distant cities.

4.25 While improved communications may increase a doctor’s productivity by the more efficient use of time, they have probably increased the demand for his services, due mainly to his greater accessibility. The educative aspects of communication through the media of newspaper, radio and television have also increased the public’s awareness of available services and of personal health needs or wants, thereby increasing the demand for these services.

4.26 The demand for doctors in public administration, teaching and research has been increasing and is likely to continue to do so. Public administration has always absorbed a certain proportion of doctors. The number employed increased at about l i per cent per year in the decade up to 1971. The development of systematic health planning which is occurring at both Commonwealth and State levels will certainly require the services of more medically qualified health administrators. Increases in the numbers engaged in teaching and research have been spectacular. This has been due to an increasing self-reliance in Australia in both these areas. University medical

staff engaged in teaching and research more than doubled in the decade to 1971, while those in research institutions increased by almost one-half. The numbers of doctors involved in these branches of medical work over the period 1961 to 1971 are set out in Table 4.3.

TABLE 4.3

DOCTORS ENGAGED IN PUBLIC ADMINISTRATION, TEACHING AN D RESEARCH, AUSTRALIA 1961 TO 1971

Number Annual Increase

1961 1966 1971 1961-66 1966-71 1961-71

per cent per cent per cent

Public administration ,. 335 361 388 1.5 1.5 1.5

Universities . .. 236 448 552 13.7 4.26 9.1

Research institutions . .. 55 83 79 8.6 - 0 . 9 3.7

Source: Censuses, university publications, and correspondence with research institutions.

INSTITUTIONAL CHANGES

4.27 National Health Insurance Scheme. It was suggested earlier that changes in government health insurance policies stimulate demand for medical services by cushioning the patient from the effect of cost increases. Even when policies do not change, the insurance principle itself provides some cushioning effect. However, the present health scheme does require the patient to bear part of the cost of the doctors’ fees and of hospital fees, and he is therefore aware to some extent of any cost increases. The new health insurance scheme under consideration by the Australian Government provides that, under certain circumstances, the patient would pay no part of such fees, which would be met from a fund financed by a levy on taxable income, together with

levies on third party and workers’ compensation insurers and subventions from consolidated revenue. Such a scheme may stimulate the demand for medical services even more than the present one; in addition to relieving the patient of the share of the

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bill that he pays at present, it would bring more patients into the scheme by providing for universal coverage.

4.28 This question was raised by the Committee during its discussions with Dr. J. S. Deeble and Dr. R. B. Scotton, Special Advisers to the Minister for Social Security, who were largely responsible for designing the proposed new health insurance scheme. The Committee was told that it was not expected that the increase in the demand for

services would be as great as the increase in the number of people covered, because a large proportion of those at present uninsured comprised young, healthy, single males who rarely used health services. It had been estimated that there could be an increase of about five per cent in the utilisation of services.

4.29 Salaried Hospital Posts. The rapid increase in the number of salaried doctors in hospitals has been discussed in Chapter 3. Table 4.4 shows the number of doctors who reported hospitals as their industry of employment in each of the four census years since June 1947.

TABLE 4 .4

DOCTORS WHO REPORTED HOSPITALS AS THEIR INDUSTRY OF EMPLOYMENT, AUSTRALIA 1947 TO 1971

Number of Doctors Annual Increase

June 1947 . . 949

per cent

June 1961 . . 2,567 7.3

June 1966 . . 3,514 6.5

June 1971 . . 4,713 6.0

Source: Censuses

4.30 The increase in the number of doctors employed in salaried posts in hospitals was discussed by the Committee with representatives of the Royal colleges and other organisations. As well as the growth in demand for hospital posts for training in the general specialties, technological change in certain areas of medicine has led to the

development of an increased number of posts for particular specialties, such as plastic and open heart surgery, which are purely hospital based. Technological advances in areas such as these tend to be labour-using rather than labour saving; more time is required to look after each patient because of specialist care. Moreover, there have

been large increases in numbers of hospital posts in pathology, radiology and other diagnostic services. In addition, there has been a trend towards post-graduate training for general practitioners. Representatives of the Royal Australian College of General Practitioners told the Committee that it was hoped that eventually all general practi­

tioners would participate in the College training programme. Given the general shortage of posts available for general practice, an increase in the number of training opportunities would be necessary. This would involve an increase in the number of salaried posts either in hospitals or within general practices.

4.31 If about one-third of graduates become general practitioners spending three years in hospital posts, and 50 per cent become specialists spending seven years in hospital posts, by 1991 a total of some 6,750 posts will be needed apart from senior staff posts. This compares with 3,276 doctors in such posts in 1972, and represents an

59

annual rate of increase which is lower than the growth rates shown in Table 4.4 and is, in fact, not much greater than the growth rate of about 3 per cent in the number of active doctors implied in the Committee’s recommendations.

4.32 Aboriginal Health. There is growing concern about, and research activity in, health problems relating specifically to Aboriginals. These include, in particular, malnutrition and other conditions due to dietary deficiencies, respiratory and parasitic diseases. During its meeting with the Commonwealth Department of Health, the Committee was told of proposals to establish a national Aboriginal health branch in its central office. In addition, the Department had taken over the responsibility of health care for Aborigines on settlements and stations in the Northern Territory. It seems likely that activity in the area of Aboriginal health will gather impetus and increasing resources, manpower and medical services will be required to grapple with the problem.

4.33 Doctors fo r Underdeveloped Countries. It has been mentioned in paragraphs 2.5 and 2.6 that places are made available in all Australian medical schools for overseas students from the developing countries of Asia and Africa. The Committee has discussed with representatives of universities and other organisations the question of the value to developing countries of medical practitioners trained in Australian universities. Generally, it was agreed that such training did not necessarily equip overseas students for practice in their home countries, where disease patterns and the general social and geographical environment differed in many respects from the Australian situation. The view was that Australia might make a greater contribution by offering post-graduate training facilities and by assisting in establishing and developing medical schools overseas. There is also the possibility of Australian medical personnel themselves working in underdeveloped areas. Such developments may well create a small but growing demand for the services of Australian doctors.

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CHAPTER 5

Trends in the Productivity of Doctors 5.1 In Chapter 4, the likely trends in the demand for medical services over the next twenty years were discussed in detail. This Chapter considers the factors which may be expected to affect the productivity of doctors, i.e. the number of medical services

that doctors, on average, provide. These factors, which fall into four main groups, relate to organisational changes, advances in medical knowledge, conditions of work and demographic factors. At the end of the Chapter, the trends in the demand for

medical services and in the productivity of doctors are considered together and the Committee’s assessment of their net effect on medical manpower requirements is set out.

ORGANISATIONAL CHANGES

P a r a m e d ic a l P e r s o n n e l i n C o m m u n it y P r a c t ic e

5.2 It is widely believed that greater use of paramedical personnel or auxiliaries will enable doctors to see more patients and hence improve their productivity. The extended use of such personnel depends on the development of community health centres or on the growth of larger group practices and their ability to employ para­

medical workers. The concept of a community health centre, as expressed to the Committee in one submission, was of a centre in a population area, in which diag­ nostic and therapeutic facilities for a wide range of medical conditions would be available to support general practitioners. Practitioners of first contact, together with

sessional consultants, x-ray and pathology services, physiotherapy, social welfare, counselling and other services, were envisaged. The whole group, serving a specified geographical area, would function as a team, providing a much wider range of integrated services for the local community than the solo general practitioner, and

thus increasing considerably the comprehensive nature of the area health services. The Report of the Interim Committee of the National Hospitals and Health Services Commission, June 1973, outlines the development and operation of a community health programme for Australia1 and envisages the development of community

health centres.

5.3 Community health centres will integrate the services of the doctor with those of nurses, social workers, other paramedical personnel and administrative officers. As a result, it is argued, the doctor will be relieved of responsibilities not strictly of a medical nature and it may be possible for certain relatively straight-forward medical

procedures to be undertaken by personnel with less than full medical training.

1 A Community Health Programme for Australia, A Report from the National Hospitals and Health Services Commission Interim Committee, June 1973.

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5.4 Practice Nurses. The nurse is already a familiar and highly regarded figure in the delivery of primary health care in Australia. The ‘bush nurse’ who works in remote parts of Australia and undertakes clinical responsibilities far beyond those normally expected of a nurse, has frequently been used as a model for the kind of doctor’s assistant that would be relevant for Australia as a whole. A nurse with special training in certain areas of general medicine could be a valuable adjunct to general and specialist practices and community health centres.

5.5 The concept and training of a nurse as a doctor’s assistant, the ‘practice nurse’, was widely discussed during the Committee’s meetings with representatives of various organisations. The concept was strongly supported. Generally, representatives favoured the introduction of either a specially designed course, or a course to be taken after basic certificate training. Representatives of the Royal Australian Nursing Federation were in favour of an extended role for some nurses and felt that special training should be provided in a tertiary level post-basic course, as an extension of, and not a substitute for, the present nursing course. The Committee’s attention was drawn to plans already in existence for nursing training at graduate level. For example, in Western Australia, negotiations are in hand for the introduction of a nursing

course at the Western Australian Institute of Technology, and in New South Wales, the School of Paramedical Studies has recently been established and has taken over the educational functions of the New South Wales College of Nursing. In the Aust­ ralian Capital Territory, a shortened two year nursing course has been introduced, followed by a post-basic course at the Canberra College of Advanced Education to combine the roles of the district, maternity and psychiatric nurse into that of the community health nurse. The Committee was also informed that both the College of Nursing of Australia and the New South Wales College of Nursing had courses which could be developed into suitable post-basic courses.

5.6 In the community environment the work load of the practitioner would be reduced by the introduction of the practice nurse who would assist in screening the degree of urgency of calls, in carrying out certain procedures, and in interviewing patients and taking histories, either by utilising a check list or assisting with a computer terminal type of screening. The combined effect of these services would be to increase the productivity of the practitioner. The practitioner, however, would still have the legal responsibility for work done on his behalf and this would involve him in checking the work and supervising the practice nurse; histories taken on his behalf would need to be checked and amplified. In the Committee’s view a better quality of service should be the result of such assistance but as the work would be done in greater detail than at the present time it is possible that productivity would be only marginally increased.

5.7 Social Workers. The development of modern society, with its rapid rate of tech­ nological and social change, leads to an increasing awareness of social problems which affect both the physical and mental health of many members of the society and which place an increasing demand on the services of medical practitioners. Australia, with its high concentration of population in urban centres and its well developed immigra­ tion programme, experiences special problems in these areas. With the development of community health centres and group practices, social workers attached to these centres or practices will provide important support services to medical practitioners.

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They will act as consultants and advisers to patients referred to them by the medical practitioners or will be able to refer people in need of assistance to the doctor or other paramedics associated with the health centre.

5.8 The increased use of the social worker should increase the productivity of medical practitioners by allowing them to devote more time to other areas of their work for which they have special skills, but more demands may be made on the practitioner’s services as a greater number of cases are brought to his attention.

5.9 Physiotherapists and Other Paramedical Personnel. The utilisation of other paramedical personnel in health centres and group practices would also allow some shedding of the doctor’s work load. For example, the physiotherapist could be used to carry out detailed examination of musculo-skeletal disorders; and the occupational therapist to assess degrees of disablement. These activities would improve the quality

of care available at the health centre but would require overall appraisal by the practitioner and therefore might increase the total time spent with an individual patient. Under present circumstances such a patient would be sent to a hospital clinic

where the same team approach would be made. To deal with the patient in a health centre would require a shift in activity from the hospital into the community.

5.10 Summary. While at first sight the development of the team work approach in community health centres may seem likely to save the doctor’s time and thus improve his productivity, in the sense of his through-put of patients, there are three reasons why this may not, in fact, be the outcome. In the first place, more time may be spent in correlating the work of the individual members of the team. Secondly, the doctor

may spend more time with each individual patient. Thirdly, the doctor may choose to lessen his work load. Moreover, the more systematic approach to health services implied in community health centre arrangements will almost certainly result in the

detection of more medical problems. Consequently, the team work approach may actually stimulate the demand for medical services.

5.11 Until community health centres and group practices have been subjected to trial and assessment, it is not possible to express an opinion as to their net effects on the productivity of combined hospital and community centre staffs and on the demand for medical services. However, irrespective of this, the Committee considers

that the extensive use of paramedical personnel at community health centres is likely to make a significant improvement in the quality of health care available to the community.

P a r a m e d ic a l P e r s o n n e l i n H o s p it a l s a n d S p e c ia l C e n t r e s

5.12 The value of these personnel in contributing to doctors’ productivity is already recognised in hospitals, but the extent of their responsibility varies according to the organisation of the particular institution. For example, speech therapists, orthoptists, clinical psychologists and medical secretaries are valued members of the team. Others,

such as vocational guidance officers who can help place intellectually and physically handicapped individuals, have been based in areas remote from the health care team, and might be better integrated in it. Nurses with special training in intensive care and other special techniques have an indispensable role in specialist hospital units using

highly sophisticated equipment. Post-basic nursing training courses are already in existence in some subjects.

D

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O r g a n is a t io n o f M e d ic a l T r a i n i n g

5.13 Undergraduate Course. All medical courses in Australia at present are of six years duration, but the University of Sydney proposes to introduce a five year under­ graduate course in 1974 and the University of New South Wales has also discussed a five year proposal. In addition, the revised course at the University of Adelaide is structured so that the sixth year can be converted to graduate training, given certain prerequisites in the hospital services and the university.

5.14 A five year undergraduate course is obtained by concentrating formal tuition in those years and reserving the sixth (pre- or post-graduation) year for practical instruction and assumption of patient care responsibility. The University of Sydney’s proposed five year undergraduate course is to be followed by one year’s pre­ registration training, which will result in a shorter training period than the current six year course plus one year pre-registration.

5.15 The effects on medical manpower of shortening an undergraduate medical course by one year are twofold. First, there would be a doubling of the output of the medical school in one year, thus adding a number of extra graduates to the pool of medical practitioners; and secondly the total length of training would be shortened so that the working lives of doctors would be potentially increased by one year. The move on the part of the University of Sydney makes it possible that there may be a general shortening of the undergraduate course in Australian universities. The Committee believes that, in view of the tendency towards a lengthening of the period of post-graduate training, moves to reduce undergraduate training to five years are highly desirable.

5.16 Internship. Compulsory pre-registration internship exists in all States and is of one year’s duration. The internship is intended to ensure that doctors practising independently have achieved a knowledge of practical procedures and therapies under the supervision of senior colleagues. In universities where curriculum revision has been undertaken, a co-ordination or continuation of undergraduate education with graduate work, as is proposed at the University of Adelaide, may be considered necessary. Generally the extent of a university’s involvement in the internship year is governed by local conditions.

5.17 It is unlikely that the period of internship, as such, will be varied. However, most graduates spend more than one year in hospital appointments. Graduates who are aiming to specialise must spend a considerable period in hospital posts and those who intend to enter general practice are increasingly remaining in hospital appointments after their internships.

5.18 Vocational Training. In the recent past, each of the professional colleges has set out a training programme which must be fulfilled before the doctor can be granted status in his chosen vocation (see paragraphs 2.31 to 2.35). This training commences after the year’s internship and varies in length according to the requirements of the college. In the case of general practice, two years of vocational training in hospital and practice are required. For surgery, medicine and obstetrics and gynaecology, the period is five or six years, except in some special branches where it is longer.

5.19 The result of these vocational training requirements will be that the effective period of medical training is substantially increased. In general, the total period spent

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in formal training could vary from eight to fourteen years. The lengthening of the training period, together with the increasing proportion of graduates who undertake vocational training, has shortened the period of practice available to the doctor independent of supervision. However, it is true that during the period of training

hospital residents and registrars do contribute medical services.

5.20 As some of the colleges have only recently announced their training programmes, it is too early to comment on their effectiveness. However, the Committee believes that, with the introduction of formal training, together with the changes expected in conditions of service for visiting specialists enabling closer supervision of trainees, the total period of training could be shortened.

D o m ic il ia r y C a r e

5.21 There appears to be a tendency on the part of medical practitioners to seek admission of patients to acute hospitals as the only means of dealing with the patient’s problems in the absence of alternative community health facilities. The result of such an admission policy leads to patients, particularly elderly patients, remaining too long

in such hospitals, except in those hospitals possessing adequate social work staffs who, in conjunction with the medical staff, are able to assess the social and therapy needs.

5.22 There is no doubt that the greater use of domiciliary nursing services, co­ ordinated by general practitioners and/or community health centres, e.g. as practised by the Royal Perth Hospital and the Royal Newcastle Hospital, would enable many patients at present occupying hospital beds to be more effectively cared for at home, thereby minimising costs in terms of medical manpower. There is a growing awareness among governments and health administrators of the economies in both manpower and finance that could be gained by the greater use of domiciliary care, and it is likely that improvements in health and hospital organisation to achieve this will take place.

R e g io n a l is a t io n i n R u r a l A r e a s

5.23 When the present structure of medical services was developing, transport between neighbouring towns and cities was slow and often inefficient, and medical specialisation was non-existent. This resulted in most country towns having their

own hospital and general practitioner(s) who performed a wide range of medical and surgical procedures. Road transport is now so efficient in most country areas that distances of 20 to 30 miles between towns can be travelled in shorter times than

smaller distances in urban areas and practitioners no longer attempt to be ‘jacks-of-all- trades’. Nevertheless, the development of regional services has been slow, each town seeking to maintain its local hospital as a matter of civic pride.

5.24 The Committee of Enquiry into Health Services in South Australia (Bright Committee)1 has recommended a regionalisation of services and has set out a possible organisation pattern. At the centre of the region would be the base hospital, with an appropriate range of specialist services, while small peripheral hospitals would serve local needs, providing a restricted range of practitioner services. In addition, com­ munity health services with regional and district health centres would be established,

1 Report of the Committee o f Enquiry into Health Services in South Australia, Adelaide, South Australia, February, 1973.

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together with infant welfare clinics and other services in the home. Doctors would practise at the health centres, where accommodation would be leased to both specialists and general practitioners. Paramedical and community welfare workers situated in the same centres would be available to provide assistance to medical practitioners as required. Implicit in the Bright Committee’s proposed regionalisation scheme is an efficient records system with computer linkage, together with a well- organised transport system, so that a patient could obtain the most appropriate care for his condition as conveniently as possible.

5.25 Regional developments such as this would create more posts for medical practitioners in regional centres and would avoid transferring patients to cities for most specialist attention. There might be some net improvement in the productivity of country practitioners, but there would certainly be more convenient and efficient treatment for the patient.

ADVANCES IN MEDICAL KNOWLEDGE AND TECHNOLOGY 5.26 Multiphasic Screening. Present facilities for multiphasic screening involve computer based questionnaires which present a print-out of relevant positive and negative responses to a programmed set of questions, together with a group of biochemical, haematological and x-ray tests. Experimental programmes to extend this type of facility to the diagnostic field have been developed but are not yet in widespread use. One of the counter-productive aspects of existing multiphasic screening is the degree to which results in the doubtful positive range lead to additional investigations and consequently to additional time and expense. The Committee considers that such technological innovations are unlikely to result in an increase in productivity of medical manpower in the near future.

5.27 Preventive Medicine. Past experience has shown that preventive medicine significantly alters disease patterns, and influences trends in mortality, morbidity and population distribution. Preventive medicine in the future is likely to be based on early recognition of factors likely to have an adverse effect on health at a later stage in life, for example, screening for early recognition of biochemical factors likely to cause cardiovascular disease and screening for phenylketoneuria. These are followed by increased medical supervision and are likely to increase the demand for medical services rather than improve the productivity of medical manpower.

5.28 Therapeutics. Improvements in therapeutics have had various effects. For example, measures to control diabetes have resulted in the prolongation of life of patients who require constant supervision and who, in later life, develop complications which create a new set of problems. These patients also have children who may carry the genetic capacity to develop the disease. The development of antibiotics has transformed the treatment of bacterial infectious disease and reduced the duration of many illnesses, often making hospital admission unnecessary. There have also been changes in disease patterns with an increase in viral infections. Other therapeutic developments have been in drugs carrying a high risk of unwanted side effects. These have increased the need for supervision, both clinical and laboratory. The term therapeutics includes other methods of treatment such as transplant surgery and joint arthroplasties, which make great demands on medical manpower.

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5.29 The Committee considers that, as with preventive medicine, developments in therapeutics are more likely to be influential on the side of the demand for medical services than to increase the number of medical services that the average doctor can provide.

5.30 Medical Records. Good medical records are an essential basis for efficient patient care; the taking of histories and the maintenance of records form a time consuming component of the work of all doctors. Some changes can be foreshadowed, e.g. the use of the practice nurse for basic history taking, either with a check list or using a computer terminal. Systems are being evolved which will utilise to a greater

degree the potentialities of the computer; the storage and retrieval of data comprising the patient’s history can be hospital based. Ultimately this system could be extended to a regional or nation-wide basis. Safeguards would be required to preserve the confidential nature of records and there might be resistance to the innovation. The

saving in time and the increase of efficiency can be expected to have a marked effect on productivity, while the improvement in patient care could be considerable.

CONDITIONS OF WORK

H o u r s

5.31 There is reason to believe that, within the period under review, doctors are likely to work shorter hours. This is certainly the case for salaried doctors, particularly those in junior posts. With the exception of Tasmania, awards or determinations in each State for resident medical officers and registrars of public hospitals now include

clauses relating to hours of work, including remuneration for ordinary hours worked and for excess hours of duty.

5.32 The effect on the productivity of hospital doctors of industrial awards leading to reduced working hours for resident medical officers and registrars in public hos­ pitals was discussed during the Committee’s meeting with State Government representatives. Some State representatives believed that such awards would reduce

productivity, while others were of the opinion that the awards would lead to increased earnings rather than reduced hours of work. The Queensland Government, in its submission to the Committee, stated 1. . . it is estimated that the Resident Medical Officers Award (handed down in 1970) resulted in an increased establishment—State wide—of approximately 45 to 50 full-time staff. There are no grounds for believing this trend will disappear . . . It is likely that any future amendments to the award will yet further reduce hours of duty, and so make additional staff provisions

mandatory’.

5.33 As far as private practitioners are concerned, discussions with individual practitioners made clear their wish to reduce their working load. As pointed out in paragraph 3.39, surveys carried out by the Australian Medical Association have

indicated an average working week for general practitioners of about 50 hours excluding time on-call of about 13 j hours. Many doctors have reduced the burden of long hours on call by the use of various kinds of deputising services. However, a view frequently put to the Committee was that general practitioners should spend longer with each patient and reduce the number seen each day. Such a reduction in the through-put of patients would contribute to a fall in productivity in the same way as

would a reduction in the hours of work.

67

5.34 The development of community health centres in Australia, with practitioners working regular hours on roster systems and the use of sessional arrangements for hospital consultants, might further reduce average hours of work, and hence product­ ivity.

5.35 Having regard to all the circumstances, the Committee is of the view that industrial awards leading to shorter hours of work for hospital medical officers, together with the trend towards reduced working hours for private practitioners, doctors attached to community health centres and consultants working on a sessional basis, may ultimately result in a substantial overall reduction in the productivity of medical practitioners.

E a r l ie r R e t ir e m e n t

5.36 The Committee was told in discussions that doctors in future were likely to seek less demanding work as they grew older and to retire earlier than in the past. There is some evidence that this tendency already exists and the introduction of a national superannuation scheme might accelerate it. These trends would further reduce the effective productivity and working life of doctors.

S t u d y L e a v e

5.37 A doctor’s training does not end when he enters active practice; it is essential for the welfare of the community that his education should be lifelong. Consequently, a doctor should have time available to keep his reading up-to-date, to attend post­ graduate courses and seminars and to spend significant periods in learning new techniques and in refreshment in a different medical milieu (e.g. a general practitioner should, from time to time, spend a period in a hospital appointment). Doctors have always been involved in this process of continuing education, but, in the Committee’s view, the trend towards devoting more time to it will accelerate in the next twenty years (see paragraphs 9.31 and 9.32). This trend will reduce the time that the doctor has available for patient care and therefore his productivity in quantitative terms.

AGE AND SEX DISTRIBUTION OF DOCTORS 5.38 With the expansion in the numbers graduating from medical schools, the medical workforce in the next twenty years is expected to become younger than at present. From the projection based on approved plans of existing medical schools only, the age distribution of doctors in 1991 shows that almost 50 per cent of doctors would be under 40, compared with 45 per cent in 1971. Those aged between 40 and 60 would be less than 40 per cent, compared with 46 per cent in 1971. Those aged 60 or more, however, would have increased their proportion to about 11 per cent com­ pared with 9 per cent in 1971, reflecting the doctors still practising from the relatively large number who graduated in the early 1950s. The retirement of this cohort is not likely to cause any replacement problems in general, but there may be particular difficulties in some country areas if general practitioners who graduated in the 1950s are still a high proportion of the medical workforce in the area.

5.39 The future age and sex distribution of the work force of doctors will affect its productivity. The results of a survey of medical graduates carried out by Mrs lone

68

Fett1 provide some indication of the relative working hours of male and female doctors, and the way in which the hours of work change with the age of the doctor. This is shown in Table 5.1, where age is assumed to vary with year of graduation.

5.40 The survey shows that female doctors appear to work longer hours on the average than is often supposed.2 The median weekly hours worked by female doctors in the survey were 39.9 hours, compared with 61.8 for male doctors. This is a ratio of 64.6 per cent. For each of the year-of-graduation groups, except the group who graduated in the 1920s, the median for female doctors was 38 hours or more, and in no case was it below 60 per cent of the median for males. For graduations before

1945 it was about 70 per cent of the median for males.

5.41 The proportion of women medical graduates doing no medical work at the time of the survey was 15.2 per cent, compared with 4.9 per cent for men graduates. For both women and men, the proportion doing no medical work increased markedly for graduations earlier than 1930; for the men in this group there was also a marked increase in the proportion working less than 30 hours. The survey relates to graduates

of Australian universities only, and is not confined to their medical work in Australia. Besides having a higher proportion reporting no medical work than the men graduates, the women graduates had a higher proportion (25 per cent) who could not be con­ tacted than the men (10 per cent), and these may of course have included a larger share of graduates doing no medical work than those who were contacted. For contact and response rates by year of graduation and sex, see Table D .2 in Appendix D.

5.42 From these figures an attempt may be made to estimate the likely effect of the expected increase in the proportion of female doctors on the productivity of the medical workforce. If it is assumed that the proportion of females among new enrolments will continue to increase, by 1991 about 22 per cent of all doctors might be females.3 If female doctors were to work on the average 64.6 per cent of the hours of male doctors (this being the ratio of the female to the male median hours worked in the Monash University survey) it can be calculated that the effect of this would be to make the productivity of the whole medical workforce about 3-j- per cent lower than it would have been if the 1971 proportions had been maintained. However, as doctors are expected to work shorter hours in future, and it seems reasonable to expect the hours for males to be reduced more than those for females, this estimate should probably be taken as an upper limit for the effect of the change in sex distrib­ ution. The effect would also be reduced further, of course, by any improvements in the organisation of medical care which enabled female doctors’ services to be used more effectively.

NET EFFECT OF DEMAND AND PRODUCTIVITY TRENDS ON MANPOWER NEEDS 5.43 Likely trends in the demand for medical services were discussed in Chapter 4. The changes expected in the age structure of the population will have little effect on

1 Department of Anthropology and Sociology, Monash University. 8 Hours worked were stated in reply to the question: How many hours of medical work are you doing per week? 3 Using the projection methods of Chapter 6, and assuming the proportion o f women amongst total gradua­

tions increases from 20 per cent to 35 per cent by 1991. In this example graduations are projected as in Table 6.2.

70

the demand for medical services. Only small changes are expected in the proportions of babies and of old people in the population. However, obstetric, paediatric and geriatric care is likely to become more complex. Morbidity trends appear to have variable effects on demand although, generally, they lead to an increased need for

medical services. In the practise of preventive medicine, the work involved in case finding is considerable and additional work is generated by screening programmes. In its submission to the Committee, the Commonwealth Department of Health pointed out that ‘the effect of preventive health programmes in reducing the level of

illness may not be generally discernable for twenty or thirty years’. In addition, early detection of disease tends to decrease the morbidity and mortality of the patient rather than reduce the doctor’s work load. On the other hand, repetitive visits to the doctor for serious illness are diminished with the development of simple vaccines and effective treatments such as antibiotics.

5.44 Economic and social trends are important factors in increasing the doctor’s workload. Growing affluence will almost certainly be accompanied by rising demands for medical services. An affluent society seeks more medical care, both prophylactic

and therapeutic, especially when cost increases are cushioned by subsidy or insurance. The Commonwealth Department of Health stated in its submission that ‘it would appear that total expenditure on health by all sectors of the Australian community rose from about 3.1 per cent of gross national product in 1948-49 to about 4.1 per

cent in 1969-70 . . . Australia could . . . be spending some 7 per cent of G.N.P. on health services by the year 2000’. At the same time, current social trends widen the spectrum of psychosomatic illness and increase problems such as alcoholism and drug addiction.

5.45 The effects on the demand for medical services of institutional changes, such as the development of community health centres, and proposals for the introduction of a national health insurance scheme, were also discussed in Chapter 4. To varying extents, all these changes will lead to an increased demand for medical services.

5.46 In this chapter future trends affecting the productivity of medical practitioners have been reviewed. Changes in the pattern of health care delivery, such as the greater use of paramedical personnel with the development of community health centres, together with certain organisational changes, for example, the regionalisation of

medical services in country areas, may increase productivity. However, these changes may be expected to take some time to evolve. The Commonwealth Department of Health, in its submission to the Committee, pointed out that ‘change in the institu­ tional framework and organisation of health services will depend upon community

and professional acceptance . . . upon ability to overcome administrative and financial problems, particularly in relation to health centres, and upon an adequate supply of supportive and assistant staff’. Moreover such institutional changes may lead to improvements in the quality of service rather than to economies in doctors’

time.

5.47 Technological innovations and the development of improved therapeutics and preventive medicine are likely to increase rather than reduce the demand for medical manpower.

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5.48 The trend towards a reduction in hours worked by doctors in both salaried and private practices is likely to continue, with a reduction in the productivity of doctors in quantitative terms. While there are several factors which might increase the productivity of medical practitioners in future years (e.g. use of paramedical personnel, some technological developments), it is likely that these factors will be

olfset by the loss due to reductions in hours worked.

5.49 Moreover, in the view of the Commonwealth Department of Health, if con­ tinuing education is undertaken by all doctors in the future, perhaps two and one half per cent of the medical practitioner workforce could be absent, at any one time, on refresher courses. In addition, improvements in research, teaching and admin­ istration of health services, are making increased demands on medical manpower. At present six per cent of doctors are employed in these areas and the Department of Health expects that, over the next thirty years, the figure will rise by two and one half percentage points.

5.50 The Committee has given careful consideration to likely trends in the demand for medical services and in the productivity of medical practitioners over the next twenty years. Taking all the factors set out above into account, the Committee believes that there will be a significant increase in the number of doctors required relative to population in Australia during the period covered by its terms of reference. In its estimation of future requirements, the Commonwealth Department of Health estimates that the doctor-population ratio might need to be raised by some 22 per cent by 1991. In the Committee’s judgement this is a conservative estimate. For this reason and to allow a margin for safety (see paragraphs 7.28 and 7.29), the Committee believes that a factor of about one-third above the 1972 level should be allowed.

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CHAPTER 6

Supply of Doctors up to 1991 According to Approved Plans

6.1 Table 6.1 sets out the number of enrolments in second year medicine in the nine medical schools on the basis of the present plans of the existing schools as recom­ mended by the Australian Universities Commission in its Fifth Report and approved by Governments. The number of medical degrees conferred or expected to be

conferred for the years 1972 to 1991, on the assumption that graduation rates con­ tinue at broadly their present levels, are projected in the table. Second year enrolments have been used, because first year enrolments are not comparable between medical schools; some universities admit students relatively freely into first year medicine

and some admit students into second year after they have passed first year science. It is possible that graduation rates will improve, although academic failure is relatively rare among medical students—the main causes of attrition being personal or

psychological. However, even if attrition were reduced, this would probably not increase the output of graduates, but, with a given capacity of clinical departments, would result in a reduction of inputs.

6.2 It can be seen from Table 6.1 that the output of graduates, which was 878 in 1972, would rise to 1,217 by 1981, without any change in present plans. It would then remain steady in conformity with the medical school quotas which would remain constant from 1975 onwards.

6.3 From analysis of figures for the recent past, assumptions can be made about immigration and emigration, both permanent and temporary, and losses through death, retirements and withdrawals from the profession. Thus the number of doctors active at points of time during the period can be calculated, together with doctor-

population ratios, in order to assess the likely future supply of doctors in the absence of any move to expand training capacity or create new schools.

6.4 The results of projecting the output of existing medical schools according to their present approved plans are shown in Table 6.2 together with corresponding actual figures for the previous decade. Table 6.2 shows that the presently approved plans of the nine existing medical schools can be expected to increase the number of

active doctors from 17,243 at 30 June 1971 to 30,410 by 1991, without the provision of any additional places for medical students. This will raise the doctor-population ratio from 1 to 740 in 1971 to 1 to 567 by 1991. This result is indicated even though the contribution of immigration assumed in the projections is below that of the decade before 1971. However, by the end of the period the rate of improvement in the

doctor-population ratio will have slowed down considerably.

73

SECOND YEAR ENROLMENTS AND DEGREES CONFERRED, AUSTRALIAN MEDICAL SCHOOLS, ACTUAL 1972 A N D ESTIMATED 1973 TO 1991 ON BASIS OF APPROVED PLANS OF EXISTING MEDICAL SCHOOLS

TABLE 6.1

Year Sydney

New South Wales

Melbourne Monash Queensland Adelaide Flinders

Western Australia

Tasmania Australia

2nd Year M.B., B.S.

2nd Year M.B., B.S.

2nd Year M.B., B.S.

2nd Year M.B., B.S.

2nd Year M.B., B.S.

2nd Year M.B., B.S.

1972 272 235 250 91 221 131 165 141 232 114 134 102

1973 258 200 247 75 230 187 166 135 230 146 138 97

1974 275 217 244 144 230 192 160 134 230 142 132 96

1975 275 238 241 184 230 187 160 136 230 158 120 92

1976 275 203 241 157 230 189 160 142 230 182 120 111

1977 275 227 238 200 230 190 160 140 230 181 120 114

1978 275 216 238 200 230 198 160 141 230 184 120 117

1979 275 458(a) 235 200 230 198 160 136 230 184 120 112

1980 275 225 235 200 230 200 160 138 230 184 120 103

1981 275 225 233 200 230 200 160 138 230 184 120 103

1982 275 225 233 200 230 200 160 138 230 189 120 103

1983 275 225 230 200 230 200 160 139 230 189 120 103

1984 275 225 230 200 230 202 160 139 230 189 120 103

1985 275 225 230 200 230 202 160 139 230 193 120 103

1986 275 225 230 200 230 202 160 141 230 193 120 104

1987 275 225 200 202 141 193 104

1988 225 200 205 141 196 104

1989 225 200 205 142 196 104

1990 225 200 205 142 196 104

1991 225 200 205 142 196 104

64 64 64 64

64 64 64 64

64 64 64 64

M.B., B.S.

2nd Year M.B., B.S.

2nd Year M.B., B.S.

2nd Year

M.B., B.S.

90 49 42 15 1,406 878

— 92 51 56 21 1,417 912

— 90 50 57 26 1,418 1,001

— 90 75 58 26 1,468 1,096

— 90 75 52 33 1,462 1,092

— 90 75 52 30 1,459 1,157

— 90 76 52 41 1,459 1,173

— 90 75 52 42 1,454 1,405

51 90 76 52 44 1,456 1,221

51 90 76 52 40 1,454 1,217

51 90 76 52 41 1,454 1,223

52 90 76 52 41 1,451 1,225

52 90 76 52 42 1,451 1,228

52 90 76 52 42 1,451 1,232

54 90 77 52 43 1,451 1,239

54 77 43 1,239

54 77 44 1,246

54 77 44 1,247

54 77 44 1,247

54 77 44 1,247

(a) Double graduation in 1979 due to change from 6 to 5 year course in 1974. Source: Universities and Committee estimates.

PROJECTIONS OF NUM BER OF DOCTORS, 1971 TO 1991 ON BASIS OF APPROVED PLANS OF EXISTING MEDICAL SCHOOLS, COMPARED WITH PERIOD 1961 TO 1971

TABLE 6.2

Actual Projected

1961-66 1966-71 1971-76 1976-81 1981-86 1986-91

Graduations . . . 3,020 4,077 4,979 6,173 6,147 6,226

Immigration— Australian residents Permanent movement(a) - 1 4 2 -2 4 1 - 2 9 9 - 3 7 0 - 3 6 9 -3 7 4

Net temporary movement . . -2 8 5 - 5 3 0 -3 2 6 -3 5 3 78 - 2 3

Settlers, net movement . 934 1,109 895 575 575 575

Visitors, long-term, net . 100 166 120 120 120 120

Net immigration . . 607 504 390 - 2 8 404 298

Total additions during period . . . . 3,627 4,581 5,369 6,145 6,551 6,524

Less deaths (b) . . . -6 1 0 - 6 5 8 -8 1 6 -9 2 9 -1 ,0 8 5 -1 ,2 5 0

Less retirements and withdrawals (b) . . - 8 9 7 -1 ,1 2 0 -1 ,3 6 7 -1 ,7 0 4 -2 ,0 5 2 -2 ,2 1 9

Net additions during period (c) . . . (2,120) (2,803) 3,186 3,512 3,414 3,055

Doctors at beginning o f period . . . . 12,320 (14,440) 17,243 20,429 23,941 27,355

Doctors at end of period . (14,440) 17,243 20,429 23,941 27,355 30,410

Population at end of period (Ό00) . . . . 11,600 12,756 13,819 14,947 16,107 17,257

Doctor-population ratio at end o f period: 1 to . . 803 740 676 624 589 567

Doctors per million of population at end of period . . . . 1,245 1,352 1,478 1,602 1,698 1,762

Annual rate of increase in doctor-population ratio since previous Census year (per cent) . . 1.3 1.7 1.8 1.6 1.2 0.7

(a) Excluding former settlers. (b) See Table 3.39. (c) For explanation of bracketed figures, see Table 3.39.

6.5 For the purposes of this calculation, immigration of doctors as settlers has been assumed to be the same proportion of total settler immigration as in the period 1966 to 1971 (after a deduction for the abnormally high immigration of Indian doctors in that period), that is, about 1 to 625. As the population projections used assume

constant net immigration of 40,000 per year, which on past experience would be consistent with settler immigration of about 90,000 per year, the number of doctor settlers was estimated at a constant 144 per year. Departures of former settlers were assumed constant at 29 per year.

6.6 Net arrivals of doctors as visitors for a year or more was also assumed constant, at 24; this is approximately the 1966-71 level after adjustment for abnormally heavy arrivals from India in the period. The remaining inflow and outflow was related to the level of graduations. In the 1961-71 period this movement of Australian residents

appears to have been predominantly one of relatively recent graduates. Thus perm­ anent departures of Australian residents were assumed a constant 6 per cent of current graduations, and temporary departures for a year or more a constant 54 per cent of

75

current graduations.1 Doctors returning from such temporary visits were assumed a constant 54 per cent of graduations three years earlier. These assumptions were in accordance with the experience of the 1966-71 period.

6.7 Deaths of doctors were estimated from male and female life tables. The projec­ tions were made for male and female doctors separately, with female graduations assumed to increase progressively from 19 per cent to 35 per cent of the total by 1991. Retirements and withdrawals from the profession were estimated by sex and age on the basis of the rates shown for the period 1966-71 in Table 3.39.

6.8 The assumption of 40,000 annual net immigration on which the population projection is based implies much lower immigration than in the past, which is probably a not unreasonable assumption. However, if a population projection based on a different assumption about immigration had been used it is unlikely that the results would have been very different. If net immigration of 60,000 a year instead of 40,000 had been assumed, the doctor-population ratio in 1991 would have been about

1 to 580 instead of 1 to 567, and if 100,000 had been assumed it would have been about 1 to 600. In these calculations it is still assumed that the doctors among the settler arrivals are a constant 1 to 625, as in the ‘normal’ 1966-71 figures, and that the other components of immigration are either constant (former settlers departing and net arrivals of long-term visitors) or a fixed proportion of graduations, either current or lagged. If these assumed relationships were varied, of course, the results would be different again, but it is difficult to see a rational basis for departing very greatly from assumptions of this kind. This does not mean that a change of circum­ stances could not produce a large inflow or outflow of doctors not provided for in the projections; but there seems to be no way of allowing for such a change in the assumptions on which the projections must be based.

6.9 The assumptions about deaths and retirements or withdrawals are based on the experience of the recent past, which of course could prove transitory, but by the nature of these events this seems unlikely. There is some uncertainty about withdrawals and retirements which, being based on residuals obtained in reconciling graduations, net immigration and deaths with the intercensal increase in the five years ending in 1971, is bound to have a considerable margin for error. However, it is unlikely to be understated; withdrawals by women in the five years on which the rates were based were a good deal higher than in the previous five years, and were possibly abnormally heavy.

6.10 The Committee believes therefore that it is reasonable to assume that plans already approved for the expansion of existing medical schools will produce a doctor- population ratio of about 1 to 567 by 1991. Whether such a ratio implies an adequate supply of doctors at that time is considered in the next chapter.

1 This is not meant to imply, of course, that only recent graduates go overseas in this way, but it is useful to employ the correlation in the projections.

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CHAPTER 7

Future Requirements for Doctors 7.1 On the basis of the presently approved plans of existing medical schools it was estimated in Chapter 6 that the projected doctor-population ratio for 1991 could be 1 to 567. On what criteria can this be judged as adequate or inadequate for Australia’s

health requirements ? An associated question is whether the rate of improvement of this ratio—estimated at 0.74 per cent per year for the period 1986 to 1991—is suf­ ficient potential growth.

CRITERIA FOR ADEQUACY OF FUTURE SUPPLY OF DOCTORS 7.2 The difficulty of assessing the adequacy of the supply of medical manpower has been referred to in Chapter 3. By its nature, the ‘absolute’ need of the population for medical services is beyond measurement and the economic demand for medical

services which is effective in the real world is greatly affected by the affluence of the consumer and the relative price of the product, which in turn is strongly influenced by government policies. There is strong reason to believe that in one sense there will always be a shortage of doctors, because of the special nature of the ‘market’ in which they offer their services (see paragraphs 4.20 and 4.21). Moreover, adequacy in overall supply may conceal shortages in particular regions and in functional categories. As was pointed out in Chapter 3 any current shortage of doctors appears

to be mainly of this kind.

7.3 The Committee has not attempted to forecast the demand for doctors in parti­ cular regions or functional categories. The Committee’s view is that a solution to a maldistribution of doctors is not do be found by adjusting the total supply. There is a popular belief that shortages of doctors’ services in particular regions or of general

practitioners could be corrected by ‘flooding the market’ with doctors, which, by reducing financial returns to doctors in some regions and some specialties, would force them into practising in less favoured regions or categories. This ignores two characteristics of the market for doctors’ services. First, doctors’ incomes are not

wholly determined by ordinary market forces but are strongly subject to determin­ ation by the doctors’ own decisions (they fix their fees and the frequency of their visits) and by institutional factors (e.g. salary determining bodies). Secondly, doctors are highly mobile and if opportunities to practise in favoured ways are not readily

available in Australia, migration is always open to them. All this is not to say that surpluses in particular regions or functions may not force some redistribution of medical manpower, e.g. the relative over-supply of general surgeons in metropolitan areas has improved the supply of general surgeons in non-metropolitan cities and towns.

7.4 The approach the Committee has followed in assessing future requirements is similar to that adopted in Chapter 3 for judging the adequacy of current manpower.

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The Committee has considered the views put to it in submissions and available from official reports, learned journals and other sources, on planned doctor-population ratios considered likely to be adequate in Australia or other countries and on standards believed applicable to the future, when medical knowledge and methods of health care delivery will have changed. In the course of this consideration, the reports of similar enquiries in other countries on the numbers of doctors to be trained to meet future health requirements have been examined with particular care.

A p p r o a c h i n O t h e r C o u n t r ie s

7.5 Great Britain. The Royal Commission on Medical Education, under the chair­ manship of Lord Todd, reported in 1968. It projected future doctor requirements by extrapolating the 1911-61 growth rate of 1.25 per cent per annum in the doctor- population ratio, raising it to allow for certain new pressures, and then reducing it slightly to provide for a change in age structure after 1975 which was expected to reduce average medical requirements. The net effect was to raise the growth rate to 1.6 per cent between 1965 and 1975, and to reduce it to 1.3 per cent between 1975 and 1995, reaching a doctor-population ratio of 1 to 555 by 1995.1

7.6 The Carnegie Commission on Higher Education (1970) in the United States adopted a particular series of projections described as ‘based on an attainable and desirable estimate of the annual medical school places to about 1978’. The doctor- population ratios projected up to about 1982 on this basis increased at 1.0 per cent per year between 1967 and 1982, slightly lower than the rate of increase between 1963 and 1969, which was 1.1 per cent, but higher than that between 1931 and 1959 when it was only 0.2 per cent.2 Further projections to 2002 on the same basis increased the doctor-population ratio at 1.3 per cent per year from 1982 on, but the Commission declined to recommend beyond the numbers of medical school entrants required by

1978. These would produce a doctor-population ratio of 1 to 584 in 1982. Its reasons for this were its expectation of a very different supply and demand situation by that period, with increases in both demand and in the productivity of doctors, the net effect of which could not be predicted.

7.7 The Canadian Royal Commission on Health Services (1964) contented itself with recommending the maintenance of the 1961 doctor-population ratio of 1 to 857 which it believed was a more realistic goal than an alternative it considered, which was to maintain the rate of improvement in the ratio shown in the period 1957 to

1961: apparently a rate of about 0.85 per cent a year, which would have produced a doctor-population ratio of 1 to 655 by 1991.

7.8 In New Zealand a Joint Committee on Medical Needs reported in 1970 that there was an existing shortage of doctors, partly on the evidence that the doctor- population ratio had reached a plateau about 1965-66 and had since declined. From separate studies and enquiries made within the various specialist colleges and societies and by the Department of Health, this shortage was estimated for the year 1968, in relation to the estimated number of doctors ‘needed’ in that year. A corresponding projection of ‘need’ was obtained from the same sources, for the year 1978. The rate of improvement in the doctor-population ratio implied by these estimates of need

1 op. cit., paragraphs 333 to 337 2 See M. S. Blumberg, Trends and Projections o f Physicians in the United States, 1967-2002 (1971)

78

(0.6 per cent per annum) was itself projected to the year 2000, for which a ratio of 1 to 610 was projected.

7.9 The doctor-population ratios representing these estimates of requirements are summarised in Table 7.1.

TABLE 7.1

PROJECTED DOCTOR-POPULATION RATIOS REPRESENTING FUTURE ‘NEEDS* PUBLISHED IN REPORTS OF ENQUIRIES

Great Britain United States^a) Canada New Zealand

1 to: 1 to: 1 to: 1 to:

1961 (actual) 857 1968 (actual) 866

(b) (c)

1965(actual) 847 1967(actual) 681 1966 856 822 1968 (needs) 738

1972 650 1971 848 787

1975 722 1977 620 1976 844 755 1978 695

1980 674 1982 584(d) 1981 842 723

1985 629 1988 549 1986 856 693

1990 591 1992 515 1991 864 655

1995 555 1997 488

2002 462 2000 610

(a) Including osteopaths. (b) Ratios shown as a result of plans to maintain 1961 ratios. (Fluctuations presumably due to steps in medical school output rates). (c) Ratios to maintain 1957-61 rate of improvement: not recommended by Royal Commission.

(d) Limit of Commission’s recommendations.

7.10 Of these projections, only that of the United States shows a higher doctor- population ratio by 1991 than the 1 to 567 projected for Australia in Chapter 6. That projection started from a higher base figure than Australia’s 1 to 721 for June 1972, and the Carnegie Commission’s actual recommendations stopped short at the mid­

eighties. The Australian projection would reach the much-quoted Todd Report figure of 1 to 555 about the same time as the Todd projection for Great Britain. In terms of growth rates the Australian projection shows a rate of improvement faster than any of these up to the mid-eighties, when it would be improving at almost the

same rate as those of Great Britain and the United States, i.e., about 1.3 per cent annually. In the five years to 1991 the rate falls below these rates, to 0.7 per cent, about the same as the New Zealand rate throughout the whole period.

7.11 The committees of enquiry differed in their views on the net effect on manpower needs of those changes in technology and health care which will increase the demand for medical services and those which will increase the productivity of doctors. The Todd Report, for Great Britain, concluded that the net effect would be to raise the

need for doctors, as demand would be raised by medical progress and economic factors, while the more efficient organisation of doctors through hospitals, group practices and health centres was likely to be more than offset by increased training, the leisure needs and the manpower requirements of diagnostic and research services—■

a conclusion similar to that reached by this Committee at the end of Chapter 5. It was for this reason that the projected rate of improvement in the doctor-population ratio was higher than the past rate. The Carnegie Commission, for the United States, declined to make a judgement on this issue, confining its recommendations to student

intake up to 1978 for this reason. The Canadian Royal Commission, while raising

79

similar questions, did not offer an answer but some inferences may perhaps be drawn from its adoption of a fixed doctor-population ratio in its projections. The New Zealand Joint Committee referred to these issues as reasons for projecting a certain rate of improvement in a doctor-population ratio assessed on a need basis. The improvement in the ratio between 1968 and 1978 was stated to be due entirely to four branches of specialist medicine: internal medicine, psychiatry, radiology and pathology. The projection of general practitioner needs (made by the New Zealand Council of the Royal College of General Practitioners) implied no improvement at all in the general practitioner to population ratio, once the estimated shortage of general practitioners in 1968 had been corrected. The reasons given were the assump­ tion that an increasing proportion of services would be given by ancillary staff ‘under direction’ and the belief that there was no level of supply at which demand could be said to be satiated.

S u b m is s io n s M a d e t o C o m m ittee

7.12 Some estimates of desirable future doctor-population ratios, taken from the submissions made to the Committee, are set out in Table 7.2.

7.13 It should be noted that the estimated actual ratios on which some of these projected desirable ratios are based are lower than the actual ratios used in this report for 1971 and 1972, which are based either on adjusted Census figures or figures from the Commonwealth Department of Health’s sample enquiry. Even when this is borne in mind, however, it is clear that the recommended ratios in all cases, except that of the University of Queensland’s recommended 1 to 500 by 1990, fall below those implied in the projections in the previous chapter on the basis of planned output of existing schools.

7.14 In its submission to the Committee, the Australian Medical Association stated: . . . it is possible that, in twenty years’ time, there may be a need for about one doctor for 500-600 people.

However, in its summing up, the Association’s submission concluded: Everything taken into consideration, however, it appears that the need for medical graduates in the whole of Australia over the next twenty years will be at least 1,000 to 1,200 per annum for all Australian medical schools.

As Table 6.1 indicates, this would be consistent with the currently planned output of existing medical schools, which would exceed 1,000 per year in 1974 and 1,200 per year in 1979.

7.15 Without submitting numerical estimates of medical needs, some State Govern­ ments in their submissions foresaw shortages of doctors developing in their own States. The Queensland Government stated: . . . we believe that there are clear indications that, by the beginning of the next

decade, the overall demand for doctors in this State will have outstripped the capacity of the Medical School to satisfy it. We believe that this can be stated even although we are largely unable to provide the quantitative data upon which real­ istic arithmetic can be performed.

7.16 The Tasmanian Government in its submission stated: We are not able to offer comment on the needs (for medical graduates) of Australia as a whole . . . We can speak only o f the position in Tasmania and it is probably

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TABLE 7.2

DESIRABLE DOCTOR-POPULATION RATIOS IN AUSTRALIA IN VARIOUS FUTURE YEARS, FROM SUBMISSIONS TO THE COMMITTEE A N D OTHER STUDIES

(/) Cs )

Commonwealth Department o f Health New South Wales

Government

Western Australian Committee on Medical Manpower Needs

Monash University University o f Queensland

University o f Western Australia Faculty o f Medicine

{Australia) {New South Wales) {Western Australia) {Australia) {Queensland) {Western Australia)

Scott,

{New South Wales and Australian Capital Territory)

1 to: 1 to: 1 to: 1 to: 1 to:

1972 741 1972 640 1971 791

1976 665 1975 800 1976 731

1981 636 1982 640 1981 800 1981 684 1980 600

1986 615 1987 800 1986 652

1991 602 1992 640 1990 500

2002 539

1 to: 1 to:

1971 699

1981 683

1991 679

2000 550

(a) Increases in ratio due to increased demand from economic and demographic factors, increased commitment to research etc., and de­ creased productivity of individual practitioners, reduced by the effect o f increased productivity o f institutional framework. Estimate for 1972 made before results of the Department’s survey were available. (This showed a ratio of 1 to 721). (b) The submission gives ratios for ‘private generalists’, ‘private specialists’ and other doctors in estimates of the number o f doctors required

for these years; these have been combined to form an overall ratio of 1 to 640. (c) ‘The 1 in 800 ratio which compares favourably with ratios elsewhere, should be adequate for the next fifteen years.’ (d) ‘If it is assumed that productivity will increase, which this balance o f evidence suggests, the present annual output o f graduates should satisfy the demand for doctors over the next 10 to 15 years. Beyond this period the future is obscure.’ The projections shown are based

on ‘medical graduates at planned input rates’ o f existing medical schools (e) Rates implied as desirable for Queensland by the recommended expansion of intake into the University of Queensland Medical School. (f) Ratio from Todd Report. The same ratio for the year 2000 was also recommended in the submission from La Trobe University. (g) Godfrey Scott, A Study o f Medical Manpower in N.S. W., Department of Preventive and Social Medicine, University of Sydney, October

1972. These ratios are derived from general practitioner ratios of 1 to 1,750 for Sydney and the Australian Capital Territory and 1 to 2,000 for the rest of the State, with the number o f resident medical officers in hospitals increasing at 20 per cent each decade, and specialists and other doctors at 1972 doctor-population ratios.

true that ‘as goes Tasmania, so goes Australia.’ In other words, we suspect that there will be a shortage of medical practitioners in Australia. However, because of its isolation, the problem is probably more acute in Tasmania than in the rest of Australia.

7.17 In discussions with representatives of the Hospitals and Charities Commission of Victoria, the Committee was told that the Commission believed the output of medical schools in Victoria was probably adequate to meet present needs in the State. It was also believed that the shortage of doctors in country areas was not as acute in Victoria as in some other States, although there were areas where there was con­ tinuing difficulty in maintaining general practitioner services.

7.18 Many submissions to the Committee, while not putting forward recommend­ ations in the numerical form of doctor-population ratios, speculated in informative ways on the likely effect of future trends in medical technology and health care deliv­ ery on the requirements for doctors. Similar observations were made in many of the submissions whose recommendations on desirable ratios have already been quoted. The New South Wales Government in its submission stated that any future increase in need for medical services for demographic reasons, in the form of increasing proportions of either old people or young children, could probably be met by increas­ ing the productivity of both generalists and specialists by the use of auxiliaries, thereby reducing the need to train more doctors.

7.19 Other State Governments did not express concern about a general shortage of medical manpower, but all States, either in written submissions or during discussions with the Committee, referred to problems due to the geographic maldistribution of manpower, and most were also concerned about functional maldistribution.

7.20 Other submissions also referred to problems of distribution. The Royal College of Obstetricians and Gynaecologists (Australian Council) submitted figures of the distribution of its members in metropolitan and country areas from which it concluded that, in most States, capital cities were well served but rural areas and country towns were not. During discussions with representatives of the Royal Australasian College

of Surgeons and in individual papers presented by members of the College, the view was expressed that Australia may be experiencing an over-supply of general surgeons. It was pointed out in the College’s submission that ‘Surgeons require a certain mini­ mum of surgery to keep dextrous. If there are too many surgeons dexterity for many will be impossible to acquire.’ The Royal Australian College of General Practitioners commented on problems of geographical distribution:

The drift of general practitioners from rural to metropolitan areas is a cause of concern. This is largely due to the established rural practitioners returning to the metropolis for various reasons and to lack of their replacement by the recent graduate.

On the manpower problem in general, the University of Adelaide concluded: Overall the problem appears to be not one of doctor numbers but of deployment within the community.

The Commonwealth Department of Health believed that solutions to problems of geographical distribution should not be sought merely by increasing the number of doctors. It is felt that, while administrative measures may in future be necessary to

complement the normal market factors in effecting a suitable deployment of

82

medical practitioners, such action would be preferable to increasing the doctor- population quotient.

7.21 The problem of distribution most widely anticipated in the submissions was related to function: particularly the problem of maintaining adequate numbers of general practitioners. The view was fairly widespread that advances in medical know­

ledge were more likely to increase than to reduce the demand for medical services, and that while improved organisation of health care delivery would raise the productivity of the general practitioner, on balance, productivity was likely to be reduced by the effects of increased leisure and training needs and the need to give more time to each

patient in the surgery. This view was put in quantitative form for doctors in general in the submission of the Commonwealth Department of Health, which suggested that if 1,350 doctors per million of population were adequate for Australia in 1972 (equal to its then estimated doctor-population ratio of 1 to 741) a further 382 doctors per

million would be needed by 1991 to cope with increased demand due to economic and demographic factors, a further 126 doctors per million to offset the reduced productivity of individual practitioners and a further 71 per million to provide for increased commitments for doctors in research, teaching etc. positions; against these increases, there would be a reduction of 268 doctors per million due to the increased

productivity of the institutional framework, leaving a net increase of 311, making 1,661 doctors per million, or a doctor-population ratio of 1 to 602.

7.22 The estimates in the previous paragraphs relate to doctors in general. With regard to general practitioners, a development frequently mentioned as likely to have a considerable effect on their productivity was the growth of community health centres. On this the Royal Australian College of General Practitioners commented:

It is sometimes argued that with the anticipated growth of the health centre concept and the provision of adequate assisting professional help, the productivity of the general practitioner will be increased and consequently there will be a reduced need to increase medical manpower. There is, however, very little evidence to show that

this will in fact be the case. Provision of adequate facilities and para-professional help and the development of the team approach should certainly improve the delivery and quality of care. It does not follow, however, that the doctors con­ cerned will be able to treat more patients in a given time. What it will do is to

enable more time to be spent with those patients whose needs demand it.

7.23 Some estimates of future requirements for general practitioners in relation to population were submitted or quoted to the Committee; these were said to have made allowances for the effects of anticipated technological and economic changes and changes in health systems. Of these, the most frequently quoted was that of the Austra­ lian Medical Association Study Group on Medical Planning, namely, one general

practitioner for every 1,500 population. The context in which this was suggested is as follows: Changing community expectations of medical care services, increased emphasis on preventive medicine, early diagnosis and treatment, including rehabilitation, in

conjunction with counselling and team-work, and changes in the future role and scope of general practice in Australia suggest that a desirable general practitioner- population ratio should be based on a minimum of 1 general practitioner : 1,500 people. In arriving at this figure, consideration has been given to many factors,

including an increased training period for general practice; involvement of general practitioners in teaching activities, including education of other members of the health team and community education; longer time spent with each patient; an

83

overall decrease in practitioners’ working hours; involvement in hospitals; re­ training and continuing education requirements; decreased working life due to the longer training period; and an earlier retirement age.1

7.24 The same ratio of 1 to 1,500 for general practitioners was recommended in the Report of the Ontario Council on Health Manpower (1970)2 and in an oral statement to the Committee by a representative of the Royal Australian College of General Practitioners. The Government of New South Wales suggested a ratio of 1 to 1,600 as a reasonable basis for planning purposes up to 1992. A ratio of 1 to 1,300 was put forward for Canberra in a study3 by Llewellyn-Davies, Weeks, Forestier-Walker and Bor (London) in November 1970, commissioned by the National Capital Develop­ ment Commission. This however is a composite ratio, made up of ratios of 1 to 2,000 for general practitioners, 1 to 10,000 for general practitioners with special interest in obstetrics and gynaecology, 1 to 7,000 for general practitioners with special interest in paediatrics, and 1 to 40,000 for general practitioners with special interest in geriatrics. The Illawarra Region Health Committee’s Report, in its Attachment III, took the view that “there is . . . some consensus that ratios approaching 1 in 1,500 are desirable for planning of future general practitioner needs for Australia.”

7.25 Whatever the ratio recommended, and whether the submissions made quanti­ tative recommendations or not, there seemed to be an extremely widespread view that in future something should be done to redress the balance of functional distri­ bution in favour of the general practitioner, and in particular that greater emphasis should be given to community medicine in the training of medical students. This view was almost universally expressed by universities, both those with and without medical schools.

7.26 The views of the universities on future requirements of medical manpower, apart from their expressed opinions, were implicit in their judgements about the adequacy of their current plans for future intake. On this, the University of Sydney believed that the planned output of the two existing medical schools in New South Wales would more than meet the State’s needs up to 1991. Monash University, as already noted, considered that in Australia as a whole the present annual output of graduates would satisfy the demand for doctors over the next ten to fifteen years. The University of Queensland suggested that to achieve its recommended ratio of

1 to 600 by 1980 an increase from 190 to 200 graduates a year would be needed from 1975 on. To achieve 1 to 500 by 1990, 250 graduates a year would be needed from 1980 on. The Faculty of Medicine at the University of Adelaide stated, in reference to South Australia’s needs:

It would seem to us likely that an overall increase in numbers of some 10 per cent would anticipate the demands for medical manpower which are purely related to population increases.

The submission of the Faculty of Medicine at the University of Western Australia aimed at achieving its suggested doctor-population ratio of 1 to 550 by 2000, and adopted the principle that Australia should not have to depend on migrants for medical manpower and that Western Australia’s output of medical graduates should be equivalent to the national average on a population basis. To meet these aims, it

1 Op. c i t paragraph 247. 2 Supplement No. 3 3 Future Health Care Services in A.C.T. (1970)

84

suggested that the medical school’s second year intake should be increased from 90 to 150 in 1976 and then progressively to 250 by 1991. The University of Tasmania remarked:

. . . it seems certain that the need for trained medical personnel will increase during the period under review at a rate greater than the increase in population because of the need to expand and improve services. The nature of the medical personnel and the training they should receive may condition the number of doctors required but is unlikely to vary the basic proposition . . . It seems unlikely, however, that the present or future output of the University Medical School will be sufficient to meet all requirements, having regard to wastage, decline in recruitment

from outside Tasmania and the rise in demand.

CONCLUSIONS ON FUTURE REQUIREMENTS 7.27 The general conclusion emerging from this Chapter is that the currently planned and approved output of Australian medical schools, which will produce a doctor- population ratio of 1 to 567 by 1991, will achieve a standard of medical manpower

which will be more favourable than most of the standards in relation to population which have been put forward in submissions to the Committee, or in references quoted as authoritative. The approved current plans are also likely to achieve the rates of growth in doctor-population ratios implied in achieving most of these stand­

ards, with some decline in the rate of improvement at the end of the period when population will be increasing while medical school output will not. However, the currently planned and approved output of existing schools, which will provide an improvement of about 27 per cent in the doctor-population ratio by 1991, falls short

of the Committee’s own judgement of requirements set out at the end of Chapter 5, namely that an improvement of about one-third in the doctor-population ratio in 1991 should be allowed for.

7.28 While the shortfall is not of great magnitude, and the presently approved plans of medical schools will provide a relatively favourable manpower situation in 1991, the Committee believes that it would be rash to fail to provide for any future expans­ ion. The ill consequences of a shortage of medical manpower are, in the Committee’s judgement, far more serious than those of an excess. The experience of the United

Kingdom in the 1960s illustrates this. In 1957 a Committee appointed by the Health Departments (the Willink Committee) advised a temporary reduction in the intake to medical schools in order to avoid the risk of a surplus of doctors which the Com­ mittee believed possible. Subsequently, the output of British medical graduates fell.

By this time a substantial shortage of doctors had developed in some areas, which caused considerable public and professional concern in the mid-1960s.1

7.29 In particular, account must be taken of the degree of reliability of both suggested standards and projections. The judgements made by those who have suggested stand­ ards for the future have necessarily been very speculative. Advances in knowledge and medical technology are likely to continue to make increasing demands on medical

services, but the magnitude of the effects of these advances on the demand for medical services is extremely hard to assess. The same is true of the effects of the changes in health care delivery systems, which, it seems to be generally agreed, are likely to be

Royal Commission on Medical Education, 1965-68, Report (Todd Report), London, 1968, paragraph 316.

85

more far-reaching in the next twenty years than for many years in the past. The projections of medical manpower that have been made by the Committee are them­ selves no more reliable than the assumptions on which they have been based. If total net migration into Australia were to be higher than the rate of 40,000 per annum assumed and if a net out-flow of doctors were to commence, the doctor-population ratio projected for 1991 could easily be five or more per cent less favourable.

7.30 The Committee is also concerned with future growth at the end of the period of review. Unless the capacity of the medical schools at that time provides for some expansion, the doctor workforce will not be able to keep growing in relation to population at anything like the previous rate of growth. Accordingly, the Committee does not favour stabilising the future output of medical schools at the levels implied by present plans.

7.31 Expanding medical schools, or creating new ones, however, are not the only ways of increasing the supply of medical services in Australia. Alternatives have been suggested to the Committee, and these should be examined.

7.32 If overseas students were no longer admitted to Australian medical schools there would be 50 to 60 additional places, equivalent to the enrolment of one small medical school, available for Australian students (see paragraphs 2.5 and 2.6). The gain in places for Australian students would have to be weighed against the loss that this would impose on some citizens of our neighbouring countries who find it valuable to train as doctors in Australia. On the other hand, it has been put forward that the main contribution that Australia can make in the training of our neighbours’ medical manpower lies more in vocational and post-graduate training than in the under­ graduate area (see also paragraph 4.33).

7.33 Some of the submissions to the Committee referred to the expected increases in the number of women in the workforce of doctors, and suggested that this would reduce the effective supply of medical manpower because women were believed to have a shorter working life and to work shorter hours. The Committee firmly rejects any suggestion that there should be a separate quota for women students to limit the growth in women doctors. Quite apart from the academic principle involved, there is evidence that the productivity of women doctors is not as far below that of men as

seems to be widely believed (see Table 5.1). Moreover, there is much room for institutional changes which would enable the services of women doctors to be more effectively employed.

7.34 Several submissions to the Committee included suggestions that there should be separate quotas for country students. The idea behind this was that country students were probably disadvantaged by the present quota system, because of their more limited educational opportunities, and that this in turn affected the supply of graduates wishing to practise in the country. The Committee found no support for the suggestion among universities. Indeed there is no clear evidence that in Australia country students wish to practise in rural areas. In the Committee’s opinion, country manpower problems will need other solutions.

7.35 Some countries have attempted to solve manpower problems by encouragement of immigration, in addition to expansion of medical schools. The Committee believes that there will probably be little scope for expanding the supply of doctors greatly

86

by special encouragement of immigration, although the regular inflow of doctors among settlers in Australia will probably continue and should be welcome.

7.36 The best hope for improving the supply of medical services, apart from ex­ pansion of medical school places, in the Committee’s opinion, lies in the opportunities for improving productivity offered by the development of regionalised hospitals and of community health centres with associated paramedical services, including the

utilisation of practice nurses. Nevertheless, as pointed out in paragraphs 5.10 and 5.11, the net outcome of new methods of organising the delivery of health care may be an improvement in the quality of service rather than an economy in the number of doctors.

7.37 To conclude, the Committee believes that the current approved plans of the existing medical schools, favourable though they might appear to be for the future manpower situation, should not be the limit. The Committee holds firmly that it is better to err on the side of producing too many doctors but emphasises that this is

not because it believes that problems of maldistribution can be solved by “flooding the market.”

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CHAPTER 8

New and Expanded Medical Schools— Recommendations 8.1 In the preceding chapter the Committee indicated its view that some expansion was required in the output of medical graduates beyond that presently planned by and approved for the existing nine medical schools. Such expansion, whether by way of increasing the size of the existing schools or by the creation of new ones, can take place only if there are available additional students, staff, patients and teaching facilities of adequate quality.

CONDITIONS FOR EXPANSION

8.2 Students. Existing quotas for entry to medical courses have been a cause for much comment, both within and outside the universities. In general the number of qualified local applicants greatly exceeds the number of places available; in one university applications for admission are three times the number, and in four others they are in excess of twice the number. In two universities where there is a quota on entry to the second year, the rejection of students who passed first year has caused public controversy. Table 8.1 sets out for 1970 to 1973, for those universities with first year quotas, the number of qualified applicants for entry who gave medicine as their first preference compared with the number admitted to the relevant medical schools. It is evident that many well-qualified students have been unable to obtain places in medical schools, and that there is no lack of qualified school-leavers for admission to medical schools.

8.3 Moreover, some flexibility of entry is desirable for mature age students and for those who have completed other first degree courses. These students usually have a high motivation for the medical course and do well in it and in their subsequent careers. Some universities are considering how best to select these students, and whether bridging or special introductory courses could be used in special cases. The

Committee supports such efforts to facilitate the entry of mature students, who are likely to be valuable members of the medical profession.

8.4 Access to medical schools in the various States is illustrated in Table 8.2, which sets out for the period 1967 to 1973 the number of second year medical students in each State per 1,000 of the 19 year old population of the State. For Australia as a whole, access has been improving. As student intakes have been expanded and new schools established the numbers entering have risen in relation to the number of the relevant age group, although not necessarily in relation to the number completing secondary school.

8.5 Staff. In 1973 a considerable number of academic staff vacancies existed in Australian medical schools. There are three main reasons for this. First, prior to the

88

TABLE 8.1

NUMBERS ADMITTED TO MEDICINE AS A PERCENTAGE OF QUALIFIED FIRST PREFERENCE APPLICANTS, AUSTRALIAN MEDICAL SCHOOLS WITH FIRST YEAR QUOTAS, 1970 TO 1973

1970 1971 1972 1973

Numbers Admitted as Pro­

Numbers Admitted as Pro­

University Applic­ Numbers portion Applic­ Numbers portion Applic­ Numbers

ants Admitted Of

Applic­ ants

ants Admitted o f

Applic­ ants

ants Admitted

Numbers Numbers

Admitted Admitted

as Pro­ as Pro­

portion Applic­ Numbers portion

o f ants Admitted o f

Applic­ Applic­

ants ants

per cent per cent per cent per cent

Sydney . . . 654 218 33.3 682 227 33.3 790 223 28.2 813 248 30.5

New South Wales . 205 204 99.5 331 259 78.2 460 237 51.5 445 241 54.2

Total New South Wales . . 859 422 49.1 1,013 486 48.0 1,250 460 36.8 1,258 489 38.9

Melbourne . . 495 230 46.5 493 222 45.0 573 229 40.0 608 224 36.8

Monash . . . 300 162 54.0 468 161 37.1 477 163 37.3 352 164 46.6

Total Victoria . 795 392 49.3 961 383 39.9 1,050 392 37.3 960 388 40.4

Adelaide . . . 296 117 39.5 309 126 40.8 352 133 37.8 383 138 36.0

Sources: New South Wales Metropolitan Universities Admissions Centre and Universities.

Campbell Inquiry1, academic salaries compared unfavourably with the rewards offering in private practice, and also with salaries offered to full-time hospital specia­ lists working side by side with university staff. The acceptance of the recommendations of the Campbell Inquiry, which included substantial clinical loadings for senior lecturers and lecturers as well as for readers and professors, should help to offset this.

TABLE 8.2

SECOND YEAR MEDICAL STUDENTS PER 1,000 OF POPULATION AGED 19 YEARS 1967 TO 1973

Year

New South Wales (a) Victoria Queensland Southed) Australia

Western Australia Tasmania Australia

1967 . 5.9 5.7 6.0 4.9 3.5 3.3 5.5

1968 . 5.3 6.8 5.1 5.1 3.5 4.5 5.8

1969 . 6.3 6.6 6.0 5.1 3.4 5.2 5.9

1970 . 6.7 6.4 6.5 4.9 5.0 5.2 6.2

1971 . 5.9 6.6 7.5 6.0 5.0 7.0 6.3

1972 . 6.3 6.3 7.0 5.8 4.7 5.5 6.2

1973 . 6.2 6.6 7 .0 6.0 4.8 7.5 6.3

(a) Includes Australian Capital Territory. (b) Includes Northern Territory. Source: Commonwealth Bureau of Census and Statistics, and universities.

8.6 Secondly, clinical academics are sometimes disadvantaged in respect of promo­ tion through the academic grades. Having both teaching and hospital service duties, most of them have less time available for research than do academics in other areas of the university. As promotion procedures within universities usually pay special attention to research output, promotion may be difficult for lecturers and senior lecturers in small clinical departments. With increasing medical experience, these persons are invaluable as university teachers, but they tend to leave the university for

private practice if promotion is not forthcoming. In such cases the Committee con­ siders there is a case for promotion on grounds not wholly related to research. Some disciplines have had recruitment problems for many years, particularly in the pre- clinical and para-clinical fields, and staffing problems have been alleviated by appoint­ ing non-medical science graduates. Provided there are some medically qualified staff members this is not necessarily an undesirable trend.

8.7 Thirdly, some departments have individual problems: a department may deterio­ rate for want of internal stimulus; the curriculum may make unduly heavy demands for teaching and preclude any research by academics. In some instances, revision of the curriculum or a shift in emphasis will correct these problems.

8.8 Vacancies apart, there appear to be genuine shortages in the establishments of some departments. Staff-student ratios, particularly in the clinical departments, are certainly less favourable than those in the United Kingdom and the United States. However, since it is difficult to make comparisons between countries with different systems, the Committee would not see the ratios in these countries as necessarily appropriate for Australia. Despite the contributions of part-time and honorary staff to teaching, the real burden of the organisation and maintenance of teaching pro­ grammes falls on full-time academic staff. This is especially so when curriculum

1 Report o f the Inquiry into Academic Salaries, May 1973.

90

revision is undertaken, and the Committee is aware that in at least one university this revision was endangered by staff shortages.

8.9 Overall, the Committee believes that staff recruitment problems should be viewed cautiously and hopefully, and that present difficulties in attracting staff are not sufficient reason for advising against expansion or creation of medical schools.

8.10 Patients fo r Teaching. Traditionally, students have been attached in groups to clinical units consisting of a senior physician or surgeon, one or two junior specialists and resident doctors in various grades of training, the most senior of whom (senior registrars) are about to become specialists. The student group observes the practice

of the clinical unit, and a small number of patients is allotted to each student for personal detailed study. Some clinical units are of much greater value to students than others, because of the type of patients admitted to them. Not all patients in a teaching hospital are, therefore, brought into regular contact with students. It has

been considered in the past that 1,000 beds with a mix of all specialties are required for an annual intake of 100 students at a hospital.1

8.11 However, in the last ten years, improved medical management and treatment methods have progressively shortened the length of stay in hospital of patients, and this, coupled with the increasing population, has resulted in a greater number of patients per 1,000 beds being treated than was the case. The ratio applicable today

may be as low as 500 beds to 100 students if the number of general medical and surgical beds is a high proportion of the total beds available. The high cost of hospital construction makes it imperative to ensure that improved utilisation of existing resources is effected before adding to the number of existing hospital beds primarily for medical education.

8.12 The development of highly specialised medical and surgical units (e.g. renal transplant units), while necessary for both the community and the medical school, tends to separate patients from the main stream of undergraduate training, and thus

diminishes the effective size of the teaching hospital. These units are specially valuable, however, for teaching in the postgraduate field.

8.13 Teaching hospitals are located generally in the main city areas where there is little or no resident population. Hence their supply of patients comes from the sub­ urban areas, referred by doctors to the teaching hospital either for its special diagnostic and therapeutic units, or because of the expertise and prestige of the specialist medical

staff. Many of these cases are complicated and suited more to postgraduate than undergraduate teaching. In addition, the teaching hospitals usually function as accident units, with large numbers of beds occupied by road and industrial accident cases which generally provide only a part of the teaching programme. Geriatric cases

also take up a disproportionate number of beds.

8.14 The development of community or district hospitals in city suburbs has led to a transfer there of specialist practice. The present National Health Scheme has contri­ buted to this trend since the cost to the individual patient of private medical care in good surroundings is minimal. These hospitals contain a wealth of patients with

1 Medical Schools. Report of the Interdepartmental Committee (Chairman: Sir William Goodenough). Joint Publication o f the Great Britain Ministry of Health and the Department of Health, Scotland, United Kingdom 1944, p. 69.

91

common medical and surgical conditions most valuable for clinical teaching, if they could be utilised. Future trends resulting from the association of teaching hospitals with both country and metropolitan community hospitals and the rotation of resident medical staff through these associated hospitals on a secondment basis will markedly improve both the quality of medical care in the latter and the availability of patients for teaching.

8.15 The proposed National Health Insurance Scheme,1 at present scheduled for introduction in 1974, could have a substantial effect on the numbers of patients available for teaching. Where the rules of a hospital preclude the general use of intermediate and private patients for teaching purposes, the new “hospital patient” classification should result in a substantial increase in the numbers of such patients.

On the other hand, hospitals depending on out-patients for a good deal of their teaching will find that patients may prefer visiting general practitioners and direct referral to specialists to attending out-patient departments. The development of community health centres, staffed by general practitioners and, possibly, specialists,

will therefore be of prime importance to future teaching of medical students.

8.16 The movement of patient care towards the suburbs, together with the develop­ ment there of hospitals with full clinical services, has led some universities to form associations with peripheral hospitals. In most cases, visiting specialists on a part-time basis teach students who are rostered for a term at the hospital. Sometimes, academic staff visit regularly and conduct classes. Provided the standard of teaching and medical care is high, the use of these hospitals is most valuable in increasing both the range and volume of medical conditions available to students. The provision of teaching facilities at peripheral hospitals is generally not expensive. Unless it is necessary to establish an academic unit at the hospital, facilities can be limited to lecture and tutorial rooms, side rooms off wards, and audio-visual aids. In larger peripheral hospitals to which many students are rostered, administrative and academic reasons may make the establishment of an academic unit desirable, with a consequent increase in cost.

8.17 It seems reasonable to expect that if visiting medical specialists are to be paid for their hospital duties, they will spend more time in these peripheral hospitals, thus upgrading their quality. Greater use of these hospitals could then be made for under­ graduate teaching. The Committee believes that at present it would not be desirable to roster students for their entire training to a peripheral hospital: the role of the latter

should be seen as complementary to that of the main teaching hospital.

8.18 With the increasing allotment of medical students to peripheral hospitals which become associated with teaching hospitals, it is essential that senior medical and surgical registrar staff or academic staff of at least equivalent status and clinical experience, be appointed to the full-time medical staffs of such hospitals to organise teaching case registers and student teaching schedules. Such senior staff, as well as maintaining liaison with the “parent” clinical school, would also be involved in the clinical work of the hospital, including the training of resident medical staff. The appointment of these officers would benefit both the university and the hospitals.

1 Report o f the Health Insurance Planning Committee, April 1973.

92

8.19 The Committee received many submissions relating to the use of community health centres and their value for medical teaching. Only a small number of com­ munity health centres is in existence at present, and their function is still largely experimental. Nevertheless, others are planned, and most universities have evinced interest in their operation and the possible establishment, in conjunction with them,

of departments or sub-departments of general practice, family medicine, or community medicine.

8.20 The introduction of the student to such a setting, allowing him to observe both the varied skills of the team and also the patient in his own home environment, would be a valuable experience. Virtually the only facilities necessary to allow student participation in such a centre are a share of cloakroom facilities, an interviewing

room, a small tutorial area, and the slight enlargement of consulting and other areas.

8.21 Those medical schools with community medicine already established in the curriculum will probably use community health centres as a base for the observation of community medical care. The Committee sees the use of community health centres as a means of increasing the breadth of medical education and of directing the interests

of medical students towards general practice, but only to a limited extent as a means of increasing the output of graduates through the availability of additional facilities for clinical training. As a means of giving students an understanding of the facilities and job satisfaction available in general practice, the use of community health centres in medical education should have considerable impact.

8.22 The Committee recognises that medical schools have been facing increasing problems in obtaining a supply of patients with disorders suitable for teaching. However a combination of the consequences of the new National Health Insurance Scheme, a greater use of peripheral hospitals and the development of community

health centres should not only alleviate the position but permit an expansion in medical education. There are of course some local problems to which attention has been drawn in connection with the foundation of new schools.

8.23 Teaching Facilities. In their submissions regarding possible expansion, some universities indicated their views that their present facilities were inadequate or that additional facilities would be required before their student intakes could be expanded. The Committee has neither attempted to assess whether facilities are actually needed

on the scale planned nor to cost the facilities proposed or considered necessary. If the Committee’s recommendations are accepted it will be necessary for universities to make submissions to the Australian Universities Commission in the normal way,

and it will be for the Commission to assess needs and costs and to recommend grants.

8.24 Where major expansion is planned, or a new school is to be created, capital costs to provide adequate facilities may be substantial. In some cases expansion of pre-clinical and para-clinical departments will be necessary to allow a greater student intake; in others, tutorial and teaching side rooms, cloakrooms and library facilities

will have to be provided in hospitals not presently used for teaching. In the case of new schools, accommodation for professorial units in teaching hospitals will need to be constructed. Given adequate notice, none of these requirements should prove a barrier to the implementation of the Committee’s recommendations.

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SIZE OF MEDICAL SCHOOLS

8.25 In deciding whether existing schools should be expanded or new ones created, the Committee must necessarily take into account whether medical schools have an optimum size. The complexity of modern medicine with its many specialties, each of which is important to some extent in undergraduate education, requires a range of expertise of such magnitude, that if all were represented by teaching units in a single clinical school the staff would almost outnumber the students. By using the skills from special units at separate hospitals, universities with large student numbers are able to offer a full range of specialist teaching to their students. Although the smallest medical school in Australia (at the University of Tasmania) has the highest staff-

student ratio, it also has the smallest range of disciplines and specialist staff.

8.26 The traditional British school had an annual intake of 60 to 80, and this was formerly considered satisfactory since teachers could know, and develop a genuine professional ethic in, each individual student. With the growth of hospitals and specialties this size is no longer generally appropriate, and the Todd Report recom­ mended that British medical schools should have annual intakes in the range 150 to 200 for reasons both of education and economy.1 The Report develops the theme of the “critical mass’ necessary to provide effective teaching and research. So far five Australian schools have reached the size recommended by the Todd Report; none of these has suggested to the Committee a reduction of numbers on academic grounds—· indeed, four of them are proposing expansion. Two smaller schools would be willing to increase their numbers if facilities and staffing were improved.

8.27 Student bodies pressed on the Committee the disadvantages of large schools, on the grounds of the absence of continuing contact between students and staff, particul­ arly senior staff. But the Committee believes that these criticisms may have been more a reflection of inadequate staff-student ratios or of organisational arrangements than

of an impersonal approach by the teachers of large classes. During the clinical years, students are usually attached to hospitals, each of which has an annual intake of 60 to 75 students broken into small tutorial groups. The criticism of oversized classes therefore can only be levelled against the pre-clinical years spent on the campus. In addition, the Committee found that the attachment of students to one hospital clinical school appeared to engender an esprit de corps which outweighed any possible disad­ vantages of size of the medical school as a whole. It is interesting to note, however, that the University of Sydney in its new curriculum intends to roster students through all hospitals rather than persist with “permanent” attachments to hospitals. The

Committee believes that the size recommended by the Todd Report is reasonable. On the other hand it would not rule out smaller schools, where local conditions make them desirable.

8.28 There is also the important question of costs. As has been pointed out in para­ graphs 2.22 and 2.23, costs per student in small schools (i.e. those with an intake of less than 100) are higher than in larger ones. The number of disciplines represented in a modern medical school, and the specialties embraced within individual disciplines, add to the cost of a school. Each specialty requires a senior staff member, and a good case can be made for many of these to be of professorial status, since recruitment to

1 op. cit. paragraphs 369 to 374.

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lower grades is difficult due to the more attractive financial conditions obtaining in private practice and in most hospital services.

8.29 A large school permits development of medical units with some members of more junior status. In the pre-clinical and para-clinical disciplines, academic depart­ ments have establishments of the typical university pyramidal structure. Equipment, both for teaching and research, is expensive in medicine; large departments can

achieve economies of equipment usage not possible in smaller schools, which still require a complete range of expensive equipment.

EXISTING VERSUS NEW SCHOOLS 8.30 The creation of a new medical school is a very costly exercise, both because of the large initial establishment costs and because it is likely to be numerically small for some time. The expansion of an existing school is certainly less costly in financial

terms. On the other hand, there may be disadvantages of the kind referred to in paragraph 8.27 arising from the growth of a large school.

8.31 The Committee has discussed this latter question with universities and with many organisations directly involved with medical education. Opinion was fairly evenly divided as to the advantages and disadvantages of increased intake to existing medical schools as against the creation of new schools. Most universities felt that, so

long as adequate facilities were provided and sufficient patients were available for clinical teaching, there were distinct advantages in a large medical school. The larger number of staff required would allow for the introduction of a more diverse range of special areas of study within departments. It would also be possible to have a greater

number of viable departments. Both these factors would lead to a more stimulating and attractive medical school.

8.32 The Committee is in no doubt that in general the medium and large sized schools have advantages both for economy and because they can provide the range of teaching necessary in modern medicine. It believes that the problem of impersonality associated with large classes is mainly one of organisation; it is important, therefore, that organ­

isational methods ensure that a continuing staff-student contact is achieved. The problem is not as pressing in the clinical years, where even large schools divide their students into clinical schools of 60 to 75 students, and then further into small groups.

8.33 The likely manpower requirements referred to in Chapter 7, when compared with the output of existing schools as at present approved (see Chapter 6), suggest that the additions needed are not so great that they could not be provided for by

expansion of existing schools. This would be simpler and less costly than the creation of new schools. However, there are other grounds for the creation of new schools that should be considered.

8.34 The case was repeatedly put to the Committee that there was a need in Australia for a different kind of medical graduate; one more versed in the ways of people as psychological and sociological beings and not simply as physically malfunctioning

organisms. It was argued that a new school could be more innovatory than an existing one. The Committee agrees that both the present methods of selecting students for medical school and the nature of the medical course inhibit the production of doctors who have a holistic approach to humans as social beings. It has therefore been inter­

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ested to receive submissions aimed at reducing the emphasis in present day medicine on science, research and the large, elaborate teaching hospital.

8.35 Proposals have been made by universities seeking to establish medical schools in either the immediate or distant future, where the emphasis is on community medi­ cine. The most common features of such proposals included curricula emphasizing social and behavioural sciences; the provision o f ‘bridging’ courses in relevant physical sciences for graduates from the humanities or social sciences who might wish to study medicine; the rotation of students through general practices or community health centres for clinical experience; and exposure to patient and clinical contact early in the medical course.

8.36 All of these proposals have merit. However, the Committee is not confident that a new school would necessarily be innovatory. It is well known that new schools strive after the respectability and good reputation which is necessary to attract well qualified and established staff. They may therefore be cautious initially about intro­ ducing too many innovations that could be regarded as radical. Having attracted the desired well-qualified and established staff, the schools may find that they have imported a hard core of conservatism. The resultant resistance to innovation generally may mean that the high hopes for a new approach that accompanied plans for the school’s establishment are submerged in a perpetuation of existing patterns.

8.37 The Committee has also been asked to consider the advantages that could flow from establishing a new medical school in a rural area. The main advantage put forward in this case is that doctors educated in rural areas are more likely to practise in rural areas. Hence, a solution to the shortage of doctors for the country. This argument is of dubious validity. It has not been demonstrated that doctors would wish to stay in the country simply because they were educated there. Indeed, there is reason to believe that the opposite might occur. The highly educated young doctor with his newly acquired skills might well seek to derive most advantage from them and further his training and opportunity for development in the diversity of a city environment. The main objection advanced by doctors against practising in rural areas is the isolation from professional stimulation by colleagues. If this is so, it could be expected that a rural medical school would counter the professional isolation. But for what radius of countryside would it be the centre? It would seem that, as a complete counter to professional isolation, a network of medical schools would need to be spread throughout the country. This is clearly not feasible.

8.38 On the other hand, there may be a strong argument for establishing a school in a major centre, in order to raise the level of medical services in the surrounding area. There is some evidence from the United Kingdom that doctors tend to practise close to the medical school at which they studied. These arguments were no doubt powerful ones in the establishment of the medical school in Hobart, and might be relevant in the cases of Newcastle, Wollongong and Townsville.

8.39 An additional point is that, as Australia is a country of enormous dimension and diversity of climate and environment, it would be reasonable to offer medical courses of differing emphasis, for example, one concentrating on medical problems in the tropics. Such training would be relevant to practice in the large tracts of northern Australia. A medical school based in Townsville, for example, would pro­

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vide special training opportunities and additionally would help balance the distribu­ tion of medical expertise in Queensland, much of which is at present concentrated in the south-east corner of the State.

8.40 The Committe has also considered the possible advantages of establishing a new school to provide training opportunities, alongside medical undergraduates, for other health professionals such as dentists, nurses, medical social workers and physio­ therapists. Such a school could be thought of as a faculty of health sciences and would

aim at facilitating the team approach to the delivery of health care. This concept is discussed in more detail in paragraphs 9.63 and 9.64.

8.41 In making its recommendations concerning new and expanded schools, the Committee has been mindful of the balance between States. It does not agree with the view that each State should be self-sufficient in its production of medical man­ power. On the contrary, the Committee has taken a national view, and its computa­ tions of manpower requirements have been made on an Australia wide basis. Never­ theless, it accepts that most medical students attend schools in their home States and that most medical graduates ultimately practise in their home States. Consequently, it has attempted to achieve reasonable balance between States, having regard to the present availability of medical education in the different States.

8.42 With regard to the establishment of new schools, the Committee believes that it is important to ensure that after an initial settling-in period, student numbers are increased to a size compatible with both economy and function, and it considers that

an enrolment of 100 in the second year of the medical course is the desirable minimum. Smaller schools should not be established unless a special local reason outweighs the disadvantages related to smallness.

POSSIBILITIES FOR EXPANSION

8.43 In this section the Committee sets out its view on all the proposals for expanded or new medical schools that it has had before it. It is convenient to consider them on a State by State basis.

N e w S o u t h W a l e s

8.44 There are five universities and one university college (which will become an independent university in 1975) in New South Wales; only one, the University of New England, did not make a submission.

8.45 Views o f the New South Wales Government. In addition to considering the Report of a special State Committee on “Medical Education and Related Issues”, the Com­ mittee held discussions with the Ministers of Education and of Health, and senior departmental officers. The Government representatives agreed with the findings in the Report, which emphasised the need for an ongoing investigation into the supply

and distribution of medical and paramedical personnel, and into difficulties which may affect the supply of personnel in any particular branch. There appeared to be a shortage of general practitioners, which would not be alleviated simply by increasing the number of medical graduates. Methods of medical education and conditions of

service after graduation were also important. The shortened course proposed at the

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University of Sydney was seen as a means of encouraging more generalists, and they were in favour of the University of New South Wales’ proposal for a five year course.

8.46 To meet the required number of doctors in New South Wales, the Government believed that an output of 500 graduates, including 50 overseas students who would return to their homes from Australia after graduation, would be sufficient, assuming an annual inflow of 100 doctors from interstate and overseas. This number could be achieved by the University of Sydney’s having a pre-clinical intake of 300 students per annum and the University of New South Wales’ increasing its pre-clinical intake to 270. The Government felt that expansion of the two existing medical schools would be preferable at this stage to any alternative course of action such as the establishment of a third medical school at Macquarie, Newcastle or Wollongong. It would, however, support the extended use of Royal Newcastle Hospital as a clinical school for one of the existing Sydney medical schools.

8.47 University o f Sydney. The current enrolment of students in the second year of the medical course at the University of Sydney is 258 and the number expected to graduate after a six year course is approximately 216. The University imposes an enrolment quota of 250 for entry to the first year of the course. Commencing in 1974 the course will be re-organised and reduced to five years. Pre-clinical studies all take place on the main campus of the University, and clinical studies are carried out in two large hospitals, Royal Prince Alfred and Royal North Shore, and two smaller hospitals, Sydney, and Concord Repatriation, together with student attachments to other peripheral hospitals including Royal Newcastle Hospital.

8.48 The University representatives said that in 1976 the Westmead Hospital was expected to be commissioned, and this would become a major clinical school. The University proposed to increase the first year quota to 300 in 1977, which would lead to a second year enrolment of 330 in 1978. In its planning, the University was assuming that the clinical students would be divided into roughly four groups of about 75, for rostering to Royal Prince Alfred, Royal North Shore, Westmead and Sydney-Concord Hospitals.

8.49 The Committee feels that this proposal could be supported. Although comment has been made to it about the disadvantages of size and Sydney is already the largest school in Australia, the effective clinical groups proposed of 75 are not unwieldy, and ample facilities as well as an adequate supply of patients with disorders suitable for teaching will be available in large hospitals. Westmead Hospital provides an exciting opportunity for university involvement right from the planning stage, and its impact on medical education should be substantial.

8.50 University o f New South Wales. The current enrolment in second year of the medical course is 247, reducing to 241 in 1975, and the number expected to graduate after a six year course is 200. A five year course has been approved in principle by the University. Pre-clinical studies are at the Kensington campus, and clinical studies

are undertaken at the Prince of Wales, Prince Henry, St. Vincent’s and St. George Hospitals, at which there are academic units, and other peripheral hospitals.

8.51 The University submitted that changes in the curriculum and methods of education were more important than increasing the total number of doctors. Grad­ uates should be more broadly trained and community oriented, and after further

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training as clinicians, could act as team leaders and supervisors of medical assistants, paramedical workers and auxiliaries. Improvements in staff and faculty structure and in physical facilities would be required to make changes of this nature. Concomit­ antly, support for the development of educational programmes for other health

professions was needed. The University suggested that further study be undertaken to identify health care needs, to find whether medical manpower presently available was used effectively, and to see whether existing medical schools could become more service oriented, especially at family and community levels.

8.52 There had been many difficulties during the early years of the school, and it was the medical faculty’s firm opinion that further consolidation, especially of the clinical schools, was necessary before any further expansion took place. Part of the

problem had been the shortage of patients, and the limited range of disorders avail­ able for teaching in the main hospitals.

8.53 The Committee believes that expansion should not take place beyond that presently envisaged within the period under review.

8.54 Macquarie University. The University does not have a medical school, but requested consideration of its introduction as a long term plan. The course proposed by the University would be innovatory in nature, and its final details would not be decided until further research had been done into problems concerning the delivery

of health care. It would favour the introduction of the student to clinical medicine early in the course, and the carrying out of much of clinical teaching in practices and community health centres in the area surrounding the University. This would require the co-operation of practitioners in their existing practices, or the construction of community health centres, or both.

8.55 The Committee has viewed these proposals with interest. However, the logistic problems involved in distributing, for example, 60 students in each of three clinical years, a total of 180 at any one time, amongst the practices of a sector of a city, are serious. If a major part of clinical teaching is to be done extramurally the demands

on the time of the local practitioners would be great. The need for instruction in the community setting was advocated by many groups, but to conduct the major part of clinical teaching there seems to the Committee to present many serious difficulties.

Even with the use of local practices a teaching hospital would be necessary. The major hospital close to Macquarie University is Royal North Shore, which is a clinical school of the University of Sydney. The establishment of a medical school at Mac­ quarie University would require the use of Royal North Shore with a consequent

diminution of student intake at the University of Sydney. A hospital could be located near the Macquarie University campus, but no plans have been made for this yet.

8.56 The main case for a new school in the metropolitan area is that it would give the opportunity for curriculum innovation, and provide a potential point of growth to increase numbers in the future. The Committee is mindful of the importance of

both these features, but in view of the cost involved in establishing a new school, and the fact that no additional students could be trained until other hospitals were built, it would not favour the establishment of a medical school at Macquarie University in the period under review.

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8.57 University o f Newcastle. The Royal Newcastle Hospital at present takes small numbers of students from the University of Sydney but is not developed as a clinical school. Submissions were received from the University of Newcastle, the Royal Newcastle Hospital, the Central Northern Medical Association and other local bodies requesting a full medical school in Newcastle. There was clear evidence of very considerable local support. In its examination of these submissions the Committee also considered whether the Royal Newcastle Hospital might function as a full clinical school of one of the Sydney universities, and in this way increase the output of medical graduates. The biological sciences are developing satisfactorily at the University of Newcastle, so that expansion to take medical students would present no difficulty.

8.58 Newcastle Hospitals. The Committee visited Newcastle, and some members inspected the hospital in the area where teaching might be conducted. These included Royal Newcastle group, Mater Misericordiae, Wallsend, Western Suburbs and Watt Street Hospitals. It was noted that plans for rebuilding a large part of Wallsend Hospital, and for additions to Royal Newcastle and Western Suburbs Hospitals, were being discussed.

8.59 If a clinical school were to be centred on Royal Newcastle Hospital, a clinical sciences block to house the professorial units and to provide teaching and research facilities would be required, and a possible location was indicated to the Committee. In all hospitals, teaching side rooms could be made available, either by conversion

of existing space, or by minor alterations. At Wallsend Hospital, these could be incorporated in the new building and a modern out-patients department to be con­ structed there would not require modification for teaching.

8.60 The Committee considers that the Royal Newcastle Hospital, by virtue of its extensive out-patient and rehabilitation services with domiciliary support, is well situated to offer opportunities for teaching in community medicine. The number and range of medical disorders presenting at the hospital provide a wider spectrum than is available at many of the teaching hospitals in the larger cities and the reputation of the Royal Newcastle group of hospitals for medical care is high. The Mater Misericordiae Hospital has a higher proportion of private and intermediate patients than the Royal Newcastle Hospital, but there is an adequate range of patients, so that students could be rostered there for part of their training.

8.61 Obstetrics presents a problem since this work is divided between the three medium sized units, Western Suburbs, Mater Misericordiae and Royal Newcastle hospitals, and there is a high proportion of private and intermediate cases managed by both specialists and general practitioners. Greater efficiency would be achieved as regards both teaching and patient care if the units were larger and all were associated with general hospitals, to provide full laboratory and ancillary medical consultative services. It would be desirable for a professorial unit in obstetrics to be sited with other professorial units at Royal Newcastle Hospital, but in the early development of a school, deployment of staff would be difficult. The number of public obstetric patients in the three institutions is barely adequate for a school of 80 annual intake, and additional numbers would be required when the intake is enlarged.

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8.62 In discussions with the Royal Newcastle Hospital representatives, it was stated that the staff structure of full-time specialists and visiting specialists would favour the introduction of professors and supporting staff. Each medical division at present has a full-time head of service. The Hospital authorities envisage that the medical pro­

fessors would be appointed heads of service in the hospital, thus integrating the teaching and service functions, and making the establishment of the school easier. The Committee agrees that this is necessary and would eliminate some of the pro­

blems that have arisen in the development of new schools elsewhere. From the Committee’s observation, and the evidence supplied, it is considered that the Royal Newcastle Hospital group, together with the other hospitals in the area, provide a nucleus adequate for the introduction of a medical school.

8.63 The proposal that the Royal Newcastle Hospital be used as a clinical school of the University of Sydney is not supported by the Committee as an alternative to a full medical school. This would lead to the separation of pre-clinical and clinical

studies and would inhibit the development in Newcastle of a curriculum which could be especially community oriented. It would also constrain any alterations to curri­ culum in the parent University. For all these reasons, therefore, the Committee considers that a full medical school should be established from the outset, rather

than a clinical school only. The timetable proposed by the University envisages an enrolment of 60 students in second year in 1978, increasing to about 100 by 1983; and this seems reasonable.

8.64 Wollongong University College. Submissions were received from the Wollongong University College and the Illawarra Region Health Committee. The proposal for the establishment of a medical school at Wollongong University College is closely associated with a scheme for graduate training of general practitioners to be developed in association with the Royal Australian College of General Practitioners. Under this

scheme the local general practitioners would be trained mainly as teachers to prepare them to play an important part in the clinical course for undergraduates in the medical school. The proposed curriculum is of four years duration and relies to a considerable degree on instruction in the environment of general practice; almost the total general

practitioner complement of the area would need to be involved in the undergraduate training programme. In the fifth and sixth years, after the award of the M.B., B.S. degree, supervised practice in community health centres would continue, under pro­ visional registration. Concurrent with the undergraduate programme would be

courses for nurses, social workers and clinical psychologists, using common facilities on and off campus. Less emphasis would be placed on training within the hospital than is normal in more conventional curricula.

8.65 Wollongong Hospital. The hospital is a 400 bed unit in a modern building with space for extension. Facilities exist for the provision of side rooms for tutorials and some lecture theatres. The obstetric service is not large, 40 per cent of the deliveries occurring at Port Kembla. While there is a normal range of services for a non-teaching hospital, there is a general lack of relevant sophisticated specialist services. Consider­

able development would be needed to bring the hospital to teaching hospital standards. In general, hospital services are not yet developed in Wollongong to the extent necessary for an undergraduate clinical school.

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8.66 The Committee considers that there are serious difficulties about this proposal. First, the proposed course is much shorter and has a weaker scientific base than any other course in the British Commonwealth; four year courses exist in Canada, but admission is restricted to those with a previous bachelor degree. The Committee has seen a communication from the General Medical Council indicating that there is considerable doubt as to whether the course in the form proposed would be recognised by the Council. Secondly, the proposal to conduct much of the teaching in general practice would involve almost all practitioners in the area in teaching. It cannot be assumed that all doctors are suited or motivated to teach, and the Committee sees such a programme as being very difficult to implement and likely to break down for both human and logistic reasons. Finally, the Committee agrees with the view put to it by student representatives and some staff members that the College should have the opportunity of consolidating its existing activities before embarking on the establish­ ment of a medical school.

8.67 Although the Committee was impressed by the seriousness of purpose of the proponents of the Wollongong scheme, on which a great deal of work had been done, and is aware of the potential growth of population in the area surrounding Wollon­ gong, it believes that, within the period under review, a medical school should not be established at Wollongong.

8.68 Conclusions. Although Macquarie University’s proposal for an innovatory curriculum is attractive in many ways, the Committee feels that the time is not yet ripe for a third metropolitan medical school in Sydney. Even if the Macquarie University proposal were implemented, it would be unlikely to increase the number of doctors, because of the need to use the Royal North Shore Hospital, presently used by the University of Sydney.

8.69 The Committee is sympathetic to the problems which have in the past existed at the University of New South Wales, and agrees that consolidation of the existing school is desirable.

8.70 The Royal Newcastle Hospital is eminently suitable as a clinical school, and its use in this capacity in conjunction with the pre-clinical facilities of a Sydney school, was considered. Although such an arrangement would be possible, the separation of pre-clinical and clinical schools poses problems, the two most important being the lack of vertical integration and the constraint on future curricular change. The

Committee considers that a full medical school should be established at the University of Newcastle.

8.71 In Wollongong, hospital facilities would require much improvement for teaching purposes and the logistic problems of organising teaching outside the hospitals appear to be too great for the proposal for a school to be considered favourably. In addition, the views of the General Medical Council on the shortened course must be noted.

V ic t o r ia

8.72 Views o f the Hospitals and Charities Commission. Commission representatives were of the opinion that there was no need to plan for a third medical school in the immediate future. Some existing clinical facilities were inadequate for medical teaching. Hospitals such as Footscray and Preston and Northcote Community could

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be brought further into the teaching held and a decision was necessary concerning the construction of a hospital on the Monash University campus. A new medical school would be necessary in the 1990s, but for the present, the Commission representatives did not favour an increase either in the number of schools or in the size of existing schools. During the Committee’s meeting with the representatives, the allocation of teaching hospitals between universities in relation to future medical schools was discussed. The representatives expressed the hope that re-allocation of hospitals would not occur.

8.73 University o f Melbourne. The University of Melbourne did not propose to increase the size of its medical school beyond an enrolment of 240 students in second year, which it expected to achieve by 1977. The present second year enrolment is 230. The clinical school at the Austin Hospital is now developed, and this, together with

the schools at Royal Melbourne and St. Vincent’s Hospitals, would be adequate to maintain an output of approximately 213 graduates.

8.74 In view of the close proximity of the Austin Hospital to La Trobe University, University of Melbourne representatives proposed that, if at any stage a medical school were developed at La Trobe University, the Austin Hospital might be con­ sidered for use as its clinical school. If this were the case, the University of Melbourne

would require another metropolitan hospital in order to maintain its intake. It was suggested that Prince Henry’s or the Alfred Hospital might revert to the University of Melbourne, such release being contingent on the establishment of a major teaching hospital for Monash University.

8.75 Monash University. Representatives of the University said that it still faced some problems regarding the number of patients available for teaching. A campus hospital at Monash University would solve these problems, but until one was built, students would continue to be rostered to peripheral hospitals. Monash University wished to maintain its present plans for a first year quota of 200 in 1978 (the present

quota is 160) and an annual output of 178 graduates by 1984. The University insisted that a campus hospital would be necessary to teach this number satisfactorily but, pending its construction, planned affiliation with hospitals such as Dandenong and Moorabbin. Students were at present being sent to Geelong.

8.76 The University considered that when a campus hospital was available it would be possible to integrate the training of medical and paramedical students to develop an emphasis on teamwork, and community orientation; without it, there would have

to be a major re-thinking of the school’s philosophy. Extramural teaching was already being carried out at health centres, and by using more of these it was hoped to graduate students of better quality than is possible from a central hospital. Consider­ ation was at present being given to the introduction of a two-tiered course. This

would consist of a three year degree in human biology, comprising a mixture of biological and psycho-social sciences, followed by a clinical course for those students who wished to become doctors. It would also be possible to take students with suitable qualifications other than the basic degree into the clinical course, thus introducing

some flexibility.

8.77 The Monash University representatives felt that the only justification for setting up a third medical school in Victoria would be its innovatory capacity, since hospital facilities would limit the total output for the State.

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8.78 The Committee believes that additional hospital facilities would be required for the Monash Medical School to go beyond a first year quota of 200, and that within the period under review this quota should not be exceeded.

8.79 La Trobe University. La Trobe University did not wish to establish a medical school at present, but considered such a possibility should not be overlooked as a long range plan. Space had been reserved on the campus for a school of medicine and a teaching hospital. One argument stressed by La Trobe was that the University was at present mainly a liberal arts and science institution and that the establishment of a professional faculty in the form of a medical school would be essential to provide an appropriate balance of the student body. The Committee is unable to accept this as an important reason for establishing a medical school.

8.80 The representatives proposed that when a third medical school was required in Victoria, it should be established at La Trobe University with entry to the medical course at the post-Bachelor of Science level. The majority of science courses necessary for pre-clinical studies was already available at the University. It was suggested that entry to medicine post-Bachelor of Science would be highly selective, students would be strongly motivated, and there would be a very low failure rate. The establishment of a school would require the use of the Austin Hospital and the nearby Repatriation General Hospital, both of which were at present used by the University of Melbourne; this would necessitate a re-allocation of the other Melbourne hospitals.

8.81 As the founding of a new school provided an opportunity for innovation, La Trobe University would undertake research into community opinions on the delivery of health care before designing a curriculum. The University proposed, however, that some teaching in community health centres and general practice should be given, with the particular objective of an increased supply of general practitioners. The University would also be anxious to avoid obsolescence in the medical profession; this could be done by introducing continuing education based on the medical school. A strong commitment to graduate education might lighten the undergraduate student’s load.

8.82 Conclusions. The two existing schools have expanded considerably over the past decade and propose some further expansion in the next few years. The completion of the Austin Hospital with additional wards, expected by 1977, and either a campus hospital at Monash University or access to major hospitals at Dandenong and Moorabbin, will be necessary. Peripheral hospitals such as Geelong are already in use, but the student numbers involved are small. It is likely that Footscray and Preston and Northcote Community Hospitals could be more effectively used.

8.83 The establishment of a third medical school in Victoria would provide scope for innovations in teaching, but the total graduate output would probably remain the same. It would, however, provide a base for an increase in output in the 1990s. The Committee, after careful consideration, did not feel that these advantages could justify the establishment of a third school in the period under review. However,

there may be a need for a new school, on the grounds of numbers alone, in the 1990s.

Q u e e n s l a n d

8.84 Views o f the Queensland Government. The Queensland Government representa­ tives stated that Queensland was under-supplied with doctors and that special

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problems of maldistribution existed both in country and urban areas. A system of cadetships with ‘bonding’ of students had been used as a method of ensuring that many small towns in remote parts of the State had resident doctors. These doctors were posted after one year’s resident training following graduation. Queensland had been a net importer of doctors, both from other States and overseas and the Govern­ ment believed it was desirable to increase the output of local graduates. It was considered likely that a medical school outside Brisbane might have more effect in encouraging doctors to practise in country areas. In addition, there were particular growth points such as the Gold Coast, Gladstone, Townsville and the outskirts of

Brisbane where demand for doctors had outstripped supply. Another important factor in increasing the demand for doctors was the upgrading of regional hospitals and their services. As the population had increased, specialists had entered these

areas and hospital facilities improved. As the hospital services developed, there was a greater demand for salaried staff and this had been magnified by the recent industrial awards which shortened regular hours of duty per week.

8.85 The alternatives of increasing the size of the medical school at the University of Queensland, of initiating a new clinical school, and of founding a full medical school were discussed with the Government representatives. They held that the present school should not expand, and that a second school would give diversity in teaching thereby allowing the quality of teaching in both schools to improve. There would be

some advantages in siting a new school outside Brisbane in that local medical services would be upgraded and graduates might be encouraged to practise in the surrounding areas.

8.86 Although there were more suitable patients available for teaching purposes in the south-eastern part of the State, it was felt that the advantages of decentralisation to a growing area would be considerable. The possibility of improving medical services in the far north made a school at Townsville an attractive proposition. The population at present was thought to be just sufficient to support a school, but pre­

dictions for the future were for strong growth.

8.87 University o f Queensland. The medical school at the University of Queensland is already one of the largest in Australia, having a second year enrolment of 230 which is expected to give an output of 184 graduates by 1978. University representatives said that enrolment could be increased to 280 in 1985, giving an output of 250 by 1990,

provided additional patients were available for clinical tuition. The University however submitted that there could be an advantage in establishing a second school, rather than allowing its own medical school to become too large. On balance, the University favoured James Cook University rather than Griffith University as a separate medical school site. One reason for this was that the University of Queens­ land would need to utilise obstetric beds at the proposed Mt. Gravatt Hospital and

to continue to use Greenslopes Hospital for the clinical tuition of its own students.

8.88 The Committee received a submission from the medical students of the Uni­ versity of Queensland which indicated over-crowding of classrooms and lecture rooms and group sizes which were too large for clinical teaching. In addition, facilities within the hospitals and the number of patients available were inadequate; for

example, outpatient cubicles are too small to accommodate student groups and obstetric deliveries have declined from 15 to 7 per student. The University’s submission

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endorsed these points and set out building requirements for St. Lucia and the teaching hospitals.

8.89 Representatives of the University said that between 1970 and 1980 the graduate output of the medical school will increase substantially and that staff increases have not kept pace with increase in student numbers. In addition to improving present staff-student ratios, the University wished to introduce new departments of clinical pharmacology and community practice. Much of the clinical teaching depended on visiting specialists. The pressures of routine hospital service were heavy, and this reduced the time available for teaching. While the University would be willing to increase the student intake to 280 enrolments in the second year, the costs involved in increasing the size of the school and improving teaching facilities would not be small.

8.90 Griffith University. The submission from Griffith University proposed a three year clinical medical course. Initially admission would be restricted to graduates in biological science, mainly biochemistry, while at a later stage it might be broadened to include graduates of other disciplines or schools. A summer course would introduce human biology, so that clinical instruction, which would begin at the commencement

of the normal academic year, could be conducted in parallel with further teaching in clinical pathology, clinical physiology and clinical pharmacology.

8.91 The clinical course would require the use of the proposed hospital at Mt. Gravatt, the obstetric section of which was expected to be commissioned by 1977; the general section, however, would be completed much later. Greenslopes Hospital was near to Griffith University and it would be hoped to use this hospital mainly in the early stages, continuing thereafter with both hospitals. In addition to clinical teaching at the hospitals, it was proposed to carry out much teaching in general practice, and the curriculum would be planned especially to train graduates for general practice.

8.92 The Committee has reservations on some aspects of the programme, although at first sight the proposal appears attractive. It is in no doubt that entry to the course after a previous science degree would be popular and that some students of mature age would apply. However, most science graduates would be lacking in instruction in behavioural science, a discipline which is most important in a modern medical course. Further, the interests of a science-type graduate entering medicine are likely to be inclined towards a more scientific type of practice rather than general practice,

so that the object of the course could be in conflict with the type of student offering. Finally, the Committee feels that it would be impossible for an introductory course in human biology, including anatomy, to be completed in a summer term. Although there would be great merit in having entry to clinical courses in the manner proposed by the University, it is felt that the introductory course could hardly be for less than one year’s duration.

8.93 Consultation with the University of Queensland representatives revealed that Greenslopes Hospital was extensively used for teaching by that University, and that it was hoped that the obstetric section at Mt. Gravatt would also become available to alleviate the present shortage of obstetric cases.

8.94 James Cook University o f North Queensland. The University proposed the establishment of a clinical school based on Townsville General Hospital, with pre-106

clinical tuition at the University of Queensland. This proposal had the support of the latter University. Teaching in first year subjects would be done at Townsville. Students would then proceed to Brisbane for pre-clinical subjects, returning to

Townsville for the fourth to sixth years of the course. This proposal would make full use of pre-clinical facilities at St. Lucia and would avoid over-crowding and further development of clinical teaching at the Brisbane hospitals.

8.95 Discussions were held with the University, Townsville Hospital, the Townsville Local Branch of the Australian Medical Association and Queensland Government representatives. Some members of the Committee inspected the Townsville General Hospital.

8.96 Townsville General Hospital. The Hospital consists of a main ward block with operating suites, a small obstetric unit, and a new outpatients block. A new wing for psychiatric and geriatric cases, connected with the main block, is nearing completion. Extensions to provide an additional ward block required for general cases, together

with expanded facilities for obstetrics, are under discussion. If a clinical school were introduced, a clinical sciences block for the University departments and student teaching would also be required. Unfortunately the present site plans would necessi­ tate demolition of some old buildings if the additions were to be on the main hospital

site, otherwise they would have to be placed on an adjacent block across a main street.

8.97 The proportion of public patients in the hospital is high. The Committee formed the view that the range of medical and surgical disorders is suitable for teaching. The out-patient department is unusually well equipped and large because many

Townsville people regard the hospital service in the same light as they regard the services of a general practitioner. Outpatients, therefore, provide the function of initial patient contact and of specialist referral. The spectrum of disorders is thus appropriate for teaching.

8.98 The specialist staff of the hospital is quite small, in both part-time and full-time categories. However, as the hospital expands, more staff can be expected to be appointed and this will give the opportunity to introduce academic clinical staff. To ensure efficient management of teaching and service in the situation at Townsville, the

Committee believes that the University heads of departments (medicine, surgery, obstetrics and gynaecology, paediatrics, psychiatry, pathology) should become heads of service in the hospital. Such an arrangement exists in some other places and has been agreed upon at the new Flinders Medical Centre in South Australia and also at the new Westmead Hospital in Sydney.

8.99 The Committee is of the firm opinion that, in a hospital the size of the Towns­ ville General Hospital, every member of the hospital staff must contribute to the teaching programme. It is necessary, therefore, to consider the relationship of the Hospital Board and the University. There is a strong case for establishing a joint

committee which would have control over appointments and certain areas of hospital management.

8.100 As is the case with many other hospitals, the number of public obstetric cases at the Townsville General Hospital is relatively small. In 1972, there were 678 such confinements, barely enough to support a professorial unit. However, the birth rate

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is high in the area, due to a high proportion of young people in the population, and it is expected that it would have increased further by the time a school was established, making a new obstetric wing a matter of high priority.

8.101 If it proves impossible to locate another acute medical ward block on the present Hospital site, conversion of the psychiatric and geriatric wing to general medicine should be considered, with erection of new wards for psychiatry and geriatrics on the adjacent site. It is important for general medical and surgical wards and teaching facilities to be contiguous.

8.102 The difficulties and expense of establishing a small school are considerable. It is clear that the growing population and necessarily expanded hospital facilities would not support a second year intake of more than 50 students. However, careful planning and integration of hospital and university staffs may achieve economies and provide better teaching and service.

8.103 There are three major considerations which led the Committee to consider the Townsville proposition with care in spite of the small student intake. First, Townsville has been identified as a possible growth area and the establishment of a medical school would contribute to its development; the population is expected to rise fairly rapidly. Secondly, the medical services in North Queensland have special problems in that recruitment is difficult, there are numerous small centres remote from base hospitals, and population densities are low. Many centres are served by graduates directed there because of ‘bonding’, a system which may become less effective when university education is free. Thirdly, although tropical infectious diseases are virtually non-existent in North Queensland, there are aspects of medical practice in the tropics which require special attention; Townsville could provide this opportunity. Taking all these factors into consideration, the Committee believes that there is a case for a clinical school at Townsville.

8.104 The Committee has had some reservations, however, about the proposal to send Townsville students to the University of Queensland for pre-clinical teaching. Although both parties are willing, and extra facilities required at St. Lucia for second and third year students would be relatively small, the proposal is considered undesir­ able. Any opportunity for vertical integration of studies in Townsville would be lost; innovations in the curriculum would be more difficult for both the University of

Queensland and the James Cook University of North Queensland. The cost of a pre-clinical school in Townsville would lie mainly in developing anatomy and physio­ logy, as biochemistry is presently being developed. Some help would also be available from the schools of environmental science and of veterinary science already established.

8.105 The Committee, therefore, believes that the establishment of a full medical school at James Cook University of North Queensland should be favoured, provided that appropriate arrangements can be made with, and buildings completed at, the Townsville General Hospital. The school would initially admit 50 students to second year, and would graduate about 38 to 42; as the population increases, the student intake might eventually rise to 90 or 100.

8.106 Conclusions. Up to 1991 the Committee sees the need for some expansion in the output of medical graduates in Queensland. This could be achieved either by

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increasing the present school or by founding a new school, at either James Cook or Griffith University.

8.107 Recent increases in the size of the medical school at the University of Queens­ land have placed stresses on staff and students. The supply of patients is considered inadequate by both the University and the students, and to increase the number of

students more hospitals would have to be brought into the clinical school.

8.108 If a new school were established at Griffith University, the projected increase in hospital facilities would all go to the new school and the latter would also require access to Greenslopes Hospital, at present used by the University of Queensland. An alternative is a new school in Townsville where the hospital has plans for expansion

which would bring it to a size suitable for a medical school and where the population is sufficient for a small school initially.

8.109 The Committee considers that in view of over-crowding and other difficulties being experienced at the University of Queensland medical school, there would be an advantage in founding a second school in Queensland. To site this at Griffith Univer­

sity would allow innovation, but would not solve the problem of hospital facilities; Brisbane students from one or both universities might have to be sent to Ipswich, Toowoomba or Southport. Townsville provides a potentially viable situation if hospital facilities are improved and a close relationship established between hospital and university. To establish a clinical school only would have disadvantages education­

ally, although it would be less costly. The Committee believes that the educational advantages of having both pre-clinical and clinical departments there are considerable. However, it wishes to emphasise that the establishment of a school at Townsville will be more costly than the expansion of the school at the University of Queensland.

While most of the additional cost will fall on the Australian Government, some hospital costs will have to be met by the Queensland Government. The extra cost should be regarded as a price to be paid for decentralisation and regional development.

S o u t h A u s t r a l ia

8.110 Views o f the South Australian Government. At the time the Committee held discussions with the Government representatives, the Committee of Enquiry into Health Services in South Australia, chaired by Mr. Justice Bright, had just published its report. As well as proposing far reaching reforms in the organisation of health

services, the Report gave details of medical manpower in the State. If the Bright Committee’s proposals for regional development were implemented, there would be a progressive need for more doctors in the State. The Report envisaged further demands because of the introduction of new techniques, shorter working hours, etc.,

all of which would require more doctors. It proposed that all health professionals work as a team, the corollary of this being that they undergo training together.

8.111 As South Australia had been greatly dependent on migrant doctors from the United Kingdom, South Africa and Asia and as the former two sources were drying up, it was the view of the Government representatives that the local output of doctors should be increased. Graduates from the Flinders University medical school would not contribute to the workforce until about 1983, when they would have completed three years of graduate training in hospitals or practice.

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8.112 University o f Adelaide. The representatives of the University said that the University had admitted 138 students to second year as a temporary measure, to provide additional graduates to staff the Flinders Medical Centre on its commission­ ing. From 1975 the Adelaide quota to second year would return to 120 students from which about 103 students would graduate by 1980. Prior to the decision to establish the Flinders medical school, the University of Adelaide had been asked by the Austra­ lian Universities Commission whether the quota of 120 could be increased to 150. The reply had been that this would not be possible without additional facilities and staff. The present medical school building had been designed for an intake of 60 to 80 students and was over-crowded. The University was making a submission to the Aust­ ralian Universities Commission for a new medical sciences block in the 1976-78 triennium to alleviate present over-crowding. If a new building were approved, it could be planned for an intake of 150 with little extra expense and the University would be willing to increase its present second year intake from 120 to 150; changes in the curriculum had made possible clinical teaching for about 140 students per clinical year at the Royal Adelaide and Queen Elizabeth Hospitals. The additional student numbers would require more staff, but these would be deployed in consolidating existing departments which were under-staffed and in making effective currently proposed developments in community medicine and clinical pharmacology.

8.113 The curriculum at the Adelaide medical school had been recently revised and the first students in the new programme would graduate in 1973. Formal teaching had been compressed into five years, making the sixth year a student internship and it would be possible to convert to a five year course without difficulty. Vertical integra­ tion was a feature; community medicine was already established, although with a limited staff establishment, and a course in behavioural science was given in first year.

8.114 Flinders University of South Australia. The University confirmed that the medical school would admit students to first year in 1974, the planned intake being 64 to second year in 1975. It had been estimated that of these about 56 would graduate. As the Flinders Medical Centre was to be built in stages, an additional intake would

be impossible before completion of the second stage for which a firm date had not been set. However, it had been assumed that this would take place in the early 1980s. At the outset, clinical teaching facilities had been provided ultimately for about 100 students per annum. An increase to an intake of 80 students in the second year could be expected in 1986, and to 96 eventually.

8.115 The new school was free to plan its curriculum without any of the usual constraints imposed by other disciplines, or by existing hospital traditions. Broadly, the interim curriculum of the Flinders medical school provided for much inter­ disciplinary work, with vertical integration beginning in the second year. After the first year, in which human biology including behavioural science represented about one-half, students would continue their human biology studies in parallel with community health studies in the Flinders Medical Centre. Throughout the course about 25 per cent of the time was allowed for elective study and the final year would be an apprenticeship type year with no formal tuition. The undergraduate course was regarded as only the foundation of a doctor’s training. Graduate education for specialities, which would include general practice, would continue at the Flinders Medical Centre and academic staff would be heavily involved. Extramurally, it was

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hoped to develop links with general practices and community health centres when these were established.

8.116 The physical facilities for the School of Medicine and the School of Nursing were under the same roof, so it was expected that students of various sectors of the health professions would learn to work together as a team from the beginning. It was to be expected that Flinders University would take part in the education of other health professionals.

8.117 Conclusions. There appears to be no long term problem of supply of doctors in South Australia, since the new Flinders medical school will take its first year students in 1974. However, there will be shortages until about 1983, when the first graduates will be ready to begin general practice, and until about 1987 in the case of

specialists. Staffing of the Flinders Medical Centre with resident medical officers and recruitment to senior posts in the period 1975 to 1977 will be difficult. This lag in production of active practitioners was predicted by a South Australian study some years ago, following which the decision to found the Flinders school was made.

Expansion of the Adelaide medical school, after completion of further building, would not provide quick relief—the first general practitioners would become available only in 1987.

8.118 Once the two schools are operating to capacity, the ratio of medical graduates to population will be somewhat greater than in other States. Notwithstanding this, the Committee is in favour of small increases in the size of both medical schools,

because, when any deficiencies are made up in South Australia, an excess of graduates would be available to other States.

W e s t e r n A u s t r a l ia

8.119 Views o f the Western Australian Government. In addition to holding discuss­ ions with Government representatives, the Committee considered the report of a State Government Committee on medical manpower needs which stated that the current doctor-population ratio in Western Australia was 1 to 817, although there

were wide variations in distribution throughout the State. The metropolitan area had 67 per cent of the population, and 88 per cent of doctors, that is, the ratio in the city was 1 to 636, while in the rural area it was 1 to 2,094. There was no shortage but only a maldistribution of doctors. Comparison with Victoria indicated that Western Australia was comparable in the supply of doctors, except in the country areas.

Government representatives indicated that inducements were required to obtain doctors for the essential services in the country, and that increasing the output from the medical school would not necessarily improve recruitment to the country. Calcul­ ation of population trends in the report suggested that a 1 to 800 doctor-population

ratio would be maintained to 1983 without any increase above the second year intake of 90 students. This doctor-population ratio was considered realistic and an increase in the size of the medical school intake was not recommended. The possibility of continuing to attract migrants especially for country areas was mentioned.

8.120 University o f Western Australia. The views of the Faculty of Medicine, which were at direct variance with those of the report referred to in the preceding paragraph, had not been endorsed by the Professorial Board or the Senate of the University.

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Recently, the University increased the second year quota to 90, with a view to graduating 75. The Faculty proposed that a doctor-population ratio of 1 to 550 should be achieved by the year 2000, and that the output of medical graduates from Australian schools should be adequate to make the country self-sufficient; that is, Australia should not have to depend upon migrants for its medical manpower needs. It also considered that the output in Western Australia should be equivalent on a population basis to the national average. To achieve these objectives, the intake to second year should be increased to 150 in 1976 and progressively to 250 in 1991. At this stage a second school should be opened at Murdoch University.

8.121 In proposing an increase in the output of doctors, the Faculty report pointed out that doctors in hospitals and in practice work long hours which, it is expected, will be shortened; and there was a trend towards increasing specialisation, with longer training periods. It had been claimed that the introduction of health profession­ als might ease the load of doctors’ work. However, the Faculty report pointed out that increased training programmes for health professionals would be required, and that medical centres with health care teams were still at a rudimentary stage of development. In addition, the development of health care teams would be dependent on a national policy, in the absence of which present requirements for doctors would continue. Trends in medical education with resulting curricular changes would require increased numbers of academic staff and the introduction of new disciplines. Access to patients in the community setting, and improvement in hospital facilities and patient numbers for clinical teaching were required. The completion of present hospital plans should make it possible to increase the intake to 150, but to go higher to the 250 envisaged would require more hospitals.

8.122 Murdoch University. The Western Australian Government was planning a major hospital adjacent to the Murdoch University site which the Murdoch Univer­ sity Planning Board submitted should be the site of a second medical school when one became necessary. Accordingly, in view of the close relationships necessary with a teaching hospital, Murdoch University already had representation on the executive and planning committees of the new hospital, and would need to have facilities incorporated in the hospital, so that when a medical school was established teaching could begin. The timing of the new medical school would depend on the size of the existing school, the need for doctors and the supply of patients suitable for teaching. Murdoch University felt that there was need to think of a new school in the 1980s, with a possible intake to first year in 1983.

8.123 Preliminary discussions had been held in the University on a possible curri­ culum. In common with the rest of the University, students would spend one and one-half years in a Part I course of studies. This would include: (a) liberal studies of relevance to medicine, (b) basic studies in natural science and (c) an introduction to animal and human biology. It was not intended to set up large pre-clinical depart­ ments, but instead to integrate the teaching of pre-clinical subjects with the clinical course. It was hoped to have paramedical students, who would also take the Part I course, with selection for medicine delayed to the end of this Part.

8.124 The University saw training for general practice as an important feature of the clinical course, which would be of three and one-half years’ duration. An impor­ tant innovation proposed was a large general practice on campus in which students

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would be taught, while emphasis throughout the course would be on social and behavioural science. It was expected that a five year course of the type proposed, together with one year’s internship, would be acceptable for medical registration. It was also expected that the cost of a five year course would be less than a conventional six year course but this might not necessarily be the case.

8.125 Conclusions. The evidence submitted from Western Australia is conflicting, in that the Western Australian Government committee on medical manpower believed that there was no shortage of doctors, only a maldistribution which would not be improved by increasing numbers. It suggested continuation of the second year quota

of 90 to provide a doctor-population ratio of 1 to 800. On the other hand the Faculty of Medicine regarded a ratio of 1 to 550 as being more realistic for the future, claiming that shortages exist and recruitment was difficult especially for those doctors with special expertise; and the Faculty wished to increase student intake eventually to 250. The Faculty also proposed that Western Australia should not be dependent on doctors

migrating from the eastern States or from overseas. In addition to these general grounds it argued that the school at its present size was not viable on academic grounds.

8.126 The Committee believes that while it may be desirable for Australia as a whole to be self-sufficient in producing doctors, it would not wish to suggest that the migra­ tion of acceptably qualified doctors who wish to come to Australia should be discour­ aged. So far as the flow between States is concerned, it is felt that some movement is

to be expected and may be desirable. If because of the foundation of a new school, one State temporarily can produce more doctors than are needed there, this is not a disadvantage; at the same time another State may be in short supply.

8.127 The Committee accepts that the medical school at the University of Western Australia has faced difficulties in the past relating to its smallness. It considers that there is a need to expand to 120 second year enrolments in 1977 and then to 150

enrolments in 1983. At some stage a further increase in the number of graduates will be required, but not before 1991. When greater numbers are required, a decision will be necessary as to whether to expand the existing school or to establish a new school at Murdoch University. Meanwhile, the Committee does not support the proposal for

a school at Murdoch within the period under review.

T a s m a n ia

8.128 View o f the Tasmanian Government. In its submission, the Tasmanian Govern­ ment quoted a paper prepared by the Tasmanian Faculty of the Australian College of General Practitioners which stated that the present doctor-population ratio could be maintained if the number of graduates from the school gradually increased to

about 43 per annum by 1995. This would allow for retirements, and a contingency factor of 20 per cent. However, the Government expected that changes in medical practice and increased demand for medical services would require more doctors, so that this calculation should be regarded as the minimum need. The Tasmanian school

was the smallest in Australia, and had not only the most favourable student-staff ratio, but also the highest proportion of professors in the academic staff. If the school were increased in size, the additional costs would not rise proportionately with the number of students; for example, more staff could be recruited at junior levels.

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8.129 The Government stated that sufficient patients would be available for teaching in the event of the school being expanded, although this would mean more use being made of Launceston and the north west coast hospitals. Approval had recently been given for building the Women’s Hospital on the Royal Hobart Hospital site.

8.130 The State Government believed that the size of the school should be increased in order to reduce the unit costs of producing doctors, but made no proposal in regard to either the extent or the timing.

8.131 University o f Tasmania. The University representatives expected that second year enrolments in the medical school would stabilise at about 52, of whom it was expected about 46 would graduate. This number of graduates over the period to 1991 would provide doctors in excess of those calculated to be necessary by the Government.

8.132 The establishment of the school had produced quite serious problems. Re­ cruitment of staff had been difficult partly because of the lack of adequate facilities for research, the supply of patients suitable for teaching had been insufficient, and students had been rostered to Launceston to reduce pressures in Hobart. There was a critical shortage of obstetric cases and although the building of the Women’s Hospital would provide adequate facilities for teaching, it would not alter the distri­ bution of patients between the public and private sectors. The Royal Hobart Hospital was the only hospital recognised for advanced training for specialist practice, and this only in certain subjects. Increased hospital staff and facilities were required. The University clinical staff were heavily involved in routine hospital clinical work. Some relief was necessary to allow them to prosecute their other duties. The pre- clinical and clinical teaching facilities were already used to capacity, and if the school were to be increased in size, capital expenditure would be required. The University strongly requested that a period of consolidation should be allowed with the present student intake.

8.133 Conclusions. There appears to be no case for the expansion of the medical school at the University of Tasmania beyond its present size. The problems of the school in its early years of development have not been entirely overcome, and some of these, such as the supply of patients for teaching, appear more acute than in other States. A period of consolidation would seem necessary before further consideration is given to any enlargement.

A u s t r a l ia n C a p it a l T e r r it o r y

8.134 Views o f the Commonwealth Department of Health. The Department’s sub­ mission dealt mainly with the current and future medical manpower requirements for the whole of Australia but, in addition, gave details of the situation in the Austra­ lian Capital Territory. Many aspects of the health services in the Australian Capital Territory were currently being planned and a decision to locate a medical school in

Canberra would alter some of the physical facilities. Community health centres, which would be invaluable for student teaching of community and general practice, were being planned. The Commonwealth Department strongly supported the found­ ation of a medical school in Canberra. The question of timing was an open one, although a decision for an early start would assist in the current planning of the Territory’s health services. As the health services of the whole area could be co-

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ordinated under the one authority, providing a regional system for the delivery of health care, this could serve as a model for medical education. The team approach to medical practice, which was possible if the liaison between group general practices, community health centres and the general hospitals was fostered, would give the

students the opportunity of observing all aspects of illness and medical practice. Within community health centres, medical and paramedical workers would together offer comprehensive primary medical care.

8.135 The supply of suitable patients for clinical teaching was expected to be suffi­ cient. Growth predictions for the Australian Capital Territory indicated a substantial increase in population, and the number of beds available when the planned hospitals

were completed should be sufficient. All patients admitted to hospitals at present were private patients and negotiations would be required for their co-operation. However, the development of hospital patient services was expected in the future.

8.136 Australian National University. The University proposal was to initiate a medical school in 1977 with an intake to first year of 65 students. This would rise to 94 in 1981 and 118 in 1984. The Canberra and Woden Valley Hospitals would be used initially as clinical schools. Calvary, Belconnen and Tuggeranong Hospitals

would be utilised as they were commissioned; the target dates for commissioning were 1976, 1979, 1986 respectively.

8.137 The course proposed was of seven years’ duration and consisted of two parts, a four-year course in human sciences leading to a degree of Bachelor of Medical Science, and a three-year second-degree course, culminating in the degree of Bachelor of Medicine. In the sixth and seventh years of their studies, students would spend

time in responsible, paid clinical service as student doctors. Each degree course would have an obligatory core of studies plus electives; streaming for specialisation would begin early and the emphasis throughout would be on fundamental principles and problem solving rather than memorizing detailed information. The study of the

human being would be in the foreground of the curriculum and behavioural science would be a prominent feature, Although the course would be of seven years’ duration, the University considered that the graduates would be equivalent to those from other universities two years after graduation.

8.138 The University acknowledged that the co-operation of private patients would have to be obtained for clinical teaching; and it was claimed that this could be achieved, as would the co-operation of practitioners in their consulting rooms and home visits. The situation would presumbly change with the introduction of the new National

Health Insurance Scheme.

8.139 Canberra Hospitals. The Canberra Hospital has a unique organisation, and has been described as the largest “private” hospital in Australia. Patients are admitted under the care of visiting specialists or practitioners, and all are fee paying. Recently, resident medical officers and registrars were introduced and they serve under the

visiting specialists. The Committee was informed during discussion with representa­ tives of the Hospital resident medical staff that initial problems had been overcome and they considered that an effective training programme for medical staff existed, even in operative procedures; no residents, however, were rostered for obstetrics.

There was no specialist out-patient department, and casualty functioned in a limited

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fashion only. By and large, patients were admitted directly by their own doctors who ordered all treatment. In the case of specialists, instructions were usually transmitted through their residents.

8.140 The Committee was informed that there were no teaching side rooms at the Hospital, and lecture and tutorial areas, as well as areas for university departments, would have to be provided for students. Space was available on the site for this purpose. Residential accommodation for students and graduates would also be required.

8.141 The Woden Hospital was opened in 1973, and is managed on the same lines as the Canberra Hospital. Being a new institution, facilities have been incorporated which make it suitable for teaching from the outset. Areas for teaching are available on each ward floor, and service areas such as the obstetric delivery suite have been planned spaciously enough to accommodate students. Space is reserved for buildings for library, pathology, laboratories and other university activities that might become necessary. Calvary and Belconnen Hospitals are not yet built, but the Committee was assured that facilities for student teaching have been incorporated.

8.142 The community health centre at Melba has been opened for a short time. The facilities here are quite adequate for the introduction of one student per practitioner. There are rooms at present available which could be used for discussion and tutorial purposes. Other centres are in the process of construction.

8.143 Conclusions. While the idea o f an innovatory curriculum taught within the framework of integrated total health care for the community is attractive, the Com­ mittee considers that there are features of the Australian National University proposal which require comment. Lengthening of the course in the way proposed seems to the

Committee to be a retrograde step in view of the proposals to introduce curricula for five-year courses in other universities. The intention to stream students at under­ graduate level towards general practice or a chosen specialty has not yet been attemp­ ted in Australia. Early streaming is practicable only in a large school with a diversity

of well established specialities. With a small school, the demands on staff in main­ taining parallel programmes for what must be small groups in each field, would be very great and an abnormally high staff-student ratio would be required; indeed, the high costs of the proposal are reflected in the budget estimates prepared by the University. The elective programmes would also create great demands for staff. The four-year Bachelor of Medical Science course with its electives would probably attract a high proportion of scientifically motivated students in which case the yield for general practice would be low. The Committee does not wish to dictate course

structure to a university, but it does have some reservations about the structure and cost of the course proposed by the Australian National University.

8.144 At least one existing medical school has considered innovatory curricula similar to the one proposed and was forced to defer the changes it wished to make, as the student-staff ratio was not strong enough, and the gains in staffing necessary would have taken up all flexibility for change in the whole of that university. The foundation of a medical school at Canberra along the lines proposed would require grants per student much larger than have been provided in establishing other new medical schools.

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8.145 In the Committee’s opinion, the availability of an adequate supply of patients with disorders suitable for teaching purposes is uncertain. It is true that private patients can be subjects for the teaching of students, but this usually requires teaching by the patient’s personal doctor in very small groups or to individual students.

Logistic problems of time-tabling become complicated, and student-staff ratios must be very favourable. General practitioners’ patients comprise a large part of those admitted to Canberra Hospital; if these practitioners were to be involved in teaching it would be expected that it would take place in community health centres or their

own practices rather than in the hospital (see paragraph 9.6).

8.146 In some teaching hospitals in other countries, it is a condition of admission that a patient, whether he is a private or hospital patient, agrees to participate in teaching. Such a condition causes no complaint since there are other non-teaching hospitals to which patients may go if they wish. In Canberra, however, where all the hospitals would be involved in the teaching programme and there are virtually no private hospitals, a mandatory condition would probably be unacceptable.

8.147 When the Report of the Health Insurance Planning Committee is implemented, it is expected that a proportion of patients in Canberra hospitals would elect to be “hospital” patients, i.e. non-private patients. That Committee has made an overall estimate of a 10 per cent swing from private to hospital care and this swing is expected to be most pronounced in the procedural specialties such as surgery and obstetrics. The extent of change in Canberra and the effect on the availability of patients for

clinical teaching remain to be determined. To have a sufficient effect, however, it is the view of this Committee that the proportion of hospital patients would require to be of the order of 30 to 40 per cent.

8.148 Obstetrics would probably remain an area of serious deficiency in the supply of patients for teaching. The delivery itself is only one part of obstetric management while observation of the patient throughout the entire pregnancy is the most important

feature of modern care. Some means of encouraging the private patients of doctors to undergo their antenatal management within the hospital would be necessary. A professorial unit would probably have difficulty in establishing a hospital obstetric service of sufficient size due to the traditions of personal practice in the Australian

Capital Territory.

8.149 Under all the circumstances, the Committee’s conclusion is that a decision on the Canberra school should be deferred until the effects in Canberra of the new National Health Insurance Scheme can be judged, and the operation of community

health centres evaluated. This would involve a deferment for three years. It has been strongly urged on the Committee that an immediate decision should be made because plans for hospitals, community health centres and other facilities are being completed now and it is necessary for the University to be involved both in the planning and

organisation from the outset. The Committee agrees that the University should be involved but is not convinced that an immediate decision on the establishment of a medical school is necessary to achieve this objective.

R ECO M M EN D A TIO N S

8.150 In the last section of Chapter 7 (see paragraphs 7.27 and 7.28), the Committee concluded that, although the currently approved output of existing medical schools

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would come close to meeting the expansion implied in the Committee’s judgement of future requirements of medical manpower set out at the end of Chapter 5 (see para­ graph 5.52), it favoured some expansion in the future output of medical graduates beyond that already approved. The preceding section of this Chapter has examined the proposals of universities for expanded or new schools and has indicated the Committee’s views on the viability and wisdom of the proposals.

8.151 The Committee favours a limited amount of expansion in some existing schools. By 1991, the output of medical graduates on the basis of currently approved places is expected to reach approximately 1,247 graduates per annum. The proposals for expanding existing schools, which are acceptable to the Committee, would permit the increase of that figure by approximately 186, and the Committee is recommending such an increase. Beyond that, the Committee favours the creation of some new schools, less on manpower grounds than for the special reasons indicated in this Chapter; it is recommending the establishment of schools at Newcastle and Towns­ ville. These would add a further 127 graduates per annum by 1991. The establishment of a school at Townsville is conditional. If the condition proves impossible to meet, the Committee recommends some expansion at the University of Queensland as an alternative.

8.152 The Committee’s recommendations are set out below:

1 .(a) The University o f Sydney should increase its second year enrolment to 330 in 1978, to make fu ll use o f its existing clinical schools and the development o f Westmead Hospital.

(b) The University o f New South Wales should maintain its projected output o f 200 graduates per year.

(c) The University o f Newcastle should establish a medical school to take its first students in 1977, maintaining a second year enrolment o f 60 until 1983 when it should be increased to 100.

(d) Proposals for new medical schools at Macquarie University and Wollongong University College should not be supported within the period under review.

2. (a) The University o f Melbourne should proceed to its projected second year enrol­ ment o f 240 in 1977.

(b) Monash University should increase its second year enrolment to 200 in 1979.

(c) A medical school should not be established at La Trobe University within the period under review. 3

3. (a) The James Cook University o f North Queensland should establish a medical school to take its first students in 1980 maintaining a second year enrolment o f 50 {ultimately increasing to 100 with the growth o f the Townsville area), subject to the clinical facilities at the Townsville General Hospital being appropriately expanded and upgraded.

(b) In the event o f this condition not being met, the University o f Queensland should increase its second year enrolment to 280 by 1981.

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(c) The proposal for a new medical school at Griffith University should not be sup­ ported within the period under review.

4. (a) The University o f Adelaide should increase its second year enrolments to 150 in 1979.

(b) The Flinders University o f South Australia should progressively increase enrol­ ments in second year to 80 by the mid-1980s, the timing to depend on the development o f hospital facilities at the Flinders Medical Centre.

5 . (a) The University o f Western Australia should increase its second year enrolment to 120 in 1977 and to 150 in 1983.

(b) The proposal for a new medical school at Murdoch University should not be supported within the period under review.

6. The University of Tasmania should not increase the intake to the medical school during the period under review.

7. A decision on the proposed medical school at the Australian National University should be deferred for three years, pending consideration o f the effects o f the new National Health Insurance Scheme and o f community health centres on medical practice in the Australian Capital Territory.

EFFECTS OF RECOMMENDATIONS ON MEDICAL MANPOWER PROJECTIONS

8.153 Table 8.3 sets out for 1972 to 1991 the expected number of second year enrol­ ments and of graduates for each medical school on the basis of the Committee’s recommendations.

8.154 In Table 6.2 the projections of the number of doctors on the basis of the approved plans of existing medical schools showed that a doctor-population ratio of 1 to 567 would be reached by 1991 on the assumptions made, and that this ratio would have improved by about 0.74 per cent per year during the period 1986 to

1991. The projection is summarised in Table 8.4, with a comparison with past doctor- population ratios and rates of improvement. Projection beyond 1991 would, of course, be extremely hypothetical, as the future of immigration in particular is extrem­ ely uncertain so far ahead, but on the basis of the same assumptions as those under­

lying the projections in Table 6.2 it could be expected that the doctor-population ratio, even without further increases in inputs into the medical schools, would con­ tinue to improve slowly to about the end of the century.

8.155 Table 8.5 summarises similar projections for the period 1976 to 1991 on the basis of the expansion in existing schools recommended by the Committee, but without the new schools recommended.

8.156 Table 8.6 summarises projections similar to those in Table 8.5 on the basis of the expansion in existing schools together with those new ones recommended by the Committee.

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SECOND YEAR ENROLMENTS A N D DEGREES CONFERRED, AUSTRALIAN MEDICAL SCHOOLS, ACTUAL 1972 A N D ESTIMATED 1973 TO 1991 ON BASIS OF COMMITTEE’S RECOMMENDATIONS

TABLE 8.3

New South James

Sydney

Wales

Newcastle Melbourne Monash Queensland

Cook

Adelaide

Western

Flinders Tasmania

Australia

Australia

2nd M .B ., 2nd M .B ., 2nd M .B . , 2nd M .B . , 2nd M .B ., 2nd M .B . , 2nd M .B ., 2nd M .B . , 2nd M .B .,

year B .S. year B .S. year B.S. year B .S. year B.S. year B .S. year B.S. year B .S . year B.S.

1972 . . 272 235 250 91 — — 221 131 165 141 232 114 — 134 102 — —

1973 . . 258 200 247 75 — — 230 187 166 135 230 146 — 138 97 — —

1974 . . 275 217 244 144 — — 230 192 160 134 230 142 132 96 —

1975 . . 275 238 241 184 — — 230 187 160 136 230 158 120 92 64 —

1976 . . 286 203 241 157 — — 230 189 160 142 230 182 120 111 64 —

1977 . . 308 227 238 200 — — 240 190 160 140 230 181 120 114 64 —

1978 . . 330 216 238 200 60 — 240 198 160 141 230 184 _ _ 120 117 64 _

1979 . . 330 458(a) 235 200 60 — 240 198 200 136 230 184 — — 150 112 64 —

1980 . . 330 237 235 200 60 — 240 200 200 138 230 184 — — 150 103 64 51

1981 . . 330 255 233 200 60 240 200 200 138 230 184 50 150 103 64 51

1982 . . 330 275 233 200 60 240 209 200 138 230 189 50 150 103 64 51

1983 . . 330 275 230 200 100 48 240 209 200 139 230 189 50 150 103 64 52

1984 . . 330 275 230 200 100 48 240 211 200 174 230 189 50 150 129 64 52

1985 . . 330 275 230 200 100 48 240 211 200 174 230 193 50 150 129 64 52

1986 . . 330 275 230 200 100 49 240 211 200 176 230 193 50 38 150 131 80 54

1987 . . 330 275 200 49 211 176 193 38 131 54

1988 . 275 200 84 213 176 196 39 131 54

1989 . 275 200 84 213 178 196 40 131 54

1990 . 275 200 85 213 178 196 41 131 54

1991 . 275 200 85 213 178 196 42 131 68

2nd M .B ., 2nd M .B.,

year B .S. year B.S.

90 49 42 15

92 51 56 21

90 50 57 26

90 75 58 26

90 75 52 33

120 75 52 30

120 76 52 41

120 75 52 42

120 76 52 44

120 76 52 40

120 101 52 41

150 101 52 41

150 101 52 42

150 101 52 42

150 102 52 43

102 43

128 44

128 44

128 44

128 44

2nd M .B .%

year B.S.

1,406 878

1.417 912

1.418 1,001 1,468 1,096 1,473 1,092 1,532 1,157

1,614 1,173 1.681 1,405 1.681 1,233 1.729 1,247

1.729 1,307 1.796 1,357 1.796 1,421 1.796 1,425

1,812 1,472 1,472 1,540 1,543

1,545 1,560

(a) Double graduation in 1979 due to change from 6 to 5 year course in 1974. Source: Universities and Committee estimates.

PROJECTIONS OF NUMBER OF DOCTORS, 1976 TO 1991 ON BASIS OF APPROVED PLANS OF EXISTING MEDICAL SCHOOLS COMPARED WITH PERIOD 1933 TO 1971

TABLE 8.4

30 Doctors Population

Doctor-Population Ratio

Doctors per Million of Population

Rate o f Increase Per Annum Since Previous Census Year

Ό00 1 to per cent

Unadjusted . 1933 4,874 6,630 1,360 735 n.a.

Census data . 1947 6,644 7,579 1,141 876 1.3

1954 9,180 8,987 979 1,022 2.2

1961 11,904 10,548 883 1,133 1.5

Adjusted . . 1961 12,320 10,548 856 1,168 n.a.

Census data . 1966 14,440 11,599 803 1,245 1.3

1971 17,243 12,756 740 1,352 1.7

Projections . 1976 20,429 13,819 676 1,478 1.8

1981 23,941 14,947 624 1,602 1.6

1986 27,355 16,107 589 1,698 1.2

1991 30,410 17,257 567 1,762 0.7

TABLE 8.5

PROJECTIONS OF NUM BER OF DOCTORS, 1976 TO 1991 ON BASIS OF EXPANSION UP TO 1991 IN EXISTING SCHOOLS RECOMMENDED BY COMMITTEE

30 Doctors Population

Doctor-Population Ratio

Doctors per Million of Population

Rate of Increase Per Annum Since Previous Census Year

Ό00 1 to: per cent

1976 20,429 13,819 676 1,478 1.80

1981 23,957 14,947 624 1,603 1.64

1986 27,656 16,107 582 1,717 1.38

1991 31,309 17,257 551 1,814 1.10

TABLE 8.6

PROJECTIONS OF NUM BER OF DOCTORS, 1976 TO 1991 ON BASIS OF EXPANSION UP TO 1991 IN EXISTING SCHOOLS AND NEW SCHOOLS RECOMMENDED BY THE COMMITTEE

June 30 Doctors Population

Doctor-Population Ratio

Doctors per Million o f Population

Rate of Increase Per Annum Since Previous Census Year

ΌΟΟ 1 to per cent

1976 20,429 13,819 676 1,478 1.80

1981 23,957 14,947 624 1,603 1.64

1986 27,757 16,107 580 1,723 1.45

1991 31,759 17,257 543 1,840 1.32

It will be seen that by 1991 the doctor-population ratio is projected to improve to 1 to 543. Extending the projection into the 1990s would show that there is still a potential in the system for the ratio to continue improving for many years without additional increases in inputs of students. It is in the years following 1991, when

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the number of graduates from the new schools will have accumulated to significant numbers, that the main impact of the creation of the new schools on medical man­ power will be felt.

8.157 The Committee is convinced that its recommendations will permit an ample supply of medical manpower up to the end of the period under review. The doctor- population ratio in Australia will have improved as follows:

1933 1 1,360 1954 1 979

1972 1 721

1991 1 543

The rise in the ratio from 1 to 721 in 1972 to 1 to 543 in 1991 is an improvement in the nineteen years of 33 per cent, which accords with the Committee’s judgement of needs. Moreover, there will still be potential for growth in the system, on the assumptions made about immigration, deaths, retirements and other losses, sufficient to provide for further improvement in the ratio into the early years of the next century, and still further improvement if the intake of medical schools is increased after 1985 or new ones created.

8.158 Table 8 .7 shows for the period 1971 to 1986 second year medical students per 1,000 of the population aged 19 years on the basis of the Committee’s recommend­ ations. The trends in the figures indicate an overall increasing access to medical

education relative to the population.

TABLE 8.7

SECOND YEAR MEDICAL ENROLMENTS PER THOUSAND OF POPULATION AGED 19 YEARS, ON BASIS OF COMMITTEE’S RECOMMENDATIONS, AUSTRALIA 1971 TO 1986.

Year

New South Wales (a) Victoria Queensland

South Australia (b)

Western Australia Tasmania Australia

1971 . . 5.9 6.6 7.5 6.0 5.0 7.0 6.3

1972 . . 6.3 6.3 7 .0 5.8 4 .7 5.5 6.2

1973 . . 6.2 6.6 7 .0 6.0 4.8 7.5 6.3

1974 . . 6.3 6.4 6.9 5.7 4.5 7.5 6.2

1975 . . 6.2 6.2 6.7 7.7 4.4 7.2 6.3

1976 . . 6.1 6.1 6.7 7.6 4.4 6.7 6.2

1977 . . 6.1 6.2 6.5 7.5 5.7 6.4 6.3

1978 . . 7.0 6.0 6.4 7.3 5.7 6.3 6.5

1979 . . 6.9 6.6 6.2 8.3 5.5 6.2 6.7

1980 . . 6.6 6.3 6.1 8.1 5.4 6.0 6.5

1981 . . 6.5 6.3 7.3 8.3 5.4 6.0 6.6

1982 . . 6.6 6.4 7.4 8.3 5.3 6.3 6.7

1983 . . 7.1 6.4 7.5 8.4 6.7 6.4 7.1

1984 . . 7.4 6.6 7.8 8.8 6.9 6.9 7.3

1985 . . 7.5 6.7 7.9 8.9 7.0 7.3 7.4

1986 . . 7.5 6.5 7.9 9.8 6.6 7.2 7.4

(a) Includes Australian Capital Territory. (b) Includes Northern Territory.

Source: Commonwealth Bureau of Census and Statistics, universities and Committee estimates. (Popula­ tion projections are based on a net gain from migration of 40,000 per annum).

8.159 Table 8.8 shows for the period 1971 to 1991 the balance between States of the output of medical graduates, on the basis of the Committee’s recommendations.

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M.B., B.S. DEGREES CONFERRED PER MILLION OF STATE POPULATIONS ON BASIS OF COMMITTEE’S RECOMMENDATIONS AUSTRALIA 1971 TO 1991

TABLE 8.8

New South South

Year Wales

(a)

Victoria Queensland Australia (b) Western Australia

Tasmania Australia

1971 . 68 80 64 79 49 51 70

1972 . 67 77 62 80 48 37 68

1973 . 56 90 78 75 48 51 69

1974 . 73 89 74 73 46 63 75

1975 . 84 87 82 69 68 62 81

1976 . 71 88 92 82 66 77 79

1977 . 82 86 91 82 65 69 83

1978 . 79 87 91 83 64 93 83

1979 . 124 85 89 78 62 94 97

1980 . 81 84 88 106 61 97 84

1981 . 83 83 86 104 59 87 84

1982 . 86 84 87 102 77 87 86

1983 . 93 83 86 101 76 86 88

1984 . 92 91 85 116 74 87 91

1985 . 90 89 85 115 72 85 90

1986 . 89 88 100 115 71 86 92

1987 . 88 87 99 113 70 85 90

1988 . 93 86 99 112 86 86 93

1989 . 92 85 98 110 84 84 92

1990 . 91 84 97 108 82 83 91

1991 . 89 83 96 115 81 82 90

(a) Includes Australian Capital Territory. (b) Includes Northern Territory. Source: Commonwealth Bureau of Census and Statistics, universities and Committee estimates. (Popula­ tion projections are based on a net gain from migration o f 40,000 per annum.)

8.160 From Tables 8 .7 and 8.8 it can be seen that South Australia will have some­ what greater capacity, relative to population, to admit medical students and to produce medical graduates. The Committee does not regard this as a matter for concern, as it is important to view Australia’s medical manpower requirements on a

national scale. The Committee would expect that, with the assumption by the Austra­ lian Government of financial responsibility for the universities, access to medical schools in particular States of students resident in other States will become freer than it has been in the past. As far as graduates are concerned, there has always been

a considerable interstate flow and this will no doubt continue. Beyond the period under review (i.e. after 1985 as far as first year medical students are concerned), further development of medical schools in South Australia may, perhaps, be less likely than in the other States.

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CHAPTER 9

Some Related Problems in Medical Education 9.1 In accordance with its terms of reference, the Committee has limited its recom­ mendations to the need for new or expanded medical schools. However, many sub­ missions were received from organisations and individuals, concerning medical education in its widest sense. These involved criticisms of present arrangements and suggestions for improvement. Many of these submissions contained valuable back­ ground material which was elaborated in discussions with the Committee. The Com­ mittee believes that use should be made of this material, and therefore has set out the main points in this chapter, together with its own observations on the major issues raised.

UNDERGRADUATE CURRICULA

C r it ic ism s

9.2 In submissions and in discussions with groups outside the universities there was a number of criticisms of medical school curricula. The Committee discussed these, examined the curricula, and questioned representatives of the medical schools at the various meetings. One major criticism often repeated was that the existing schools are not innovatory, and do not take into account the changes occurring in modern life and our environment which may lead to new requirements in medical care. The evidence presented by the Deans of medical schools, however, indicated that not only are the schools aware of these problems, but that many have taken steps to deal with them. The new course at the University of Sydney, for example, has major changes in emphasis. Subjects have been removed, others introduced and the course structure changed and shortened by one year. At the University of Adelaide, although subjects have not been deleted, new ones have been introduced and teaching methods and inter-relationships of one subject with another have been altered so that learning is facilitated. In most schools behavioural science and community medicine courses are either in existence or being planned.

9.3 Proposals for innovation by universities seeking the establishment of medical schools emphasised two factors. These were first, the need to seek patients for teaching in the community and thus to fit the doctor better for community practice, and secondly, the desirability of admitting graduates from non-medical disciplines to the clinical schools. It seems likely that existing schools will have organised community medicine courses long before any new schools could be established. The acceptance of students from other disciplines to later years of the course is a matter which can be arranged at any school, by introducing some flexibility into its own pre-clinical programme. The Committee certainly favours such flexibility. On the other hand, the strong trend amongst those schools with ‘reformed’ courses is to introduce ‘medical’ teaching to the early years of the course and enhance motivation of the

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student for his vocation. This is probably more desirable than selecting students directly to clinical schools after science or other courses.

9.4 The Committee’s general conclusion was that most existing medical schools were well-disposed towards innovation and some were markedly enthusiastic. In a number of schools major innovations had already taken place. In some cases additio­ nal funds may have to be directed towards specific innovations (see paragraphs 9.17 to 9.20). There is no reason to believe that innovation can take place only in new

schools.

9.5 A second recurring criticism is that existing schools are too ‘scientific’, that is, that the emphasis in teaching is on medical science and not on clinical practice or community care. Academic clinical teachers have been accused of being too research oriented and of having narrow horizons for their own specialty. While this may be

true in some cases, the hard fact is that medicine without a scientific foundation cannot exist. The doctor will spend his whole life in practice, but has only a short initial period as a student to absorb the principles of scientific method as they relate to the patho-physiology of disease, and consequently its diagnosis and treatment, and

to prepare for a lifetime of continuing education and critical evaluation of advances in medical knowledge. However compassionate the doctor may appear at the bedside, if he lacks a scientific approach his effectiveness in diagnosis and therapy will be negligible.

9.6 A third major criticism is that medical schools are not interested in family medical care. This may have been truer five years ago than it is today. In most schools there is at least a minimum exposure to family practice in the later years of the course. Experience in those schools where this has been done for years is that it is not easy

to find practitioners who are willing and able to act as preceptors. The minimum programmes presently arranged are barely continuing because of this difficulty. To mount larger and more ambitious programmes runs the risk of a complete break­ down of the present preceptorship system, which is working to capacity in most

schools. However, the development of community health centres offers very favour­ able opportunities for teaching in family medicine and the Committee believes that medical schools will avail themselves of these opportunities.

G e n e r a l P r a c t ic e a n d t h e C u r r i c u l u m

9.7 Persistent demands have been made by general practitioner groups for university departments of general practice, but there is as yet no chair of general practice in Australia and there are only six in the United Kingdom, although there are eleven departments. The main argument put forward against such a chair is that general practice is a method of practice, not an intellectual discipline, and that all the techni­

ques relating to general practice are already taught by recognised academic depart­ ments. However, proposals for departments of community medicine, which embrace the teaching of general practice, are being actively discussed in a number of medical schools.

9.8 It is necessary to evolve a new philosophy in respect of general practice in the medical curriculum. Training in general practice as such is vocational, and is best carried out after graduation. But exposure to the problems of human beings in the

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community is part of the orientation of the student to his scientific training and his future life’s work. In some universities, teaching of medical problems in the com­ munity setting therefore begins in the earliest years of the course, so that the student may relate his scientific learning to the problems of living and being ill in the com­ munity itself.

9.9 The Committee therefore concurs with the view that university departments based on the philosophy of human health and disease in the community itself will have greater impact on the student than those based narrowly on the object of training doctors to become general practitioners. The student who is community- minded and interested in people and their problems should thus become more stimul­ ated to practice medicine in a community setting as a general practitioner than he would if, towards the end of the course, he were merely instructed in some of the practical aspects of general practice.

9.10 General practitioner groups frequently see the creation of chairs of general practice as a solution to the problem of recruitment to this branch of medicine. Such a development might have some effect on recruitment, by increasing its academic ‘respectability’ and by increasing the student’s exposure to general practice. However, it was put to the Committee that it would be more important to make the working environment of the practitioner more attractive. At present, solo practice is often conducted in premises converted to a surgery, in isolation in a suburb or town. Group practices do not suffer from this disadvantage, since they can afford properly designed consulting centres, and the partners have professional contact with each other, and with other consultants.

9.11 The setting up of community health centres and group practices, with proper facilities and back-up from groups of allied health professionals, would provide a setting within which medical students can see the problems of the community, while at the same time providing an attractive setting to improve recruitment. Financial security, either by profit sharing in a private group or by salary and superannuation if employed by a local authority, may be inducements. If students were taught in community health centres or group practices, medical practice would be seen under favourable conditions. Students and young graduates are accustomed to being mem­ bers of a group, and their introduction to practice in a group at a community health centre would be much easier and less threatening professionally.

9.12 Another factor which has led some to prophesy the demise of general practice has been the trend towards specialisation and the development o f ‘super-specialties’. Because of geographical problems in Australia and also the desire of most individuals to have their own doctor, the Committee believes it is unlikely that this will occur. It has assumed that general practice will continue.

9.13 The trend to increasing specialisation has led to a mushrooming growth of hospital training posts to provide for the apparently ever increasing opportunities for specialist practice. In some branches it is claimed that there is already an over-supply, and that recruitment to training posts is not occurring, there being many vacancies.

9.14 The time now appears ripe for a significant development of departments of community medicine which will demonstrate the problems of community health care in practice. In addition to helping to stimulate interest in general practice such a

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philosophy of training will also assist those students destined to become specialists or medical scientists, giving them a greater appreciation of community problems and needs so that they will practise their own vocation with greater understanding. Attempts to provide some tuition in general practices have shown that community

health centres are essential for this exercise. If such departments of community medicine embrace multiple responsibilities: general practice, epidemiology, preven­ tive and occupational medicine, a comprehensive intellectual discipline can be estab­ lished. In some schools, chairs of general practice might be established in such depart­

ments without attracting the criticism that general practice is not a university discipline.

9.15 The establishment of community health centres presents a problem in manage­ ment and funding; but a useful parallel is the teaching hospital. Some community health centres may have only a service function, i.e. the provision of health services to the local community; but some will have a major teaching role. The service function of these will have to be funded as part of the health service system, but the teaching function should be funded from grants recommended by the Australian

Universities Commission. The Committee sees merit in the establishment in the near future of a number of community health centres associated with medical schools and suggests that special ear-marked funding might be provided for these by the Austra­

lian Universities Commission to parallel special funding for the service component by the National Hospital and Health Services Commission. The Australian Universi­ ties Commission grants would permit the appointment of academic and support staff in departments of community medicine. Some of the staff would spend most of their time in teaching, practice and community research in the community health centre just as clinical academics do in the teaching hospital. The Committee wishes

to emphasize that it does not support the creation of departments of general practice or community medicine located entirely in an academic setting and divorced from actual practice in the community.

S p e c ia l A s p e c t s o f t h e C u r r i c u l u m

9.16 Many submissions made by the professional colleges, professional groups and individuals argued for changes in the curriculum, generally in the direction of greater coverage of some particular discipline or specialty. The extent to which each discipline is covered in the curriculum at each medical school is, of course, a matter for the

individual curriculum committee. However, it should be pointed out that to give every subject increased coverage would lengthen the medical course to nine or ten years; in many cases the additional emphasis might best be given in post-graduate training.

9.17 In the Committee’s view, disciplines to which additional emphasis might be given are community medicine, clinical pharmacology and geriatrics. The Committee believes that there are good grounds for encouraging universities to expand their medical schools into these fields, and suggests that this might be done by making

available earmarked grants to universities for these purposes on the understanding that they would be absorbed into general recurrent grants after one triennium.

9.18 Community Medicine. The creation of departments of community medicine has already been discussed in some detail in paragraphs 9.14 and 9.15.

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F

9.19 Clinical Pharmacology. One of the more neglected fields of practice is the area of therapeutics. The administrators of health schemes complain of the ever-rising costs of pharmaceutical benefits. They place emphasis on counselling as opposed to prescribing as an ideal towards which the medical profession might strive. The increasing complexities of the drugs available and their potential for good and ill present the planners of a medical curriculum with a challenge which requires to be answered at the undergraduate level as well as at the postgraduate level. A sound knowledge of pharmacology, both theoretical and clinical, and of the therapeutic value and possible dangers of the many products available should be acquired at the under­ graduate level, with an adequate scientific basis on which to build further post­ graduate knowledge.

9.20 Geriatrics. As can be seen from Table 4.1, the proportion of old people in the population is not expected to rise significantly in the next twenty years. However, the break-up of the extended family, a greater awareness of the social and physical problems of the aged and the higher morbidity of older people are grounds for an increasing emphasis on the care of the aged. This should not lead to too great a

separation of geriatrics from general medicine and surgery, but rather to an appreci­ ation of the problems—medical, social and economic, which confront the community generally in the total care of older persons.

POSTGRADUATE MEDICAL EDUCATION

9.21 University Higher Degrees. At present, higher degrees in medicine fall into two categories: those obtained by thesis after supervised or personal research and those obtained by examination after completion of course work or pre-requisite practical training. In all universities the degree of Doctor of Medicine is awarded by thesis, while in two it may be awarded by thesis plus examination. Masters degrees are taken by thesis only in five universities and after course work (with clinical examin­ ation and thesis) in two. Professional diplomas are offered in up to eight specialties in three universities. The degree of Doctor of Philosophy is being increasingly taken

by medical graduates, especially those working in pre-clinical and para-clinical sciences.

9.22 Both types of degree (thesis and course work) have some advantages. The degrees obtained by thesis ensure that the candidate has carried out original work under rigorous conditions. The degrees obtained by clinical examination with thesis ensure that the candidate has reached a standard of medical excellence in his chosen branch. Generally speaking, higher degrees are taken by aspirants to university academic or teaching hospital staffs, or by those with special research interests; they are highly valued by their holders, and the universities are rightly jealous of their standards.

9.23 Pre-Registration Training. This is a transitional phase between undergraduate studies and vocational training. It ensures a minimum standard of professional competence in medical procedures. Although no examination is held at its end, medical superintendents at hospitals must certify that the doctor’s work has been

satisfactory. There have been suggestions that the pre-registration period be extended

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to two years, but this is unlikely in view of the Royal Colleges’ re-organisation of vocational training. ·

9.24 Under “ old” curricula, when formal undergraduate teaching lasted six years, at the end of which there was a searching final examination, it was found that many graduates had a temporary revulsion against study during the first year after gradua­ tion. In “new” curricula, in which the learning process is intended to be continuous,

both before and after graduation, the emphasis on examinations is less. The final year of studies being mainly practical, continuing study during the pre-registration year is more likely. It has been suggested that there is a case for universities to con­ tinue some supervision over the learning process after graduation, so that it forms a

continuum with the advanced vocational training for the specialties.

9.25 Vocational Training. In 1972 a re-organisation of vocational training began. Previously, each college had its own pre-requisites for admission to its final examin­ ation, but there was little systematic attempt at training. The colleges acted virtually as examining bodies, conferring membership or fellowship on those successful in the final examination. To the public eye, a college diploma indicated specialist status.

Recognising the necessity for systematic training and the multiplicity of special branches, the Ad Hoc Combined Education Committee of the four Royal Colleges was formed. This succeeded in establishing common ground and to some extent, common types of training programme. The general pattern now is: one year intern­ ship, two years basic (general) training during which a Part I examination is taken, and three or more years advanced (specialised) training during which a Part 2 examin­ ation is taken. Successful completion of training leads to the award of a fellowship and the holder is entitled to apply for specialist registration.

9.26 The colleges, while laying down standards, play varying roles in the educative process. All exercise supervision over the accreditation of hospital appointments. All conduct their own examinations. But the extent of formal tuition varies and it is mainly done by other bodies, such as the Postgraduate Committees (which include representatives of the hospitals, the universities, the colleges and the Australian

Medical Association) which utilise university and hospital staff members for lectures, tutorials and seminars. With the increasing complexity of medical specialties, the advanced training courses have been drawing more and more heavily on the full-time

academic and hospital staff with their greater expertise in medical science. It seems clear that these advanced courses are now so complex that formal university involve­ ment is unavoidable. Four universities have made submissions to the Australian Universities Commission along these lines in the past.

9.27 In the light of the administrative and other facilities of the colleges, any attempt to increase their involvement so that they become self-sufficient in advanced training would be very expensive. The university medical departments, being already heavily committed in this area, could assume more responsibility if funding were adequate.

9.28 A proposal for a postgraduate diploma in clinical science is under discussion at one university. The object of the course is to give formal tuition in anatomy, biochemistry, physiology and pathology of a more advanced nature than in the undergraduate curriculum, as they relate to the practice of the particular branches

of clinical medicine. Such a course would be a substantial part-time one with the

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formal commitment of university teachers, especially in the pre-clinical and para- clinical areas.

9.29 Postgraduate Committees. There are ten postgraduate committees in the States and Territories of Australia. All except two, in Melbourne and the Northern Territory, are based on universities through their establishment by authority of the governing bodies of the universities. Each is composed of representatives from the various bodies concerned with medical education; the faculty or teaching staff of the university, the professional colleges, the teaching and affiliated hospitals, the local branch of the Australian Medical Association and members of the medical profession involved in postgraduate teaching. The Postgraduate Committees, together with the Australian

Medical Association, professional colleges, universities and medical professional societies are members of an incorporated body known as the Australian Postgraduate Federation in Medicine, which acts at the federal level to co-ordinate the activities of the postgraduate committees and to meet and discuss the wider aspects of post­ graduate education. Many of these postgraduate committees have been operating for more than 40 years and have made a significant contribution, not only to the continu­ ing education of the practising doctor, but also to vocational education and to the

development of improved standards of health care in the community. In discussing the role of the universities and professional colleges in the sphere of medical education the Committee is mindful of the contribution which must be made by the postgraduate committees acting in conjunction with the universities and professional colleges.

9.30 Courses of instruction for vocational training are conducted variously by these postgraduate committees. If universities were to offer formal courses leading to diplomas or degrees, funding through the Australian Universities Commission could occur in the normal way. In the Committee’s view, the maintainance of high quality specialist training will require in the future the increasing involvement of medical schools and the Committee believes that universities should be financed accordingly. It recognizes that courses conducted for the diplomas of the professional colleges have hitherto not

been recognised by the Australian Universities Commission for funding purposes and appreciates that it may be undesirable for them to be so. However, in its opinion, the Commission should give further consideration to the extent to which tuition connected with vocational training should or could be recognised.

9.31 Continuing Education and Refresher Courses. The present expansion of medical knowledge is likely to continue. Certification as a specialist or practitioner in 1973 is unlikely to ensure competence in 1993, without further study and continuing edu­ cation. The post-graduate committees in medicine have long accepted this challenge, and have offered refresher courses for practitioners in many branches of medicine. The colleges themselves have fostered the concept of continuing education by scientific meetings. The Royal College of Obstetricians and Gynaecologists, in addition to its regular scientific meetings, has conducted an advanced course for its members, and is planning to offer further courses at regular intervals.

9.32 The responsibility for continuing education must lie with the individual, so it is reasonable that post-graduate committees and colleges should depend on their members for finance for this aspect of their work. Nevertheless, the administrative costs are considerable and some government contribution towards overheads may be desirable.

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TEACHING HOSPITALS AND MEDICAL SCHOOLS N a t u r e o f T e a c h in g H o s p it a l s

9.33 Teaching hospitals differ from non-teaching hospitals basically because they are responsible for giving the undergraduate medical student his clinical education. This requires that the medical staff, visiting and full-time, combines excellence of teaching with outstanding clinical ability. To do so, a medical teacher must maintain a high

standard of professional skills and scholarship to cope with the exacting task of responding appropriately to the quest for knowledge and also of providing the explanations demanded by the medical student. The corollary of this is that a much higher quality of professional capability is demanded of both the visiting and full-time specialist or resident medical staff; this leads to the development of special medical

services not usually found in the non-teaching hospitals where the emphasis is on individual care of the particular staff member’s patients. In addition, the full-time clinical specialist and the full-time academic often devote a substantial proportion of their time to medical research. This may be clinical or fundamental research.

Indeed, some full-time specialists and academics are solely concerned with research and not with the clinical care of patients.

9.34 In this medical climate, the hospital departments of pathology, including biochemistry, microbiology, haematology, serology and morbid anatomy, together with radiology, radiotherapy, and nuclear medicine are highly developed as an aid to clinicians. These departments also support or develop their own research interests.

9.35 The sum total of this knowledge and medical excellence determines the reput­ ation of the teaching hospital and its ability to attract high quality medical staff. It also determines its ability to attract medical students to the hospital clinical school, and resident and registrar staff to the post-graduate education programme. In its

turn, this raises the quality of the nursing and paramedical services in a teaching hospital to a level seldom found in a non-teaching hospital. Generally, standards of practice throughout the teaching hospital are much higher than in a non-teaching hospital. It should be borne in mind that the very sophisticated specialties cannot

function in isolation nor will specialists in the broader based medical disciplines find the same stimulus outside the teaching hospital unless the hospital is near, or in excess of, the 500 bed level and a substantial post-graduate teaching programme has been developed.

A d m in is t r a t io n o f H o sp it a l s

9.36 In addition to a well organised administrative staff, the teaching hospital requires clearly defined objectives and a good understanding of the primary roles of the hospital (patient care) and of the medical school (student teaching). The board of a hospital requires adequate representation of all related interests, e.g. the government, the

consumer, the university, the medical staff and administration, to ensure a proper balance between patient care, teaching and research. The appointment of a medical staff to meet these needs requires a Medical Staff Appointments Advisory Committee with adequate university representation or a conjoint Board of the Hospital and the

University.

9.37 For the hospital to discharge its undergraduate teaching role, a clinical school or faculty is necessary to organise the medical staff of the hospital to meet the curri­

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culum requirements of the medical school and to carry out clinical teaching in the wards and ambulatory care departments of the hospital. Whilst the chief executive officer of the hospital must necessarily be involved, the director of medical services (medical superintendent) is the full-time hospital officer responsible for hospital administration aspects. In some hospitals separate boards of studies exist for both undergraduate and post-graduate programmes.

9.38 The Australian Universities Commission makes grants to provide adequate facilities to enable teaching to be properly carried out and this requires teaching side rooms, lecture and study rooms and examination areas together with student living-in accommodation, change and locker rooms, and common rooms. Adequate facilities in the form of administrative offices, research laboratories and animal houses are required for the professorial and other academic university staff. Submissions from student associations were critical of inadequate facilities in many hospitals, especially as regards library and study areas.

9.39 Where a teaching hospital has an association with a district or community hospital affiliated with the medical school of a university, there needs to be an admin­ istrative link between the two with accreditation in the affiliated hospital of the tutor medical staff of the teaching hospital. If cross accreditation is possible, this is desirable. Where the resident medical staff establishments of the hospitals can be amalgamated and the appointments can be made to the staff of the teaching hospital with rotation through the affiliated hospital, great benefits accrue to patient care and to the medical staff of the affiliated hospital.

R e l a t io n b e t w e e n S t a f f s o f M e d ic a l S c h o o l a n d H o s p it a l

9.40 From a university viewpoint, it might be argued that the ideal administrative arrangements between a university and a teaching hospital would be either for the university to be responsible for the administration of the hospital and appoint the hospital board or for an independent hospital board to accept the principle of academic headship of the hospital medical departments. The latter occurs in some teaching hospitals in Australia. In the newly planned hospitals at Flinders and Westmead, agree­ ment on such an arrangement has been reached between the State and the universities concerned. In these hospitals the professorial department in each major discipline will be responsible for the provision of patient care, teaching and research. In these two cases, the professor will be the academic and clinical head of his department and will have divided responsibilities. He will be directly responsible to the director of medical

services of the hospital board for clinical work in the hospital and to the dean of the faculty of medicine for the teaching function of the university.

R o le o f T e a c h in g H o s p it a l s

9.41 Until recently, the central teaching hospital has been the only place in which clinical teaching has been conducted. However, because of the lack of patients with disorders suitable for teaching, many universities now send students to peripheral hospitals. In addition, students are rostered to general practices. A number of sub­ missions received suggested that, as a result of the use of community hospitals, community health centres and group practices, the place of the teaching hospital in medical education could become less important. On the other hand, the submission

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from the Association of University Clinical Professors of Australia re-emphasised the essential role of the central teaching hospitals.

9.42 Although some aspects of medical training and research must move into the community, this is not a reason for playing down the role of the teaching hospital. Without a scientific basis, medical practice is inept, pragmatic and potentially dangerous. There is no place where a proper scientific basis can be taught better than

in a teaching hospital. Careful observation and investigation of patients both by day and by night, controlled medication or operative procedure, noting of after-effects and effective rehabilitation to a reasonable level of activity before discharge from hospital, all demonstrate the best of medical practice to students and young doctors.

The only deficiency of such teaching lies in the lack of communication with the past and future of the patient, his history and management before admission and his progress to full normal activity at home after treatment. Too often hospitalisation is, for the student, an isolated episode, necessary but traumatic in its effect on the

patient, with the result that the student comes to regard the patient as a case and not a person.

9.43 Where good liaison exists with local practitioners the previous history of patients is provided. Where good aftercare services exist the student may see the patient in his own surroundings and follow him to complete cure. For the student, the failure of the hospital is in its follow-up, in that he sees only a segment of the

medical care; for the patient, the failure of the hospital may be in its impersonality and remoteness, whereby he appears to be an illness and not a person. The develop­ ment of community links with a teaching hospital is therefore vital. The pilot studies of some hospitals in after-care and the liaison of others with community health centres

should prove these points and become models for their extension.

9.44 Another aspect of teaching hospitals is their development of ‘super specialties’, some of which may have an ivory tower tendency. One way of improving the hospital’s role and maintaining community links would be to develop associations with a group of peripheral hospitals, where general management is the normal event and patients

requiring specialised treatment are referred to the main teaching centre. It is important to emphasise that the development of super specialties is not necessarily a concomitant of a hospital’s teaching functions. In any major centre of population, irrespective of the requirements of medical education, a sophisticated central hospital has to be

provided, if the community is to receive modern medical attention.

SELECTION OF MEDICAL STUDENTS 9.45 Selection of students for admission to medical schools in Australia is at present based almost wholly on academic merit as measured by an aggregate of marks obtained at matriculation examinations or at university examinations at the end of

the first year of a science course. In discussions with the Committee, this method was frequently criticised, particularly by members of the medical profession, for placing too much emphasis on academic achievement at school and ignoring motivation, aptitude, or other attributes which might contribute to the production of an effective

doctor. Moreover, it was argued that the method of selection was particularly biased in favour of able students who had studied mainly science subjects at school and that such students were more likely to be interested in research and specialties rather

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than in general practice. The total effect of present selection methods was to favour ‘clever’ young men and women and these did not necessarily make the best doctors.

9.46 There has been a good deal of research in Australia on the effectiveness of present selection methods. This has shown that, for university courses in general, selection on the basis of school leaving results, while by no means a perfect predictor of success at university, is nevertheless the best predictor available and there is as yet no evidence that there are simple ways of improving it. The failure rate in medicine is very low and most attrition is due to non-academic factors. If the efficiency of a selector is measured by success at the university, the present methods of selecting medical students must be deemed to be successful. However, the Committee recog­ nises that there are many factors other than sheer academic success which contribute to a person’s being a good doctor. On the other hand, the Committee would not accept the view, which was put to it on a number of occasions, that ‘clever’ young men and women are not the best to be selected for a medical course. The medical profession involves complex knowledge and an analytical ability of high order and it is difficult to see how high quality medical services can be provided without making use of intellectually able people.

9.47 It is, of course, impossible to prove that other methods for selecting students would provide better doctors. Nevertheless Australian medical faculties have been concerned for some time that their selection of students relies so heavily on a single criterion. Alternative criteria for selection include academic reports from the candi­ date’s secondary school, secondary school reports on non-academic activities of the candidate (e.g. sporting and cultural activities, personality characteristics), interviews, psychological and aptitude tests and random selection. The latter two can operate objectively but school reports and interviews involve a significant subjective element. One of the great advantages claimed for the current method is that once the examin­ ations have been marked, the rank order of candidates is quite objective and known to be independent of personal influence.

9.48 School reports are used in many medical schools overseas and at least one medical faculty in Australia has considered the use of such reports for candidates near the borderline of entry. It is argued that the aggregate of marks at matriculation examinations does not have such a high degree of reliability as to be precise to the last mark, so that candidates within, say, plus or minus ten marks of the cut off point, are being included or excluded on almost a chance basis. The use of school reports as additional evidence for such candidates would produce a fairer and more sensitive method.

9.49 The question of whether non-academic considerations should be taken into account is, of course, debatable and is one of the main arguments against the use of interviews. These are used extensively in the United Kingdom and the United States, especially for borderline candidates. There is, however, considerable doubt as to their validity. There is no clear evidence that the interview is an effective selection procedure and it is now generally believed that interviews tend to place too much emphasis on irrelevant personality characteristics. They certainly are more favourable to students with higher socio-economic backgrounds. The Committee found no

substantial support for interviews during its discussions with representatives of medical schools.

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9.50 Psychological and aptitude tests are used for entry to American medical schools, but the Committee was told that there were now doubts as to the value of such testing. It was told that extensive investigation in the United States had shown no significant differences in the effectiveness of doctors selected by different criteria,

including aptitude tests. This is not surprising when one considers that whatever the tests, admission to medical schools is highly selective and for candidates of such high quality the various criteria are likely to be highly correlated.

9.51 A recent report on post-secondary education in Ontario, Canada, recommended that professional schools should admit a representatives cross section of Ontario students and that steps to achieve this should include ‘admission on the basis of a random selection among qualified applicants whose aptitudes and attainments indicate a reasonable probability of success’1. It is certainly true that random selection would

increase the heterogeneity of the student body, although the extent to which it would do so would depend on the composition of the pool of students regarded as being qualified for medical studies. It is important to emphasise that the definition of ‘qualified applicants whose aptitudes and attainments indicated a reasonable pro­

bability of success’ itself involves the use of selection criteria. If the definition were very broad (for example every person over the age of, say, 20 years) then hetero­ geneity would be greatly increased but at the cost of selecting very many people who would be unable to cope with a medical course. Another major difficulty with random

selection is that the psychological consequences of determining a person’s future by a lottery are likely to be adverse. It may be true that there is an element of chance in a borderline student’s obtaining admission at a medical school, but nevertheless the present method of selection ensures that admission depends, in general, upon

achievement.

9.52 The present selection arrangements make it difficult for older men and women to take up medicine. A small proportion of applicants to the medical course consists of older persons who have begun some other career, and later been attracted to medicine. When these students are admitted, they usually do well in their studies and

in their later vocation. Selection is difficult, but the Committee considers that some places might be reserved for such applicants. Medical faculties should consider to what extent bridging courses should be provided for each individual in order to give maximum credit for studies in disciplines cognate to pre-clinical subjects.

PHYSICIAN ASSISTANTS

9.53 As a solution to the apparent increasing shortage of general practitioners, it is sometimes proposed that a new category of health professional — a physician- assistant — should be introduced. The objective of the innovation would be to train health professionals who could carry out many traditional functions of the general

practitioner under the direction and supervision of a physician, thereby extending the physician’s coverage to a greater patient population. It is held that such personnel could be trained more quickly and therefore at considerably less cost than the present medical graduate.

1 The Learning Society, Report of the Commission on Post-secondary Education in Ontario, 1972, Recom­ mendation 65.

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9.54 In the United States of America, a physician-assistant (now termed ‘physician- associate’) programme has been operating at Duke University since 1965. It was introduced initially to utilise the services of Vietnam veterans who had received basic medical training for use in the field. Specifically, physician-associates are taught to elicit detailed patient histories, perform comprehensive physical examinations and collect and interpret data from intricate technical procedures including gastric analyses, venous and arterial punctures, bone marrow examinations, lumbar punc­ tures, pulmonary function studies, and electrocardiographic tracings. In addition, physician-associates provide patient care services such as cast application and removal, wound suturing, dressing changes, after-hours laboratory studies, and assess­ ing and monitoring the progress of patients.

9.55 It is claimed that, with the physician-associate performing tasks and providing services that do not require the physician’s sophisticated background, the physician’s career is more challenging and stimulating. In addition, the productivity of the doctor is raised and a larger population base can be served. Other less highly trained physician-assistants are also used in the United States of America.

9.56 The idea of the physician-assistant as an addition to the range of health per­ sonnel available in Australia was raised during discussions with universities, State Governments, Royal Colleges and other interested organisations or persons. Gener­ ally, there was little enthusiasm for the idea in any quarter. There was a general feeling that, in Australian conditions, with the traditions of the “bush” nurse and the

‘district’ nurse, specially trained practice nurses would provide an appropriate back-up to doctors.

9.57 There is little doubt that trained medical assistants can fulfil a useful role, both for routine duties and for first aid. The sterling service of bush nurses in the outback is an example of this. Rather than set up a second university programme for assistant doctors, the Committee favours offering a graduate training programme to registered nurses, to fit them for more responsible tasks and to act as assistants to doctors in practice. The title ‘practice nurse’ might be appropriate. Their graduate education, being paramedical in type, would best be given in association with medical schools and teaching hospitals. This is the case whether the course is under the aegis of a university or a college of advanced education. The Committee envisages the practice nurse as working in a group practice or community health centre, or making routine follow-up domiciliary visits, performing minor check ups in the consulting rooms and reporting to medical colleagues as required. She (or he) would be a person with much more training and experience than nurses presently employed in doctors’ rooms.

FINANCING OF MEDICAL SCHOOLS 9.58 During discussions with university representatives, the Deans of two medical schools submitted that the clinical components of the medical school should be financed separately, preferably through the Commonwealth Department of Health, rather than through the Department of Education on the recommendation of the Australian Universities Commission. The arguments in favour of this proposal were that the clinical side of medical education imposed very heavy costs on universities and thereby produced an imbalance in their budgets, that the clinical departments had difficulty in persuading their colleagues to yield to them a ‘proper’ share of

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university resources, since their colleagues did not understand the additional respon­ sibilities of clinical departments, and that it would be administratively simpler to integrate the costs of running clinical teaching with those of patient care within the hospital.

9.59 After this matter had been raised, the Committee canvassed it with the Deans of other medical schools, Vice-Chancellors and State Departments. It is important to emphasise that the view expressed in the preceding paragraph is by no means universally held and that a number of medical Deans are opposed to a transfer of

the financing of clinical teaching in the way suggested. It is certainly the case that most university Vice-Chancellors are unenthusiastic about the proposition.

9.60 One strong practical argument against such a transfer of financial responsibility is that it would make more difficult the vertical integration of clinical and pre-clinical work. Pre-clinical departments typically teach a substantial number of non-medical students and there could be no question of their being financed other than in the

ordinary way. If the clinical work were to be financed separately, the co-ordination of pre-clinical and clinical work in an integrated teaching programme would become difficult.

9.61 However, in the Committee’s view, there are more important objections of principle. The first is that the medical school has essentially a teaching and research function which should be kept separate from the service function of hospitals. It is

an educational responsibility and ought to be regarded as a normal part of a univer­ sity. The costs of medical education that are imposed on the university are not greatly different from the costs imposed by other scientifically or technologically based pro­ fessional faculties. The relatively high cost of training medical students is due to the additional costs incurred in hospital teaching and these are already borne by health

or hospital departments. In the Committee’s view there ought to be one source of permanent finance for all university activities, including medicine, and that should be through the channels of the Australian Universities Commission.

9.62 Secondly, if the financing of clinical university departments were to be related to hospital finance, there would be a considerable risk that the departments might lose a great deal of their independence and might become very much a part of the hospital operation. It seems to the Committee, that at a time when a deliberate effort

is being made to remove the training of teachers from the control of the principal employing authorities, it would be anomalous to move in the opposite direction as far as the training of medical practitioners is concerned. The quality of medical training is much more likely to be guaranteed by independent medical schools than

by schools dependent financially on health or hospital authorities.

PARAMEDICAL EDUCATION

9.63 Universities in Australia have always been involved in some paramedical studies. However, in 1964 the Martin Report1 recommended that paramedical studies should generally not be undertaken at universities (see Chapter 13 of that Report). Since then some universities have arranged for the transfer of diploma courses to

1 Committee on the Future o f Tertiary Education in Australia: Vol. II, Commonwealth of Australia, August 1964.

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colleges of advanced education and others have raised diploma courses to degree standard. At present degrees are offered in pharmacy in two universities, and in physiotherapy, occupational therapy and speech therapy in one university. In the last few years the main developments in paramedical studies have taken place in colleges of advanced education.

9.64 A number of the submissions received by the Committee emphasized the importance of training paramedical workers in the same environment as medical students and at least two of the newer universities envisage the development of faculties of health science. The Committee certainly supports the view that there would be advantages in health personnel being trained together so that they will more easily work together in their professional lives. It considers that, since teaching hospitals will be the main areas for practical work in many fields, it should be possible for personnel of varying kinds to be trained together even though they are attached to different educational institutions. It is therefore not suggesting a reversal of developments which have taken place since the Martin Report. However, in the light of developments in health care since the completion of the Martin Report and of likely future trends, for the future it would see merit in some universities involving

themselves directly in the training of paramedical personnel. From the point of view of the training of medical undergraduates in an appreciation of the role of para­ medical disciplines, contact with fully qualified paramedical personnel in the hospital environment would be beneficial.

RESEARCH INTO HEALTH ADMINISTRATION

9.65 In a number of the submissions to the Committee, reference was made for the need to undertake research into the delivery of health care, and into health manpower and health administration. In particular, four universities suggested that research units should be established either within universities or as government agencies. The Committee has no doubt as to the importance of these proposals. It understands that the National Hospitals and Health Services Commission is taking a particular interest in this area. The Committee suggests that that Commission and the Australian

Universities Commission should consult on proposals for the establishment of such units.

9.66 The Committee has found its own work greatly handicapped not only by the lack of research into many aspects of health administration in Australia but also by the paucity of information on medical manpower. There would be few people, outside those who have worked in the field of medical manpower, who would realise the great difficulties in obtaining an accurate count of the number of active medical practi­ tioners of various kinds in various areas in Australia. The situation is even less satisfactory for other branches of health personnel, for example, nurses. Since basic data are a prerequisite for any research into health administration matters, the Committee suggests that the Australian Government should attempt to obtain the agreement of the State Governments to the filling in of standard statistical forms by medical practitioners on annual re-registration. Such forms are already used by some

State medical registration boards, but to provide useful statistics for Australia there would need to be a core of standard questions in all States and Territories, and non-138

respondents would need to be followed up thoroughly. Given basic data, more detailed information about medical manpower could be sought on a sample basis.

CONCLUSIONS

9.67 The history of medical education in Australia has been a mixture of expediency and design. Clinical teaching has been carried out mainly by honorary teachers, even into recent years when full time academic departments had become the rule. With the exception of the two new hospitals and clinical schools (Flinders and Westmead)

in which joint university-hospital planning has been undertaken from the outset, there is a dichotomy of interests in teaching hospitals which can and does lead to conflicts and inefficiencies of management, particularly in regard to education.

9.68 The Committee firmly believes that, in the interests of achieving high standards of medical education, joint committees of university and hospital management should control the appointment of clinical medical staff in teaching hospitals in respect of both patient care and teaching, where this does not already exist. Wherever

necessary, all medical staff should have responsibilities for service and teaching and these should be designated at the time of their appointment. In order to preserve the autonomy of medical schools, they should continue to be funded through the Austra­ lian Universities Commission.

9.69 The organisations involved in the total field of medical education are the universities, hospitals, professional colleges and postgraduate committees. Fragment­ ation of activities due to multipartite responsibilities leads to gaps, redundancies and inefficiencies. Proper integration with a planned educational programme from first

year undergraduate studies at university to full specialist training is essential. Since the universities are necessarily involved in undergraduate and some postgraduate training, it would seem logical for university departments to be involved formally in training courses to advanced levels. The standards laid down by professional colleges

would be the basis for such courses.

9.70 Continuing education (or refresher courses) to up-date knowledge in a specialty should be the responsibility of the professional body concerned, or of university departments of continuing education, where these exist. Some postgraduate com­ mittees are strong enough to stand in their own right, but others might merge with

departments of continuing education.

9.71 Many specialties feel that teaching in their branch is under-represented in the undergraduate curriculum. This view stems from the old responsibility of the doctor to be competent in all branches of medicine on registration for practice. This is no longer possible and a limited introduction to basic principles is all that is required,

the technical minutiae being absorbed later if that specialty, or a cognate branch of medicine, is the chosen vocation. However, some areas of medicine are under­ represented in the undergraduate curriculum. These are clinical pharmacology, community medicine, and geriatrics; and special funding may be necessary to allow

their introduction.

9.72 The role of the general practitioner is likely to remain a key one in the delivery of health care in Australia. There is, however, the question of maintaining a sufficient

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flow of young graduates into general practice. The development of community health centres or group practices in which the health team, including general practitioners and paramedical personnel, can operate, offers the best prospect of maintaining an appropriate number of general practitioners. In these arrangements, the practice nurse will play an important role. It is envisaged that she (or he) would receive special graduate training. There is no question that in the Australian environment the practice nurse would gain an acceptance which is unlikely to be accorded a newly created vocation such as that of physician-assistant.

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APPENDIXES

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APPENDIX A

FORM OF ADVERTISMENT INVITING SUBMISSIONS

COMMONWEALTH OF AUSTRALIA

COMMITTEE ON MEDICAL SCHOOLS

The Minister for Education and Science has appointed a committee of the Australian Universities Commission with the following terms of reference:

to enquire into and make recommendations to the Australian Universities Com­ mission on the need for new or expanded medical schools in the light of likely trends in the delivery of health care in Australia over the next twenty years.

In assessing the needs for medical practitioners in the future, the Committee will have regard to possible changes in the type of health services available to the com­ munity and in the nature of the training of medical students.

Interested persons and organisations are invited to make written submissions relevant to the above matters.

Notice of intention to make a submission together with a brief outline of topics to be covered in it should be sent to the Secretary, Australian Universities Commission, P.O. Box 250, Canberra City, A.C.T. 2601 by 31 July 1972. Submissions should be forwarded in time to reach the same address by 30 September 1972.

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APPENDIX B

ORGANISATIONS AND INDIVIDUALS WHO MADE WRITTEN SUBMISSIONS TO THE COMMITTEE

ORGANISATIONS

Adelaide Medical Students’ Society Association of University Clinical Professors of Australia Australasian College of Dermatologists Australasian Medical Students’ Association

Australasian Society of Clinical and Experimental Pharmacologists Australian Association of Neurologists, Committee for Education and Recreation Australian Association of Surgeons Australian College of Allergists, Scientific Sub-Committee

Australian College of Medical Administrators Australian College of Ophthalmologists Australian Council of Social Service

Australian Federation of Medical Record Librarians Australian Hospital Association Australian Medical Association Australian Medical Librarians’ Group

Australian National University Australian Physiological and Pharmacological Society Australian Society of Occupational Medicine Australian Vice-Chancellors’ Committee

Ballarat Mayoral Sub-Committee on Medical Education Brisbane Water District Medical Association

Central Medical Library Organization Central Northern Medical Association Commonwealth Department of Defence Commonwealth Department of Health

Council of the City of Newcastle

Department of Pharmacology, University of Melbourne Department of Physiology, Monash University Departments of Surgery, University of Melbourne and Monash University

Flinders University of South Australia

Government of New South Wales Government of Queensland

143

Government of Tasmania Government of Western Australia Griffith University

Illawarra Region Health Committee

James Cook University of North Queensland

La Trobe University Lewisham Hospital Liberal Party of Australia, Newcastle Branch Liberal Party of Australia, New Lambton Branch Lions International, District 201D

Macquarie University Maitland Hospital Medical Education Committee of the University of Queensland Medical Society Melbourne Medical Post-Graduate Committee Mental Health Authority of Victoria Mental Health Services Commission, Hobart Monash University Murdoch University Planning Board

Newcastle Chamber of Commerce Newcastle Mater Misericordiae Hospital Newcastle Western Suburbs Maternity Hospital

Professors of Pathology of the Nine Universities with Medical Schools

Royal Australasian College of Physicians Royal Australasian College of Radiologists Royal Australasian College of Surgeons Royal Australasian College of Surgeons, Faculty of Anaesthetists Royal Australian College of General Practitioners Royal Australian College of General Practitioners, Tasmanian Faculty Royal Australian Nursing Federation Royal College of Obstetricians and Gynaecologists Royal College of Pathologists of Australia Royal Flying Doctor Service of Australia Royal Newcastle Hospital Royal Victorian Eye and Ear Hospital Repatriation Commission

Small Towns Action Group — Murtoa, Victoria

University of Adelaide University of Adelaide, Dental School University of Adelaide, Post-Graduate Committee in Medicine

144

University of Melbourne University of Newcastle University of New South Wales University of Queensland

University of Sydney University of Tasmania University of Western Australia, Faculty of Medicine

Wallsend District Hospital Western Australian Tertiary Education Commission Wollongong Hospital Wollongong University College

Wollongong University College, Students’ Representative Council

INDIVIDUALS

Baillie, J., Victoria Bethune, D. E., Victoria Burke, Frances T., Tasmania Dunn, Rodger, South Australia

Fraenkel, Professor G. J. Friend, Dr K. J., Tasmania Gordon, Professor D., Queensland Howard, Merle, Victoria

Keeson, G. W., New South Wales Korner, Dr N. H., New South Wales McLean, Dr A. G., Victoria Menzies, G. C., New South Wales

Morley, Dr A., South Australia Murrell, Dr T. G. C., South Australia Pacy, Dr J. R., New South Wales Richards, Dr W. T., Victoria

Rudge, B. A., New South Wales Schneider, Μ. P., Victoria Simpson, Μ. E., Victoria Simpson, R. A., South Australia

Stoutjesdijk, Dr A. D. J., Victoria Scragg, Professor R. F. R., New Guinea Tatz, Professor C. M., New South Wales Williams, Dr J. F., Victoria

145

APPENDIX C

LIST OF ORGANISATIONS AND INDIVIDUALS WHO APPEARED BEFORE THE COMMITTEE

Australian Commission on Advanced Education:

Australian Medical Association:

Australian National University :

Australian Vice-Chancellors’ Committee

Canberra Hospital:

Central Northern Medical Association:

Commonwealth Department of Health:

Commonwealth Department of Social Security:

Flinders University of South Australia:

Government of New South Wales:

Government of Queensland :

Government of South Australia:

Government of Tasmania:

Griffith University:

Mr T. B. Swanson, Dr E. S. Swinbourne

Dr E. S. Stuckey, Professor W. B. Macdonald, Dr J. R. Magarey.

Professor Sir John Crawford, Dr.R.M. Williams, Professor D. N. F. Dunbar, Professor F. J. Fenner, Professor Η. M. Whyte.

Sir George Cartland, Professor Z. Cowen, Professor D. P. Derham, Dr J. A. L. Matheson. Professor R. F. Whelan, Mr F. S. Hambly.

Dr T. Sale, Dr B. Bailey, D r P. Brady.

D r A. D. Hewson, Dr K. L. Cocking, D r P. V. Lightfoot, Dr R. M. Mills, Dr A. L. A. Reid, Dr A. R. G. Watson.

Sir William Refshauge, Mr M. Carroll, M r P. Pflaum, Dr R. Wells.

M r D. Corrigan, Dr J. S. Deeble, D r R. B. Scotton

Professor R. W. Russell, Professor G. J. Fraenkel, Dr A. Kerr-Grant.

The Hon. E. A. Willis, the Hon. A. H. Jago, M r P. Correy, Mr H. L. Craig, Mr A. G. Day, M r W. Henry, Dr H. Selle, Dr D. Storey, M r M. Totterdell.

D r P. R. Patrick, Mr R. H. Fields, Dr O. W. Powell.

Mr Justice Bright, Dr B. Shea, Mr J. Blandford, Dr P. Last, Mr C. Rankin.

Mr L. V. Beilis, Mr K. J. Binns, Mr D. R. Goodwin, Dr J. F. Lawson, Dr J. R. MacIntyre.

Professor F. J. Willett, Mr T. C. Bray, Professor R. D. Guthrie, Professor S. Lipton, Professor C. W. Rose, Mr J. Topley, Mr W. Wood.

146

Hospitals & Charities Commission of Victoria:

Illawarra Region Health Committee:

Interim Committee on Hospitals and Health Services:

Mr A. J. McLellan, Dr E. Wilder

Professor K. A. Blakey, Mr K. Bond, Dr W. Corliss, Mr J. C. Steinke.

Dr S. Sax

James Cook University of North Queensland:

La Trobe University:

Macquarie University:

Dr K. J. C. Back, Professor R. S. F. Campbell, M r E. A. Dews, Professor G. N. Richards, Mr G. V. Roberts, Professor R. Sussex.

Dr D. M. Myers, Professor S. P. Burley, Professor D. Elwyn Davies, Professor R. J. Goldman, Professor P. A. Parsons, Professor J. A. Salmond, Miss D. Sherwin, Professor

G. Singer, Mr G. Stecher, Professor B. A. Stone, Major General T. S. Taylor.

Emeritus Professor A. G. Mitchell, Dr S. W. Cohen, Professor P. Mason, Professor S. Mercer, Professor H. W. Philp, Professor A. H. Pollard, Professor A. J. Rose, Professor G. B. Sharman, Professor I. K. Waterhouse.

Monash University:

Murdoch University Planning Board:

Queensland Branch of the Australian Medical Association:

Dr J. A. L. Matheson, Professor R. Andrew, Professor J. Bornstein, Professor A.C.L. Clark.

Professor S. Griew, Mr D. D. Dunn, Sir Stanley Prescott.

Dr J. Lee, Dr. A. G. Biggs, Dr J. G. Ryan.

Royal Australasian College of Physicians

Royal Australasian College of Surgeons:

Royal Australian College of General Practitioners:

Dr B. Hudson, Dr R. H. Mulhearn

Professor J. Loewenthal, Mr E. S. R. Hughes, Mr B. Morgan.

Dr F. Farrar, Dr N. A. Andersen, Dr R. F. Harbison, Dr J. G. Radford.

Royal Australian Nursing Miss Joan Godfrey, Miss Mary Patten. Federation:

Royal College of Obstetricians and Gynaecologists:

Royal Newcastle Hospital:

Townsville General Hospital:

Mr I. A. McDonald, Mr F. M. C. Forster, Dr Barry Kneale.

Dr E. G. Currow, Dr J. M. Duggan, Mr J. Η. M. Evans, Dr A. D. Hewson, Mr T. A. Loveday, Mr J. M. Monteath, Professor B. Nashar, Dr T. J. Woolard.

Dr D. P. Bowler, Mr J. E. Barnes, Dr R. A. Douglas, Mr F. J. Henderson, Dr N. R. Scott-Young.

147

Townsville Local Branch of the Dr A. D. Campbell, Dr I. Dickson, Australian Medical Association: Dr R. A. Douglas, Dr K. L. McLachlan,

University of Adelaide:

Dr J. Morrissey, Dr A. H. Murphy.

Emeritus Professor G. M. Badger. Dr R. A. Burston, Professor D. J. Deller, Mr V. Edgeloe, Professor A. M. Horsnell, Dr C. L. Kimber, Professor J. Ludbrook, Professor J. Priedkalns, Professor D. Rowley.

University of Melbourne: Professor D. P. Derham, Professor D. E. Caro, Professor J. R. Poynter, Professor L. J. Ray.

University of Newcastle: Professor J. J. Auchmuty, Professor B. Boettcher, Professor E. 0 . Hall.

University of New South Wales: Professor F. F. Bundle, Professor J. B. Hickie, Professor G. D. Tracy.

University of Queensland: Professor Z. Cowen, Professor W. Burnett, Professor D. Gordon, Mr D. G. Greenwood, Dr D. A. Henderson, Professor G. S. Molyneux, Dr S. A. Rayner, Professor E. G. Saint, Emeritus Professor E. C. Webb.

University of Sydney: Professor B. Williams, Professor D. Maddison, Dr Godfrey Scott.

University of Tasmania: Sir George Cartland, Professor A. F. Cobbold, Mr D. A. Kearney, Professor R. M. Mitchell, Mr N. D. West.

University of Western Australia: Emeritus Professor R. F. Whelan, Mr R. Angeloni, Professor A. F. J. Boyle, M r J. A. Crawley, Associate Professor M. Hobbs, Professor R. A. Joske, Professor G. G. Lennon, Dr E. H. Morgan, Professor D. J. Payne, Mr N. C. Rees, Mr N. S. Stenhouse.

Western Australian Department of Health:

Wollongong Hospital:

Dr W. S. Davidson, Dr Marlene Lugg.

Dr I. Dixon, Dr R. Boden, Dr W. Corlis, Mr K. Davis, Dr M. Diment, Dr B. Knott, Dr P. Mowbray, Dr J. Pickering, Mr T. J. Wren.

Wollongong University College: Professor C. A. M. Gray, Dr B. S. Hillier, M r D. E. Parry, Professor B. Smith, M r R. Stewart.

148

APPENDIX D

STATISTICAL APPENDIX

S o u r c e s o f D a t a

D. 1 Censuses. The population censuses are the main source of statistics illustrating trends in manpower over a period of time, and providing dissections by sex, age, occupational status, industry etc.. In Scotton1 statistics on the numbers of medical practitioners enumerated at the Censuses from 1933 to 1961 are set out, for each

State, showing also the number of medical practitioners in private practice and in metropolitan and country areas, the latter being partly estimated. Figures for 1954 in Scotton’s table were estimated by him using unpublished official figures, as statistics of occupations were not published for that Census. In this report the Census figures

are drawn from those presented by Scotton, updated to include the results of the 1966 and 1971 Censuses.

D .2 Medical practitioners, like other members of the work force, are enumerated at the Census according to their physical whereabouts on Census night, and they are counted in the work force according to their own description of their activities. Since the 1966 Census, stated qualifications have been used in checking the coding of

doctors. Part-time practitioners are not excluded, unless they report that their main occupation is something else. Medical graduates teaching in the medical faculties of universities are believed to be understated in the Censuses, as they may have tended to record themselves as university lecturers or professors. Medical officers in the

armed forces also appear to be understated. A third source of understatement is temporary absence overseas of doctors on Census night; this is not offset by temporary presence of overseas doctors visiting Australia as these are excluded from the work­ force. Adjustments have been made in this report for these three types of understate­

ment for 1961, 1966 and 1971. In earlier Censuses the understatement is probably not important enough to prevent the Census series from being used as an indicator of trends.

D. 3 The Census has tables of doctors by ‘industry’, but does not distinguish between general practitioners and specialists.

D . 4 Medical Registers. The numbers on the register can be used as an upper limit in the estimation of medical manpower, and as a source of coverage in surveys. However, there is considerable duplication of names in the register, through doctors being registered in more than one State, and many registrations are maintained by

doctors who are quite inactive in the profession or are practising outside the country.

D .5 In all States, but not the Territories, annual re-registration is now compulsory, and the New South Wales and Victorian registration boards send out statistical

1 R. B. Scotton, Medical Manpower in Australia, Medical Journal o f Australia, 1967, Vol. 1, No. 19 (13 May).

149

questionnaires at the time of re-registration to enable manpower statistics to be compiled. The published figures for New South Wales, unfortunately, relate to about 70 per cent only of the registered doctors. Re-registration dates differ for most of the States. Although a source of coverage for surveys, registers have limitations as a source of information on potential medical manpower, as some married women graduates leaving the workforce let their registration lapse, and some medical admin­ istrators are not on the registers.

Table D.l

Derivation of Registered, Resident, Active Medical Practitioners from Total Registrations, Australia, June 1972

Total registrations 28,269

Excluding duplicated names 23,863

Excluding registered address overseas 21,928

Excluding not resident in Australia 19,477

Excluding inactive 17,972

Source: Department of Health Sample Survey.

D .6 Pensioner Medical Service. Doctors authorised to treat pensioners under the Pensioner Medical Service are enrolled by the Commonwealth Department of Health and statistics are compiled from enrolled doctors who provide at least one service a year under the scheme. These are published in the Department’s Quarterly Review of Health Statistics. It is believed that these doctors are very largely general practi­ tioners, but not all general practitioners are enrolled under the Pensioner Medical

Service. It appears also that some who are enrolled are not very active. However, Scotton1 2 believes that from 1965 onwards, when a number of downward revisions to remove duplication was completed, the series may be considered a substantially accurate measure of the number of general practitioners. Dr. Godfrey Scott has tested the lists in New South Wales by spot checks, and believes that they are accurate

enough to form the basis of the general practitioner part in his Study o f Medical Manpower in New South Wales.2 There are probably compensating errors in the series as a measure of the number of general practitioners, overstatement due to inclusion of some semi-retired doctors being offset by understatement due to the omission of non-participating general practitioners. At June 1972 the figure was 5 per cent below that of the Commonwealth Department of Health’s sample estimate. In this report the series has been used mainly to indicate trends.

D .7 Medical Benefits Scheme. Since 1 July 1970, with the change in the National Health Scheme, lists of consultant physicians and specialists recognised under the National Health Act have provided a new source of statistics of specialist manpower. To be recognised in this way, a consultant physician or specialist must have accept­

1 R. B. Scotton, Medical Care and Health Insurance in Australia, unpublished thesis, University of Melbourne, 1970. 2 Department of Preventive and Social Medicine, University of Sydney, October 1972.

150

able qualifications or experience. However, he need not be a full-time consultant or specialist, and some would be general practitioners as well, some even mainly general practitioners. Some doctors are therefore on both the Pensioner Medical Service and the specialist lists. Because the lists are used only to authorise payment of medical

benefits they are not confined to specialists currently active in Australia, and some who are retired or resident overseas are still included. At June 1972 the figure was 22 per cent above the Commonwealth Department of Health’s sample estimate. In this report the series has been used only to indicate trends.

D. 8 Pemail. A commercial mailing service operated by Permail Pty. Ltd.1 provides statistics of the number of doctors several times a year, distinguishing States, metro­ politan and country areas, and four kinds of doctor: general practitioner, specialist, hospital and salaried. The lists are updated from new registrations, which are followed up by mail questionnaire. Much use is made of reports from representatives of drug

companies subscribing to the mailing list, who report on changes of address, deaths, retirements, departures overseas etc. disclosed in the course of their field work. The continuity of the series appears to have been affected occasionally by revisions to the lists, for example the recent re-classification of many general practitioners as special­

ists. Doctors declining to be listed are not included in the statistics; these numbered about 500 to 600 in September 1972.

D .9 Definitions of types of doctor are not published, but the rules followed are relevant to the interpretation of the series:

General practitioners: Includes part-specialist, part-salaried, part-hospital. In­ cludes locums, part-time general practitioners and doctors of unknown type. Specialist: Full-time specialists only; includes full-time hospital and salaried specialists.

Hospital: Full-time hospital. Includes doctors working full-time in hospital on salary, but not full-time hospital specialists. Tends to include armed services, because addresses are usually at hospitals.

Salaried: Full-time salaried only. Excludes those who are full-time in hospital or full-time specialists.

Doctors are recorded as specialists on their own description, not according to quali­ fications; it is believed that some may not be fully qualified. At June 1972 the figure exceeded the Department of Health’s sample estimate by 16 per cent.

D. 10 Special Surveys. The Commonwealth Department of Health’s sample survey of June 1972 has already been mentioned. A sample of registered medical practitioners was selected from the registers, in the form of two alphabetical segments amounting to approximately 5 per cent of all doctors. Information on the current medical

activity of each of these doctors was obtained. Doctors classified as specialists all have appropriate medical qualifications or are recognised as specialists under the National Health Act.

D. 11 Other surveys useful for the work of the Committee were the surveys of medical practitioners in Victoria carried out by the Victorian Government Statist in 1964 and

1 54-56 Whiting Street, Artarmon, N.S.W., 2064.

151

1970.1 A Census of Medical Manpower in South Australia was carried out by the Committee of Enquiry into Health Services in South Australia in 1972. Results of this survey were not available in time to be used for this report.

D. 12 The questionnaires despatched in 1971 and 1972 by the New South Wales Medical Board with annual re-registration forms, as already mentioned, have met with incomplete response and the results have not been used in this report. A ques­ tionnaire was used in 1972 by the Victorian Registration Board as an integral part of the re-registration document. No results from this source are yet available.

D. 13 The Monash University Survey of Medical Graduates was conducted by Mrs lone Fett of the Department of Anthropology and Sociology in the last quarter of 1971 and the first half of 1972. The survey attempted to cover all female graduates of Australian medical schools since 1920, and a 12 per cent sample of the male grad­ uates in the same period. The questionnaire included questions on current and previous

occupations, hours worked, field of specialism, qualifications, family and home circumstances, and a number of questions on attitudes to medicine and other matters. Contact was made with 75.1 per cent of the females and 90.2 per cent of the males, and returns were received from 64.2 per cent of the females (1,632 returns) and 75.0 per cent of the males (1,414 returns). A high proportion of the missing 35.8 per cent of females and 25.0 per cent of males were among those who graduated in the years 1965 to 1969; this was due entirely to difficulties of making contact. Some of the older women graduates were also difficult to contact. The contact and response rates for each cohort and sex, as a percentage of all graduates intended to be covered (i.e. all females and 12 per cent of males) are shown in Table D.2.

TABLE D .2

MONASH UNIVERSITY SURVEY OF MEDICAL GRADUATES, 1972, CONTACT A N D RE­ SPONSE RATES, BY YEAR OF GRADUATION A N D SEX

Year of Graduation: 1920 1925 1930 1935 1940 1945 1950 1955 1960 1965 Total

- 2 4 - 2 9 - 3 4 - 3 9 - 4 4 - 4 9 - 5 4 - 5 9 - 6 4 - 6 9

Males

Not contacted per cent Contacted and return . 6.7 6.3 3.1 9.3 0.6 1.3 3.1 6.2 8.1 28.9 9.8

received per cent . Number of returns . 73.9 74.8 73.4 76.9 77.0 78.7 80.0 71.4 75.7 71.1 75.0

received . . . 88 83 47 83 124 118 232 162 206 271 1,414

Females

Not contacted per cent Contacted and return . 51.1 39.4 19.3 18.4 19.1 11.8 9.4 16.9 22.7 38.3 24.9

received per cent . Number of returns . 41.6 46.5 66.7 70.2 64.4 70.6 75.5 65.9 63.6 61.6 64.2

received . . . 57 46 38 80 125 173 256 207 238 412 1,632

D . 14 A survey2 by Dr K. Melville Kelly, Director of Research, Royal Australian College of General Practitioners, of all medical students who graduated in Australia in 1965, shows the result set out in Table D . 3.

1 Survey o f Medical Practitioners 1970, Office o f the Government Statist and Actuary, Melbourne 1971. 1 K. Melville Kelly, Survey o f Recruitment to General Practice, 285 Monaco Street, Surfers Paradise, Queensland.

152

1965 GRADUATES, AUSTRALIAN MEDICAL SCHOOLS, 1972 SURVEY

TABLE D.3

Number Total

Analysed

1965

Graduates

Occupation in 1972: per cent per cent

In general practice . . . 158 31.9 22.8

In general practice with specialty . . . . . 10 2. 0 1. 4

Specialist only . . . . 48 9. 6 6. 9

Hospital salaried officer . . . 179 36.1 25.8

Other full-time salaried position . 64 12.9 9.2

Other . . . . . . 22 4. 4 3. 2

Present occupation not stated 15 3.0 2.2

Total analysed . . . 496(a) 100.0(b) 71.5

Reply not received, believed overseas temporarily . . . . 42 6. 1

Reply not received, believed overseas permanently . . . . 26 3. 8

Other, reply not received . . . 77 11.1

Total reply not received . . 145 21.0

Reply received, excluded from analysis: . . . . .

Overseas permanently . . . 47 6.8

Deceased . . . . . 5 0. 7

Total excluded from analysis . 52 7.5

TOTAL 1965 graduates . . 693 100.0

(a) Of whom, studying for higher degree 156 (b) Of whom, studying for higher degree 31.5%

T A B L E D . 4

D I S T R I B U T I O N O F D O C T O R S I N P E N S I O N E R M E D I C A L S E R V I C E B Y D O C T O R - P O P U L A T I O N R A T I O S

I N L O C A L G O V E R N M E N T A R E A S , 1968 T O 1972

1 to

1200

1 to

1 2 0 0 — 1599

1 to

m o -

1999

1 to

2 0 0 0 — 2 3 9 9

1 to

2 4 0 0 — 2799

1 to

2 8 0 0 ^ -

3 1 9 9

1 to

3 2 0 0 — 3 5 9 9

1 to

3 6 0 0 a n d over T o ta l

Sydney Statistical D ivision . 1968 7 9 11 6 2 3 1 39

N um ber of ‘areas’ . . 1972 6 9 11 6 3 3 39

N um ber o f general . . 1968 267 461 376 2 5 6 51 67 13 1,491

practitioners . . . 1972 292 360 415 265 110 65 47 — 1,554

Newcastle Statistical D istrict . 1968 —. — 1 1 3 — — — 5

N um ber o f ‘areas’ . . 1972 —. — 3 2 — — — 5

N um ber o f general . . 1968 — — 18 13 105 — — — 136

practitioners . . . 1972 — — — 95 53 — — — 148

W ollongong Statistical D istrict 1968 — — 1 2 — — — — 3

N um ber of ‘areas’ . . 1972 — — 2 1 3

N um ber of general . . 1968 3 81 84

practitioners . . . 1972 — — — 77 — — 9 — 86

R ural Areas . . . . 1968 4 22 33 18 9 4 4 6 100

N um ber o f ‘areas’ . . 1972 5 22 31 20 7 3 2 10 100

N um ber o f general . . 1968 37 256 208 91 35 7 6 8 648

practitioners . . . 1972 48 138 312 106 22 6 10 12 654

T otal New S outh W ales . 1968 11 31 46 27 14 7 5 6 147

N um ber of ‘areas’ . . 1972 11 31 42 31 12 6 4 10 147

N um ber of general . . 1968 304 717 605 441 191 74 19 8 2,359

practitioners . . . 1972 340 498 727 543 185 71 66 12 2,442

N ote: ‘A r e a s ’ in t h e a b o v e a n d th e fo llo w in g ta b le s r e la te t o lo c a l g o v e r n m e n t a r e a s , o r c o m b in a tio n s o f lo c a l g o v e r n m e n t

a r e a s , b e lie v e d to p r o v id e s u ita b le u n it s f o r t h e c a lc u la tio n o f d o c t o r - p o p u la ti o n r a tio s . T h e r e s u lts a r e n a t u r a ll y a n

a p p r o x i m a t io n t o w h a t is a im e d a t ; f o r a r e a s a d jo in in g S ta te o r m e tr o p o li ta n b o u n d a r ie s , in p a r t ic u l a r , t h e r a t io s

m a y b e d is to r t e d w h e n u s e d f o r th is p u r p o s e .

Source: G o d f r e y S c o tt, A Study o f Medical Manpower in N .S.W ., U n iv e rs ity o f S y d n e y , 1972.

153

O t h e r S t a t is t ic a l T a b l e s

D. 15 Tables D .4 to Table D .8 are the sources for a number of tables in the text.

TABLE D .5

D ISTR IB UTIO N O F F U L L -T IM E DOCTORS M A IN LY IN PRIVATE PRA C TIC E O U TSID E M ETR O PO LITA N A REA BY SIZE O F D O C T O R -PO PU L A T IO N RA TIO O F TH E A REA , VICTORIA, 1964 A N D 1970

1 to 1 to 1 to 1 to 1 to 1 to 1 to 1 to

1 2 0 0 — 1 6 0 0 — 2 0 0 0 — 2 4 0 0 — 2 8 0 0 — 3 2 0 0 — 3 6 0 0 & T o ta l

1 2 0 0 1 5 9 9 1 9 9 9 2 3 9 9 2 7 9 9 3 1 9 9 3 5 9 9 o ve r

N um ber of ‘areas’ . . 1964 1 18 17 14 9 6 3 4 72

1970 5 20 17 15 5 3 2 5 72

N um ber of doctors . . 1964 6 239 147 61 32 33 10 4 532

1970 38 332 103 87 15 6 4 10 595

S o u r c e : Victorian Statist’s surveys. See paragraph D . 11.

TABLE D . 6

D ISTR IB UTIO N O F M ED IC A L PRA CTITIO N ERS R EC O RD E D IN CENSUSES O F 1961, 1966 and 1971 O U T­ SIDE M ETRO PO LITA N STATISTICAL DIVISIONS, AUSTRALIA, BY SIZE OF D O CTO R -PO PU L A T IO N R A TIO O F TH E A REA , A LL STATES EXCEPT VICTORIA

1 to 1 to 1 to 1 to 1 to 1 to 1 to 1 to

U n d er 1 2 0 0— 1 6 0 0 — 2 0 0 0 — 2 4 0 0 — 2 8 0 0 — 3 2 0 0 — 3 6 0 0 & T o ta l

1 2 0 0 1 5 9 9 1 9 9 9 2 3 9 9 2 7 9 9 3 1 9 9 3 5 9 9 o ve r

N e w S o u th W a le s N um ber o f ‘areas* . . 1961 20 31 35 18 11 7 — 5 127

1966 22 6 33 19 7 7 3 9 127

1971 29 20 25 17 12 5 3 16 127

N um ber of doctors . . 1961 539 409 175 57 26 12 5 1,223

1966 752 260 190 68 15 14 6 11 1,316

1971 1,024 204 141 54 29 13 6 18 1,489

Q u e e n s la n d Num ber of ‘areas’ . . 1961 5 12 10 6 8 2 2 6 51

1966 7 10 6 10 3 6 2 7 51

1971 9 7 13 7 6 1 2 6 51

N um ber o f doctors . . 1961 136 249 66 28 36 6 4 7 532

1966 286 176 38 55 12 22 6 10 605

1971 320 130 95 41 22 1 2 7 618

S o u th A u s tr a lia N um ber of ‘areas’ . . 1961 5 14 11 6 5 — 2 1 44

1966 6 9 11 10 3 3 1 1 44

1971 7 3 17 6 4 3 1 3 44

N um ber of doctors . . 1961 22 64 43 15 19 — 6 1 170

1966 27 43 43 40 12 12 1 2 180

1971 37 27 62 31 13 5 1 3 179

W e s te r n A u s tr a lia N um ber of ‘areas’ . . 1961 3 9 5 2 4 1 1 1 26

1966 2 3 4 7 4 1 5 26

1971 1 6 4 4 1 3 1 6 26

N um ber of doctors . . 1961 14 35 45 9 27 2 2 3 137

1966 8 20 34 42 20 3 8 135

1971 14 58 18 36 12 8 4 8 158

T a sm a n ia N umber of ‘areas’ . . 1961 6 7 6 5 2 5 31

1966 10 6 1 4 7 1 2 31

1971 11 8 3 3 4 — — 2 31

Num ber of doctors . . 1961 88 43 17 11 2 — — 5 166

1966 164 20 3 9 13 — 1 2 218

1971 180 28 12 7 7 — — 1 235

N o t e : The fact th a t the Census data include doctors not in private practice would explain a t least in p art the heavier dis­ tribution among the higher ratios, as compared w ith Scott’s results and the Victorian survey results. However, because areas with hospitals and specialists are probably areas with high general practitioner to population ratios, it seems likely that the results for the areas with lower ratios would be more comparable with Scott’s and the Victorian results.

154

FU L L -T IM E SA LARIED M ED ICA L O FFICER S EM PLO YED IN HOSPITALS, AUSTRA LIA , JU N E 1972 By Type of Employment

TABLE D .7

New

S o u th A u s tr a lia

S o u th W a le s

V ic to ria Q u e e n s la n d

W e s te rn A u s tr a lia T a sm a n ia N o r th e r n

T e r rito r y C a p ita l T e r r ito r y A u str a lia

I n in -s e rv ic e tr a in in g p o s ts F i r s t Y e a r .

( I n te r n s )

320 239 172 85 67 32 — 18 933

S e c o n d Y e a r . 282 182 79 72 41 25 — 16 697

T h i r d Y e a r . 143 102 ) f (153) )

F o u r t h Y e a r .

F i f t h Y e a r o r .

122 100 I

1 2 , 1 1

( 42) 1 178

1

26 9 15 1,646

H ig h e r . 361 161 J l j

T o t a l . . 1,228 784 485 352 286 83 9 49 3,276

I n a d m in is tr a tiv e 128 77 64 13 17 10 6 3 318

S p e c ia lis ts . 333 202 39 101 57 37 13 4 786

O th e r . . 167 212 11 — — 10 18 2 420

T o t a l . . 1,856 1,275 599 466 360 140 46 58 4,800

B y T y p e o f H o s p i ta l (a )

N e w

S o u th A u s tr a lia

S o u th W a le s

V ic to ria Q u e e n s la n d

W e s te r n A u s tr a lia T a sm a n ia N o r th e r n

T e r r ito r y C a p ita l T e r r ito r y A u s tr a lia

M e tr o p o l ita n .

te a c h in g . .

h o s p ita ls

1,009 786 372 398 307 63 — — 2,935

O th e r m e tr o p o li­ t a n h o s p ita ls . 297 104 22 1 _ _ 31 58 513

C o u n tr y h o s p ita ls 258 104 151 27 64 15 619

M e n ta l h o s p ita ls 227 193 32 66 25 9 552

O t h e r h o s p ita ls .

a n d s e rv ic e s(b ) .

65 88 22 1 1 4 181

T o t a l . . 1,856 1,275 599 466 360 140 46 58 4,800

(a) Private hospitals are excluded; m ost of these are unlikely to employ salaried medical staff. (b) M ainly homes for the care of the aged or children. Also includes institutions specialising in particular types o f medical service (e.g. dental hospitals, cancer clinics, blood transfusion and dialysis services), in some cases without resident patient accommodation.

S o u r c e : Commonwealth Statistician.

TABLE D .8

NUMBERS OF DOCTORS AT CENSUSES, 1933 TO 1971, BY SEX

Census Male Female Total

June 1933 . 4,574 300 4,874

June 1947 . 6,065 579 6,644

June 1954 . 8,300 880 9,180

June 1961 . 10,595 1,309 11,904 (12,320)

June 1966 . 12,209 1,488 13,697 (14,440)

June 1971 . 14,003 2,104 16,107 (17,243)

Note: Figures in brackets are Census figures adjusted, for purposes of this report, for understatement of doctors employed by universities and defence services, and doctors overseas at Census date for periods of less than

a year (see paragraph 3.2). (a) Includes adjustment for female doctors 65 and over in 1966. See Table 3.39, footnote (b). Source: Population Censuses. June 1954 not published; in­

cluded in R. B. Scotton, Medical Manpower in Australia, Medical Journal o f Australia, 1967, Vol. 1, No. 19 (13 May).

155