THE LOST YEARS

If Aotearoa New Zealand is to make the most of the domestic supply of doctors, we need to understand what is happening to a significant number of graduates who don’t appear to make it to vocational registration.

But with many already saying there are too few medical graduates entering the workforce ‘pipeline’ – ASMS estimates we need another 300 a year by 2027 – the whereabouts of these ‘lost doctors’ is a significant concern.

This loss in the supply of specialists from the country’s graduate pool was identified as “an area of potential concern” in a Health Workforce New Zealand report back in 2017. But the same report said a lack of data made it unclear if this represented “a long-term deficit or risk to service delivery”.

In 2018, unpublished Ministry of Health data showed 29 per cent of full-time employed registrars were not in a specialist training programme. At the same time, there were a growing number of registrar training positions that were not being filled, with the most significant vacancies being in anaesthesia, intensive care medicine, psychiatry, paediatrics and obstetrics and gynaecology.

Alarmingly, at that point the Ministry stopped collecting data on the issue, due to resource constraints. The risk that these vacancies posed was never investigated further.

But that question remains, as do the questions about why these gaps occurred. Are ‘Establishment FTE’ training positions not being advertised? Does overstretched training capacity mean those positions can’t be supported? Are trainee applicants simply not finding positions in their preferred speciality and location? Or is the fundamental driver simply funding constraint?

Aside from the direct loss of potential specialists to our health workforce, the growing number of non-training or ‘unaccredited’ registrars has been criticised as evidence of inefficiency in medical training. Their lack of formal training, appraisal, or supervision also hinders their ongoing development. There is no cap to the number of years someone can work as an unaccredited registrar, and there is no guarantee of career progression.

As the workforce ages, it is registrar trainees who will replace older specialists as they retire. Health Workforce New Zealand’s 2017 report noted that “just over half” of specialties had fewer registrars in training than SMOs aged 55 or over.

Again, collection of that information was discontinued soon after. In its absence, ASMS analysis found that in 2020 there were 28 of 36 specialties with fewer trainees than specialists (private and public) aged 55+, and 16 specialties where 15 per cent of the workforce was aged over 65. These included psychiatry, dermatology and general surgery.

To date, after years of health sector groups calling for a comprehensive health workforce strategy, and official acknowledgement that such a plan is needed, there is no sign of one yet from government. Until one does appear, ASMS has some clear recommendations for a way forward that were reported in Workforce: The make or break of the health reform (https://asms.org. nz/workforce-the-make-or-break-of-thehealth-reform/).

RECOMMENDATIONS FROM WORKFORCE: THE MAKE OR BREAK OF THE HEALTH REFORM

1 Reform primary and oral health services.

2 Reduce potentially avoidable hospitalisation rates through whole-of-government action.

3 Commit to supporting efforts at the flax-roots which integrate hospital and community-based care.

4 Understand workforce capacity constraints.

5 Understand unmet need for hospital and secondary care.

6 Develop a comprehensive Health and Disability Workforce Plan and Implementation Road Map.

7 Investment decisions are data-driven.

8 Grow capacity at undergraduate level.

9 Strengthen postgraduate pathways.

10 Sustain support for SMOs and IMGs.

11 Make cultural safety a priority for all health sector organisations.

12 Approach health service design and delivery collectively, harnessing the clinical experience within the health workforce and engaging with communities.

13 Act to reduce the risk of future health policy failures.