The Obstetrics and Gynaecology Workforce in Australia

AMWAC 1998.6 i

Australian Medical Workforce Advisory Committee

THE OBSTETRICS AND GYNAECOLOGY WORKFORCE IN AUSTRALIA

SUPPLY AND REQUIREMENTS

1997 - 2008

AMWAC Report 1998.6

August 1998

AMWAC 1998.6 ii

Australian Medical Workforce Advisory Committee 1998 ISBN 0 7313 4096 5 This work is copyright. It may be reproduced in whole or part for study or training purposes subject to the inclusion of an acknowledgement of the source. Reproduction for purposes other than those indicated above requires the written permission of the Australian Medical Workforce Advisory Committee. Enquiries concerning this report and its reproduction should be directed to: Executive Officer Australian Medical Workforce Advisory Committee c/- New South Wales Department of Health Locked Mail Bag 961 NORTH SYDNEY NSW 2059 Telephone: (02) 9391 9933 E-mail: [email protected] Internet: http://amwac.health.nsw.gov.au Suggested citation: Australian Medical Workforce Advisory Committee (1998), The Obstetrics and Gynaecology Workforce In Australia, AMWAC Report 1998.6, Sydney Publication and design by Australian Medical Workforce Advisory Committee. Printing by Copybook, Sydney.

AMWAC 1998.6 iii

CONTENTS Abbreviations vi List of Tables and List of Figures viii Terms of Reference of AMWAC and the AMWAC Obstetrics and Gynaecology Workforce Working Party xi Membership of AMWAC xii Membership of the AMWAC Obstetrics and Gynaecology Workforce Working Party xiii Introduction, Guiding Principles and Methodology 1 Part A: The Specialist Obstetrics and Gynaecology Workforce 5 Summary of Findings and Recommendations 6 Description of the Current Obstetrics and Gynaecology Workforce 19

The Number of Practising Obstetrics and Gynaecology Specialists 19 Distribution of the Obstetrics and Gynaecology Workforce 20 Age Profile 22 Gender Profile 26 Hours Worked 27 Practice Profiles 31 Services Provided 32

Training Arrangements 34 Summary of Main Characteristics of the Specialist Obstetrics and

Gynaecology Workforce 39

Adequacy of the Current Obstetrics and Gynaecology Workforce 41 Obstetrics and Gynaecology Specialist:Population Ratio 41 Public Hospital Vacancies 45 Provider Shortages 45 Consultation Waiting Times 45 Survey of Divisions of General Practice 46 Professional Satisfaction 47 Conclusions on Adequacy of the Current Obstetrics and

Gynaecology Workforce 47 Projections of Requirements 48

AMWAC 1998.6 iv

Female Population 48 Fertility Rate 49 Birth Rate 50 Cancer of the Cervix, Ovary and Uterus 52 Trends In Utilisation 53 The Impact of Changes in Technology 55 Specialists’ Perceptions of Factors Affecting Workforce Requirements 55

Projections of Supply 56

Additions and Losses to the Obstetrics and Gynaecology Workforce 56 Female Participation in the Workforce 56 Provision of Services in Rural and Remote Areas 57 Substitution of Services 57

Balancing Supply Against Requirements 62

Requirement Trends 62 Supply Trends 64 Projected Balance 65

Recommendations 71 Part B: The Sub-Specialist Obstetrics and Gynaecology Workforces 73 Introduction 74 Characteristics of the Obstetrics and Gynaecology Sub-specialist Workforce 77

Number of Practising Sub-specialists in Obstetrics and Gynaecology 77 Distribution of the Sub-specialist Workforce 77 Age Profile 79 Gender Profile 81 Hours Worked 82 Practice Profiles 84 Training Arrangements 84 Obstetrics and Gynaecology Sub-specialist:Population Ratios 87

AMWAC 1998.6 iv

Appendices Appendix A: Rural, Remote and Metropolitan Areas Classification 90 Appendix B: RACOG/AMWAC Survey of Fellows of the Royal Australian

College of Obstetricians and Gynaecologists 92 Appendix C: AIHW National Medical Labour Force Survey 1995 111 Appendix D: Service Provision and Requirements of Obstetrics and

Gynaecology 116 Appendix E: RACOG Obstetrics and Gynaecology Training Program 119 Appendix F: General Practitioners Providing Obstetrics and Gynaecology

Services 123 Appendix G: AMWAC Survey of Divisions of General Practice 131 Appendix H: Data on Midwives 137 Appendix I: AIHW National Hospital Morbidity Data for Obstetrics and

Gynaecology 145 References 161

AMWAC 1998.6 v

ABBREVIATIONS ABS Australian Bureau of Statistics ACT Australian Capital Territory AHMAC Australian Health Ministers' Advisory Council AIHW Australian Institute of Health and Welfare AMWAC Australian Medical Workforce Advisory Committee AN-DRGs Australian National Diagnostic Related Groups Aust Australia CREI Certificate of Reproductive Endocrinology and Infertility CSCT Certificate of Satisfactory Completion of Training in Women’s

Reproductive Health DHFS Commonwealth Department of Health and Family Services DRACOG Diploma of the Royal Australian College of Obstetricians and

Gynaecologists FRACOG Fellow of the Australian College of Obstetricians and

Gynaecologists FRACP Fellow of the Royal Australian College of Physicians FTE Full time equivalent GONC Gynaecological Oncology GP General Practitioner HIC Health Insurance Commission HMO Hospital Medical Officer

(also known as Career Medical Officer or CMO) ICD-9 International Classification of Diseases, Ninth Revision ITP Integrated Training Program MBS Medicare Benefits Schedule MDC Medical Diagnostic Category MDS Minimum Data Set MFM Maternal Fetal Medicine

AMWAC 1998.6 vi

MRACOG Member of the Royal Australian College of Obstetricians and Gynaecologists

NASOG National Association of Specialist Obstetricians and Gynaecologists NSW New South Wales NT Northern Territory O&G Obstetrics and Gynaecology O&GULT Obstetrical and Gynaecological Ultrasound OS Overseas Pop Population Qld Queensland RACGP Royal Australian College of General Practitioners RACOG Royal Australian College of Obstetricians and Gynaecologists RRMA Rural, Remote Metropolitan Areas classification SA South Australia Spec Specialist SPR Specialist:Population ratio SRAC Specialist Recognition Advisory Committee SSPR Sub-specialist:Population ratio Tas Tasmania Terr Territory TRD Temporary Resident Doctor UK United Kingdom UROG Uro-gynaecology Vic Victoria VMO Visiting Medical Officer WA Western Australia

AMWAC 1998.6 vii

LIST OF TABLES 1. Obstetrics and gynaecology specialists to population, by State/Territory 2. Distribution of obstetrics and gynaecology specialists, by State/Territory and

geographic location (RACOG data), 1998 3. Age profile of the total obstetrics and gynaecology specialist workforce, by

State/Territory and gender (RACOG data), 1998 4. Age profile of the total obstetrics and gynaecology specialist workforce, by

State/Territory, gender and major age group (RACOG data), 1998 5. Age profile of obstetrics and gynaecology specialists, by State/Territory and

gender (RACOG data), 1998 6. Age profile of obstetrics and gynaecology specialists, by State/Territory and

major age group, 1998 7. Specialists and sub-specialists in obstetrics and gynaecology average hours

provided per week, annual labour supply hours by State/Territory, 1998 8. Specialists and sub-specialists in obstetrics and gynaecology average hours and

annual hours worked, by gender and age group, 1998 9. Hours worked by specialists in obstetrics and gynaecology, by geographic

location, 1997 10. Obstetrics and gynaecology services attracting Medicare benefits provided by

specialists, 1986-87 to 1996-97 11. Accredited obstetrics and gynaecology training positions, by hospital and

State/Territory, 1998 12. RACOG trainees, by year of training, age group and gender, 1998 13. RACOG trainees, by full time and part time status, age group and gender, 1998 14. Obstetrics and gynaecology trainees, by State/Territory and gender, 1998 15. Obstetrics and gynaecology specialists in training average hours worked, by

gender and age, 1995 16. Obstetrics and gynaecology specialists in training average hours worked, by

State/Territory, 1995 17. Obstetrics and gynaecology trainees, by gender, 1992 to 1998 18. Specialists in obstetrics and gynaecology to female population ratio, by

State/Territory 1998 (number per 100,000 population) 19. Specialists in obstetrics and gynaecology to female population ratio, by

State/Territory and geographic location, 1998 20. Obstetrics and gynaecology average waiting time (days) for a standard first

consultation and an urgent procedure, by private rooms/public outpatients department and State/Territory, 1997

21. Australian female population estimates and projections, 1997 to 2006 22. Total fertility rate, by State/Territory, 1976, 1986 and 1996 23. Total births, by State/Territory, 1996 24. Total births, by State/Territory, 1996 25. Incidence of cancer of the cervix among women aged 20 to 74 years, by

State/Territory

AMWAC 1998.6 viii

26. Age standardised rates for incidence of cancer of the cervix, ovary and uterus, selected years 1983 to 1994, with projections to 1999

27. Projected increases in utilisation for obstetrical and gynaecological procedures, 1998 to 2018

28. Summary of obstetrics and gynaecology services attracting Medicare benefits; by provider, selected years 1986-87 to 1996-97

29. Obstetrics and gynaecology Medicare services, by provider and State/Territory, 1995-96

30. Distribution of obstetrics and gynaecology Medicare service providers, by geographic location, 1995-96

31. Projected requirements for obstetrics and gynaecology services (in full time equivalent hours per week) for selected indicators, 1995 to 2009

32. Projected supply of obstetrics and gynaecology services, high, low and average retirement rates, by FTE hours worked per week, 1999, 2004 and 2009

33. Projected obstetrics and gynaecology supply and requirements (FTE hours), 0.4% growth per year, 1998 to 2004

34. Obstetrics and gynaecology graduate output needed to move projected supply into balance with projected requirements, 0.4% growth per year, (in FTE hours), 1998 to 2009

35. Estimated obstetrics and gynaecology graduate output required to move projected supply into balance with projected requirements, 0.4% growth per year, (in FTE hours), by selected graduate outputs, 1998 to 2009

36. Distribution of obstetrics and gynaecology first year advanced trainee positions, by State/Territory, 1999 to 2002

37. Number of obstetrics and gynaecology sub-specialists, by sub-specialty, State/Territory and gender, 1998

38. Distribution of obstetrics and gynaecology sub-specialists; by geographic location, 1998

39. Age profile of obstetrics and gynaecology sub-specialists, by State/Territory and gender, 1998

40. Age profile of obstetrics and gynaecology sub-specialists, by State/Territory, gender and major age group, 1998

41. Sub-specialists in obstetrics and gynaecology average hours worked per week and annual labour supply hours, by State/Territory, 1998

42. Sub-specialists in obstetrics and gynaecology average hours and annual hours worked, by gender and age group, 1998

43. Sub-specialists in obstetrics and gynaecology average hours worked per week, by geographic location of main job, 1997

44. Obstetrics and gynaecology sub-specialty trainees, by year of training, gender and major age group, February 1998

45. Obstetrics and gynaecology sub-specialty trainees, by State/Territory and gender, February 1998

46. Sub-specialists in obstetrics and gynaecology female population: population ratio, by State/Territory, 1997

AMWAC 1998.6 ix

LIST OF FIGURES 1. Obstetrics and Gynaecology Specialists supply (Average Attrition Rates) vs

Demand Projections working a 60 hour week, incorporating the current intake of 58 trainees per year.

2. Obstetrics and Gynaecology Specialists supply (Average Attrition Rates) vs Demand Projections - Birth Rates and Fertility Rates - working a 60 hour week, incorporating the current intake of 58 trainees per year.

AMWAC 1998.6 x

TERMS OF REFERENCE OF AMWAC AND THE AMWAC OBSTETRICS AND GYNAECOLOGY WORKFORCE WORKING PARTY The Australian Health Ministers' Advisory Council (AHMAC) established the Australian Medical Workforce Advisory Committee (AMWAC) to advise on national medical workforce matters, including workforce supply, distribution and future requirements. AMWAC held its first meeting in April 1995. AMWAC Terms of Reference 1. To provide advice to AHMAC on a range of medical workforce matters, including:

- the structure, balance and geographic distribution of the medical workforce in Australia;

- the present and required education and training needs as suggested by population health status and practice developments;

- medical workforce supply and demand; - medical workforce financing; and - models for describing and predicting future medical workforce

requirements. 2. To develop tools for describing and managing medical workforce supply and

demand which can be used by employing and workforce controlling bodies including Governments, Learned Colleges and Tertiary Institutions.

3. To oversee the establishment and development of data collections concerned

with the medical workforce and analyse and report on those data to assist workforce planning.

Obstetrics and Gynaecology Workforce Working Party Terms of Reference The AMWAC Obstetrics and Gynaecology Workforce Working Party was established as a sub-committee of AMWAC and was asked to provide a report to AMWAC on the optimal supply and appropriate distribution of obstetrics and gynaecology specialists and sub-specialists across Australia, including projections for future requirements. The Working Party held its first meeting on 5 August 1997 and presented its report to the AMWAC meeting of August 1998. The report was accepted at the October 1998 AHMAC meeting.

AMWAC 1998.6 xi

MEMBERSHIP OF AMWAC Independent Chairman Professor John Horvath Physician, Sydney Members Mr Eric Brookbanks Assistant Secretary, Business and Temporary Entry

Branch, Commonwealth Department of Immigration and Multicultural Affairs

Ms Meredith Carter Director, Health Issues Centre Dr William Coote Secretary General, Australian Medical Association Mr Michael Gallagher First Assistant Secretary, Higher Education Division,

Commonwealth Department of Employment, Education, Training and Youth Affairs

Dr Susan Griffiths General Practitioner, Minlaton, South Australia Assoc. Prof. Jane Hall Director, Centre for Health, Economics, Research and

Evaluation, University of Sydney Dr Richard Madden Director, Australian Institute of Health and Welfare Mr Ronald Parker Secretary, Tasmanian Department of Community and

Health Services Professor Nick Saunders Dean, Faculty of Medicine, Monash University, Melbourne Dr Robert Stable Director General, Queensland Department of Health Dr David Theile Surgeon, Brisbane (former President, Royal Australasian

College of Surgeons) Dr Lloyd Toft Chairman, Medical Board of Queensland Mr Robert Wells First Assistant Secretary, Office of the National Health and

Medical Research Council, Commonwealth Department of Health and Family Services

AMWAC 1998.6 xiii

MEMBERSHIP OF THE AMWAC OBSTETRICS AND GYNAECOLOGY WORKFORCE WORKING PARTY Chairman Professor Ross Kalucy President, Medical Board of South Australia Members Dr John Bates Gynaecologist, Perth Mr Maurie Breust Executive Director, Strategic Planning and

Development, North West Adelaide Health Service Dr Lawrence Brunello President, Royal Australian College of Obstetricians

and Gynaecologists Ms Dell Horey Consumer representative, Maternity Alliance, New

South Wales Dr Alan Sandford Senior Medical Adviser, Manager Health Workforce

Section, Public Health and Development Division, Department of Human Services Victoria

Dr Geoff Westwood Director of Medical Services, Alice Springs Hospital Ms Anastasia Ioannou Senior Policy Officer, AMWAC This report was written by Ms Anastasia Ioannou, Senior Policy Officer, AMWAC. The Working Party would also like to acknowledge the assistance of the following people in preparation of the report: - Professor John Horvath and Mr Paul Gavel (AMWAC) for helpful editorial

comments; - Mr John Harding and Mr Warwick Conn (AIHW) and Ms Angela Tirrizzi and Ms

Emma Gilbert (RACOG) for assistance with data collection; - Chairs of the RACOG sub-specialty committees and Professors of Obstetrics

and Gynaecology for helpful comments on particular aspects of the specialty; - Dr David Molloy, National Association of Specialist Obstetricians and

Gynaecologists (NASOG) for providing comments on the draft report; - Dr Kathy Innes and Dr Mark Henschke for providing data on general practitioner

(GP) provision of obstetrics and gynaecology services;

AMWAC 1998.6 xiv

- Mr Dean Carson (Centre For Rural Health) for data collection through the National Rural General Practitioner Survey;

- Ms Patricia Brodie (New South Wales Health Department) for editorial comment on the summary of trends in midwife numbers; and,

- Dr Derrick Bui, Medical Management Trainee, Victorian Department of Human Services for assisting with RACOG data collection.

AMWAC 1998.6 1

INTRODUCTION, GUIDING PRINCIPLES AND METHODOLOGY Introduction In preparing this report, the Working Party’s aim has been to promote appropriate obstetric and gynaecology services throughout Australia. The main objective of the Working Party has been to promote an optimal supply and distribution of specialist obstetricians and gynaecologists, including projections for future supply and requirements to the year 2008. Obstetrics and gynaecology is a ‘fused’ profession in the sense that specialists are licensed to undertake specialist treatments in both obstetrics and gynaecology. In addition, there are five associated sub-specialties, namely maternal fetal medicine, uro-gynaecology, obstetrical and gynaecological ultrasound, gynaecological oncology and reproductive endocrinology and infertility. This report attempts to accommodate the subdivisions within the obstetrics and gynaecology workforce by presenting information on the total workforce and the sub-specialist workforce. To this end the report is provided in two parts: • Part A: The Specialist Obstetrics and Gynaecology Workforce • Part B: The Sub-Specialist Obstetrics and Gynaecology Workforce Part A includes a description of the total workforce, an assessment of the adequacy of the total workforce and projections of total workforce supply and requirements to 2008. Part B provides a summary of the main characteristics of each of the five sub-specialist workforces. The report also examines obstetric services provided by general practitioners (GPs) and midwives and most of this examination is detailed in appendices H and J respectively. Guiding Principles In compiling this report, the Working Party adopted the following guiding principles: • the Australian community should have available an adequate number of trained

obstetric and gynaecology specialists, appropriately distributed to provide the obstetric and gynaecology services it requires;

• there should be high standards of training leading to qualification which ensures high quality of practice;

• the working life of specialists should be embedded within a process of continuing education and quality assurance;

• challenges to the provision of a good standard of care in obstetrics and gynaecology need to be identified and addressed;

• Australians should have access to a good standard of obstetric and gynaecology services including related sub-specialty services, irrespective of geography and economic status. In achieving this, convenience to the patient must be balanced against the quality of services that can be distributed to meet that convenience;

• the guiding principles should apply equally to private and public sectors.

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The Working Party defined an obstetric and/or gynaecology specialist as:

A qualified specialist who is conducting obstetric and gynaecological consultations, obstetrics and gynaecology assessments/procedures and medico legal consultations in obstetrics and gynaecology medicine, including being in a full time or part time academic position relating to obstetrics and gynaecology. The definition includes specialists in salaried positions and private practice.

An obstetrician provides medical care before, during and after childbirth. Gynaecologists diagnose, treat and aid in the prevention of disorders of the female reproductive system.

This definition does not include registrars in training or registrars who have completed their training but have not successfully passed their final examination for specialty recognition. Methodology The approach of the Working Party has been to analyse existing data sources and to undertake consultation with relevant persons and organisations in order to make informed comments on the factors affecting the current and future requirements for obstetric and gynaecology services. In estimating workforce numbers, establishing a profile of the workforce and assessing its adequacy, the main sources of data were: 1. Royal Australian College of Obstetricians and Gynaecologists (RACOG) RACOG keeps a variety of data, principally on the number of Fellows and training posts and age and gender information of Fellows and trainees. A survey of the 954 members was conducted in 1997 with a response rate of 53%. A summary of the findings of the survey is provided in Appendix B. The profile and projections of the workforce has been based on the March 1998 RACOG figures of Australian active Fellows/Members, both specialist and sub-specialist. 2. Australian Institute of Health and Welfare (AIHW) The principle AIHW data source is the annual Medical Labour Force Survey. The Medical Labour Force Survey presents national labour force statistics for registered medical practitioners, principally through a survey collected as part of the annual renewal of registration. The survey data used in this report is for 1995. A summary of the key findings for the obstetrics and gynaecology workforce are included in Appendix C. 3. Commonwealth Department of Health and Family Services (DHFS) Medicare

AMWAC 1998.6 3

provider database Medicare provider statistics define medical practitioners according to the predominant services billed to Medicare. The Medicare statistics include all practitioners who have billed Medicare for at least one service during a financial year. The major deficiency with the use of Medicare data for workforce planning purposes is that it does not provide data on practitioners who are salaried obstetricians and gynaecology specialists/sub-specialists in the public hospital system and who do not render services on a fee for service basis. Medicare data thus excludes services rendered free of charge to public hospital patients, to Veterans' Affairs patients and to compensation cases. 4 Casemix data on hospital activity The AIHW National Hospital Morbidity database (ICD-9-CM groupings) has been used as a key source of data on service trends. The data is sourced from the AIHW Australian hospital morbidity database for all patients in public and private hospitals in Australia from 1993-94 to 1996-97. 5. AMWAC Survey of Divisions of General Practice To assist the Working Party in its assessment of the adequacy of the workforce AMWAC administered a mailed survey of each Division of General Practice. Of a possible 122 Divisions, 77 responded (63.1%). The results of the survey are summarised in Appendix I. 6. Sources of data on the non specialist workforce. Obstetrics and gynaecology services can also be provided by non-specialists, mainly GPs, principally in rural and remote areas, and midwives. In order to gain an insight into the use of non-specialists and the types of services provided by non specialists the Working Party also examined the following data sources: AIHW, Nursing Labour Force Survey 1995

This survey presents national labour force statistics for registered nurses, principally through a nurse labour force survey conducted by each State/Territory nurses board on behalf of the Institute. The survey data used in this report is for 1995. The National Rural General Practitioner Survey conducted by the Centre for Rural

Health at Moe The survey was conducted in 1996 and collected information in regards to rural GPs working in obstetrics and gynaecology. The majority of respondents were qualified in either the Diploma of the RACOG (DRACOG) or the Certificate of Satisfactory

AMWAC 1998.6 4

Completion of Training in Women’s Reproductive Health (CSCT). The response rate of the survey was approximately 70% (2,100). 7. Australian Bureau of Statistics The Australian Bureau of Statistics (ABS) population data and projections are used as the sole source on population data. In making its population projections ABS uses four different series. The population projections in this report are based on Series A/B, where constant fertility and low overseas migration are assumed (ABS 1994 and ABS 1997). It should also be noted that where population data is provided in this report it relates to female population only. 8. Rural, Remote Metropolitan Areas classification Wherever possible, distributional data has been interpreted using the rural, remote and metropolitan areas classification (RRMA) developed by the Commonwealth Departments of Health and Family Services and Primary Industries and Energy (DPIE & DHSH 1994). A summary of the RRMA classification is provided in Appendix A: Rural, Remote and Metropolitan Areas Classification. Key Assumption The Working Party would like to emphasise that the projections on supply and requirements are based on the existing national health structure. If there is a change to the national health structure the Working Party recommends the supply requirements and projections be reviewed. The Working Party also assumed that the current length of the RACOG training program would remain unchanged and that the majority of candidates would complete the program within this time frame. In addition, the Working Party has assumed that the pattern of workforce participation of the current workforce provides a suitable basis on which to project future workforce requirements.

AMWAC 1998.6 5

PART A:

THE SPECIALIST OBSTETRICS AND GYNAECOLOGY WORKFORCE IN AUSTRALIA

AMWAC 1998.6 6

SUMMARY OF FINDINGS AND RECOMMENDATIONS This report describes the current specialist obstetrics and gynaecology workforce, assesses the adequacy of that workforce, and projects workforce supply and requirements to the year 2008. Obstetrics and gynaecology, with an estimated 1,049 specialists, is one of the largest single specialties in Australia (only the psychiatry and anaesthesia workforces are noticeably larger). However, the specialty is one of the more difficult to examine and assess and there are several reasons for this: 1. Obstetrics and gynaecology is a complex profession to analyse in that specialists

can practice obstetrics, gynaecology or a mixture of both, and even some of the obstetrics and gynaecology sub-specialists continue to practice general obstetrics and gynaecology. There also appears to be a tendency for older specialists to do less obstetrics work. All this makes it difficult to assess who is doing what and the level of service that is being provided.

2. The above issue is further complicated by the variable contribution of some

service provision through the provision of obstetrics services by GPs and midwives. Assessment of services trends is further compounded by the general absence of national data collections that allow the separation of data by service provider. Reliable data on the trends in GP and midwife numbers has also been difficult to obtain.

Nevertheless the Working Party has attempted to provide information and estimates to overcome these data shortcomings. The report concludes that there is a slight shortage in the current workforce, perhaps due more to maldistribution than any widespread general shortages. The Working Party also concluded that the current level of trainee intake will need to be maintained for projected supply to be adequate to meet estimated future requirements. Obstetrics and gynaecology trainee intake was dramatically boosted in 1995 (from 208 trainees in 1994 to 282 trainees in 1995) and has been maintained at this level in 1996, 1997 and 1998. As a result, no short term measures have been recommended by the Working Party to temporarily boost specialist supply because it is recognised that shortages should begin to improve once the higher number of trainees commence making a contribution to the workforce from 2001 onwards. In projecting workforce supply, there were two key factors identified that would influence the future level of trainee intake. The first is the significant number of specialists aged 55 years and over, 32.0% (336) of the workforce; and therefore likely to proceed through to retirement in the next five to ten years. Average retirement age for this

AMWAC 1998.6 7

workforce is estimated at 63 years and only 7.0% (74) of the current workforce are aged 65 years and over. The other key supply factor is that 55.3% of current trainees are female. This is one of the highest levels of female trainee participation in any specialty and has potentially significant implications for lifetime workforce contribution, given that estimates based on current participation patterns suggests that female lifetime participation in obstetrics and gynaecology is 74% of that of male lifetime participation. This trend is projected to continue and has been factored into the supply projections. Notwithstanding the future uncertainties considered above, the Working Party anticipate that actual requirements are not expected to grow by much, only an estimated 0.4% per annum. This estimation was arrived at following examination of eight requirement trend indicators, including fertility rate, birth rate and service growth trends. As indicated above, the results of the projection analysis indicate that first year trainee intake should be maintained at the current level. Future workforce requirements have indicated that first year trainee intake be 58 so that no significant shortfall emerges in the workforce. However, the Working Party was advised by RACOG that a more practical intake is around 55 trainees. Accordingly, a training program intake of 55 first year trainees has been recommended for the next four years. It should be noted however, that on present indications it is unlikely that this level of intake will need to be sustained indefinitely and as such the Working Party has recommended that before the level of trainee intake for 2003 is determined the workforce should again be reviewed, that is by the end of 2000 to allow sufficient time to recruit the 2003 intakes. In particular, the Working Party acknowledged that the higher level of trainee intake of 58 may cause some difficulties for RACOG in terms of available trainers and the accumulation by trainees of necessary clinical experience. Hence, the recommended first year trainee intake of 55 per year for the next four years, which is in fact similar to the intake over the period 1995 to 1997. Description of the Current Obstetrics and Gynaecology Workforce There were various data sources used to identify the current obstetrics and gynaecology workforce. The total workforce numbers were derived from 1998 RACOG and were supplemented by data from the 1997 RACOG/AMWAC survey of College Fellows. The 1995 AIHW Medical Labour Force Survey was used for comparison. Number of Practising Consultants in Obstetrics and Gynaecology The current size of the practising obstetrics and gynaecology workforce is estimated

to be 1,049 and was based on RACOG figures, as of March 1998. The workforce consists of 951 obstetrics and gynaecology specialists. In addition,

there are an estimated 98 sub-specialists, some of whom also provided obstetrics

AMWAC 1998.6 8

and gynaecology services. RACOG records further show that 502 specialists consider their predominant clinical

practice to be in obstetrics (although time was also spent in gynaecology) and 79 Fellows consider their predominant area of clinical practice to be in gynaecology. 370 Fellows have indicated to the College that they spend roughly the same amount of time in obstetrics and gynaecology.

There are five sub-specialties within obstetrics and gynaecology. The Working Party

identified 10 maternal fetal medicine specialists, 13 uro-gynaecologists, 23 obstetrical and gynaecological ultrasound specialists, 24 gynaecological oncology specialists and 28 reproductive endocrinology and infertility specialists, as of February 1998. Specialists can also contribute to these sub-specialty areas.

The number of sub-specialists is relatively small, making up approximately 9.3% per

cent of the profession. The main characteristics of the sub-specialists workforce are outlined in part B of this report.

Geographic Distribution Using three data sources (RACOG, AIHW and Medicare) the total specialist

obstetrics and gynaecology to population ratio (SPR) is estimated to range from 1:6,954 to 1:7,547 or (13.3 to 14.4 specialists per 100,000 female population 15 years and over).

RACOG data estimates the national SPR to be 1:6,954 female population. The

RACOG data shows Victoria and South Australia have the highest SPR and Tasmania and the Northern Territory the lowest SPRs. Other States/Territories, with a SPR better than the national average are New South Wales and the Australian Capital Territory. The SPRs in Queensland and Western Australia are noticeably lower than the national average. AIHW and Medicare data show a similar pattern.

77.5% of specialists and sub-specialists had their primary practice in a capital city

(64% of the female population), 7.2% in other metropolitan areas (7.5% of the female population) and the remaining 15.3% in rural and remote centres (28.5% of the female population).

Sub-specialties are generally located in the metropolitan areas and capital cities.

Only obstetrics and gynaecology ultrasound sub-specialists are represented in rural centres.

Age Profile The RACOG data indicated that the average age of the workforce was 51.1 years.

The largest five year age group was aged between 51 and 55 years (19.4%), followed by the 46 to 50 year age group (17.5%), 7.0% (74) of the workforce was

AMWAC 1998.6 9

aged over 65 years and 32.0% (336) of the workforce was aged over 55 years. Currently, 48.6% (510) of the total obstetrics and gynaecology workforce was aged

less than 50 years, and 17.2% (180) were aged over 60 years. The workforce is predominantly (51.4%) over 50 years of age (539).

Tasmania has a noticeably older workforce with 29.2% (7) of specialists aged over

60 years. Victoria also has a higher proportion of specialists aged over 60 years, 19.0% (54). Queensland has the youngest age structure with 51.2% (87) of its workforce aged under 50 years of age. The Northern Territory has a high proportion of younger specialists, although the actual number is small, 50.0% (4).

Gender Profile Women make up 15.1% of the total obstetrics and gynaecology workforce, and this

compares with women comprising 14.0% of all specialists. In comparison to other specialties obstetrics and gynaecology appears to be one

speciality that is relatively attractive to women. As well as the proportion of women in the specialty being above the national average for specialists, obstetrics and gynaecology has the fifth highest proportion of female specialists of all specialties.

55.3% (156) of the current trainees in obstetric and gynaecology and 43.6% (17) of

the sub-specialist trainees are female; and this is one of the highest levels of female participation in a specialist training program.

The largest proportion of female obstetrics and gynaecology specialists is in the 41

to 45 year age group (29.7%) followed by the 36 to 40 year age group (24.7%) and the 46 to 50 year age group (15.2%).

Hours Worked The average hours worked per week is estimated at 62.0; 42.6 hours per week were

spent in direct patient care and an additional 19.4 hours were worked on call. In 1997, it is estimated specialists worked on average 62.0 hours per week, 64.0 for

males and 54.0 for females. For both males and females, those under 55 years of age averaged around 62.5 hours per week; this declined to 54.1 hours for the 55 to 64 years age group and to 45.8 hours for 65 to 74 years age group. The highest average hours worked per week were 71.2 hours by males aged 45 to 54 years and for females 60.7 hours per week in the 35 to 44 age range.

Average hours worked increase with remoteness from a capital city and range from

an estimated 60.4 hours per week for capital city based specialists to 74.5 hours per week for specialists located in remote areas. The proportion of the workforce on call in small rural and remote areas is higher than in metropolitan and large rural centres.

AMWAC 1998.6 10

There is little difference in hours worked, practitioners on call and average age between metropolitan and large rural centres.

Type of Practice Of the 501 specialists who responded to the RACOG/AMWAC survey, 63.7% were

in a private practice and/or undertaking public hospital work; 15.8% were salaried in a public hospital; 14.2% were in a private practice with no public hospital role; 2.2% were public hospital salaried and in a private practice; 0.6% were salaried in private hospital and in a private practice and/or undertake public hospital role; 0.5% had a university appointment with a public hospital role.

Services Provided The Working Party analysed obstetrics and gynaecology procedures performed on

private and public patients in Australian hospitals for the period 1993-94 to 1995-96. The national hospital morbidity data is outlined in full in Appendix K but notable trends are; between 1993-94 and 1995-96 the overall growth in gynaecological procedures was 7.7% and the overall growth in obstetrical procedures was 11.8%, for the same period.

Proportions of private versus public patients for given procedures varied widely

especially for gynaecological procedures. The overall proportion of gynaecological procedures undertaken on private patients was 51.3%; this ranged from a high of 91.8% for the incision of vagina and cul-de-sac to a low of 33.8% for other bilateral destruction or occlusion of fallopian tubes. Overall, obstetrics procedures were less likely to be performed on private patients than were gynaecological procedures Β (34.9% of obstetrical procedures compared with 51.3% of gynaecological procedures were performed on private patients).

The Working Party also examined services attracting Medicare benefits and found

that over the ten year period, 1986-87 to 1996-97, all obstetrics and gynaecology Medicare services provided by specialists increased by 27.2%. This represents a growth of 2.7% per annum.

For gynaecological items there was an increase of 8.0% in the period 1986-87 and

1996-97 (0.8% growth per annum). During the period 1995-96 and 1996-97, Medicare services provided by obstetrics

and gynaecology specialists for obstetric items increased by 42.7% (growth of 21.3% per annum over the two year period). Only the period 1995-96 to 1996-97 was examined because in 1995-96 ante-natal visits were included in the number of services for the first time.

Confinement services provided by specialists in obstetrics and gynaecology

decreased by 33.0% in the period 1986-87 to 1996-97.

AMWAC 1998.6 11

Training Arrangements In March 1998 there were 282 advanced trainees in obstetrics and gynaecology, the

bulk of whom are in years 1, 2 and 3 of the program (60.1%); reflecting the large increase in annual intake from 1995 onwards.

Women represent 55.3% of current trainees.

In terms of the State/Territory distribution of trainees, the number in Queensland and

Western Australia is noticeably below those States population shares, and conversely South Australia has a noticeably higher proportion of trainees compared to population. The bulk of the trainees are located in New South Wales and Victoria (57.2%/152). These two States share of trainees is roughly in proportion to their respective population shares. Female trainees are well represented in each State/Territory with the highest proportions in Queensland (63.8%), the Australian Capital Territory (60.0%) and New South Wales (58.0%).

There has been a 34.3% increase in the number of trainees during the period 1992

to 1998. Trainee numbers increased dramatically in 1995, with a 35.6% increase on the previous year. Female trainees increased by 85.7% during the period 1993 to 1998.

There were 39 sub-specialist trainees, the majority (79.5%) of whom were aged

under 40 years of age. Females represented 43.6% (17) of sub-specialist trainees. Adequacy of the Current Obstetrics and Gynaecology Workforce Overall, the Working Party concluded that there is some indication of a slight workforce shortage, particularly when public hospital vacancies and consultation waiting times are considered. Waiting times for a standard public patient were found to be noticeably higher for patients in Queensland, Western Australia, Tasmania, South Australia and Northern Territory. However, these regional shortages may relate more to maldistribution of the workforce than any significant shortage in the workforce as a whole, especially as the SPR data indicated that most States/Territories had an SPR above the suggested benchmark. The SPR data also showed that in capital cities/metropolitan areas all States/Territories are currently well supplied with obstetrics and gynaecology specialists, with the exception of the Northern Territory. In rural/remote areas South Australia and Western Australia remain below the national rural/remote SPR. Specialist (including sub-specialist) to Population Benchmarks RACOG has indicated that an acceptable specialist (including sub-

specialist):population ratio (SPR) for females in urban areas is 1:10,000 and for rural areas is 1:15,000. As the majority of the female population (64%) is situated in capital cities/metropolitan areas the national ratio is skewed towards the urban areas

AMWAC 1998.6 12

and is estimated to be 1:12,500. Examining the SPR by State and Territory and RRMA classification for the female

population age ranges indicated that in general capital city/metropolitan areas were well supplied with specialists with the exception of the Northern Territory.

The distribution of specialists in rural/remote areas indicated that generally South

Australia, Western Australia, Queensland and Tasmania fall below the rural RACOG SPR benchmark for the female population. RACOG has recommended that there should ideally be at least two to four specialists (depending on the size of the catchment population) resident in any one location which will allow appropriate cover for those specialists who are in large remote areas. The above analysis of rural/remote SPR levels indicates that these States/Territories may not have appropriate cover.

The Working Party considered that where population size is below the necessary

critical mass to support a resident specialist, or there are no specialists interested in establishing a practice in a community large enough to support a resident obstetrics and gynaecology service, a regular visiting outreach service may become an appropriate form of service delivery.

Consultation Waiting Times The average waiting time for a standard first consultation with a specialist in

obstetrics and gynaecology in his/her private rooms is 16.9 days (standard deviation 18.0) while public patients wait, on average, 31.9 days (standard deviation 48.4). The waiting time in the Australian Capital Territory for a standard first consultation is well above the average for both private and public patients.

For a serious condition, private patients wait less time (2.0 days, standard deviation

4.1) than do patients in public outpatient departments (7.1 days, standard deviation 18.5); with public patients in Queensland and Northern Territory waiting above average times for urgent conditions.

Public Hospital Vacancies The 1997 AMWAC survey of public hospital specialist vacancies found there were

17 obstetrics and gynaecology vacancies (13.5 full time equivalents). There were 6 (4.2 FTEs) vacancies in New South Wales, one (1 FTE) in Victoria, 8 (6.3 FTEs) in Queensland, one (1 FTE) in South Australia and one (1 FTE) in Tasmania. There were no vacancies in Western Australia. In addition, nine vacancies were filled by TRDs; seven TRDs in New South Wales and one TRD in both Queensland and Western Australia.

Survey of Divisions of General Practice To gain a GP perspective on the adequacy of the specialist workforce, AMWAC

AMWAC 1998.6 13

surveyed the Divisions of General Practice. The survey found that 55.4% of Divisions considered that a shortage of obstetrics and gynaecology specialists existed in their area, with the remaining proportion predominantly of the view that supply was about right. A greater proportion of rural divisions (61.5%) perceived the supply of specialists to be inadequate than did Divisions located in urban areas (50.0%).

Projections of Requirements Population Over the next ten years, the total Australian female population is expected to

increase at an annual rate of 1.1% per annum. During the same period the female population greater than 15 years will increase approximately by 1.1% per annum, those aged 15-49 years will increase approximately 0.2% per annum, those aged greater than 25 years will increase approximately 1.0%per annum and those ages over 49 years will increase by 2.7% per annum.

Birth Rate There has been a growth in births in Australia from 243,408 live births in 1986 to

253,834 in 1996, this represents a growth of 4.3%, or 0.4% per annum. Future projections indicate that birth rates will remain constant.

Fertility Rate The total fertility rate since 1992 (1.894) has steadily declined, with the fertility rate

for registered births at 1.796 in 1996, the lowest rate on record. The fertility rate is considered to be more likely to fall or remain stable in the longer term, and the age distribution will continue to change in favour of ages over 30 years. It can be assumed that as the mean age of women giving birth to their first child in Australia increases it will in turn increase the likelihood of increased demand for specialist in obstetrics and gynaecology.

Medicare and ICD-9-CM Data Trends Medicare obstetrics and gynaecology services provided by obstetricians and

gynaecologists have shown a 2.7% per annum growth over the period 1986-87 to 1996-97.

ICD-9-CM data on obstetrics and gynaecology have indicated that for gynaecological

procedures there will be overall growth of 14.0% over the next 20 years (1998-2018) or 0.7% per annum. For obstetrical procedures it is forecasted to rise by only 2.2% or by 0.1% per annum in the same period.

The Working Party concluded that the birth rate provided the best indicator of likely

future obstetrics and gynaecology services requirements, that is requirements growth of an estimated 0.4% per annum. This projection trend is the mid point of all the indicators examined. It is lower than most of the population trends, but higher

AMWAC 1998.6 14

than the fertility rate and the incidence of cancer trend. It is actually close to the trend in growth in obstetrics and gynaecology ICD-9-CM national hospital morbidity data

Projections of Supply The average expected age of retirement from the workforce was 63 years.

Examining the age and sex distribution of the specialist workforce shows that the

majority (52.7%) of the workforce is aged over 50 years, 32.0% of the workforce is aged 55 years and over and 18.0% are aged over 60 years. Assuming the average retirement age from the RACOG/AMWAC survey of 63 years, it can be estimated that there could be approximately 200 (21%) specialists intending to retire in the next five years.

RACOG expects trainee graduations over the next seven years to be: 45 in 1998, 21

in 1999, 50 in 2000, 47 in 2001, 57 in 2002, 49 in 2003 and 42 in 2004; that is an average of 48 graduates per year (excluding 1999 graduates).

It is expected that the proportion of women in the workforce will increase; given the

continuing increase in the number of female trainees. Women represent 15.5% the current total workforce, but 55.3% of trainees. In addition, of the 336 specialists aged 55 years and over, only 21 are female.

The expected lifetime hours worked by a female obstetrics and gynaecology

specialist has been estimated at 74.1% of that of a male. In conducting the projection analysis, the expected supply has been adjusted to account for increasing female participation and for the expected lower lifetime workforce contribution.

Contribution of Services by Non-specialist Providers One of the features of obstetrics and gynaecology is the scope for non specialist

providers to provide at least some of the services in obstetrics and minor gynaecological procedures. There are no definitive data sources that enable the level of substitution to be assessed, however Medicare data does provide an indication of the number of services provided by specialists and non specialists.

When private services alone are considered the majority of Medicare obstetrics and

gynaecology services are provided by specialist obstetricians and gynaecologists. In 1996-97, 86.5% of confinements were provided by obstetricians and gynaecologists, 57.2% of obstetric items and 75.3% of gynaecological items. There has been a fall of 5.6 percentage points in the number of obstetric services provided by a GP during the period 1995-96 and 1996-97. Similarly, obstetrics services provided by specialists increased by 5.7 percentage points and confinement items provided by specialists increased by 1.5 percentage points.

AMWAC 1998.6 15

In terms of obstetrics it is clear that there has been a relative decline in the provision of privately provided services by GPs against the backdrop of a falling number of private deliveries overall. In 1986, 23.1% of private deliveries were performed by GPs, in 1996-97, the proportion was down to 13.3%, in other words, a dominant trend has been declining involvement of GPs in private obstetrics. As a consequence the proportion of private deliveries undertaken by obstetrics and gynaecology specialists has risen markedly, to the point that nearly 90% of all private deliveries are undertaken by specialists.

In terms of States/Territories, Queensland and Western Australia show GP

involvement above the national average. In antenatal care South Australia and Northern Territory GP involvement is also above the national average, as is the involvement of GPs in the management of labour in Tasmania and the Northern Territory.

States/Territories with GP involvement below the national average are New South

Wales, Tasmania and the Australian Capital Territory. These figures indicate that there is a predominant role taken by GPs in providing obstetrics and gynaecology services in some of the less populous States/Territories, much of which is likely to be in provincial and rural/remote areas.

Balancing Supply Against Requirements A balance in supply to match a continued growth rate in the requirement indicators

of 0.4% per annum can be achieved by ensuring the same number of graduates currently entering the six year program is maintained; that is a trainee intake of 58 per year.

If trainee intakes remain at around 58 per year, it is expected that there will be no

significant shortfall emerging in the workforce. Notional shortages are expected to peak at 2.9% in 2002 but for requirements and supply to move back towards balance thereafter. It is projected that there will only be 1.6% shortfall in 2008.

Ideally trainee intake should be around 58 per year so that no significant shortfall

emerges in the workforce. However, RACOG has indicated that the initial intake of 58 trainees per year may not be achievable as there are limited potential training positions currently available and an already stretched resource of trainers. Maintenance of trainee intake at this level could also impact on trainees obtaining the necessary accumulated training experience. Accordingly, to accommodate this concern several scenarios based on trainee intake ranging from 50 per year to 58 per year were examined. Notional shortfalls range from a near balanced scenario with a trainee intake of 58 per year to an estimated shortfall of 3.6% with a trainee intake of 50 per year.

AMWAC 1998.6 16

In recognition of RACOGs concern the Working Party has recommended that an intake of 55 trainees per year may be a more practical target to reach. A trainee intake of 55 per year, will produce an estimated workforce shortfall of 2.1% in 2009.

Of course this does not address the issue of maldistribution of the workforce and in

this respect it will be necessary for RACOG and State/Territory health departments to make internal adjustments to the distribution of training positions.

The Working Party recommends that training positions should be increased

proportionately less in the comparatively well endowed state of South Australia, and to a lesser extent Victoria, although it needs to be remembered that Victoria has a significant proportion of older specialists. This is also the case in New South Wales. In particular, emphasis needs to be given to increasing training positions in New South Wales, Western Australia and Queensland.

Given the sensitivity of the assumptions in the projection modelling, it will be

important that obstetrics and gynaecology requirements and supply projections be monitored regularly so that they can be amended if new trends emerge. The Working Party recommends that a review of the specialist obstetrics and gynaecology workforce be undertaken before the level of trainee intake for 2003 is determined, that is by the end of 2000 to allow sufficient time to recruit the 2003 intakes. In this context, it will also be important for AMWAC to continue to monitor the trend in the numbers of non specialist providers.

It should also be noted that whilst RACOG has recently introduced a compulsory six

month rural training placement for trainees, in an effort to improve awareness of rural practice, this scheme will need the continued support of State/Territory health departments in terms of funding and support of suitable rural training positions.

The Working Party would also like the Commonwealth and State/Territory health

departments to consider the establishment of rural cadetships aimed at providing financial assistance to those training in their last year and are interested in remaining and establishing a rural practice. This process coupled with the compulsory experience to rural practice through the training program may help to alleviate some of the geographical maldistribution inherent in the workforce. In the first instance the Commonwealth Department of Health and Family Services and RACOG should jointly examine the feasibility of such a scheme.

AMWAC 1998.6 17

RECOMMENDATIONS The Working Party recommends: 1. There be an increase in the number of funded obstetrics and gynaecology

training positions to maintain trainee intake during the period 1999 to 2002 at 55 per year.

2. That State and Territory health departments undertake negotiations with the

RACOG to ensure intake numbers for first year trainees remain constant at 55 per year to 2002 and distributed as shown below.

Distribution of obstetrics and gynaecology first year advanced trainee positions, by State/Territory, 1999 to 2002

State/Territory

1997

1998

1999

2000

2001

2002

actual intakes

required intake

NSW

18

14

20

20

20

20

Victoria

12

10

14

14

13

12

Queensland

9

5

11

11

11

11

South Australia

5

6

4

4

4

4

Western Australia

5

2

4

4

4

4

Tasmania

0

2

1

1

2

2

ACT

0

3

1

1

1

2

Northern Territory*

0

0

0

0

0

0

Australia

49

42

55

55

55

55

* Trainees to the Northern Territory are on a rotational basis from other States Source: AMWAC

3. State/Territory based obstetrics and gynaecology services working groups,

comprising RACOG and State/Territory department of health representatives, be organised to oversee the funding and establishment of any new training positions.

4. That obstetrics and gynaecology requirements and supply projections be

monitored regularly so that they can be amended if new trends emerge, and that the specialist obstetrics and gynaecology workforce be reviewed before the level of trainee intake for 2003 is decided, that is at the end of 2000.

AMWAC 1998.6 18

5. That this monitoring be coordinated by RACOG and AMWAC and the results incorporated into the AMWAC annual report to AHMAC. AMWAC will provide all necessary support.

6. AMWAC also to continue to monitor the trend in the numbers of non specialist

obstetric and gynaecology providers (general practitioners and midwives). 7. The RACOG and the Commonwealth Department of Health and Family Services

examine the feasibility of establishing a rural obstetric and gynaecology graduate cadetship scheme to encourage graduates from the obstetrics and gynaecology training program to consider rural practice.

AMWAC 1998.6 19

DESCRIPTION OF THE CURRENT OBSTETRICS AND GYNAECOLOGY WORKFORCE As discussed in the introduction, there are a variety of data sources on the numbers, attributes and distribution of obstetrics and gynaecology specialists and sub-specialists in Australia. While each of these data collections has some deficiencies, it is possible to piece together a reasonably accurate and up-to-date profile of the workforce. In establishing the profile of the current obstetrics and gynaecology and sub-specialty workforce the Working Party defined: the number of practising obstetrics and gynaecology specialists; the distribution of the workforce; the age and gender profiles of the workforce; the hours worked; and the services provided.

The Number of Practising Obstetrics and Gynaecology Specialists in Australia Specialists in obstetrics and gynaecology are generally Fellows of the Royal Australian College of Obstetricians and Gynaecologists (FRACOG). Fellows may practice as obstetricians, gynaecologists, or both, or in the sub-specialities of maternal fetal medicine, uro-gynaecology, obstetrical and gynaecological ultrasound, gynaecological oncology and reproductive endocrinology and infertility. The Working Party estimated that in March 1998 the current size of the practising obstetrics and gynaecology workforce was 1,049 which includes both specialists and sub-specialists. This figure was provided by RACOG, and includes members who identified themselves as being a FRACOG and are registered under the National Specialist Qualification Advisory Committee as a specialist or sub-specialist in obstetrics and gynaecology. Of the 1,049, ninety eight (9.3%) were identified as sub-specialists. It is important to note, however, that this is not a strict division of the area of practice because many specialists may provide sub-speciality services and sub-specialists may provide general obstetrics and gynaecology services. RACOG records further show that 502 specialists consider their predominant clinical practice to be in obstetrics (although time was also spent in gynaecology) and 79 Fellows consider their predominant area of clinical practice to be in gynaecology. 370 Fellows have indicated to the College that they spend roughly the same amount of time in obstetrics and gynaecology. Of the practitioners who are sub-specialists, 10 are maternal fetal medicine specialists, 13 uro-gynaecology specialists, 23 obstetrical and gynaecological ultrasound specialists, 24 gynaecological oncology specialists and 28 reproductive endocrinology and infertility specialists. More detailed data on each of the sub-specialist workforces is provided in Part B of the report.

AMWAC 1998.6 20

Distribution of the Obstetrics and Gynaecology Workforce State/Territory Distribution The distribution of the total specialist obstetrics and gynaecology workforce is shown in Table 1. Using three data sources (RACOG, AIHW and Medicare) the total specialist obstetrics and gynaecology to population ratio (SPR) is estimated to range from 1:6,954 to 1:7,547 or (13.3 to 14.4 specialists per 100,000 female population). RACOG data estimates the national SPR to be 1:6,954 female population. The RACOG data shows Victoria and South Australia have the highest SPR and Tasmania and the Northern Territory the lowest SPRs. Other States/Territories, with a SPR better than the national average are New South Wales and the Australian Capital Territory. The SPRs in Queensland and Western Australia are noticeably lower than the national average. AIHW and Medicare data show a similar pattern. Geographic Distribution Table 2 shows the geographic distribution for the total workforce, using 1998 RACOG data. Overall, 77.5% of the workforce had their primary practice in a capital city (64% of the female population), 7.2% in metropolitan areas (7.5% of the female population) and the remaining 15.3% in rural/remote areas (28.5% of the female population) - (8.5% in a large rural centre, 3.4% in a small rural centre, 2.5% in other rural areas and 0.9% in remote areas). The data from the 1995 AIHW survey indicates a similar distribution pattern; 83.7% of specialists had their main job in a capital city or other major urban area, 9.1% in a large rural centre, 4.3% in a small rural centre, 2.3% in other rural areas and 0.6% in remote areas.

AMWAC 1998.6 21

Table 1: Obstetrics and gynaecology specialists/sub-specialists to population, by State/Territory State/ Territory

O&G spec.

and sub-spec.

% of total O&G

spec. and sub-spec.

% of Australian

female pop. >15 years a

O&G

SPR

O&G per

100,000 pop.

Total number of specialists and sub-specialists (RACOG 1998)

NSW

361

34.4

34.0

1:6,879

14.5

Vic.

284

27.1

25.3

1:6,498

15.4

Qld

170

16.2

17.9

1:7,694

13.0

SA

92

8.8

8.2

1:6,515

15.3

WA

92

8.8

9.4

1:7,465

13.4

Tas.

24

2.3

2.6

1:7,852

12.7

NT

8

0.8

0.9

1:7,820

12.8

ACT

18

1.7

1.7

1:6,777

14.8

Australia

1,049

100.0

41.1

1:6,954

14.4

Total number of specialists and sub-specialists (AIHW 1995) b

NSW

309

31.7

34.0c

1:7,904

12.7

Vic.

258

26.5

25.3

1:7,035

14.2

Qld

165

16.9

17.9

1:7,791

12.8

SA

91

9.1

8.3

1:6,547

15.3

WA

89

8.9

10.8

1:8,699

11.5

Tas.

25

2.6

2.6

1:7,460

13.4

NT

11

1.1

0.4

1:2,730

35.8

ACT

26

2.7

1.7

1:4,561

21.9

Australia

974

100.0

100.0

1:7,371

13.6

Total number of specialists and sub-specialists (Medicare 1995-96)c

NSW

339

35.0

34.0

1:7,325

13.7

Vic.

264

27.3

25.3

1:6,990

14.3

Qld

147

15.2

17.9

1:8,898

11.2

SA

77

8.0

8.2

1:7,787

12.8

WA

85

8.8

9.4

1:8,079

12.4

Tas.

*

*

2.6

*

*

NT

*

*

0.9

*

*

ACT

*

*

1.7

*

*

Australia

968

100

100

1:7,537

13.3

Notes: a - 1996 ABS female population figures; b - specialists whose main specialty of practice is obstetrics and gynaecology; c - 1995 ABS female population figures; * - number less than three. Source: RACOG & AIHW

AMWAC 1998.6 22

Table 2: Distribution of the total obstetrics and gynaecology workforce, by State/Territory and geographic location (RACOG data), 1998 State/ Territory

Total

% of Aust

% capital

city

% other

metro

% large

rural centre

% small

rural centre

% other

rural centre

%

remote

NSW/ACT

379

36.1

76.5

10.6

7.1

4.8

1.1

0.0

Vic

284

27.1

82.0

3.2

6.2

3.2

4.9

0.0

Qld

170

16.2

63.5

12.9

21.8

0.6

0.6

0.6

SA

92

8.8

91.3

. .

2.2

1.1

5.4

0.0

WA

92

8.8

85.9

5.4

. .

4.3

0.0

4.3

Tas

24

2.3

66.7

. .

16.7

12.5

4.2

0.0

NT

8

0.8

37.5

. .

0.0

. .

12.5

50.0

Australia

1,049

100.0

77.5

7.2

8.5

3.4

2.5

0.9

Notes: . . - not applicable Source: RACOG 1998 Age Profile The RACOG data indicated that the average age of the workforce was 51.1 years. The largest five year age group was aged between 51 and 55 years (19.4%), followed by the 46 to 50 year age group (17.5%), while, 7.0% (74) of the workforce was aged over 65 years and 32.0% (336) of the workforce was aged over 55 years (Table 3). Table 4 provides a summary of the workforce by major age categories. It shows that for Australia, 48.6% (510) of the total obstetrics and gynaecology workforce was aged less than 50 years, and 17.2% (180) were aged over 60 years. The workforce is predominantly (51.4%) over 50 years of age (539). Tasmania has a noticeably older workforce with 29.2% (7) of specialists aged over 60 years. Victoria also has a higher proportion of specialists aged over 60 years, 19.0% (54), than the national average. Queensland has the youngest age structure with 51.2% (87) of its workforce aged under 50 years of age. The Northern Territory also has a high proportion of young specialists, although the actual number is small, 50.0% (4). The 1995 AIHW data indicated that the average age of the workforce was 51.1 years, with 103 specialists (10.5%) aged 65 years and over (Appendix C).

AMWAC 1998.6 23

Table 3: Age profile of the total obstetrics and gynaecology specialist workforce, by State/Territory and gender (RACOG data), 1998

State/ Terr.

31-35

yrs

36-40

yrs

41-45

yrs

46-50

yrs

51-55

yrs

56-60

yrs

61-65

yrs

66-70

yrs

71 + yrs

Total

Male

NSW

12

26

46

52

77

48

29

22

1

313

Vic.

8

19

30

39

52

35

24

15

1

233

Qld.

5

18

15

34

22

29

13

10

4

150

SA

3

6

9

13

15

13

11

3

0

73

WA

3

7

5

15

17

15

6

4

4

76

Tas.

1

2

4

3

4

2

5

2

0

23

ACT

1

2

3

2

2

4

1

0

1

16

NT

0

1

0

2

1

2

0

1

0

7

Aust.

33

81

112

160

190

148

99

57

11

891

Female

NSW

4

13

14

8

3

1

3

0

2

48

Vic.

5

12

17

7

4

2

1

3

0

51

Qld.

2

6

4

3

3

2

0

0

0

20

SA

2

4

6

2

2

2

0

1

0

19

WA

1

3

5

4

0

1

2

0

0

16

Tas.

0

1

0

0

0

0

0

0

0

1

ACT

0

0

0

0

1

0

1

0

0

2

NT

0

0

1

0

0

0

0

0

0

1

Aust.

14

39

47

24

13

8

7

4

2

158

Total

NSW

16

39

60

60

80

49

32

22

3

361

Vic.

13

31

47

46

56

37

35

18

1

284

Qld

7

24

19

37

25

31

13

10

4

170

SA

5

10

15

15

17

15

11

4

0

92

WA

4

10

10

19

17

16

8

4

4

92

Tas.

1

3

4

3

4

2

5

2

0

24

ACT

1

2

3

2

3

4

2

0

1

18

NT

0

1

1

2

1

2

0

1

0

8

Aust.

47

120

159

184

203

156

106

61

13

1,049

% total

4.5

11.4

15.2

17.5

19.4

14.9

10.1

5.6

1.2

100.0

% female

29.8

32.5

29.6

13.0

6.4

5.1

6.6

6.6

15.4

15.1

Source: RACOG 1998

AMWAC 1998.6 24

Table 4: Age profile of the total obstetrics and gynaecology specialist workforce, by State/Territory, gender and major age group (RACOG data), 1998

State/Terr.

NSW

Vic

Qld

SA

WA

Tas

NT

ACT

Aust

Number of specialist obstetricians and gynaecologists

Male

under 50 years

136

96

72

31

30

10

3

8

386

51-60 years

125

87

51

28

32

6

3

6

338

over 60 years

52

50

27

14

14

7

1

2

167

Total

313

233

150

73

76

23

7

16

891

Female

under 50 years

39

41

15

14

13

1

1

0

124

51-60 years

4

6

5

4

1

0

0

1

21

over 60 years

5

4

0

1

2

0

0

1

13

Total

48

51

20

19

16

1

1

2

158

Total

under 50 years

175

137

87

45

43

11

4

8

510

51-60 years

129

93

56

32

33

6

3

7

359

over 60 years

57

54

27

15

16

7

1

3

180

Total

361

284

170

92

92

24

8

18

1,049

Percentage

Male

under 50 years

43.5

41.2

48.0

42.5

39.5

43.5

42.9

50.0

43.3

51-60 years

40.0

37.3

34.0

38.4

42.1

26.1

42.9

37.5

37.9

over 60 years

16.5

21.5

16.0

19.1

18.4

30.4

14.2

12.5

18.7

Female

under 50 years

81.3

80.4

75.0

73.7

81.3

100.0

100.0

0.0

78.5

51-60 years

8.3

11.8

25.0

21.1

6.2

0.0

0.0

50.0

13.3

over 60 years

10.4

7.8

0.0

5.2

12.5

0.0

0.0

50.0

8.2

Total

under 50 years

48.5

48.2

51.2

48.9

46.7

45.8

50.0

44.4

48.6

51-60 years

35.7

32.7

32.9

34.8

35.9

25.0

37.5

38.9

34.2

over 60 years

15.8

19.1

15.9

16.3

17.4

29.2

12.5

16.7

17.2

% Female

13.3

18.0

11.8

20.7

17.4

4.2

12.5

11.1

15.1

Source: RACOG 1998

AMWAC 1998.6 25

With respect to the specialist workforce of 951, the data shows that the largest five year age group is the 51 to 55 year age group (19.2%), followed by the 46 to 50 year age group (16.8%), and that 7.6% (72) of the workforce were aged over 65 years of age. The youngest specialist was 33 and the oldest was 76 with an average age of 51.5 years. The youngest obstetrician was 35 years and the oldest was 77 years with a mean age of 45.4 years. The youngest gynaecologist was 39 years and the oldest was 76 years with a mean age of 47.9 years. Table 6 provides a summary of specialists by major age categories. It shows that for Australia, 47.2% (449) of specialists was aged less than 50 years, and 18.0% (171) were aged over 60 years. The specialist workforce is predominantly (52.8%) over 50 years of age (502). Table 5: Age profile of obstetrics and gynaecology specialists, by State/Territory and gender (RACOG data), 1998 State/Terr.

Sex

31-35

yrs

36-40

yrs

41-45

yrs

46-50

yrs

51-55

yrs

56-60

yrs

61-65

yrs

66-70

yrs

71+ yrs

Total

NSW

M

11

21

37

47

68

45

27

22

1

279

F

4

12

12

7

3

1

3

0

2

44

Victoria M

8

17

27

30

46

35

31

13

1

208

F

5

12

15

7

4

2

1

3

0

49

Queensland M

5

17

13

31

22

29

12

10

4

143

F

2

6

3

3

3

2

0

0

0

19

South Aust. M

3

6

9

11

14

11

10

3

0

67

F

2

4

5

2

1

2

0

1

0

17

West. Aust. M

3

6

4

11

15

12

6

4

4

65

F

1

2

4

4

0

1

2

0

0

14

Tasmania M

0

2

4

3

3

2

5

2

0

21

F

0

1

0

0

0

0

0

0

0

1

North. Terr. M

0

1

0

2

1

2

0

1

0

7

F

0

0

1

0

0

0

0

0

0

1

ACT M

1

1

2

2

2

4

1

0

1

14

F

0

0

0

0

1

0

1

0

0

2

Australia M

31

71

96

137

171

140

92

55

11

804

F

14

37

40

23

12

8

7

4

2

147

Total

45

108

136

160

183

148

99

59

13

951 % Total

4.7

11.4

14.3

16.8

19.2

15.6

10.4

6.2

1.4

100.0 % Female

31.1

34.3

29.4

14.4

6.6

5.4

7.1

6.8

15.4

15.5

Source: RACOG 1998

AMWAC 1998.6 26

Table 6: Age profile of obstetrics and gynaecology specialists, by State/Territory, gender and major age group, 1998

State/Terr.

Sex

NSW

Vic

Qld

SA

WA

Tas

NT

ACT

Aust

under 50 years

M

116

82

66

29

24

9

3

6

335

F

35

39

14

13

11

1

1

0

114

51-60 years

M

113

81

51

25

27

3

3

6

311

F

4

6

5

3

1

0

0

1

20

over 60 years

M

50

45

26

13

14

7

1

2

158

F

5

4

0

1

2

0

0

1

13

Total

323

257

162

84

79

22

8

16

951

Source: RACOG 1998 Gender Profile Women make up 15.1% of the total obstetrics and gynaecology workforce, and this compares to women comprising 14.0% of all specialists. In comparison to other specialties obstetrics and gynaecology appears to be one speciality that is relatively attractive to women. As well as the proportion of women in the specialty being above the national average for specialists, obstetrics and gynaecology has the fifth highest proportion of female specialists of all specialties (AIHW 1997). In addition, 55.3% (156) of the current trainees in obstetric and gynaecology and 43.6% (17) of the sub-specialist trainees are female; and this is one of the highest levels of female participation in a specialist training program (MTRP 1997). The largest proportion of female obstetrics and gynaecology specialists is in the 41 to 45 year age group (29.7%) followed by the 36 to 40 year age group (24.7%) and the 46 to 50 year age group (15.2%). Males represent 84.9% of the total workforce, with the largest proportion of male specialists/sub-specialists in the 51 to 55 year age group (21.3%) followed by the 46 to 50 year age group (18.0%) and the 56 to 60 year age group (16.6%). The upward trend in female participation will need to be monitored as it has implications for the future available workforce. Previous AMWAC studies have shown that female specialists have a lower lifetime workforce participation than male specialists. The AMWAC/AIHW report on female participation in the medical workforce estimated the lifetime workforce participation of female obstetrics and gynaecology specialists at 74% of the male lifetime hours worked (AMWAC/AIHW 1996). However, feedback received from RACOG indicated that there is a possibility that the younger cohort of females entering the profession intend to provide a longer lifetime contribution than their predecessors. Increased levels of female participation are also likely to have an effect

AMWAC 1998.6 27

on patterns of practice. Hours Worked The data used in this section have been derived from the 1997 RACOG/AMWAC survey, comparative data from the 1995 AIHW medical labour force survey are provided in Appendix C. The level of active supply in any medical workforce is affected by the participation rate of practitioners, in terms of hours worked. Accordingly, obstetrics and gynaecology specialists working different hours can be converted to a standard estimate of productivity by the number of hours worked. This approach is an important aspect of the projection analysis used later in this report. Table 7 details the average hours provided by the total workforce. The average hours worked per week is estimated at 62.0; 42.6 hours per week were spent in direct patient care and an additional 19.4 hours were worked on call. It is estimated that specialists worked a total of 2,747,138 hours in 1997; of these hours 1,869,458 hours were in direct patient care. This equates to 37,654 hours per 100,000 female population (>15 years) in total hours worked, with the provision of hours worked per 100,000 population significantly above the average in Victoria and South Australia, and below the average in Western Australia and the Australian Capital Territory.

AMWAC 1998.6 28

Table 7: Specialists and sub-specialists in obstetrics and gynaecology average hours worked per week and annual labour supply hours, by State/Territory, 1998

State/Terr.

NSW

Vic

Qld

SA

WA

Tas

ACT

NT

Total

Total hours worked

Ave. hours per week

58.7

70.8

66.2

64.7

49.5

52.2

48.9

57.0

62.6

Annual hours worked >000)a

855.9

846.8

493.3

255.9

188.9

52.2

35.9

18.4

2,747.1

Hours worked per 100,000 female pop.

34,470

45,885

37,715

42,701

27,521

29,314

29,524

29,319

37,654

Direct patient care hours worked

Ave. hours per week

41.9

43.2

44.7

42.1

41.3

35.8

36.4

52.0

42.6

Annual hours worked (>000)a

610.9

516.7

333.1

166.5

157.7

37.9

26.8

16.7

1,869.5


24,604

27,998

25,467

27,786

22,962

20,104

21,977

26,748

25,624

Hours on call worked

Ave. hours per week

17.6

21.1

21.7

24.7

13.0

18.2

6.6

26.7

19.4


256.0

252.3

161.7

97.7

49.6

19.3

4.8

8.6

851.3


10,335

13,674

12,363

16,301

7,228

10,221

3,984

13,734

11,669

Hours on call not worked

Ave. hours per week

63.0

61.3

64.3

66.8

58.9

82.2

45.6

84.0

63.1


918.7

733.1

479.2

264.3

224.9

86.9

33.6

27.1

2,769.1


36,995

39,728

36,633

44,087

32,747

46,161

27,532

43,208

37,955

Female pop. > 15 years (>000)

2,483.2

1,845.4

1,308.0

599.4

686.7

188.4

121.9

62.6

7,296.6

Specialists

317

260

162

86

83

23

16

7

954

AMWAC 1998.6 29

Note: a - calculated as average hours multiplied by persons multiplied by 46 weeks per year . Source: RACOG

AMWAC 1998.6 30

Table 8 details the average hours provided by the total workforce in obstetrics and gynaecology by gender and age. In 1997, specialists worked on average 62.0 hours per week, 64.0 for males and 54.0 for females. For both males and females, those under 55 years of age averaged around 62.5 hours per week; this declined to 54.1 hours for the 55 to 64 years age group and to 45.8 hours for 65 to 74 years age group. The highest average hours worked per week were 71.2 hours by males aged 45 to 54 years and for females 60.7 hours per week in the 35 to 44 age range. Table 8: Specialists in obstetrics and gynaecology average hours and annual hours worked, by gender and age group, 1998 Gender

25-34

yrs

35-44

yrs

45-54

yrs

55-64

yrs

65-74

yrs

75 yrs &

over

Total

Total hours worked

Male

51.9

70.5

71.2

54.9

47.1

10.0

64.0

Female

48.7

60.7

44.8

30.0

10.0

0.0

54.0

Total

51.0

67.1

69.4

54.1

45.8

10.0

62.0

Annual hrs worked (>000)a

70.4

762.4

1,209.9

652.0

69.5

1.4

2,733.9


Male

37.9

45.4

47.7

38.2

31.0

10.0

43.1

Female

40.5

40.8

35.1

33.5

nr

0.0

39.0

Total

38.4

43.8

46.7

38.0

31.0

10.0

42.6


52.9

497.6

814.2

457.9

47.1

1.4

1,869.5


Male

67.9

59.7

67.1

63.6

51.5

0.0

63.7

Female

50.0

54.1

59.7

102.7

0.0

0.0

58.6

Total

65.9

57.9

66.6

64.8

51.5

0.0

63.1


90.9

657.6

1,161.1

780.9

78.2

0.0

2,769.1


Male

13.3

21.6

18.7

15.8

26.7

0.0

18.6

Female

5.0

2.5

25.4

1.5

0.0

0.0

21.9

Total

12.3

21.9

19.1

15.6

26.7

0.0

19.4


16.9

248.8

332.9

188.0

40.5

0.0

851.4

Note: a - calculated as average hours multiplied by persons multiplied by 46 weeks per year Source: RACOG and RACOG/AMWAC Survey 1997

AMWAC 1998.6 31

There were 10% (50) specialists who worked less than 35 hours per week and 14% (71) who reported working 80 hours per week or more. By way of comparison the AIHW Labour Force survey found that in 1995 specialists worked on average 55.0 hours per week, 55.7 for males and 49.3 for females. Those under 55 years of age averaged around 60 hours per week, and this declined to 49.5 hours for 55 to 64 years age group, 31.7 hours for 65 to 74 years age group and 27.3 hours for those aged 75 years or more. The highest average hours worked per week were 54.0 hours by males aged 45 to 54 years. There were 13.5% (132) specialists who worked less than 35 hours per week and 12.3% (119) who reported working 80 hours per week or more. Table 9 shows the average hours worked by location and reveals several interesting trends: - average hours worked increase with remoteness from a capital city and range

from an estimated 60.4 hours per week for capital city based specialists to 74.5 hours per week for specialists located in remote areas;

- the hours worked on call are higher in rural and remote areas, and this appears as the main reason for the higher average hours per week in these areas;

- the proportion of the workforce on call in small rural and remote areas is higher than in metropolitan and large rural centres;

- specialists in small rural centres and remote areas are, on average, three to five years older than their metropolitan counterparts; and

- there is little difference in hours worked, practitioners on call and average age between metropolitan and large rural centres.

Table 9: Hours worked by specialists in obstetrics and gynaecology, by geographic location, 1997

Hours worked

Major urban centre

Large rural

centre

Small rural

centre

Other rural area

Remote

Total

Total

60.4

60.7

62.3

73.8

74.5

62.6

Direct patient care

41.9

43.8

45.7

45.7

60.0

42.5


17.1

20.1

39.1

20.2

27.0

19.4

Hours on call

60.3

59.1

64.9

59.6

66.5

63.1

Per cent practitioners on call (%)

81.7

80.0

93.3

100.0

100.0

80.8

Average age (years)

50

50

53

49

55

51

% of the specialist workforce

82.3

9.6

3.9

2.3

1.9

100.0

Source: RACOG and RACOG/AMWAC Survey 1997

AMWAC 1998.6 32

Similar results were found with the AIHW data (Table C5) which showed that 63.6% reported being on call . The proportion on call and the number of hours on call rose with distance away from a metropolitan area, with remote area specialists reporting working 100% on call hours. The average hours worked varied by region, increasing from 46.1 hours a week in urban areas to to 68.3 hours a week in remote areas. Intentions to Change Hours Worked 55% (263) of respondents of the RACOG/AMWAC survey indicated that they planned to change the hours they work, with 43.1% (207) of respondents anticipating their work hours to decrease, 12.2% (60) expecting their work hours to increase and 44.7% (214) of respondents expected their hours to remain the same (n=476). Table B14 indicates the change in hours worked by State/Territory, with the most significant anticipated change being that of the obstetric and gynaecology workforce in New South Wales, with 50% (75) of practitioners indicating an anticipated a reduction in their work over the next five years. Significant associations were observed between respondents indicating an anticipated reduction in the hours over the next five years and gender, geographic location, rising medical indemnity insurance, lifestyle preferences, family considerations, health considerations and retirement. A significant association was observed between intention to increase hours worked and an expected increase in demand for obstetrics and gynaecology services (p<0.01). Other reasons cited by respondents that would increase the hours worked by specialists over the next five years included: financial incentives and children beginning school. Practice Profiles Of the 501 specialists who responded to the RACOG/AMWAC survey, 63.7% were in a private practice and/or undertaking public hospital work; 15.8% were salaried in a public hospital; 14.2% were in a private practice with no public hospital role; 2.2% were public hospital salaried and in a private practice: 0.6% were salaried in private hospital and in a private practice and/or undertake public hospital role; 0.5% had a university appointment with a public hospital role. The proportion reporting employment in public hospitals was much higher in New South Wales (32.9%) and lower (1.3%) in Tasmania. Private practice employment was highest in the New South Wales (20.0%) and lowest in the Northern Territory (1.4%) (Table B10, Appendix B). The majority (67.1%) of respondents indicated they worked as solo-specialists; 20.8% worked with other obstetricians and gynaecologists and 3.2% worked with a multi-disciplinary group (Table B8 in Appendix B).

AMWAC 1998.6 33

Services Provided Obstetrics and gynaecology services in Australia are provided through Medicare and other insurance arrangements in fee for service practice and through the government funded public hospital system. Detailed service specific data on medical services which attract Medicare benefits is available for twelve years. Public and private hospital casemix activity data is only available for the last few years. It is also important to note that there are data limitations in determining the number of services provided by specialists in obstetrics and gynaecology, this is due in part to the substitution of services by other providers, particularly GPs and midwives (see later discussion on substitution of services); and in this respect there is no definitive national data set available to separate the number of services contributed by each provider. In addition, Medicare data only covers private practice billing activity; with only a minority of the population with private health insurance (approximately 30% in 1998), consequently the Medicare data needs to be interpreted with this shortcoming in mind. One advantage of the Medicare data, however, is that it can be separated into services provided by specialists and those provided by non-specialists. National Hospital Morbidity Data One of the key sources of services data is AIHWs National Hospital Morbidity data. The Working Party analysed obstetrics and gynaecology procedures performed on private and public patients in Australian hospitals for the period 1993-94 to 1995-96. The data is outlined in full in Appendix I but notable trends are: Between 1993-94 and 1995-96 the growth in gynaecological procedures was 7.7%

(Table I9); However, the growth in individual procedures varied widely eg growth in

salpingotomy and salpingostomy procedures was 38.7% (Table I9); The overall growth in obstetrical procedures was 11.8% from 1993-94 to 1995-96.

Procedures with considerably more than the overall growth included medical induction of labour which showed 65.3% growth (Table I10);

Proportions of private versus public patients for given procedures varied widely especially for gynaecological procedures (Tables I1 to I2, I11 to I12). The overall proportion of procedures undertaken on private patients was 51.3%. This

ranged from a high of 91.8% for the incision of vagina and cul-de-sac to a low of 33.8% for other bilateral destruction or occlusion of fallopian tubes (excluding those procedures with low incidence of less than 1,000) (Table I11);

Overall, obstetrics procedures were less likely to be performed on private patients than were gynaecological procedures Β (34.9% of obstetrical procedures compared with 51.3% of gynaecological procedures were performed on private patients, Tables I11 and I12);

The proportions of specific obstetrical procedures performed on private patients varied less than for gynaecological procedures. They ranged from a high of 50.2% for forceps rotation of fetal head to a low of 15.0% for other intrauterine operations

AMWAC 1998.6 34

on fetus and amnion (excluding those with low incidence of less than 1,000) (Table I12);

Analysis of age profile data is limited to 1995-96 data: Gynaecological procedures were more commonly performed on 25 to 34 year olds

than other age groups (30.9% were undertaken on females in this age group, Table I5);

Young aged females (0-24 years) and older aged females (65 years and over) were less likely to undergo gynaecological procedures as private patients. About 39% of procedures on 0 to 24 year olds were performed on private patients Β the proportion is about 45% for over 65 year olds (Table I7). This compared with around 57% of the procedures being undertaken on 25 to 64 year olds as private patients;

On average more patients aged 45 to 54 years underwent gynaecological procedures as private patients than other age groups (Table I7);

Obstetrics age trends were more consistent than gynaecological trends. The age range of patients was relatively narrow and there was less variation between individual procedures. Obstetrics procedures were more commonly performed on 25 to 34 year olds than other age groups (62.4% were undertaken on females of this age bracket, Table I6);

Obstetrics procedures undertaken on private patients tended to be performed on a slightly older age group (Tables I3 and I4). Obstetrical procedures on public patients were more likely to be undertaken on 25 to 34 year old age group and next most likely the younger 15 to 24 years (56.5% and 32.7% of procedures on public patients, respectively). The peak age for procedures on private patients was also 25 to 34 years followed by the older 35 to 44 group (73.4% and 19.3% of procedures on private patients, respectively); and

35 to 44 year olds were on the whole more likely to undergo the procedures as private patients than other age groups (Table I8).

Services Attracting Medicare Benefits Over the ten year period, 1986-87 to 1996-97, all obstetrics and gynaecology Medicare services provided by specialists increased by 27.2%. This represents a growth of 2.7% per annum. For gynaecological items there was an increase of 8.0% in the period 1986-87 and 1996-97 (0.8% growth per annum). During the period 1995-96 and 1996-97, Medicare services provided by obstetrics and gynaecology specialists for obstetric items increased by 42.7% (growth of 21.3% per annum over the two year period). Only the period 1995-96 to 1996-97 was examined because in 1995-96 ante-natal visits were included in the number of services for the first time. Confinement services provided by specialists in obstetrics and gynaecology decreased by 33.0% in the period 1986-87 to 1996-97.

AMWAC 1998.6 35

Table 10: Obstetrics and gynaecology services attracting Medicare benefits provided by specialists, 1986-87 to 1996-97 Derived specialty/item

1986-87

1991-92

1992-93

1993-94

1994-95

1995-96

1996-97

Change 1986-87 1996-97

All obstetrics and gynaecology specialists

Confinement items Providers

775

778

767

720

709

690

681

-12.1%

Confinement items Services

105,334

97,004

91,287

82,400

79,091

73,524

70,537

-33.0%

Obstetrics Providers

787

762

753

706

700

706

725

-7.9%

Obstetrics Services

253,189

174,602

174,507

178,278

173,653

620,074

885,259

42.7%a

Gynaecology Providers

834

893

894

934

849

845

853

2.3%

Gynaecology Services

293,433

368,837

360,012

324,714

375,216

344,549

316,849

8.0%

IVF Providers

-

116

128

80

82

96

102

-12.1%b

IVF Services

-

89,414

90,187

10,673

12,099

12,803

14,326

-83.9b

Total Providers

837

899

902

838

862

859

870

3.9%

Total Services (>000)

2,142.6

2,269.5

2,244.7

1,993.9

2,137.9

2,505.8

2,725.2

27.2%

Notes: a - from 1995-96 ante-natal visits were included in the number of services therefore percentage change has been calculated for the period 1995-96 to 1996-97; b - percentage difference calculated from 1991-92 to 1996-97 Source: AIHW 1998 Training Arrangements The RACOG is the governing body overseeing the obstetrics and gynaecology profession in Australia and was established in 1978. The RACOG administers the training program for new specialists and a programme of continuing education and continuing certification for the Fellows of the College. The training program is currently six years duration with an introductory four year Integrated Program and a two year Elective Program. Specialists are initially conferred the status of Members of the RACOG and subsequently become Fellows with full practising rights. Fellowships are granted on a time limited basis and Fellows are required to document their participation in continuing education and quality assurance activities to retain their Fellowship status (see Appendix E). RACOG also offers certificates in five sub-specialties: gynaecological oncology, maternal fetal medicine, uro-gynaecology and reproductive endocrinology and infertility. The training for which is of three years duration. The certificate in the sub-specialty of obstetrical and gynaecological ultrasound requires two years of training. In March 1998, there were a total of 208 integrated training positions in obstetrics and gynaecology medicine as shown in Table 11.

AMWAC 1998.6 36

Table 11: Accredited obstetrics and gynaecology training positions, by hospital and State/Territory, 1998 State/Territory

Hospital

Accredited positions

New South Wales (61) John Hunter 6

King George V

10

Liverpool

12

Nepean

3

Royal Hospital for Women

11

Royal North Shore

7

St George

5

Westmead

7

ACT (6) Canberra

6

Victoria (53) Ballarat Base 1

Geelong

1

Mercy Hospitals Inc.

7

Mildura Base

1

Monash Medical Centre

14

Peter MacCallum Cancer Institute

1

Northern Hospital

1

Royal Women’s

23

Sunshine

1

West Gippsland

1

Warnambool

1

Western General

1

Queensland (40) Bundaberg Base 1

Caboolture

1

Cairns Base

1

Gold Coast

2

Ipswich

2

Kirwan Hospital for Women

2

Logan

4

Mackay Base

1

Mater Mothers

9

Nambour General

2

Princess Alexandra

1

Queen Elizabeth II

2

Redcliffe

3

Rockhampton Base

1

Royal Women’s

7

Toowoomba Base

1

South Australia (26) Flinders Medical Centre 5

The Lyell McEwin

5

Modbury

2

Mt Gambier

1

Queen Elizabeth

4

Royal Adelaide

3

Women’s and Childrens

6

Western Australia (14) King Edward Memorial 14 Tasmania (5)

Launceston

1

Northwest Regional

1

Queen Victoria

1

Royal Hobart

2

Northern Territory (3) Royal Darwin

3

Total trainees in an ITP (Integrated Training Program)

208 Source: RACOG 1998

AMWAC 1998.6 37

In March 1998 there were 282 advanced trainees in obstetrics and gynaecology, the bulk of whom are in years 1, 2 and 3 of the program (60.1%); reflecting the large increase in annual intake from 1995 onwards (Table 12). Table 13 shows that 22.3% of trainees are part time, with female trainees representing 53.9% of part time trainees. In terms of the State/Territory distribution of trainees, the number in Queensland and Western Australia is noticeably below those States population shares, and conversely South Australia has a noticeably higher proportion of trainees compared to population. The bulk of the trainees are located in New South Wales and Victoria (57.2%/152). These two States share of trainees is roughly in proportion to their respective population shares (Table 14). Female trainees are well represented in each State/Territory with the highest proportions in Queensland (63.8%), the Australian Capital Territory (60.0%) and New South Wales (58.0%). Table 12: RACOG trainees, by year of training, age group and gender, 1998

21-25 yrs

26-30 yrs

31-35 yrs

36-40 yrs

41-45 yrs

>45 yrs

Unknown

Total

Male

Year 1

0

11

2

6

1

2

3

25 Year 2

0

7

4

4

1

1

1

18

Year 3

0

6

15

4

2

0

0

27 Year 4

0

2

12

8

1

0

0

23

Year 5

0

1

15

1

2

0

0

19 Year 6

0

0

3

6

1

1

0

11

Unknown

0

0

1

0

1

1

0

3 Total

0

27

52

29

9

5

4

126

Female Year 1

1

15

10

3

0

1

2

32

Year 2

0

18

5

5

2

0

0

30 Year 3

0

13

9

5

2

1

0

30

Year 4

0

5

13

2

2

0

0

22 Year 5

0

0

20

8

1

1

1

31

Year 6

0

0

5

5

0

0

0

10 Unknown

0

1

0

0

0

0

0

1

Total

1

52

62

28

7

3

3

156 Total

Year 1

1

26

12

9

1

3

5

57 Year 2

0

25

9

9

3

1

1

58

Year 3

0

19

24

9

4

1

0

57 Year 4

0

7

25

10

3

0

0

45

Year 5

0

1

35

9

3

1

1

50 Year 6

0

0

8

11

1

1

0

21

Unknown

0

1

1

0

1

1

0

4 Total

1

79

114

57

16

8

7

282

%Female

100.0

65.8

54.4

49.1

43.8

37.5

42.9

55.3Source: RACOG March 1998

AMWAC 1998.6 38

Table 13: RACOG trainees, by full time and part time status, age group and gender, 1998 Gender

21-25 yrs

26-30 yrs

31-35 yrs

36-40 yrs

41-45 yrs

>45 yrs

Unknown

Total

Full time

Male

0

19

39

23

8

4

4

97 Female

1

45

46

20

6

2

2

122

Total

1

64

85

43

14

6

6

219 % female

100.0

70.3

54.1

46.5

42.9

33.3

33.3

55.7

Part time Male

0

8

13

6

1

1

0

29

Female

0

7

16

8

1

1

1

34 Total

0

15

29

14

2

2

1

63

% female

0.0

46.7

55.2

57.1

50.0

50.0

100.0

54.0 Total

Male

0

27

52

29

9

5

4

126 Female

1

52

62

28

7

3

3

156

Total

1

79

114

57

16

8

7

282 % part time

0.0

19.0

25.4

24.6

12.5

25.0

14.3

22.3

Source: RACOG March 1998 Table 14: Obstetrics and gynaecology trainees, by State/Territory and gender, 1998 Gender

NSW

Vic

Qld

SA

WA

Tas

ACT

NT

Not

known

Aust

Male

37

29

17

15

9

3

2

2

12

126

Female

51

35

30

16

11

2

3

2

6

156

Total

88

64

47

31

20

5

5

4

18

282

% trainees

33.3

24.2

17.8

11.7

7.5

2.0

2.0

1.5

-

100.0

% popn.

33.9

24.8

18.3

8.1

9.7

2.4

1.7

1.0

-

100.0

% female

58.0

54.7

63.8

51.6

55.0

40.0

60.0

50.0

33.3

55.3

Source: RACOG March 1998 and ABS The AIHW medical labour force survey figures for 1995 indicate that specialists in training in obstetrics and gynaecology worked, on average, a total of 60.8 hours per week, 61.2 for males and 60.7 hours for females (Tables 15 and 16).

AMWAC 1998.6 39

Table 15: Obstetrics and gynaecology specialists-in-training average hours worked, by gender and age, 1995 Gender

<35 years

35-44 years

45-54 years

Total

Total hours worked

Male

61.3

60.0

60.0

61.2

Female

59.6

61.5

70.5

60.7

Total

60.4

60.6

67.0

60.8


Male

52.4

57.2

60.0

54.7

Female

56.9

54.2

60.5

57.0

Total

54.8

55.9

60.3

55.7


Male

26.4

32.6

0.0

30.7

Female

39.5

47.5

48.0

40.4

Total

32.1

37.6

48.0

34.8

Source: AIHW Table 16: Obstetrics and gynaecology specialists in training average hours worked, by State/Territory, 1995 Hours

NSW/ACT

Vic

Qld

WA

SA/NT

Tas

Total

Total worked

67.6

69.0

52.8

52.5

61.0

65.0

60.8

Direct patient care

60.0

55.1

49.5

49.2

53.3

60.0

55.7

On all not worked

43.7

19.1

26.5

39.2

33.4

57.0

34.8

Source: AIHW Table 17 shows there has been a 34.3% increase in the number of trainees during the period 1992 to 1998. Trainee numbers increased dramatically in 1995, with a 35.6% increase on the previous year. Female trainees increased by 85.7% during the period 1993 to 1998.

AMWAC 1998.6 40

Table 17: Obstetrics and gynaecology trainees, by gender, 1992 to 1998 Year

Male

Female

Total

% Female

1992

na

na

185

-

1993

126

84

210

40.0

1994

103

105

208

50.5

1995

139

143

282

50.7

1996

143

150

293

51.2

1997

126

150

276

54.3

1998

126

156

282

55.3

na - not available *This includes all registered trainees in RACOG approved training sites in Australia and overseas training posts; special training sites (eg. Masters Degree at Townsville University, laparoscopic surgery post, research), which are not an accredited training post; and RACOG sub-specialty training posts in Australia, as well as prospectively approved posts overseas. Source: RACOG March 1998 Summary of Main Characteristics of the Specialist Obstetrics and Gynaecology Workforce Obstetrics and gynaecology is one of the larger single specialist workforces, representing 6.4% of all specialists (only anaesthesia and psychiatry have significantly larger workforces). The Working Party estimates there are currently 1,049 practising obstetrics and gynaecology specialists in Australia. This represents 14.4 specialists per 100,000 female population (aged 15 years and over) and an estimated SPR of 1:6,954 (female population aged 15 years and over). Specialist obstetricians and gynaecologists practise mainly in capital cities and metropolitan areas (84.7% of the workforce). 15.3% of specialists are located in rural areas (28.5% of the female population). The workforce is unevenly spread between States/Territories, with Tasmania, Western Australia, Queensland and the Northern Territory all having an SPR below the national average. The average age of the workforce is 51.1 years. The largest five year age groups are the 51 to 55 years (19.4%) and the 46 to 50 years (17.5%). In total, 32.0% (336) of the workforce are aged 55 years and over; but of this number only 7.0% (74) are aged 65 years and over. Most of the specialists aged 55 years and over are located in New South Wales and Victoria (197/58.6%). Women make up 15.1% (158) of the workforce, with this proportion expected to increase given that 55.3% of current trainees are female and only 21 women are aged 55 years and over. The five year age group with the largest number of women specialists is the 41 to 45 years (47/29.6% of female specialists). The Working Party estimated that obstetric and gynaecology specialists work on

AMWAC 1998.6 41

average 62 hours per week. The large majority of the workforce (63.7%) work in private practice and undertake some public hospital work. Most specialists practice both obstetrics and gynaecology, and even some of the 98 subspecialists continue to practice general obstetrics and gynaecology.

AMWAC 1998.6 42

ADEQUACY OF THE CURRENT OBSTETRICS AND GYNAECOLOGY WORKFORCE There are a number of indicators of the adequacy of a medical workforce. No single measure can provide a definitive assessment, however by examining each it is possible to gain an indication of whether a workforce is adequately meeting current demand or if there is a significant shortfall or oversupply. The indicators chosen by the Working Party were: specialist (including sub-specialist):population ratio; public hospital vacancies; consultation waiting times; views of the Divisions of General Practice; and views of Fellows of RACOG.

Obstetrics and Gynaecology Surgeons:Population Ratio When considering SPR the Working Party determined that three female population age groups were important. First, the best general indicator is the population aged 15 years and over (and this indicator was used in calculating the SPRs shown in Table 1). Second, obstetric services were really provided to the population aged 15 to 49 years. Comparisons using the female population aged 25 years and over are also provided. RACOG has indicated that an acceptable SPR for females in urban areas is 1:10,000 and for rural areas 1:15,000 (see Appendix F: Service Provision and Requirements of Obstetrics and Gynaecology). The national ratio would therefore be skewed towards the urban areas as the majority of the female population (64%) is situated in capital cities/metropolitan areas and could be considered to be approximately 1:12,500. Table 18 summarises the SPR by State and Territory for each of the three female population groups. The SPR for females aged 15 to 49 years is estimated at 1:4,439 or 22.5 specialists/sub-specialists per 100,000 female population or 2.8 per 12,500 female population. State provision ranged from 15.2 per 100,000 population in the Northern Territory and 25.2 per 100,000 population in South Australia. Using the national SPR indicator from RACOG 1:12,500 all States/Territories are well endowed with specialists. The SPR for females aged over 15 years is estimated at 1:6,954 or 14.4 specialists/sub-specialists per 100,000 female population or 1.8 per 12,500 female population. Using the national SPR indicator from RACOG 1:12,500, all States/Territories are well endowed with specialists. The SPR for females aged over 25 years is estimated at 1:5,629 or 17.8 specialists/sub-specialists per 100,000 female population or 2.2 per 12,500 female population. Using the national SPR indicator from RACOG 1:12,500, all States/Territories are well endowed with specialists.

AMWAC 1998.6 43

Table 18: Specialists/sub-specialists in obstetrics and gynaecology to female population ratio, by State/Territory, 1998 (number per 100,000 population)

NSW

Vic

Qld

SA

WA

Tas

ACT

NT

Total

Specialists

361

284

170

92

92

24

18

8

1,049

Females aged 15 years and greater Population (>000)

2,483.2

1,845.4

1,308.0

599.4

686.7

188.4

121.9

62.6

7,295.7

SPR:1

6,879

6,498

7,694

6,515

7,465

7,852

6,777

7,820

6,954

No./100,000

14.5

15.4

13.0

15.3

13.4

12.7

14.8

12.8

14.4

No. /12,500

1.8

1.9

1.6

1.9

1.7

1.6

1.8

1.6

1.8

Females aged 25 years and greater

Population (>000)

2,010.4

1,458.6

1,099.4

486.6

515.0

150.6

92.9

55.6

5,905.2

SPR:1

5,569

5,136

6,467

5,289

5,598

6,275

5,161

6,950

5,629

No./100,000

18.0

19.5

15.5

18.9

17.9

15.9

19.4

14.4

17.8

No. /12,500

2.2

2.4

1.9

2.4

2.2

2.0

2.4

1.8

2.2

Females aged 15 to 49 years

Population (>000)

1,552.1

1,159.7

865.3

364.9

456.4

117.7

87.5

52.8

4,656.5

SPR:1

4,299

4,083

5,090

3,966

4,961

4,904

4,861

6,600

4,439

No./100,000

23.2

24.5

19.6

25.2

20.2

20.3

20.6

15.2

22.5

No./12,500

2.9

3.1

2.5

3.2

2.5

2.5

2.6

1.9

2.8

Source: RACOG 1998 and ABS 1996 Census: Population by Sex and Age Table 19 examines the SPR by State and Territory and RRMA classification for the three female population age ranges. The capital city/metropolitan SPR for females aged between 15 and 49 years is estimated at 1:3,817 or 26.2 specialists per 100,000 female population or 2.6 per 10,000 female population. Using the urban SPR indicator from RACOG 1:10,000, only the Northern Territory falls below this ratio. The capital city/metropolitan SPR for females aged 15 years and over is estimated at 1:5,796 or 17.3 specialists per 100,000 female population or 1.7 per 10,000 female population. Using the urban SPR indicator from RACOG of 1:10,000, only the Northern Territory falls below this ratio.

AMWAC 1998.6 44

The rural/remote SPR for females aged between 15 and 49 years is estimated at 1:7,894 or 12.7 specialists per 100,000 female population or 1.9 per 15,000 female population. Using the rural SPR indicator from RACOG of 1:15,000 all States/Territories are well endowed with specialists. There are no rural/remote centres in ACT. The rural/remote SPR for females aged 15 years and over is estimated at 1:12,614 or 7.9 specialists per 100,000 female population or 1.2 per 15,000 female population. Using the rural SPR indicator from RACOG of 1:15,000 South Australia and Western Australia fall below this SPR indicator. For the female population aged 25 years and over, Western Australia falls below this rural SPR benchmark. In areas where there are outreach services provided to large remote areas such as Cairns, RACOG has recommended that there should ideally be at least four specialists which will allow appropriate cover for those specialists who are on call and/or are visiting remote areas. The distribution of specialists in rural/remote areas indicates that generally South Australia, Western Australia, Queensland and Tasmania fall below the rural RACOG SPR benchmark for the female population. As indicated earlier RACOG has recommended that there should ideally be at least two to four specialists (depending on the size of the catchment population) resident in any one location which will allow appropriate cover for those specialists who are in large remote areas. The above analysis of rural/remote SPR levels indicates that these States/Territories may not have appropriate cover. The Working Party considered that where population size is below the necessary critical mass to support a resident specialist, or there are no specialists interested in establishing a practice in a community large enough to support a resident obstetrics and gynaecology service, a regular visiting outreach service may become an appropriate form of service delivery.

AMWAC 1998.6 45

Table 19: Specialists/sub-specialists in obstetrics and gynaecology to female population ratio, by State/Territory and geographic location, 1998

NSW

Vic

Qld

SA

WA

Tas

ACT

NT

Total

Capital cities and metropolitan areas

Workforce

312

242

130

84

84

16

18

3

889


Population (>000)

1,195.7

896.8

522.6

275.3

340.7

50.1

24.7

87.5

3,393.4

SPR:1

3,832.

3,706

4,020

3,278

4,056

3,132

1,370

29,164

3,817

No./100,000

26.1

27.0

24.9

30.5

24.7

31.9

73.0

3.4

26.2

No./10,000

2.6

2.7

2.5

3.1

2.5

3.2

7.3

0.3

2.6


Population (>000)

1,837.2

1,350.3

795.8

437.5

504.7

77.0

32.0

118.3

5,152.9

SPR:1

5,889

5,580

6,122

5,208

6,008

4,814

1,780

39,450

5,796

No./100,000

17.0

17.9

16.3

19.2

16.6

20.8

56.2

2.5

17.3

No./10,000

1.7

1.8

1.6

1.9

1.7

2.1

5.6

0.3

1.7

Rural and remote areas

Workforce

49

42

40

8

8

8

0

5

160


Population (>000)

356.4

262.9

342.7

89.6

115.6

67.6

28.1

85

1,263.1

SPR:1

7,273

6,259

8,568

11,206

14,456

8,449

0

5,624

7,894

No./100,000

13.7

16.0

11.7

8.9

6.9

11.8

0

17.8

12.7

No./15,000

2.1

2.4

1.8

1.3

1.0

1.8

0.0

2.7

1.9

Females aged 15 years and greater Population (>000)

591.1

421.4

545.7

145.0

171.2

105.3

38.2

112

2,018.2

SPR:1

12,064

10,034

13,644

18,126

21,401

13,163

0

7,644

12,614

No./100,000

8.3

10.0

7.3

5.5

4.7

7.6

0

13.1

7.9

No./15,000

1.2

1.5

1.1

0.8

0.7

1.1

0.0

2.0

1.2


Population (>000)

499.2

353.9

455.9

124.4

142.9

87.6

87

30.0

1,694.1

SPR:1

10,187

8,427

11,399

15,546

17,860

10,951

0

6,019

10,587

No./100,000

9.8

11.9

8.8

6.4

5.6

9.1

0

16.6

9.4

No./15,000

1.5

1.8

1.3

1.0

0.8

1.4

0.0

2.5

1.4

Source: RACOG 1998, ABS 1996 Census: Population-Capital city/Metropolitan & Rural/Remote

AMWAC 1998.6 46

Public Hospital Vacancies The 1997 AMWAC survey of public hospital specialist vacancies found there were 17 obstetrics and gynaecology vacancies (13.5 full time equivalents). There were 6 (4.2 FTEs) vacancies in New South Wales, one (1 FTE) in Victoria, 8 (6.3 FTEs) in Queensland, one (1 FTE) in South Australia and one (1 FTE) in Tasmania. There were no vacancies in Western Australia. In addition, nine vacancies were filled by TRDs; seven TRDs in New South Wales and one TRD in both Queensland and Western Australia. Provider Shortages Respondents to the RACOG/AMWAC survey were asked to specify any providers in short supply in their primary practice location. Table B15, Appendix B indicates that according to respondents there is a need for more obstetricians and gynaecologists, midwives, anaesthetists, paediatricians and psychiatrists. The survey data revealed a strong association between perceived need for more obstetricians and gynaecologists and geographic location. In total, 80.2% (219) metropolitan and 17.2% (47) of rural specialists indicated a need for more obstetricians and gynaecologists compared with respondents (n=273). In rural and remote areas respondents indicated a greater need for more midwives, obstetric GPs, anaesthetists, paediatricians, psychologists and psychiatrists than obstetricians and gynaecologists. Consultation Waiting Times For dedicated obstetrics and gynaecology units, respondents to the 1997 RACOG/AMWAC survey were asked to estimate the average waiting time for a standard first consultation and an urgent condition. Table 20 shows that the average waiting time for a standard first consultation with a specialist in obstetrics and gynaecology in his/her private rooms was 16.9 days (standard deviation 18.0) while for public patients the wait, on average, was 31.9 days (standard deviation 48.4). The waiting time in Tasmania for public patients was noticeably above the national average. For an urgent condition, private patients were shown to wait much less time (2.0 days, standard deviation 4.1) than did patients in public outpatient departments (7.1 days, standard deviation 18.5) (p<0.01); with public patients in Queensland and the Northern Territory waiting above average times.

AMWAC 1998.6 47

Table 20: Obstetrics and gynaecology average waiting time (days) for a standard first consultation and an urgent procedure, by private rooms/public outpatients department and State/Territory, 1997 (n=501)

State/Territory

Standard consultation

Urgent condition

Private patients

NSW

16.0

2.4

Victoria

19.1

1.9

Queensland

17.2

2.3

Western Australia

15.4

1.7

South Australia

12.7

1.1

Tasmania

15.9

1.0

Northern Territory

10.5

2.5

ACT

40.8

2.7

Total

16.9

2.0

Public patients

NSW

21.9

4.5

Victoria

23.4

5.4

Queensland

37.6

14.0

Western Australia

47.8

7.7

South Australia

32.1

5.7

Tasmania

141.5

5.8

Northern Territory

38.5

14.0

ACT

16.3

5.3

Total

31.9

7.1

Source: RACOG/AMWAC Survey Survey of Divisions of General Practice To gain a GP perspective on the adequacy of the specialist workforce, AMWAC surveyed the Divisions of General Practice, and the results of the survey are detailed in Appendix G. The survey found that 55.4% of Divisions considered that a shortage of obstetrics and gynaecology specialists existed in their area, with the remaining proportion predominantly of the view that supply was about right. A greater proportion of rural divisions (61.5%) perceived the supply of specialists to be inadequate than did Divisions located in urban areas (50.0%).

AMWAC 1998.6 48

Professional Satisfaction Overall, 69.9% (n=485) of respondents (both specialists and sub-specialists) to the RACOG/AMWAC survey were satisfied with their work. Aspects of their work with which they were most satisfied were sufficient work to maintain competence, physical working conditions, opportunity to use your abilities and the availability of other specialists. Aspects of their work with which they were most dissatisfied (in order of percentage of people expressing dissatisfaction) were industrial relations between management and workers in their health service (26.5%), workload sufficient to maintain income (25.5%), hours of work (22.6%), and amount of work (22.4%) (Table B18, Appendix B). Medical Indemnity Insurance One of the issues confronting the obstetrics and gynaecology profession is the real and potential withdrawal of specialists from obstetrics, in part induced by the fear of being sued and high indemnity insurance premiums. Any trend has to be seen against the backdrop of the traditional career changes of obstetrics and gynaecology specialist away from obstetrics as they get older, and the effect on recruitment of trainees to the profession. Respondents to the RACOG/AMWAC survey indicated that rising medical indemnity insurance premiums will affect the way they practice with 83% (403) indicating that they would either cease practising obstetrics or retire early and 9% indicating that they would pass cost on to patients. Conclusions on the Adequacy of the Current Obstetrics and Gynaecology Workforce Overall, the Working Party concluded that there is some indication of a slight workforce shortage, particularly when public hospital vacancies and consultation waiting times are considered. Waiting times for a standard public patient were found to be noticeably higher for patients in Queensland, Western Australia, Tasmania, South Australia and Northern Territory. However, these regional shortages may relate more to maldistribution of the workforce than any significant shortage in the workforce as a whole, especially as the SPR data indicated that most States/Territories had an SPR above the suggested benchmark. The SPR data also showed that in capital cities/metropolitan areas all States/Territories are currently well supplied with obstetrics and gynaecology specialists, with the exception of the Northern Territory. In rural/remote areas South Australia and Western Australia remain below the national rural/remote SPR. However, despite the conclusion of possible shortages, no short term remedial action is recommended by the Working Party, mainly because RACOG dramatically boosted trainee numbers in 1995 and when these trainees commence making a contribution to the workforce from 2001 onwards it is anticipated that shortages in the workforce should begin to diminish.

AMWAC 1998.6 49

PROJECTIONS OF REQUIREMENTS Female Population In 1997 Australia's female population was estimated to be 9.31 million compared to 8.72 million in 1991. The ABS estimates that the female population will reach 9.631 million by 2001 and 10.11 million by 2006 (ABS 1997) (Table 21). Between now and 2006 there is a projected growth of 0.9% growth per annum in the female population. Between now and 2011 the projected growth per annum of females will be 0.93%. The projected growth of the female population is expected to fall to 0.85% per annum by 2036 and to 0.81% per annum by the year 2041. This slow down in growth is being caused by the ageing of the population and a decline in the fertility rate. Table 21: Australian female population estimates and projections, 1997 to 2006

Females

1993

1995

1997

2001

2006

> 15 years

6,998,724

7,108,294

7,403,647

7,697,000

8,142,200

>25 years

5,657,321

5,858,964

6,097,953

6,412,600

6,813,500

15 to 49 years

4,660,453

4,734,965

4,820,066

4,843,900

4,932,100

> 49 years

2,338,271

2,445,329

2,583,581

2,853,100

3,210,100

Total female population

8,866,241

9,073,430

9,314,231

9,631,900

10,105,300

Source: ABS, Australian Demographic Statistics, 3101.0, June quarter 1997 and ABS, Projections of the Populations of Australia, States and Territories, 1995 - 2051, Series A/B

The projected growth rate of the female population differs across age cohorts. For example the population growth of younger women should be fairly small over the next 20 years (numbers of women under 45 years of age are expected to increase by only 3.4%) whilst growth in numbers of women aged 45 or over should be relatively high (50.3%). Increasing proportions of elderly people and decreasing proportions of births due to a fall in fertility rates will also result in the median age of the total population rising from 34.1 years currently to between an estimated 39.4 and 41.8 years in 2041 (ABS 1994). Overall, the ageing of the female population, combined with the heavy utilisation of medical services by this group, can be expected to lead to an increase in the demand for services by the older female population.

AMWAC 1998.6 50

Fertility Rate The total fertility rate is the number of births that a woman could expect to have, based on current age-specific birth rates. Australia’s total fertility rate has been falling over the last two decades, from 2.9 babies per woman in 1971 to 1.8 in 1996. Since the mid 1970s, the total fertility rate has remained below the natural replacement level of 2.1 babies per woman. The decline in the fertility rate has been accompanied by changes in the age pattern of fertility, with the median age of confinement increasing to 28.7 years. Associated with this trend has been an increase in the proportions of births occurring to older women and a decline in the number of women having three or more births. The age group for peak fertility in 1996 was 25 to 29 years old, followed by 30 to 34 years old (ABS 1997). Most of the decline in the fertility rate over the period 1976 to 1996 occurred among younger women. The fertility of women aged less than 24 years declined by 48%, while that for women aged 25 to 29 years declined by about 20%. On the other hand, the fertility of women aged 30 to 34 years and 35 to 39 years increased during the period (ABS 1997). The total fertility rate in 1996 varied substantially between the States and Territories, from 1.7 births per woman in Victoria to 2.3 in the Northern Territory. Between 1976 and 1996, the total fertility rate declined in all States and Territories. However, between 1986 and 1996, the rate for the Northern Territory increased slightly, while the rate for South Australia and Tasmania remained largely unchanged (Table 22) Table 22: Total fertility rate, by State/Territory, 1976, 1986 and 1996

NSW

Vic

Qld

SA

WA

Tas

NT

ACT

Aust

1976

2.04

2.03

2.18

1.86

2.14

2.09

3.06

2.09

2.06

1986

1.91

1.78

1.91

1.76

1.98

1.93

2.21

1.74

1.87

1996

1.83

1.71

1.84

1.75

1.81

1.92

2.29

1.68

1.80

Source: ABS, Births, September 1997, 3301.0 For all States and Territories, expect the Northern Territory, the largest contribution to the total fertility rate in 1996 was made by women aged 25 to 29 years followed by women 30 to 34 years. In the Northern Territory, the age group of peak fertility was 20 to 24 years, followed by 25 to 29 years. The Northern Territory has a much younger fertility age structure, with women aged less than 25 years comprising 43% of the total fertility rate, compared to contributions of between 18% and 30% for the other States. The age-specific birthrate for 15 to 19 year old women was more than three to four

AMWAC 1998.6 51

times as high in the Northern Territory as it was in other States and the Australian Capital Territory, while the age-specific birth rate for women aged 20 to 24 years in the Northern Territory was one to two times higher than rates for other States and the Australian Capital Territory. Indigenous women have an above average fertility when compared with women in the total Australian female population. For example, in 1996, the total fertility rate of Indigenous women ranged between 2.1 in South Australia to 2.7 in the Northern Territory. Indigenous women having a baby in 1996 were, on average, younger than women in the total Australian population. The median age at confinement among Indigenous women was between 23 and 24 years compared to 29 years among all Australian women. Birth Rate The 253,834 births registered in 1996 represented an 11.3% increase over the number registered in 1976 (228,000) and a 4.3% increase over the number registered in 1986 (243,408). However, despite an increase in the total number of births, the actual birth rate declined between 1976 and 1996. Crude birth rate refers to the number of live registered births during a calender year per 1,000 population. Table 23 shows the Australian birth rate falling from 15.2 births per 1,000 population in 1986 to 13.9 births per 1,000 population in 1996. In addition, the average age of women giving birth to their first child in Australia has increased substantially over the last twenty years, from 25.9 years in 1976 to 29.2 years in 1996 (ABS Births 1997). Table 23: Total births, by State/ Territory, 1996

Birth rates

1986

1991

1992

1993

1994

1995

1996

Total births

243,408

257,247

264,151

260,229

258,051

256,190

253,834

Crude birth rate

15.2

14.9

15.1

14.7

14.5

14.2

13.9

Total fertility rate

1.870

1.855

1.894

1.865

1.846

1.824

1.796

Female net reproduction rate

0.895

0.890

0.909

0.896

0.886

0.876

0.860

Source: ABS, Births, September 1997, 3301.0 New South Wales, Victoria and Queensland accounted for nearly three-quarters of births registered in 1996. Out of the total 254,834 births registered in 1996, 34.1% were registered in New South Wales, 24.1% were registered in Victoria and 18.8% were registered in Queensland (Table 24). These proportions broadly reflect the distribution of

AMWAC 1998.6 52

the female population in the reproductive ages. Table 24: Total births, by State/ Territory, 1996

NSW

Vic

Qld

SA

WA

Tas

NT

ACT

Aust

Births

86,595

61,143

47,769

19,056

24,793

6,457

3,562

4,396

253,834*

% births

34.1

24.1

18.8

7.5

9.8

2.6

1.4

1.7

100.0

Indigenous births

-

-

-

557

1,538

-

1,343

66

3,504

Crude birth rate

14.0

1.5

14.2

12.9

14.1

13.6

20.0

14.3

13.9

Total fertility rate

1.825

1.712

1.840

1.746

1.812

1.916

2.286

1.677

1.796

* includes 63 births recorded in other Territories Source: Births, ABS September 1997, 3301.0 At the national level, while the overall number of births registered grew by 11% between 1976 and 1996, among States and Territories the rate of growth varied. The number of births registered grew faster in Queensland (35.4%), the Northern Territory (32.5%) and Western Australia (19.8%) than in New South Wales (10.6%), the Australian Capital Territory (2.0%), Victoria (1.2%) and South Australia (1.0%). In Tasmania the number of births declined by 4.1%. In 1996, the crude birth rate was 20.0 per 1,000 population for the Northern Territory and between 12.9 and 14.3 for the remaining States and the Australian Capital Territory. South Australia had the lowest crude birth rate (12.9) followed by Victoria (13.5) and Tasmania (13.6). The high crude birth rate in the Northern Territory is attributable to its young age structure and the large proportion of Indigenous people; a population characterised by a comparatively high fertility rate and low life expectancy (ABS/AIHW 1997). There has been a trend towards greater numbers of mothers planning to give birth in a birth centre from 2,405 in 1992 to 4,199 in 1995 (Perinatal Statistics, Australia=s Mothers and Babies 1995). This may also be explained by the availability of birth centres. There has also been a trend towards the implementation and increased utilisation of midwifery focused models of care in antenatal clinics and an expansion of domiciliary midwifery programs, with a move to integrate these services with community based care. Cancer of the Cervix, Ovary and Uterus Cervical cancer is the seventh most common cancer in women. However, the incidence of cervical cancer is declining in Australia, with an average annual rate of decline of 1.3% between 1983 and 1994. The incidence on the whole is expected to decrease

AMWAC 1998.6 53

from 13.73 women per 100,000 population in 1989 to a projected 10.41 women per 100,000 population in 1999, a decrease of 1.5% per annum. However, an age-dependent variation has been noted in trends. Among women aged 50 years and over, the incidence of cancer of the cervix has fallen since 1983, while rates for those under the age of 50 years have increased slightly. The incidence of cervical cancer varies substantially at the State and Territory level. Of the States, Queensland (18.2) and Western Australia (20.9) showed the highest rates, whereas South Australia (15.9) showed the lowest rate among women aged 20 to 74 years for the period 1988-90. Table 25: Incidence of cancer of the cervix among women aged 20 to 74 years, by State/Territory

State/Territory

Average 1983-85

Average 1988-90

% change

NSW

17.5

16.6

-4.7

Victoria

16.8

16.5

-1.8

Queensland

22.7

18.2

-20.1

West. Aust.

22.3

20.9

-6.4

South Aust.

18.3

15.9

-13.2

Tasmania

20.7

20.0

-3.6

ACT

18.0

18.4

2.0

North. Terr.

31.5

30.3

-3.8

Australia

18.7

17.4

-7.3

Source: AIHW, National Health Priority Areas 1996 The incidence rate of ovarian cancer is marginally declining in Australia with the incidence rate 11.10 per 100,000 female population in 1989 to a projected 10.93 per 100,000 female population in 1999, a decrease of 0.1% per annum. The incidence rate of cancer of the uterus is increasing in Australia with the incidence rate at 11.85 per 100,000 female population in 1989 projected to 14.86 per 100,000 female population in 1999, an increase of 0.03% per annum. (Cancer in Australia 1991-1994 (with Projections to 1999), AIHW 1998). Table 26 shows projections for the age standardised incidence rates of cancer of the cervix, ovary and uterus and indicates a fall for both cancer of the cervix and ovarian cancer but an increase in cancer of the uterus.

AMWAC 1998.6 54

Table 26: Age standardised rates for incidence of cancer of the cervix, ovary and uterus, selected years 1983 to 1994, with projections to 1999

Cancer

1983

1989

1994

1995

1996

1997

1998

1999

Cervix

13.73

12.37

11.97

11.17

10.98

10.79

10.60

10.41

Ovary

11.10

11.35

10.75

10.90

10.90

10.91

10.92

10.93

Uterus

11.85

11.84

13.38

13.67

13.97

14.26

14.56

14.86

Source: AIHW, Cancer in Australia 1991-1994 (with Projections to 1999), 1997

Trends in Utilisation Forecasts of future obstetrics and gynaecology procedure usage have been calculated by applying projections of the female population to the hospital age utilisation data for 1995-96. It should be noted that this is a simple approach which assumes that population change is the only factor affecting the demand for obstetrics and gynaecology procedures. The projections ignore, for example, the impacts of new technology and change in medical practice, which are extremely difficult to assess let alone quantify. In general, obstetrics procedures are mainly undertaken on younger females and are therefore forecast to increase by a relatively small amount, while gynaecology procedures, which are distributed more widely across the age spectrum, are expected to increase more rapidly. The utilisation projections suggest that in general the demand for gynaecology procedures over the next 20 years will not increase as quickly as the population. Over this period female population is expected to increase by 19.8%, whereas gynaecology services, based on current rates, are expected to grow by 14.0% or 0.7% per annum. The reason for the lesser growth is that the majority of gynaecological procedures are undertaken on young to middle aged women, and this younger female age group is growing less rapidly than the population aged 45 years and over (in 1995-96, 72.4% of procedures were undertaken on women up to age 44 years, Table I5). Growth in the number of obstetrics procedures over the next 20 years is expected to be considerably less than population growth. Female population growth of 19.8% is anticipated, while the demand for obstetrics procedures is only forecast to rise by 2.2% or 0.1% per annum. This is because proportionally more obstetrics procedures are performed on women in the younger age groups, which as already indicated, are growing less rapidly than older age groups (in 1995-96, 86.3% of procedures were undertaken on women up to age 34 years, Table I6).

AMWAC 1998.6 55

Table 27: Projected increases in utilisation for obstetrical and gynaecological procedures, 1998 to 2018

A. Female population

Age (years) Year

0-14

15−24

25−34

35−44

45−54

55−64

65−74

75+

Total

Actual 1995Β96

1,891,00

4

1,321,347

1,425,973

1,386,449

1,118,065

754,395

679,305

52,346

9,128,884

Forecasts: 1998

1,921,33

0

1,298,799

1,455,691

1,444,970

1,223,172

800,255

677,122

604,266

9,425,605

2018

1,992,80

4

1,409,417

1,456,720

1,466,979

1,530,796

1,427,175

1,117,264

892,450

11,293,605

% increase

3.7

8.5

0.1

1.5

25.1

78.3

65.0

47.7

19.8

B. Gynaecological procedures

Age (years) Year

0−14

15−24

25−34

35−44

45−54

55−64

65−74

75+

Total

Actual: 1995Β96

1,417

71,379

165,873

149,950

84,783

31,983

21,615

9,922

536,922

Forecasts: 1998

1,440

70,161

169,330

156,279

92,753

33,927

21,546

10,855

556,291

2018

1,493

76,137

169,450

158,660

116,080

60,506

35,551

16,031

633,907

% increase 1998-2018

3.7

8.5

0.1

1.5

25.1

78.3

65.0

47.7

14.0

C. Obstetrics procedures

Age (years) Year

0−14

15−24

25−34

35−44

45−54

55−64

65−74

75+

Total

Actual: 1995Β96

193

84,437

221,612

48,556

231

6

0

0

355,037

Forecasts: 1998

196

82,996

226,231

50,606

253

6

0

0

360,287

2018

203

90,065

226,391

51,376

316

11

0

0

368,366

% increase 1998-2018

3.7

8.5

0.1

1.5

25.1

78.3

0.0

0.0

2.2

Sources: ABS population projections, series A and AIHW National Hospital Morbidity Database.

AMWAC 1998.6 56

It should also be noted that the number of obstetrics and gynaecology confinements in the private sector has decreased by 40.5% over the last ten years (AIHW, 1995). The Working Party considers the major driving factor has been the declining levels of people with private health insurance and a corresponding increase in patient co-payments. In 1986-87 there were approximately 105,334 private sector confinements and in 1996-97 there were 70,537 representing a fall of 33%. It is anticipated that confinements in the private sector will continue to fall. In turn, this is likely to have an adverse effect on the participation of obstetricians who are faced with a smaller pool of private patients and an increasing level of medical indemnity insurance making the practice of obstetrics less attractive. Despite this trend, the utilisation projections suggest that the Australian female population will continue to require obstetric and gynaecology specialist services (Table 27) and that the specialist obstetric and gynaecology workforce will be required to meet these demands. The Impact of Changes in Technology From a technological perspective, there is no current trend which will have any radical impact on the general configuration of service delivery. However, telehealth is an emerging technological development which is expected to improve access for rural patients and doctors to consultations with specialists. Such developments will be evolutionary and are currently underway in several Australian States. These developments require evaluation along the way. Conceivably, this might impact on costs of service delivery and training/education support as well as improve care outcomes. The future of ultrasonography in obstetric practice may also need to be closely monitored as it may significantly change current practices. Specialists’ Perceptions on Factors Affecting Workforce Requirements Respondents to the RACOG/AMWAC survey of obstetricians and gynaecologists were asked to indicate whether they believed particular factors would increase workforce requirements, decrease workforce requirements or whether requirements would stay the same (refer to Table B19, Appendix B). Among the important issues that respondents (both specialists and sub-specialists) considered would increase requirements included: the practice of more defensive medicine, patients expectations and knowledge, advances in medical technology, and need for improved geographic distribution of specialists. Factors perceived as most likely to decrease workforce requirements were substitution of specialist services by other providers, requirements for procedural practice, and government cost containment strategies.

AMWAC 1998.6 57

PROJECTIONS OF SUPPLY Additions and Losses to the Obstetrics and Gynaecology Workforce The RACOG/AMWAC Survey asked respondents to provide details of their retirement intentions. The average expected age of retirement from the workforce was 63 years (range 50 to 80 years; standard deviation 4.6). Table B7 Appendix B, indicates that 22.7% (113) of survey respondents intend retiring in the next five years. Examining the age and sex distribution of the specialist workforce shows that the majority (52.7%) of the workforce is aged over 50 years, 32.0% of the workforce is aged 55 years and over and 18.0% are aged over 60 years. Assuming the average retirement age from the RACOG/AMWAC survey of 63 years, it can be estimated that there could be approximately 200 (21%) specialists intending to retire in the next five years. In 1997 there were approximately six losses from the total workforce migrating overseas; however, this was balanced with an equal number of specialists in obstetrics and gynaecology entering Australia. It is probably safe to assume that on balance immigration and emigration will be roughly equal. RACOG expects trainee graduations over the next seven years to be: 45 in 1998, 21 in 1999, 50 in 2000, 47 in 2001, 57 in 2002, 49 in 2003 and 42 in 2004; that is an average of 47 graduates per year. Respondents to the RACOG/AMWAC survey indicated that rising medical insurance indemnity premiums will affect the way they practice with 83% (403) indicating that they would either cease practising obstetrics or retire early. Female Participation in the Workforce It is expected that the proportion of women in the workforce will increase; given the continuing increase in the number of female trainees. Women represent 15.5% the current total workforce, but 55.3% of trainees. In addition, of the 336 specialists aged 55 years and over, only 21 are female. The expected lifetime hours worked by a female obstetrics and gynaecology specialist has been estimated at 74.1% of that of a male (AMWAC/AIHW 1996). In conducting the projection analysis, the expected supply has been adjusted to account for increasing female participation and for the expected lower lifetime workforce contribution.

AMWAC 1998.6 58

Provision of Services in Rural and Remote Areas Provision of specialist services outside capital cities and major urban areas will continue to be of concern, as there appears to be little incentive to practice in rural areas. This was evident in the findings of the RACOG/AMWAC Survey (Appendix B) and RACOGs Women’s Career Survey (Appendix E). Reasons stated included the long hours, professional isolation, career dislocation, lack of relative financial reward, the strain on the family and spouse, lifestyle issues, and the lack of locum cover when on leave. There are obviously some communities where there is insufficient workload to warrant recruitment of consultant obstetrics and gynaecology specialists/sub-specialist. In those locations it will be important to encourage GPs and midwives to obtain, maintain and utilise their skills in obstetrics and gynaecology to provide some of these services. The biggest challenge for RACOG and the government is to make visiting posts and resident rural posts attractive for specialists. Respondents from the RACOG/AMWAC survey (refer to Appendix B) indicated that the basic requirements for providing a sustainable rural outreach obstetrics and gynaecology service and/or a resident rural practice do not exist in many locations or are only partially provided. For example, respondents noted problems with: inadequate local hospital facilities/equipment, such as appropriate consulting

facilities and surgical equipment; limited or absent numbers of allied health professionals and ancillary staff such as

midwives/nursing, physiotherapists and dieticians; limited or absent number specialist services such as anaesthetists, paediatricians,

psychiatrists, psychologists, neonatologists; a lack of interest and support of local GPs; good transport to the area for both patients and specialist; and the absence of local accommodation for patients to attend clinics particularly in the

case of the Northern Territory for the Indigenous population. The Working Party recommends that a rural cadetship be established to attract specialists to rural areas who desire to set up in rural practice. Commonwealth and State/Territory health departments should oversee the funding and establishment of rural cadetships to attract final year trainees to rural areas who desire to set up in rural practice. Contribution of Services by Non-specialist Providers One of the features of obstetrics and gynaecology is the scope for non-specialist providers to provide at least some of the services in obstetrics and minor gynaecological procedures. There are no definitive data sources that enable the level of substitution to be assessed, however Medicare data does provide an indication of the number of services provided by specialists and non specialists

AMWAC 1998.6 59

When private services are alone considered the majority of Medicare obstetrics and gynaecology services are provided by specialist obstetricians and gynaecologists. Table 28 shows that in 1996-97, 86.5% of confinements provided by obstetricians and gynaecologists, 57.2% of obstetric items and 75.3% of gynaecological items. Table 28 also shows there has been a fall of 5.6 percentage points in the number of obstetric services provided by a GP during the period 1995-96 and 1996-97. Similarly, obstetrics services provided by specialists increased by 5.7 percentage points and confinement items provided by specialists increased by 1.5 percentage points. Table 28: Percentage of obstetrics and gynaecology services attracting Medicare benefits, by provider, selected years 1986-87 to 1996-97

Provider

Confinement

items

Obstetrics

Gynaecology

IVF group

Total

Percentage of services provided by provider, 1996-97

O&G specialists

86.5

57.2

75.3

12.1

59.1

Other specialists

0.1

0.2

1.0

1.7

0.4

GPs

13.3

42.6

23.7

86.3

40.6


O&G specialists

85.0

51.5

75.4

11.2

56.0

Other specialists

0.2

0.3

1.1

2.2

0.7

GPs

14.8

48.2

23.5

86.6

43.3


O&G specialists

84.0

36.9

79.2

92.3

73.1

Other (incl. GPs)

16.0

63.1

20.8

7.7

26.9


O&G specialists

76.9

53.1

72.4

-

67.5

Other (incl. GPs)

23.1

46.9

27.6

-

22.5

Source: AIHW 1998 In terms of obstetrics it is clear that there has been a relative decline in the provision of privately provided services by GPs against the backdrop of a falling number of private deliveries overall. In 1986, 23.1% of private deliveries were performed by GPs, in 1996-97, the proportion was down to 13.3%, in other words, a dominant trend has been declining involvement of GPs in private obstetrics. As a consequence the proportion of private deliveries undertaken by obstetrics and gynaecology specialists has risen markedly, to the point that nearly 90% of all private deliveries are undertaken by specialists.

AMWAC 1998.6 60

Table 29 indicates the numbers of services attracting Medicare benefits provided by GPs compared to obstetric and gynaecology specialists by State/Territory. In each of the four groupings shown in Table 29 and overall, Queensland and Western Australia show GP involvement above the national average. In antenatal care South Australia and Northern Territory GP involvement is also above the national average, as is the involvement of GPs in the management of labour in Tasmania and the Northern Territory. States/Territories with GP involvement below the national average are New South Wales, Tasmania and the Australian Capital Territory. These figures indicate that there is a predominant role taken by GPs in providing obstetrics and gynaecology services in some of the less populous States/Territories, much of which is likely to be in provincial and rural/remote areas. Table 29: Obstetrics and gynaecology Medicare services, by provider and State/Territory, 1995-96

NSW

Vic

Qld

SA

WA

Tas

ACT

NT

Total

Antenatal care: item numbers 16500 to 16514

O&G spec.

210,194

188,971

88,268

45,019

46,589

17,86

1

14,135

4,691

615,728

GP

151,425

161,719

97,523

47,915

86,611

10,63

9

9,583

5,739

571,154

Sub-total

361,619

350,690

185,791

92,934

133,20

0

28,50

0

23,718

10,430

1,186,88

2 % O&G spec.

58.1

53.9

47.5

48.4

35.0

62.7

59.6

45.0

51.9

% GP

41.9

46.1

52.5

51.6

65.0

37.3

40.4

55.0

48.1

Management of labour and delivery: item numbers 16515 to 16525

O&G spec.

25,565

19,255

13,055

5,808

6,333

1,892

1,360

670

73,938

GP

2,866

2,949

3,227

676

2,093

495

211

180

12,697

Sub-total

28,431

22,024

16,282

6,484

8,426

2,387

1,571

850

86,635

% O&G spec.

89.9

86.7

80.2

89.6

75.2

79.3

86.6

78.8

85.3

% GP

10.1

13.3

19.8

10.4

24.8

20.7

13.4

21.2

14.7

Interventional techniques: item numbers 16600 to 16636

O&G spec.

1,431

625

281

1,191

437

116

130

98

4,309

Other spec.

916

148

37

31

70

0

152

0

1,354

GP

2,616

3,079

1,722

108

983

19

27

0

8,554

Sub-total

4,963

3,852

2,040

1,330

1,490

135

309

98

14,217

AMWAC 1998.6 61

NSW

Vic

Qld

SA

WA

Tas

ACT

NT

Total

% O&G spec.

28.8 16.2 13.8 89.5 29.3 85.9 42.1 100.0 30.3

% oth. spec.

18.5

3.8

1.8

2.3

4.7

-

49.2

-

9.5

% GP

52.7

79.9

84.4

8.1

66.0

14.1

8.7

-

60.2

Gynaecological: item numbers 35500 to 35729

O&G spec.

127,714

87,812

52,179

23,026

36,190

8,237

8,455

1,887

345,500

Other spec.

1,467

1,256

603

280

875

97

95

11

4,684

GP

41,893

24,104

19,814

2,655

15,018

898

2,042

101

106,535

Sub-total

171,074

113,172

72,596

25,971

52,083

9,232

10,592

1,999

456,719

% O&G spec.

74.7

77.6

71.9

88.7

69.5

89.2

79.8

94.4

75.6

% oth. spec.

0.9

1.1

0.8

1.1

1.7

1.1

0.9

0.6

1.0

% GP

24.5

21.3

27.3

10.3

28.8

9.7

19.3

5.1

23.3

All obstetrics and gynaecological : item numbers 13200 to 3579

O&G spec.

367,760

298,980

157,603

75,794

90,832

28,70

2

24,929

7,351

1,051,95

1 Other spec.

3,106

1,533

1,182

923

1,425

418

250

15

8,852

GP

231,365

219,525

143,299

60,650

112,03

2

13,15

7

12,572

6,040

798,640

Sub-total

602,231

520,038

302,084

137,367

204,28

9

42,27

7

37,751

13,406

1,859,44

3 % O&G spec.

61.1

57.5

52.2

55.2

44.5

67.9

66.0

54.8

56.6

% oth. spec.

0.5

0.3

0.4

0.7

0.7

1.0

0.7

0.1

0.5

% GP

38.4

42.2

47.4

44.2

54.8

31.1

33.3

45.1

43.0

Percentage of obstetrics and gynaecological services provided by GPs: items 16500 to 35729*

% GP total

35.1

39.2

44.2

40.5

53.6

29.9

32.8

45.0

40.1

* Items commonly performed by specialists/sub-specialists in obstetrics and gynaecology Source: AIHW 1997 Training of General Practitioners GPs wishing to provide obstetrics and gynaecology services complete an additional training program in obstetrics and gynaecology overseen by the Joint Consultative Committee - RACOG and RACGP. Data provided by RACOG shows that currently there are 2,845 GPs who have completed the training. The majority of these GPs are located in Victoria (35.1%) and New South Wales (25.0%). The 1996 Centre For Rural Health

AMWAC 1998.6 62

Rural General Practitioner survey had 541 respondents who indicated they practised in obstetrics and gynaecology and of these respondents the majority (75.1%) were located in small rural and remote areas. Further data on GPs providing obstetrics and gynaecology services is provided in Appendix H. Medicare data indicates that in 1995-96, 60.1% obstetrics service providers (including GPs) were located in a capital city, 6.7% in another metropolitan area, 9.2% in a large rural centre, 9.4% in a small rural centre, 11.8% in another rural area, and 2.9% in remote areas (Table 30). Comparing this data with the distribution of obstetrics and gynaecology specialists indicates that GPs represent an increasingly higher proportion of obstetrics providers, as a function of remoteness of the locality from a metropolitan area. Table 30: Distribution of obstetrics and gynaecology Medicare service providers, by geographic location, 1995-96

Patient location

Provider location

Capital

city

Other metro

Large rural

centre

Small rural

centre

Other rural

centre

Remote

centre

Other

remote

Total

Capital city

97.8

4.9

1.6

3.9

11.3

5.6

12.4

60.1

Other metropolitan

0.5

92.3

0.4

2.0

2.1

1.0

1.1

6.7

Large rural centre

0.2

0.2

94.7

3.2

11.8

5.6

7.4

9.2

Small rural centre

0.5

0.8

1.4

87.7

7.5

1.0

10.3

9.4

Other rural centre

0.8

1.7

1.6

2.8

66.2

0.8

8.4

11.8

Other rural area

0.1

0.1

0.2

0.1

0.4

82.4

12.4

1.6

Other remote

0.1

0.2

0.2

0.2

0.6

3.6

47.9

1.3

Total

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

Source: DHFS The other key alternative providers are midwives. The AIHW Nursing Labour Force Survey shows that in 1995 there were 13,913 registered midwives and 1,540 nurses employed in obstetrics and gynaecology. These two groupings represented 7.9% of the nursing workforce. There is no trend data available on the number of midwives but information provided by several State/Territory health departments indicated the number was declining. More information is provided on midwife numbers in Appendix J.

AMWAC 1998.6 63

BALANCING SUPPLY AGAINST REQUIREMENTS Requirement Trends The Working Party assessed various indicators of future obstetrics and gynaecology requirements. These included: female population growth; birth rates; crude birth rates; fertility rates; cancer of the cervix, uterus and ovary incidence rates; and trends in obstetrics and gynaecology national hospital morbidity data and Medicare services. Australian female population growth: Over the next ten years, the total Australian female population is expected to increase at an annual rate of 1.1% per annum. During the same period it is expected that the female population aged 15 years and over will increase by 1.1% per annum, those aged 15-49 years will increase by approximately 0.3% per annum, and those aged 25 years and over will increase by approximately 1.0% per annum (ABS 3222.0) Birth rate: There has been a growth in births in Australia from 243,408 live births in 1986 to 253,834 in 1996, this represents a growth of 4.3%, or 0.4% per annum. Future projections indicate that birth rates will remain constant (ABS Births 1996, 3301.0). Fertility rate: The total fertility rate since 1992 (1.894) has steadily declined, with the fertility rate for registered births at 1.796 in 1996, the lowest rate on record. The fertility rate is considered to be more likely to fall or remain stable in the longer term, and the age distribution will continue to change in favour of ages over 30 years (ABS Births 1996, 3301.0). Incidence of cervical, uterine and ovarian cancer (per 100,000): Birth rate and fertility rate can be used to give an indication of likely future obstetrics requirements. Useful indicators of likely future gynaecological requirements are less readily available. The Working Party used the trend in the incidence of cervical, uterine and ovarian cancer as a proxy indicator for gynaecological service trends. The incidence rate of cancer of the uterus is increasing in Australia with the incidence rate at 11.85 in 1989 projected to 14.86 in 1999, an increase of 1.6% per annum. Whereas the incidence rate of ovarian cancer is marginally declining in Australia with the incidence rate 11.10 in 1989 to a projected 10.93 in 1999 (a decrease of 0.1% per annum) as is the incidence rate of cervical cancer which indicated an average annual decline of 1.3% between 1983 and 1994. Medicare and ICD-9-CM data: Medicare obstetrics and gynaecology services provided by obstetricians and gynaecologists have shown a 2.7% per annum growth over the period 1986-87 to 1996-97.

AMWAC 1998.6 64

ICD-9-CM data on obstetrics and gynaecology have indicated that for gynaecological procedures there will be overall growth of 14.0% over the next 20 years (1998-2018) or 0.7% per annum. For obstetrical procedures it is forecasted to rise by only 2.2% or by 0.1% per annum in the same period. In projecting requirements the Working Party chose not to use Medicare data because it only covers private practice billing activity; with only a minority of the population with private health insurance and with that minority declining. Accordingly, with the exception of the Medicare data, all the indicators were projected over the period 1999 to 2009. Table 31 below shows projected requirements for obstetrics and gynaecology, using each of the main indicators. The projections have been converted to hours per week using the average hours worked figure of 60 hours per week. Conversion of the data to hours of service allows comparisons to be made with projected supply data, which is similarly adjusted and converted. It is also recognised that a ten year projection period is a long time frame for assumptions to be remain valid. However, this time frame was chosen because five years was considered to be too short for any impact on training numbers to move through, given that the training program is six years in duration. Table 31: Projected requirements for obstetrics and gynaecology services (in full time equivalent hours per week) for selected indicators , 1999 to 2009a

Year

Cancer

incidence

Fertility

rates

Birth rates

Female

pop. 15-49 yrs

ICD-9-CM

Female

pop. growth >15

years

Female

pop. growth >25

years

Female pop.

growth >49 years

1999

56,686

57,041

57,513

57,522

57,647

57,943

58,097

58,685

2000

56,105

56,811

57,755

57,773

58,025

58,621

58,934

60,133

2002

54,962

56,355

58,241

58,279

58,788

60,002

60,645

63,138

2004

53,842

55,901

58,732

58,789

59,561

61,415

62,405

66,292

2006

52,745

55,452

59,226

59,304

60,344

62,862

64,216

69,604

2008

51,670

55,006

59,725

59,823

61,137

64,343

66,079

73,082

2009

51,141

54,784

59,976

60,084

61,538

65,096

67,031

74,885

Note: a - assumes an average of 60 hours worked per week Source: AMWAC

AMWAC 1998.6 65

The Working Party concluded that the birth rate provided the best indicator of likely future obstetrics and gynaecology services requirements, that is requirements growth of an estimated 0.4% per annum. This projection trend is lower than most of the population trends, but higher than the fertility rate and the incidence of cancer trend. It is actually close to the trend in growth in obstetrics and gynaecology ICD-9-CM national hospital morbidity data. Accordingly, the choice of 0.4% represents roughly the mid point of all the indicators examined, and can be considered a conservative choice. Supply Trends The supply of obstetric and gynaecology specialists was projected by ageing the RACOG specialist numbers through each year of age, subtracting expected retirements and attrition due to deaths and specialists leaving the workforce and adding expected new graduates. Importantly, supply trends over the next ten years will be dominated by the large cohort of specialists aged 55 years and over proceeding through to retirement and to a lesser extent by the influx of a comparatively large number of female graduates. The number of specialists was converted to hours per week by applying the average number of hours worked to headcounts in each major age cohort. In doing so the Working Party assumed that the pattern of workforce participation of the current workforce provides a suitable basis on which to project future workforce requirements. In addition, the increasing female participation and the average lower lifetime workforce contribution of female specialists has been assumed. The supply projections show that supply will increase from the estimated current level of 57,272 FTE hours per week to an estimated 59,260 FTE hours per week in 2009, assuming average retirements; with an upper and lower projection range of 58, 084 FTE hours and 62,025 FTE hours per week respectively (Table 32). Table 32: Projected supply of obstetrics and gynaecology services, high, low and average retirement rates, by FTE hours worked per week, 1999, 2004 and 2009

Year

Low retirement rate

Average retirement rate

High retirement rate

1999

56,968

57,191

57,414

2004

56,309

57,359

58,469

2009

58,084

59,260

62,025

Source: AMWAC Using average retirement rates, current workforce supply, average hours worked per week and graduate output, future supply projections indicate that the workforce will fall slightly below the estimated obstetrics and gynaecology service requirements levels growth of 0.4% per annum, representing an estimated 0.6% shortage in 1999, an

AMWAC 1998.6 66

estimated 2.7% shortage in the year 2000 and an estimated 2.4% in the year 2004 (Table 33). Table 33: Projected obstetrics and gynaecology supply and requirements (FTE hours), 0.4% growth per year, 1998 to 2004a

Year

Projected supply

Projected requirements

% shortage

1998

57,272

57,272

base year

1999

57,191

57,513

0.6

2000

56,220

57,755

2.7

2002

56,603

58,241

2.9

2004

57,359

58,732

2.4

Note: a - based on average retirement rates, a working week of 60 hours and constant intake of trainees per annum Source: AMWAC Projected Balance A balance in supply to match a continued growth rate in the requirement indicators of 0.4% per annum can be achieved by ensuring the same number of graduates currently entering the six year program is maintained; that is a trainee intake of 58 per year. This assumes that the length of the RACOG training program would continue to be six years and that all candidates will complete the program within this time frame. This assumption has been necessary in the absence of data from RACOG on average training program completion times. In part, this reflects the difficulty of knowing what, if any, impact on completion will be caused by the increase in female trainees and the introduction of part time training arrangements. If trainee intakes achieve 58 per year, it is expected that there will be no significant shortfall emerging in the workforce. Table 34 shows the obstetrics and gynaecology trainee output needed, to move projected supply into balance with projected requirements for this workforce. The projected requirement used is based on 0.4% growth per year. Under this scenario notional shortages are expected to peak at 2.9% in 2002 but for requirements and supply to move back towards balance thereafter. It is projected that there will only be 1.6% shortfall in 2008.

AMWAC 1998.6 67

Table 34: Obstetrics and gynaecology graduate output needed to move projected supply into balance with projected requirements, 0.4% growth per year, (in FTE hours), 1998 to 2009

Year

Number of graduates

Projected

supply

Projected

requirements

Balance

(shortage)

% shortage

1998

45

57,272

57,272

base year

0.0

1999**

21

57,191

57,513

322

0.6

2000

50

56,220

57,755

1,534

2.7

2001

47

56,466

57,997

1,531

2.7

2002

57

56,603

58,241

1,638

2.9

2003

49

57,153

58,486

1,333

2.3

2004

42

57,359

58,732

1,372

2.4

2005**

58

57,244

58,978

1,734

3.0

2006

58

57,764

59,226

1,462

2.5

2007

58

58,272

59,475

1,203

2.1

2008

58

58,770

59,725

955

1.6

2009

58

59,260

59,976

717

1.2

*Training period is six years ** Constant trainee intake beginning 1999 and graduating in 2005 Source: AMWAC Table 34 is shown graphically in figures 1 and 2 below. Figure 1 includes all demand indicators: female population growth greater than 15 years of age, female population growth in the 15 to 49 year age group, female population growth greater than 25 years of age, birth rates, crude birth rates, fertility rates, female reproduction rate and cancer cervix index and projected trends in ICD-9-CM, plotted against the workforce supply using graduating trainee figures (Table 32) in FTE demand hours per week to the year 2009. Figure 2 shows the workforce supply versus the demand indicators for birth rates and fertility rates in FTE demand hours per week to the year 2009.

AMWAC 1998.6 68

-

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Year

FTE

hour

s pe

r wee

k

Population growthFemale population growth (>15yrs)Female growth in the 15-49 age groupFemale population growth >25Birth rates Fertility ratesICD-9-CMFemale population growth > 49cancer cervix index (20 to 74)W orkforce (FTEs hrs/week)

52,000

53,000

54,000

55,000

56,000

57,000

58,000

59,000

60,000

61,000

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Birth rates

Fertility rates

W orkforce (FTEs hrs/week)

AMWAC 1998.6 69

Ideally trainee intake should be around 58 per year so that no significant shortfall emerges in the workforce. However, RACOG has indicated that the initial intake of 58 trainees per year may not be achievable as there are limited potential training positions currently available and an already stretched resource of trainers. Maintenance of trainee intake at this level could also impact on trainees obtaining the necessary accumulated training experience. Accordingly, to accommodate this concern several scenarios based on trainee intake ranging from 50 per year to 58 per year were examined and the results are summarised in Table 35. Notional shortfalls range from a near balanced scenario with a trainee intake of 58 per year to an estimated shortfall of 3.6% with a trainee intake of 50 per year. In recognition of RACOGs concern the Working Party has recommended that an intake of 55 trainees per year, which in fact is similar to the trainee intake over the period 1995 to 1997, is a more practical target to aim for as this should lessen any impact in terms of available trainers and accumulation of clinical experience by trainees. A trainee intake of 55 per year, will produce an estimated workforce shortfall of 2.1% in 2009. The Working Party believes that there will be no emerging shortage of obstetrics and gynaecology specialists if the trainee intake is set at 55 per year. Of course this does not address the issue of maldistribution of the workforce and in this respect it will be necessary for RACOG and State/Territory health departments to make internal adjustments to the distribution of training positions.

AMWAC 1998.6 70

Table 35: Estimated obstetrics and gynaecology graduate output required to move projected supply into balance with projected requirements, 0.4% growth per year, (in FTE hours), by selected graduate outputs, 1998 to 2009

Year 2005

2006

2007

2008

2009

Projected requirements

58,978

59,226

59,475

59,725

59,976 Projected supply for 50 graduates per year, beginning in 1999 and graduating in 2005

57,244

57,428

57,591

57,736

57,870 Balance (shortage)

1,734 (3.0%)

1,798 (3.1%)

1,885 (3.3%)

1,989 (3.4%)

2,106 (3.6%) Projected supply for 52 graduates per year, beginning in 1999 and graduating in 2005

57,244

57,512

57,761

57,995


1,734 (3.0%)

1,714 (3.0%)

1,714 (3.0%)

1,731 (3.0%)


57,244

57,638

58,016

58,382


1,734 (3.0%)

1,588 (2.8%)

1,459 (2.5%)

1,343 (2.3%)


57,244

57,764

58,272

58,770


1,734 (3.0%)

1,462 (2.5%)

1,203 (2.1%)

955 (1.6%)

717(1.2%)

Source: AMWAC The Working Party recommends that training positions should be increased proportionately less in the comparatively well endowed state of South Australia, and to a lesser extent Victoria, although it needs to be remembered that Victoria has a significant proportion of older specialists. This is also the case in New South Wales. In particular, emphasis needs to be given to increasing training positions in New South Wales, Western Australia and Queensland. The Working Party recommends that the training positions up to the year 2002 should be distributed as shown below in Table 36. Table 36 also shows the actual intake level for 1997 and 1998.

AMWAC 1998.6 71

Table 36: Distribution of obstetrics and gynaecology first year advanced trainee positions, by State/Territory, 1999 to 2002

State/Territory

1997

1998

1999

2000

2001

2002

actual intake

required intake

NSW

18

14

20

20

20

20

Victoria

12

10

14

14

13

12

Queensland

9

5

11

11

11

11

South Australia

5

6

4

4

4

4

Western Australia

5

2

4

4

4

4

Tasmania

0

2

1

1

2

2

ACT

0

3

1

1

1

2

Northern Territory

0

0

0

0

0

0

Australia

49

42

55

55

55

55

Source: AMWAC Given the sensitivity of the assumptions in the projection modelling, it will be important that obstetrics and gynaecology requirements and supply projections be monitored regularly so that they can be amended if new trends emerge. The Working Party recommends that a review of the specialist obstetrics and gynaecology workforce be undertaken before the level of trainee intake for 2003 is determined, that is by the end of 2000. In this context, it will also be important for AMWAC to continue to monitor the trend in the numbers of non specialist providers. It should also be noted that whilst RACOG has recently introduced a compulsory six month rural training placement for trainees, in an effort to improve awareness of rural practice, this scheme will need the continued support of State/Territory health departments in terms of funding and support of suitable rural training positions. The Working Party would also like the Commonwealth and State/Territory health departments to consider the establishment of rural cadetships aimed at providing financial assistance to those training in their last year and are interested in remaining and establishing a rural practice. This process coupled with the compulsory experience to rural practice through the training program may help to alleviate some of the geographical maldistribution inherent in the workforce. In the first instance the Commonwealth Department of Health and Family Services and RACOG should jointly examine the feasibility of such a scheme.

AMWAC 1998.6 72

RECOMMENDATIONS The Working Party recommends: 1. There be an increase in the number of funded obstetrics and gynaecology

training positions to maintain trainee intake during the period 1999 to 2002 at 55 per year.

2. That State and Territory health departments undertake negotiations with the

RACOG to ensure intake numbers for first year trainees remain constant at 55 per year to 2002 and distributed as shown below.

Distribution of obstetrics and gynaecology first year advanced trainee positions, by State/Territory, 1999 to 2002

State/Territory

1997

1998

1999

2000

2001

2002

actual intake

required intake

NSW

18

14

20

20

20

20

Victoria

12

10

14

14

13

12

Queensland

9

5

11

11

11

11

South Australia

5

6

4

4

4

4

Western Australia

5

2

4

4

4

4

Tasmania

0

2

1

1

2

2

ACT

0

3

1

1

1

2

Northern Territory

0

0

0

0

0

0

Australia

49

42

55

55

55

55

Source: AMWAC 3. State/Territory based obstetrics and gynaecology services working groups,

comprising RACOG and State/Territory department of health representatives, be organised to oversee the funding and establishment of any new training positions.

4. That obstetrics and gynaecology requirements and supply projections be

monitored regularly so that they can be amended if new trends emerge, and that the specialist obstetrics and gynaecology workforce be reviewed before the level of trainee intake for 2003 is decided, that is at the end of 2000.

AMWAC 1998.6 73

5. That this monitoring be coordinated by RACOG and AMWAC and the results incorporated into the AMWAC annual report to AHMAC. AMWAC will provide all necessary support.

6. AMWAC also to continue to monitor the trend in the numbers of non specialist

obstetric and gynaecology providers (general practitioners and midwives). 7. The RACOG and the Commonwealth Department of Health and Family Services

examine the feasibility of establishing a rural obstetric and gynaecology graduate cadetship scheme to encourage graduates from the obstetrics and gynaecology training program to consider rural practice.

AMWAC 1998.6 74

PART B:

THE OBSTETRICS AND GYNAECOLOGY SUB-SPECIALIST WORKFORCE

AMWAC 1998.6 75

INTRODUCTION As indicated in the Introduction to the main, part A, report, the Working Party decided that the various obstetrics and gynaecology sub specialist workforces should also be examined in some detail. There are five obstetrics and gynaecology sub specialties - maternal fetal medicine, uro-gynaecology, obstetrical and gynaecological ultrasound, gynaecological oncology and reproductive endocrinology and infertility. The main data sources used in preparing this section of the report where the RACOG information on Fellows and trainees and the RACOG/AMWAC survey of Fellows. Where available data from the AIHW Medical Labour Force Survey and Medicare has also been used. It should also be noted that the 98 sub specialists identified by the RACOG and the Working Party are not in addition to the 1,049 obstetrics and gynaecology specialists identified in part A of this report as the total specialist workforce, rather they are part of that total. Sub-specialist Definitions The Working Party defined a gynaecological oncology specialists as:

A Gynaecological Oncologist is a FRACOG who has completed a formal three year training program in gynaecological cancer care and passed the examination for Certified Gynaecological Oncologist. She/he is competent in the comprehensive management of the women with a genital malignancy. The sub-specialist will work in gynaecology with at least 66% of the time in gynaecological oncology. She/he will submit themselves for reaccreditation every five years, and only those actively practising will continue to be accredited.

The aims of sub-specialisation are to: improve the education and skills of those treating women with genital malignancy; improve outcomes for these women; promote research into the management of these diseases; ensure that women receive the highest standards of care; and, to ensure that all women have access to sub-specialist care in the management of gynaecological cancer.

The Working Party defined a sub-specialist in maternal fetal medicine as :

A specialist in obstetrics and gynaecology, possessing the FRACOG, who is trained and assessed as being competent in the comprehensive management in obstetrical, medical and surgical complications of pregnancy and their effect on both the mother and fetus. It requires expertise in the most current approaches to diagnosis and treatment of patients with complicated pregnancies and also requires a setting where requisite technical support is available. Personnel with advanced knowledge of newborn adaptation also are necessary to ensure a continuum of excellence in care from the fetal to newborn periods.

AMWAC 1998.6 76

A sub-specialist in this field should spend the majority of their time in clinical work and have a practice profile that demonstrates in excess of 80% of clinical time is spent in this specialty area. Such a person must have a full time tertiary base which satisfies the definition of a Maternal Fetal Medicine Unit. Activities conducted outside this base may be permitted where the primary purpose is teaching, research or administration in fields related to maternal-fetal medicine. To maintain status as a specialist the practitioner would need to remain affiliated with a hospital providing the facilities of a tertiary referral perinatal centre.

The Working Party defined a sub-specialist in obstetrical and gynaecological ultrasound specialists as:

A Sub-specialist in Obstetrical and Gynaecological Ultrasound is a Fellow in good standing of RACOG who is trained and has been assessed as being competent in all aspects of ultrasound diagnosis relating to obstetrics and gynaecology including ultrasound guided interventional diagnostic and therapeutic techniques. Such an individual would spend of at least 22 hours per week in obstetrical and gynaecological diagnostic ultrasound practice. It is desirable but not mandatory that he/she work part of this time in a tertiary care institution where the ultrasound department provides a comprehensive diagnostic service to general obstetrics and gynaecology and to the sub-specialties.

The Working Party defined a sub-specialist in reproductive endocrinology and infertility as :

A gynaecological sub-specialist in Reproductive Endocrinology and Infertility is a specialist in obstetrics and gynaecology, possessing the FRACOG, who is trained and assessed as being competent in the comprehensive management of patients with reproductive endocrine disorders and infertility. His or her continued medical activity may be in gynaecology and/or obstetrics, but with at least 67% of his or her clinical time being spent in the area of reproductive endocrinology and/or infertility. At least part of this work must be within a professional setting that provides a comprehensive service for patients with infertility or gynaecological endocrine disorders. This may include private units as well as public hospitals.

The Certificate of Reproductive Endocrinology and Infertility (CREI) is recognised by the National Specialist Qualification Advisory Committee as a registrable degree only for individuals who hold the qualification of Fellow of the Royal Australian College of Obstetricians and Gynaecologists (FRACOG). It is not intended that only persons with their CREI should treat infertile couples. It is probable, though, that leaders in this area and directors of assisted conception units will have this qualification.

AMWAC 1998.6 77

The Working Party defined a sub-specialist in uro-gynaecology as: A specialist in obstetrics and gynaecology, possessing the FRACOG, who is trained and assessed as being competent in the comprehensive management of patients with uro-gynaecological disorders. Continued medical activity may be in gynaecology and/or obstetrics, but with at least 50% of their time spent in the area of uro-gynaecology.

All the sub-specialist certificates are recognised by the National Specialist Qualification Advisory Committee as a registrable degree only for individuals who hold the qualification of FRACOG.

AMWAC 1998.6 78

CHARACTERISTICS OF THE OBSTETRICS AND GYNAECOLOGY SUB-SPECIALTY WORKFORCE Number of Practising Sub-specialists in Obstetrics and Gynaecology The current size of the practising obstetrics and gynaecology sub-specialist workforce is estimated to be 98. The number of sub-specialists is relatively small, making up approximately 9.3% per cent of the profession. The estimated numbers within each of the five sub-specialties are 10 maternal fetal medicine specialists, 13 uro-gynaecologists, 23 obstetrical and gynaecological ultrasound specialists, 24 gynaecological oncology specialists and 28 reproductive endocrinology and infertility specialists. Distribution of the Sub-specialist Workforce Table 37 shows the sub-specialties by State/Territory and indicates that 38.8% of all sub-specialties are located in New South Wales with none in the Northern Territory. Table 38 shows the geographic distribution of sub-specialists and indicates that the majority (91.8%) are located in capital cities. Only obstetrics and gynaecology ultrasound is represented in rural centres (1.0%). 7.2% of sub-specialists are located in other metropolitan areas (16.8% of the female population).

AMWAC 1998.6 79

Table 37: Number of obstetrics and gynaecology sub-specialists, by sub-specialty, State/Territory and gender, 1998

NSW

Vic

Qld

SA

WA

Tas

ACT

NT

Aust

Gynaecological oncology

Males

8

6

4

1

3

1

0

0

23

Females

0

0

0

1

0

0

0

0

1

Total

8

6

4

2

3

1

0

0

24

Maternal fetal medicine

Males

4

0

0

0

1

0

2

0

7

Females

0

0

1

1

1

0

0

0

3

Total

4

0

1

1

2

0

2

0

10

Obstetrical and gynaecological ultrasound

Males

5

10

2

0

2

0

0

0

19

Females

1

2

0

0

1

0

0

0

4

Total

6

12

2

0

3

0

0

0

23

Reproductive endocrinology and infertility

Males

12

7

1

4

1

1

0

0

26

Females

2

0

0

0

0

0

0

0

2

Total

14

7

1

4

1

1

0

0

28

Uro-gynaecology

Males

5

2

0

1

4

0

0

0

12

Females

1

0

0

0

0

0

0

0

1

Total

6

2

0

1

4

0

0

0

13

All obstetrics and gynaecology sub-specialists

Males

34

25

7

6

11

2

2

0

87

Females

4

2

1

2

2

0

0

0

11

Total

38

27

8

8

13

2

2

0

98

% distribution

38.8

27.6

8.2

8.2

13.2

2.0

2.0

0.0

100.0

% female

10.5

7.4

12.5

25.0

15.4

0.0

0.0

0.0

11.2

Source: RACOG

AMWAC 1998.6 80

Table 38: Distribution of obstetrics and gynaecology sub-specialists; by geographic location, 1998 State/Territory

Total

% of

Australia

% capital city

% other

metro.

% large

rural centre

% small

rural centre

Gynaecology Oncology

24

24.5

100.0

0.0

0.0

0.0

Maternal Fetal Medicine

10

10.2

80.0

20.0

0.0

0.0

Obstetrics and Gynaecology Ultrasound

23

23.5

87.0

8.7

4.3

0.0

Reproductive Endocrinology & Infertility

28

28.6

89.3

10.7

0.0

0.0

Uro-gynaecology

13

13.3

100.0

0.0

0.0

0.0

Australia

98

100.0

91.8

7.2

1.0

0.0

Source: RACOG Age Profile The youngest sub-specialist was aged 35 years and the oldest were aged between 66 and 70 years, with a mean age of 46.5 years. The largest five year age groups were the 46 to 50 year age group (24.5%), and the 41 to 45 year age group (23.5%). Nine individuals (9.2%) are aged over 60 years. In Victoria, 18.5% (5) of the total sub-specialists were aged over 60 years. Queensland had the youngest group (under 50 years of age) of specialists in the workforce representing 87.5% (7) followed by New South Wales at 63.2% (24). For all sub-specialties the majority of individuals were aged under 50 years, that is, 90% (9) of maternal fetal medicine specialists, 61.5% (8) uro-gynaecology specialists, 65.2% (15) obstetrical and gynaecological ultrasound specialists, 62.5% (15) gynaecological oncology specialists and 50% (14) reproductive endocrinology and infertility specialists.

AMWAC 1998.6 81

Table 39: Age profile of obstetrics and gynaecology sub-specialists, by State/Territory and gender, 1998 State/Terr.

Sex

31-35

yrs

36-40

yrs

41-45

yrs

46-50

yrs

51-55

yrs

56-60

yrs

61-65

yrs

66-70

yrs

71+ yrs

Total

NSW

M

1

5

9

5

9

3

2

0

0

34

F

0

1

2

1

0

0

0

0

0

4

Vic M

0

2

3

9

6

0

3

2

0

25

F

0

0

0

2

0

0

0

0

0

2

Qld M

0

0

1

2

3

0

1

0

0

7

F

0

0

0

1

0

0

0

0

0

1

SA M

0

0

0

2

1

2

1

0

0

6

F

0

0

1

0

1

0

0

0

0

2

WA M

0

1

1

4

2

3

0

0

0

11

F

0

1

1

0

0

0

0

0

0

2

Tas M

1

0

0

0

1

0

0

0

0

2

F

0

0

0

0

0

0

0

0

0

0

NT M

0

0

0

0

0

0

0

0

0

0

F

0

0

0

0

0

0

0

0

0

0

ACT M

0

1

1

0

0

0

0

0

0

2

F

0

0

0

0

0

0

0

0

0

0

Australia M

2

10

16

23

19

8

7

2

0

87

F

0

2

7

1

1

0

0

0

0

11

Total

2

12

23

24

20

8

7

2

0

98 % female

0.0

16.7

30.4

4.2

5.0

0.0

0.0

0.0

0.0

11.2

Source: RACOG Table 40 provides a summary of the sub-specialists by major age categories. It shows that for Australia, 62.2% (61) of sub-specialists were aged less than 50 years, and 9.2% (9) were aged over 60 years. The sub-specialist workforce is predominantly under 50 years of age.

AMWAC 1998.6 82

Table 40: Age profile of obstetrics and gynaecology sub-specialists, by State/Territory, gender and major age group, 1998

State/Terr

Sex

NSW

Vic

Qld

SA

WA

Tas

NT

ACT

Aust

under 50 years

M

20

14

6

2

6

1

0

2

51

F

4

2

1

1

2

0

0

0

10

51-60 years

M

12

6

0

3

5

1

0

0

27

F

0

0

0

1

0

0

0

0

1

over 60 years

M

2

5

1

1

0

0

0

0

9

F

0

0

0

0

0

0

0

0

0

Total

38

27

8

8

13

2

0

2

98

Source: RACOG Gender Profile Women represent 11.2% (11) of the sub-specialist workforce (Table 39). The largest proportion of female sub-specialists is in the 41 to 45 year age group (30.4%) followed by the 36 to 40 year age group (16.7%). Hours Worked Table 41 details the average hours provided by obstetrics and gynaecology sub-specialists by State and Territory. The average hours worked per week by sub-specialists was 64.2, 42.3 hours per week were worked in direct patient care and an average of 13.4 hours per week were worked on call.

AMWAC 1998.6 83

Table 41: Sub-specialists in obstetrics and gynaecology average hours worked per week and annual labour supply hours, by State/Territory, 1998 State/Terr.

NSW

Vic

Qld

SA

WA

Tas

ACT

NT

Total

Total hours worked

Average

69.5

63.1

54.0

64.8

60.0

70.0

54.0

-

64.2

Annual hours

121,486

78,370

19,872

23,846

35,880

6,440

4,968

-

289,414

hrs worked per 100,000 female pop

4,892

4,247

1,519

3,978

5,225

3,418

4,075

-

3,967


Average

40.5

48.4

35.2

36.2

53.3

40.0

20.0

-

42.3

Annual hours

70,794

60,113

12,954

13,322

31,873

3,680

1,840

-

190,688


2,851

3,257

990

2,222

4,642

1,953

1,509

-

2,614


Average

19.8

16.7

1.7

2.0

0.0

0.0

4.0

-

13.4

Annual hours

34,610

20,741

626

736

0.0

0.0

368

-

60,407


911

768

78

92

0.0

0.0

184

-

616


Average

63.8

23.0

6.0

58.0

0.0

0.0

24.0

-

38.3

Annual hours

114,457

24,334

2,208

21,344

0.0

0.0

2,208

-

172,656


2,935

1,058

276

2,668

0.0

0.0

1,104

-

1,762

Female pop >15 years (>000)

2,483.2

1,845.4

1,308.0

599.4

686.7

188.4

121.9

62.6

7,296.6

Note: a - calculated as average hours multiplied by persons multiplied by 46 weeks per year Source: RACOG/AMWAC Survey 1997 Table 42 details the average hours provided by sub-specialists by gender and age. In 1997 sub-specialists worked on average 64.2 hours per week, 62.6 for males and 77.6 for females. However, those under 55 years of age averaged around 66.6 hours per week; this declined to 58.4 hours for males in the 55 to 64 years age group, and 51.3 hours for males in the 65 to 70 years age group.

AMWAC 1998.6 84

Table 42: Sub-specialists in obstetrics and gynaecology average hours and annual hours worked, by gender and age group, 1998

Gender

35-44 yrs

45-54 yrs

55-64 yrs

65-70 yrs

Total

Total hours worked

Male

60.5

67.4

58.4

51.3

62.6

Female

77.6

-

-

-

77.6

Total

65.8

67.4

58.4

51.3

64.2

Annual total hours worked

111,922

136,418

40,296

4,720

289,414


Male

48.5

42.7

33.3

43.7

42.4

Female

41.6

-

-

-

41.6

Total

46.2

42.7

33.3

43.7

42.3

Annual direct hours worked

78,632

86,425

22,977

4,020

190,688


Male

38.8

41.8

16.8

0.0

33.9

Female

58.4

-

-

-

58.4

Total

48.6

41.8

16.8

0.0

38.3

Annual hours on call not worked

82,717

84,603

11,592

0

172,656


Male

31.0

3.3

32.6

0.0

15.2

Female

4.3

-

-

-

4.3

Total

18.9

3.3

32.6

0.0

13.4

Annual hours on call worked

32,168

6,679

22,494

0.0

60,407

No. of sub-specialists

37

44

15

2

98

(a) Calculated as average hours multiplied by persons multiplied by 46 weeks per year Source: RACOG/AMWAC Survey The RACOG/AMWAC survey indicated that the average hours worked by sub-specialists varied by region with the average hours in direct patient care in major urban areas at 42.5 hours a week compared to 32.0 hours a week in large rural centres. 64.5% of sub-specialists from major urban centres reported being on call for after hours worked as is shown in Table 43.

AMWAC 1998.6 85

Table 43: Sub-specialists in obstetrics and gynaecology average hours worked per week, by geographic location of main job, 1997

Major urban centre

Provincial/ rural

town

Total

Total hours worked

65.3

32.0

64.2


42.5

32.0

42.3


13.9

0.0

13.9


39.7

0.0

38.3


64.5

0.0

64.5

Average age

50

44

50

Source: RACOG/AMWAC Survey Practice Profiles The majority (58.3%) of sub-specialists worked as solo specialists, 18.6% worked with other obstetricians and gynaecologist and 16.7% worked with a multi-disciplinary group and the remaining 6.4% made no response. Of the 48 sub-specialists from the RACOG/AMWAC Survey, 41.7% were in a private practice and/or undertake public hospital work; 31.3% were salaried in a public hospital; 16.7% were in a private practice with no public hospital role; 4.2% were public hospital salaried and in a private practice and 6.1% made no response. There were 45 sub-specialists respondents who indicated their appointment by State/Territory. The proportion reporting employment in public hospitals was much higher in New South Wales (46.7%) and lower (6.7%) in the Australian Capital Territory. There was no public hospital representation in Western Australia, Tasmania and the Northern Territory (Table B11, Appendix B). Training Arrangements RACOG offers certificates in each of the five sub-specialties. With the exception of obstetrical and gynaecological ultrasound each of the sub-specialty training programs are of three years duration. The ultrasound training is a two year program. Sub-specialty trainees by age group and year of training is shown in Table 44. There are 17 (43.6%) female sub-specialist trainees, the majority (23.5%) of which are aged under 40 years.

AMWAC 1998.6 86

Table 44: Obstetrics and gynaecology sub-specialty trainees, by year of training, gender and major age group, February 1998 Sub-specialty trainees

Sex

31-35 yrs

36-40 yrs

41-45 yrs

46-50 yrs

Total

Gynaecological Oncology

Year 1 M

2

1

-

-

3

F

-

-

-

-

0 Year 2

M

1

-

-

-

1

F

-

-

-

-

0 Year 3

M

-

-

-

-

0

F

-

2

-

-

2 M

0

1

1

-

2

Completed clinical training but not all assessment requirements

F

-

-

-

-

0 Total

3

4

1

0

8

Maternal-Fetal Medicine Year 1

M

-

-

-

1

1

F

-

-

1

-

1 Year 2

M

-

1

-

-

1

F

-

2

-

-

2 Year 3

M

-

-

-

-

0

F

-

-

-

-

0 M

-

0

0

-

0


F

-

1

-

-

1 Total

1

4

1

1

7

Obstetrical and Gynaecological Ultrasound (2 year program only) Year 1

M

0

2

-

-

2

F

1

-

-

-

1 M

-

1

1

-

2


F

-

2

1

-

3 Total

1

5

2

0

8

Reproductive Endocrinology and Fertility Year 1

M

-

-

-

-

0

F

-

1

-

-

1 Year 2

M

-

-

-

-

-

F

-

1

-

-

1 Year 3

M

1

1

-

-

2

F

1

1

-

1

3 M

-

1

1

0

2


F

-

-

-

-

- Total

2

5

1

1

9

AMWAC 1998.6 87

Uro-gynaecology Year 1

M

1

-

-

-

1

F

-

1

-

-

1 Year 2

M

-

1

-

-

1

F

1

-

-

-

1 Year 3

M

1

1

-

-

2

F

-

-

-

-

- M

-

-

-

-

-


F

-

-

1

-

1 Total

3

3

1

0

7

Total Sub-specialists

9

22

6

2

39 % Females Sub-specialists

33.3

45.5

50.0

50.0

43.6

Source: RACOG Currently there are no sub-specialty trainees in the Australian Capital Territory, the Northern Territory, Tasmania and Western Australia. Trainees in their last year represent 20.5% of the total trainee numbers. Table 45: Obstetrics and gynaecology sub-specialty trainees, by State/Territory and gender, February 1998 Sex

NSW

ACT

Vic

Qld

SA

WA

NT

TAS

OS

Total

No. in 3rd

year

Clinical training


M

3

-

1

1

1

-

-

-

-

6

2 F

-

-

2

-

-

-

-

-

-

2

2

Maternal-Fetal Medicine

M

2

-

-

2

-

-

-

-

3

7

1 F

1

-

1

-

1

-

-

-

-

3

1 Obstetrical and Gynaecological Ultrasound

M

2

-

2

1

-

-

-

-

-

5

2

F

2

-

1

-

1

-

-

-

-

4

1 Reproductive Endocrinology and Infertility

M

2

-

-

1

1

-

-

-

1

5

2

2 F

3

-

1

1

-

-

-

-

-

5

3

Uro-gynaecology

M

2

-

1

-

-

-

-

-

-

3

2 F

2

-

1

-

-

-

-

-

1

4

3 Sub-specialist total

19

0

10

6

4

0

0

0

5

44

9

12 Female sub-specialist total

8

0

6

1

2

0

0

0

1

18

5

5 Female sub-specialist %

42.1

0

60.0

16.7

50.0

0

0

0

20.0

40.9

55.6

41.7* Obstetrical and gynaecological ultrasound is a two year program Source: RACOG

AMWAC 1998.6 88

Obstetrics and Gynaecology Sub-Specialist:Population Ratios Table 46 indicates the five sub-speciality ratios by State and Territory for the female population age ranges. The sub-specialist:population ratio (SSPR) are based upon the 1998 number of sub-specialists in the workforce. The number of sub-specialists per 100,000 population indicates the current level nationally. The RACOG sub-specialist committees have indicated the following sub-specialist:population ratio (SSPR) benchmarks for females. For gynaecological oncologist 0.4 per 100,000; 0.33 per 100,000 for maternal fetal medicine sub-specialists; 0.4 per 100.000 for sub-specialists in ultrasound; 2 per 100,000 for sub-specialists in reproductive endocrinology and infertility and 0.32 per 100,000 for uro-gynaecologists. No national SSPR benchmark has been derived, however, Table x shows that the current national SSPR for females aged greater than 15 years in Australia is estimated at 1:72,955 or 1.4 per 100,000 population. State/Territory provision ranged from 0 per 100,000 population in the Northern Territory to 1.9 per 100,000 population in Western Australia. The gynaecological oncology SSPR for females aged 15 years and greater in Australia is estimated at 1:303,979 or 0.3 per 100,000 population. The RACOG Gynaecological Oncology Committee recommends an acceptable SSPR for the Australian female population as 0.4 per 100,000 population. State/Territory provision ranged from 0 per 100,000 population in the Territories to 0.5 per 100,000 population in Tasmania. Western Australia is also in line with the Committee’s recommended benchmark. The maternal fetal medicine SSPR for females aged 15 to 49 years in Australia is estimated at 1:665,200 or 0.2 per 100,000 population. The RACOG Maternal Fetal Medicine Committee has estimated an acceptable SSPR as 0.33 per 100,000 population. State/Territory provision ranged from 0 per 100,000 population in the Northern Territory, Tasmania South Australia, Queensland and Victoria to 2.2 per 100,000 population in the Australian Capital Territory. The ultrasound SSPR for females aged 15 years and greater in Australia is estimated at 1:383,973 or 0.3 per 100,000 population. The RACOG Ultrasound Committee has estimated an acceptable SSPR as 0.4 per 100,000. State/Territory provision ranged from 0 per 100,000 population in the Northern Territory, Tasmania, and the Australian Capital Territory to 0.5 per 100,000 population in Victoria. The reproductive endocrinology and infertility SSPR for females aged 15 to 49 years in Australia is estimated at 1:179,092 or 0.6 per 100,000 population. The RACOG Reproductive Endocrinology and Infertility Committee has estimated an acceptable SSPR as 2 per 100,000 population. State/Territory provision ranged from 0 per 100,000 population in the Territories to 1.1 per 100,000 population in South Australia. All

AMWAC 1998.6 89

States/Territories fell below the Committee SSPR level. The uro-gynaecology SSPR for females aged 25 years and greater in Australia is estimated at 1:590,510 or 0.2 per 100,000 population. The SSPR for the Australian female population that has been recommended by RACOG as 0.32 per 100,000. State/Territory provision ranged from 0 per 100,000 population in the Australian Capital Territory and the Northern Territory, Tasmania and Queensland to 0.7 per 100,000 population in Western Australia. New South Wales and South Australia are also in line with the RACOG benchmark.

AMWAC 1998.6 90

Table 46: Sub-specialists in obstetrics and gynaecology female population: population ratio, by State/Territory, 1997

NSW

Vic

Qld

SA

WA

Tas

ACT

NT

Total

Total number of sub-specialists Number

38

27

8

8

13

2

2

0

98

Pop A (x 1000)

2,483.2

1,845.4

1,308.0

599.4

686.7

188.4

121.9

62.6

7,295.7

SPR:1x1000

65.3

68.3

163.5

74.9

52.8

94.2

60.9

0

72.9

No. per 100,000

1.5

1.5

0.6

1.3

1.9

1.1

1.6

0.0

1.4


Number

8

6

4

2

3

1

0

0

24

Pop A (x 1000)

2,483.2

1,845.4

1,308.0

599.4

686.7

188.4

121.9

62.6

7,295.7

SPR:1x1000

310.4

307.6

327.0

299.7

228.9

188.4

0

0

304.0

No. per 100,000

0.3

0.3

0.3

0.3

0.4

0.5

0.0

0.0

0.3

Maternal Fetal Medicine

Number

4

0

0

0

1

0

2

0

7

Pop B (x 1000)

1,552.1

1,159.7

865.3

364.9

456.4

117.7

87.5

52.8

4,656.4

SPR:1x1000

388.0

0

0

0

456.4

0

43.7

0

665.2

No. per 100,000

0.3

0.0

0.0

0.0

0.2

0.0

2.2

0.0

0.2

Obstetrical and Gynaecological Ultrasound

Number

5

10

2

0

2

0

0

0

19

Pop A (x 1000)

2,483.2

1,845.4

1,308.0

599.4

686.7

188.4

121.9

62.6

7,295.7

SPR:1x1000

496.6

184.5

654.0

0

343.4

0

0

0

383.9

No. per 100,000

0.2

0.5

0.2

0.0

0.3

0.0

0.0

0.0

0.3

Reproductive Endocrinology and Infertility

Number

12

7

1

4

1

1

0

0

26

Pop B (x 1000)

1,552.1

1,159.7

865.3

364.9

456.4

117.7

87.5

52.8

4,656.4

SPR:1x1000

129.3

165.7

865.3

91.2

456.4

117.7

0

0

179.1

No. per 100,000

0.8

0.6

0.1

1.1

0.2

0.8

0.0

0.0

0.6

Uro-gynaecology

Number

5

2

0

1

4

0

0

0

12

Pop C (x 1000)

2,048.4

1,458.6

1,099.4

486.6

551.0

150.6

92.9

55.6

5,905.1

SPR:1x1000

402.1

729.3

0.0

486.6

137.8

0

0

0

492.1

No. per 100,000

0.2

0.1

0.0

0.2

0.7

0.0

0.0

0.0

0.2

Notes: Pop A - females aged 15 years and greater; Pop B - females aged 15 to 49 years; Pop C - females aged 25 years and greater. Source: RACOG and ABS 1997

AMWAC 1998.6 91

APPENDIX A: RURAL, REMOTE AND METROPOLITAN AREAS

CLASSIFICATION The Commonwealth Departments of Health and Family Services and Primary Industries and Energy, Rural, Remote and Metropolitan Areas classification, has been used to classify the geographic location of the job of responding medical practitioners in the following seven categories. Metropolitan areas: 1. Capital cities consist of the State and Territory capital cities of Sydney,

Melbourne, Brisbane, Perth, Adelaide, Hobart, Darwin and Canberra. 2. Other metropolitan centres consist of one or more statistical subdivisions which

have an urban centre of population of 100,000 or more in size. These centres are: Newcastle, Wollongong, Queanbeyan (part of Canberra-Queanbeyan), Geelong, Gold Coast-Tweed Heads, Townsville-Thuringowa.

Rural zones: 3. Large rural centres are statistical local areas where most of the population reside

in urban centres of population of 25,000 to 99,999. These centres are: Albury-Wodonga, Dubbo, Lismore, Orange, Port Macquarie, Tamworth, Wagga Wagga (NSW); Ballarat, Bendigo, Shepparton-Mooroopna (Vic); Bundaberg, Cairns, Mackay, Maroochydore-Mooloolaba, Rockhampton, Toowoomba (Qld), Whyalla (SA); Launceston (Tas) and Alice Springs (NT).

4. Small rural centres are statistical local areas in rural zones containing urban

centres of population between 10,000 and 24,999. These centres are: Armidale, Ballina, Bathurst, Broken Hill, Casino, Coffs Harbour, Forster-Tuncurry, Goulburn, Grafton, Griffith, Lithgow, Moree Plains, Muswellbrook, Nowra-Bombaderry, Singleton, Taree (NSW); Bairnsdale, Colac, Echuca-Moama, Horsham, Mildura, Moe-Yallourn, Morwell, Ocean Grove-Barwon Heads, Portland, Sale, Traralgon, Wangaratta, Warrnambool (Vic); Caloundra, Gladstone, Gympie, Hervey Bay, Maryborough, Tewantin-Noosa, Warwick (Qld); Mount Gambier, Murray Bridge, Port Augusta, Port Lincoln, Port Pirie (SA); Albany, Bunbury, Geraldton, Mandurah (WA); Burnie-Somerset, Devonport (Tas).

5. Other rural areas are the remaining statistical areas within the rural zone.

Examples are Cowra Shire, Temora Shire, Guyra Shire (NSW); Ararat Shire, Cobram Shire (Vic); Cardwell Shire, Whitsunday Shire (Qld); Barossa, Pinnaroo (SA); Moora Shire, York Shire (WA); George Town, Ross (Tas); Coomalie, Litchfield (NT).

AMWAC 1998.6 92

Remote zones: These are generally less densely populated than rural statistical local areas and hundreds of kilometres from a major urban centre. 6. Remote centres are statistical local areas in the remote zone containing urban

centres of population of 5,000 or more. These centres are: Blackwater, Bowen, Emerald, Mareeba, Moranbah, Mount Isa, Roma (Qld); Broome, Carnarvon, East Pilbara, Esperance, Kalgoorlie/Boulder, Port Hedland, Karratha (WA); Alice Springs, Katherine (NT).

7. Other remote areas are the remaining areas within the remote zone. Examples

are: Balranald, Bourke, Cobar, Lord Howe Island (NSW); French Island, Orbost, Walpeup (Vic); Aurukun, Longreach, Quilpie (Qld); Coober Pedy, Murat Bay, Roxby Downs (SA); Coolgardie, Exmouth, Laverton, Shark Bay (WA); King Island, Strahan (Tas); Daly, Jabiru, Nhulunbuy (NT).

AMWAC 1998.6 93

APPENDIX B: SURVEY OF FELLOWS OF THE ROYAL AUSTRALIAN COLLEGE OF OBSTETRICIANS AND GYNAECOLOGISTS

METHODOLOGY To assist with the establishment of a profile of the obstetrics and gynaecology workforce in Australia, a mailed survey of all RACOG fellows was conducted. The survey was administered by AMWAC in consultation with the RACOG. 501 Fellows of the RACOG responded to the questionnaire, which is a response rate of 53%. RESULTS Distribution of Respondents Table B1 shows that the distribution of respondents to the RACOG/AMWAC Survey is similar to the overall State/Territory distribution of RACOG members and the AIHW Medical Labour Force Survey (1995). Victoria was the only State with a low representation of respondents compared to the RACOG membership. Table B1: Distribution of survey respondents compared to RACOG members and AIHW survey, by State/Territory, 1997

State/Territory

NSW/ACT

Vic

Qld

SA

WA

Tas

NT

Aust

RACOG/AMWAC Survey (n=501)

% respondents

35.6

24.2

18.6

9.8

8.8

2.4

0.6

100.0

RACOG members (n=954)

% of members

34.9

27.3

17.0

9.0

8.7

2.4

0.7

100.0

AIHW 1995 Survey (n=974)

%respondents

34.4

26.5

16.9

9.3

9.1

2.5

1.1

100.0

Source: AIHW, RACOG and RACOG/AMWAC survey Table B2 indicates that the geographic distribution of respondents to the RACOG/AMWAC Survey is consistent with the distribution of the workforce as defined by the AIHW 1995 Survey. Table B2: Geographic distribution of RACOG/AMWAC survey respondents compared to AIHW survey, 1997

Major urban centre

Rural area

No response

Aust

RACOG/AMWAC Survey (n=501)

% respondents

81.0

14.6

4.4

100.0

AIHW 1995 Survey (n=896)

% workforce

83.8

16.2

-

100.0

Source: AIHW and RACOG/AMWAC Survey

AMWAC 1998.6 94

Table B3 indicates the RACOG specialists and sub-specialists that responded to the questionnaire. Table B3: Response rate of specialists/sub-specialists, by gender, 1997 Qualifications

Male

Female

Total

RACOG members

Obstetrics and gynaecology

389

64

453

854

Maternal -fetal medicine

2*

1*

3

7

Uro-gynaecology

3*

1*

4

13

Obstetrical and gynaecological ultrasound

12*

2*

14

26

Gynaecology oncology

9

0

9

25

Reproductive endocrinology and infertility

17

1

18

29

Total

432

69

501

954

*not available for confidentiality reasons Source: RACOG/AMWAC survey Age Profile From the RACOG/AMWAC Survey, the age range of respondents was from 33 years to 76 years with an average age of 50.5 years. The largest group of respondents was the 45 to 54 year age group (40.24%), followed by the 35 to 44 year age group (27.3%); 29% of respondents were aged 55 years and over (Table B4). Compared to the AIHW Survey, obstetricians and gynaecologists in the 65 years and over age group are under reported in the RACOG/AMWAC survey. Table B4: Age profile of RACOG/AMWAC survey compared to AIHW survey, 1997

<35 yrs

35-44 yrs

45-54 yrs

55-64 yrs

65-74 yrs

75+yrs

RACOG/AMWAC survey (n=501)

% respondents

3.5

27.3

40.2

24.4

3.4

1.2

AIHW (n=974)

% respondents

1.5

26.3

35.6

26.1

8.4

2.1

Source: AIHW and RACOG/AMWAC survey Gender Profile 13.8% of respondents to the RACOG/AMWAC survey were female obstetricians and gynaecologists compared with the data from RACOG of 13.4%. Overall, the Working Party concluded that a response rate of 53% was reasonable and that the profile of respondents was sufficiently consistent with the profile of the

AMWAC 1998.6 95

workforce to provide representative data. Qualifications As indicated in Table B5, the majority of survey respondents obtained their Fellowship of the RACOG between 1971 and 1990. B5: Year of RACOG qualifications obstetrics and gynaecologists, 1997 (n=501) Year

Number

%

<1960

13

2.8

1961-1970

88

17.6 1971-1980

140

27.9

1981-1990

137

27.3 1991-1997

91

18.2

No response

32

6.4Source: RACOG/AMWAC survey Year of sub-specialty qualifications are outlined in Table B6. Table B6: Year of RACOG qualifications obstetrics and gynaecologists, 1997 (n=501) Year

Number

%

1961-1970

1

0.2

1971-1980

12

2.4 1981-1990

18

3.6

1991-1997

31

6.2 No response

439

87.7

Source: RACOG/AMWAC survey Hours Worked The RACOG/AMWAC survey asked respondents to indicate the hours worked in a typical week. The definitions used were: Total hours worked in a typical week The total hours spent in patient care, including hours on call back worked and time spent on non patient care activities such as administration, continuing medical education, teaching and research. Hours worked excluded time spent on travel between work locations (except travel to calls out) and unpaid professional and/or voluntary activities.

Total hours on call back worked in a typical week Once called to duty, the time spent on duty, including travel time. Total hours on call not worked in a typical week The average hours per week for which the practitioner was on standby for a call to duty

AMWAC 1998.6 96

but were not worked. Once called to duty, the time spent on duty including travel time is counted in total hours worked and should have been indicated in the total hours on call back worked in a typical week. On average, respondents worked a total of 62.6 hours per week (mode 60 hours; median 60 hours; standard deviation 31.6). 22.4% of respondents worked less than 45 hours per week and 55.1% worked 55 hours or more. A significant difference was observed between the total hours worked by males and females, with 36% of women working less than 45 hours per week compared with 23% of men and 53% of women working 55 hours or more per week compared with 70.8% of men. Table B7 details the average hours provided by obstetrics and gynaecology specialists/sub-specialists by State and Territory. The number of The average hours worked per week was 62.0, 42.6 hours per week were worked in direct patient care and an additional 19.4 hours on average per week were worked on call. It is estimated that specialists/sub-specialists worked a total of 2,747,138 hours in 1997; of these hours 1,869,458 hours were in direct patient care. This equates to 37,654 hours per 100,000 female population (>15 years) in total hours worked, with the provision of hours worked per 100,000 population significantly above the average in Victoria and South Australia because of its higher local and regional catchment population and higher workforce provision, and below the average with 27,521 in Western Australia. This compares with the RACOG data shown in Table 1 on obstetricians and gynaecologists population ratio per 100,000 where Victoria and South Australia have higher specialists/sub-specialists per 100,000 and Western Australia which has one of the lower number of specialists/sub-specialists per 100,000 ratio. The average amount of time spent on direct patient care was 42.6 hours per week (range 1-90 hours; median 42.0; mode 40; standard deviation 15.8). 80.8% of respondents indicated they worked on-call hours out of work hours. The average time worked on-call out of hours was 19.4 hours per week (median 8.0; mode 10.0; standard deviation 34.8).

AMWAC 1998.6 97

Table B7: Specialists and sub-specialists in obstetrics and gynaecology average hours worked per week and annual labour supply hours, by State/Territory, 1998

State/Terr.

NSW

Vic

Qld

SA

WA

Tas

ACT

NT

Total

Total hours worked

Ave. hours per week

58.7

70.8

66.2

64.7

49.5

52.2

48.9

57.0

62.6

Annual hours worked >000)a

855.9

846.8

493.3

255.9

188.9

52.2

35.9

18.4

2,747.1


34,470

45,885

37,715

42,701

27,521

29,314

29,524

29,319

37,654


Ave. hours per week

41.9

43.2

44.7

42.1

41.3

35.8

36.4

52.0

42.6


610.9

516.7

333.1

166.5

157.7

37.9

26.8

16.7

1,869.5


24,604

27,998

25,467

27,786

22,962

20,104

21,977

26,748

25,624


Ave. hours per week

17.6

21.1

21.7

24.7

13.0

18.2

6.6

26.7

19.4


256.0

252.3

161.7

97.7

49.6

19.3

4.8

8.6

851.3


10,335

13,674

12,363

16,301

7,228

10,221

3,984

13,734

11,669


Ave. hours per week

63.0

61.3

64.3

66.8

58.9

82.2

45.6

84.0

63.1


918.7

733.1

479.2

264.3

224.9

86.9

33.6

27.1

2,769.1


36,995

39,728

36,633

44,087

32,747

46,161

27,532

43,208

37,955

Female pop. > 15 years (>000)

2,483.2

1,845.4

1,308.0

599.4

686.7

188.4

121.9

62.6

7,296.6

Specialists

317

260

162

86

83

23

16

7

954

Note: a - calculated as average hours multiplied by persons multiplied by 46 weeks per year Source: RACOG and RACOG/AMWAC survey

AMWAC 1998.6 98

Table B8 details the average hours provided by specialists/sub-specialists in obstetrics and gynaecology by sex and age. In 1997 specialists/sub-specialists worked on average 62.6 hours per week, 64.0 for males and 54.0 for females. For both males and females, those under 55 years of age averaged around 62.5 hours per week; this declined to 54.1 hours for 55 to 64 years age group, 45.8 hours for 65 to 74 years age group and 10.0 hours for those aged 75 years or more. The highest average hours worked per week were 71.2 hours by males aged 45 to 54 years and for females 60.7 hours per week in the 35 to 44 age range. Table B8: Specialists and sub-specialists in obstetrics and gynaecology average hours and annual hours worked, by gender and age group, 1998

Sex

25-34

yrs

35-44

yrs

45-54

yrs

55-64

yrs

65-74

yrs

75 yrs & over

Total

Total hours worked

Male

51.9

70.5

71.2

54.9

47.1

10.0

64.0

Female

48.7

60.7

44.8

30.0

10.0

0.0

54.0

Total

51.0

67.1

69.4

54.1

45.8

10.0

62.0


70.4

762.4

1,209.9

652.0

69.5

1.4

2,733.9


Male

37.9

45.4

47.7

38.2

31.0

10.0

43.1

Female

40.5

40.8

35.1

33.5

nr

0.0

39.0

Total

38.4

43.8

46.7

38.0

31.0

10.0

42.6


52.9

497.6

814.2

457.9

47.1

1.4

1,869.5


Male

67.9

59.7

67.1

63.6

51.5

0.0

63.7

Female

50.0

54.1

59.7

102.7

0.0

0.0

58.6

Total

65.9

57.9

66.6

64.8

51.5

0.0

63.1


90.9

657.6

1,161.1

780.9

78.2

0.0

2,769.1


Male

13.3

21.6

18.7

15.8

26.7

0.0

18.6

Female

5.0

2.5

25.4

1.5

0.0

0.0

21.9

Total

12.3

21.9

19.1

15.6

26.7

0.0

19.4


16.9

248.8

332.9

188.0

40.5

0.0

851.4

Specialists

30

247

379

262

33

3

954

Note: a - calculated as average hours multiplied by persons multiplied by 46 weeks per year Source: RACOG and RACOG/AMWAC survey

AMWAC 1998.6 99

Expected Age of Retirement 99.2% (497) of respondents provided details of their retirement intentions. The average expected age of retirement from the workforce was 63 years (range 50 to 80 years; standard deviation 4.6). Table B9 indicates that 22.7% of survey respondents intend retiring in the next five years. Table B9: Actual year of intended retirement in obstetrics and gynaecology, by State/Territory, 1997 Year

NSW

Vic

Qld

SA

WA

Tas

NT

ACT

Aust

% Aust

to 2002

24

25

18

12

11

2

-

21

113

22.7

2003-4

24

20

14

4

2

2

-

-

66

13.3

2005-7

27

16

22

8

9

1

1

-

84

16.9

2008-9

8

7

2

3

3

-

-

2

25

5.0

2010-11

28

19

14

7

7

2

1

-

78

15.7

2012-14

15

10

6

5

4

4

1

1

46

9.3

2015-17

14

12

10

7

4

1

-

-

48

9.7

2018-21

11

11

3

2

4

-

-

-

31

6.2

2022-26

6

4

7

2

1

-

-

1

6

1.2

Total

152

121

91

49

44

12

3

25

497

100.0

Source: RACOG/AMWAC survey Type of Practice Table B10 indicates the different practice groups of the respondents and Table B9 the percentage of appointments in the public or private sector. Table B10: Obstetrics and gynaecology specialists practice profiles, 1997 (n=501) Solo and group practices

% of respondents

solo specialist

67.1

with other obstetricians and gynaecologist

20.8

No response to type of practice

8.1

multi-disciplinary group

3.2

solo and with other specialists not in obstetrics and gynaecology

0.8

Source: RACOG/AMWAC survey

AMWAC 1998.6 100

Table B11: Appointments (percentage) in the public or private sector, 1997 (n=501) Type of practice

%

respondents in private practice and/or undertake public hospital work

63.7

salaried in a public hospital

15.8

in private practice with no public hospital role

14.2

public hospital salaried and private practice

2.2

salaried in private hospital & in private practice &/or undertake public hospital role

0.6

university appointment with public hospital role

0.5

No response

3.0

Source: RACOG/AMWAC survey The university appointment response rate (0.5%) is low allowing for the number of teaching units in Australia and may be explained by respondents classifying themselves as salaried in a public hospital role. There were 480 respondents who indicated appointment by State/Territory as shown in Table B12. The proportion reporting employment in public hospitals was much higher in New South Wales (32.9%) and lower (1.3%) in Tasmania, Northern Territory and the Australian Capital Territory. Private practice employment was highest in the New South Wales (20.0%) and lowest in the Northern Territory (1.4%). There were 45 sub-specialists respondents who indicated their appointment by State/Territory. The proportion reporting employment in public hospitals was much higher in New South Wales (46.7%) and lower (6.7%) in the Australian Capital Territory and with no representation in Western Australia, Tasmania and the Northern Territory (Table B13).

AMWAC 1998.6 101

Table B12: Obstetrics and gynaecology specialists appointments in the public or private sector (%), by State/Territory, 1997a Main job (% of total)

NSW

Vic

Qld

SA

WA

Tas

ACT

NT

Total

salaried in a public hospital

32.9

14.5

27.6

15.8

5.3

1.3

1.3

1.3

100.0

in private practice and/or undertake public hospital work

33.6

29.2

13.2

8.8

11.0

2.5

1.3

0.3

100.0

in private practice with no public hospital role

20.0

18.6

38.6

8.6

7.1

2.9

2.9

1.4

100.0


45.5

36.4

0.0

18.1

0.0

0.0

0.0

0.0

100.0

salaried in private hospital & in private practice &/or undertake public hospital role

50.0

0.0

0.0

0.0

0.0

50.0

0.0

0.0

100.0

university appointment with public hospital role

0.0

33.3

33.3

33.3

0.0

0.0

0.0

0.0

100.0

Total

31.9

25.2

19.0

10.2

9.2

2.5

1.5

0.6

100.0

Notes: a - n=480 for respondents who indicated main job and State/Territory Source: RACOG/AMWAC survey Table B13: Practice profiles of sub-specialists in obstetrics and gynaecology (%), by State/Territory, 1997(n=45) Main job (% of total)

NSW

Vic

Qld

SA

WA

Tas

ACT

NT

Total

Sub-specialists Salaried in a public hospital

46.7

20.0

13.3

13.3

0.0

0.0

6.7

0.0

100.0

in private practice and/or undertake public hospital work

35.0

30.0

5.0

10.0

15.0

5.0

0.0

0.0

100.0

In private practice with public hospital role

12.5

50.0

12.5

0.0

12.5

12.5

0.0

0.0

100.0


50.0

50.0

0.0

0.0

0.0

0.0

0.0

0.0

100.0

Sub-specialists

33.3

29.2

10.4

10.4

8.3

4.2

2.1

0.0

100.0

Source: AMWAC/RACOG survey

AMWAC 1998.6 102

Consultation Waiting Times Table B14 shows that the average waiting time for a standard first consultation with a specialist in obstetrics and gynaecology in his/her private rooms is 16.9 days (standard deviation 18.0) while public patients wait, on average, 31.9 days (standard deviation 48.4). The waiting time in the Australian Capital Territory for a standard first consultation is well above the average for private patients. Tasmania exceeds that national average waiting time (31.9 days) for public patients with a waiting period of 141.5 days for public patients and may be contributed to an undersupply of specialists.These waiting times are not benchmarks but are self reported. Table B14: Obstetrics and gynaecology average waiting time (days) for a standard first consultation and an urgent procedure, by private rooms/public outpatients department and State/Territory 1997

State/Territory

Standard consultation

Urgent condition

Private patients

NSW

16.0

2.4

Victoria

19.1

1.9

Queensland

17.2

2.3

South Australia

12.7

1.1

Western Australia

15.4

1.7

Tasmania

15.9

1.0

Northern Territory

10.5

2.5

ACT

40.8

2.7

Total

16.9

2.0

Public patients

NSW

21.9

4.5

Victoria

23.4

5.4

Queensland

37.6

14.0

South Australia

32.1

5.7

Western Australia

47.8

7.7

Tasmania

141.5

5.8

Northern Territory

38.5

14.0

ACT

16.3

5.3

Total

31.9

7.1


AMWAC 1998.6 103

For an urgent condition, private patients wait less time (2.0 days, standard deviation 4.1) than do patients in public outpatient departments (7.1 days, standard deviation 18.5) (p<0.01) with public patients in Queensland and Northern Territory waiting above average times for urgent conditions. Table B15 shows that the average waiting times for a standard first consultation with sub-specialists in his/her private rooms ranging from 5.5 to 35 days while public patients wait, on average, from 9.6 to 63 days. The waiting time in Victoria for a standard first consultation is well above the average for both private and public patients (Table B 11). Waiting times for public patients in Western Australia exceed the national average. Table B15: Sub-specialists average waiting time (days) for a standard first consultation and an urgent procedure, by private rooms/public outpatients department and State/Territory 1997 (n=48)

Gynaecological

Oncology

Maternal-fetal

medicine

Ultrasound

Reproductive

Endocrinology and Infertility

Uro-gynaecology

State/ Territory

Standard

Urgent

Standard

Urgent

Standard

Urgent

Standard

Urgent

Standard

Urgent

Private patients

NSW

3.0

2.0

-

-

1.0

.5

24.0

2.3

49.0

4.0

Vic

14.0

2.5

-

-

7.7

0.6

29.8

4.0

-

-

Qld

4.0

4.0

-

1.0

4.5

1.0

7.0

1.0

-

-

WA

2.0

1.0

-

-

4.5

1.0

14.0

2.0

-

-

SA

-

-

-

-

-

-

26.3

4.0

7.0

1.0

Tas

7.0

1.0

-

-

-

-

5.0

0

-

-

NT

-

-

-

-

-

-

-

-

-

-

ACT

-

-

7.0

1.0

-

-

-

-

-

-

Total± (std dev)

6.25 5.1

2.14 1.2

7.0 0

1.0

0

5.5 4.6

0.7 0.5

23.2 18.7

2.8 2.8

35.0 25.2

3.0 2.0

Public patients

NSW

8.3

6.1

-

-

1.0

1.

35.0

2.0

98.0

1.0

Vic

14.0

4.5

-

-

18.8

1.8

46.7

13.3

-

-

Qld

4.0

4.0

14.0

1.0

-

-

45.0

5.0

-

-

WA

14.0

7.0

-

-

5.5

1.0

120.0

-

-

-

SA

-

-

-

-

-

-

35.0

4.3

28.0

7.0

Tas

7.0

1.0

-

-

-

-

-

-

-

-

NT

-

-

-

-

-

-

-

-

-

-

ACT

-

-

7.0

1.0

-

-

-

-

-

-

Total± (std dev)

9.6

6.4

4.6 4.2

10.5 4.9

1.0

0

12.4 11.4

1.5 2.3

43.7 25.2

5.3 7.1

63.0 49.5

4.1 4.2


AMWAC 1998.6 103

In general for an urgent condition, private patients wait less time (0.7 to 3.0 days) than do patients in public outpatient departments (1.0 to 4.6 days) (p<0.01). Plans to Change Hours Worked 55% (263) of respondents indicated that they planned to change the hours they work with 43.1% (207) of respondents anticipating their work hours to decrease, 12.2% (60) expecting their work hours to increase and 44.7% (214) expecting their hours to remain the same. Table B16 indicates the change in hours worked by State/Territory with 50% (75) of the obstetric and gynaecology workforce from New South Wales anticipating a reduction in hours over the next five years. Table B16: Obstetricians and gynaecologists plans to change the hours they work by State/Territory, 1997 (n=476) State/Territory

Reduce work hours (%)

Increase work hours (%)

Remain the same (%)

NSW

50

10

40

Victoria

48

12

40

Queensland

38

8

54

South Aust.

38

16

46

West. Aust.

29

19

52

Tasmania

33

33

33

North. Terr.

0

0

100

ACT

43

14

43

Total

43.1

12.2

44.7

Source: RACOG/AMWAC survey Significant associations were observed with those respondents indicating an anticipated reduction in the hours over the next five years worked and (p<0.01): - Gender - 46.4% of males indicated that they anticipate to reduce the hours worked

over the next five years compared to 20.3% of females. - Geographic location - 43.3% (172) of the metropolitan workforce and 44.4% (32) of

rural areas will reduce the hours worked over the next five years. Other reasons stated include: rising medical indemnity insurance - 80.7% (167); lifestyle preferences - 93.5% (143); family considerations 86.5% (96); health considerations - 66.7% (62); work place change - 62.8% (59); retirement - 60.0% (63). Respondents also sited the following would decrease the hours worked over the next five years: work is being done by midwives; the risk of burnout due to long hours and

AMWAC 1998.6 104

lack of appropriate support; oversupply of fellow obstetricians and gynaecologists; the fall in private patients and dissatisfaction with the public health sector. A significant association was observed between intention to increase hours worked and an expected increase in demand for obstetrics and gynaecology services (p<0.01). Other reasons sited by respondents that would increase the hours worked over the next five years included: financial incentives and children beginning school. Provider Shortages Respondents were asked to specify any providers in short supply in their primary practice location. Table B17 indicates that there is a need for more obstetricians and gynaecologists in New South Wales/Australian Capital Territory, Victoria and Queensland. Respondents from these three States/Territories also perceived a need for more midwives, anaesthetists, paediatricians, psychiatrists and sub-specialists in obstetrics and gynaecology and a range of other specialists. Among the other specialties identified by respondents were neonatologists, general physicians, psychologists, psychiatrists, dieticians, physiotherapists and genetic counsellors. Table B17: Obstetricians and gynaecologists= estimates of provider shortages in the area of their main job, by State/Territory 1997 State/ Territory

Obstetrician/

Gynaecologists

Sub-

specialist

Anaesthetists

Nurses/

midwives

Other

specialists NSW

8

5

10

20

16

Victoria

6

3

29

9

12

Queensland

5

8

18

12

17

South Aust.

4

1

6

5

5

West. Aust.

3

-

10

3

-

Tasmania

1

1

2

1

2

North. Terr.

3

-

2

2

1

ACT

-

3

2

-

-

Total

30

21

79

52

53

Source: RACOG/AMWAC survey There was a strong association observed between perceived need for more obstetricians and gynaecologists and geographic location. 80.2% (219) metropolitan respondents indicated the need for more obstetricians and gynaecologists compared to 17.2% (47) of rural respondents (n=273). Rural respondents indicated a need for more midwives, anaesthetists, paediatricians, neonatologists, psychologists and psychiatrists

AMWAC 1998.6 105

Metropolitan Specialists Providing Rural Outreach Services 72 out of 501 (14.4%) metropolitan obstetricians and gynaecologists that responded to the survey reported that they provided services to rural areas with the majority being males 94.4% (68). The average time spent by obstetricians and gynaecologists in rural areas was 23 hours per month (mode 4 hours; median 12 hours; standard deviation 34.5). The gynaecologists spending less than half a day and others up to 10 days per month. The majority of metropolitan obstetricians and gynaecologists that indicated they provided services to rural areas were aged between 41 and 55 years (53.4%). Table B18 shows wide variation across States/Territories in the percentage of respondents involved in the provision of rural outreach services. For example, 25.3% of metropolitan based obstetricians and gynaecologists in Victoria and 23.9% in South Australia reported providing rural outreach services while 15.5% of metropolitan providers in New South Wales indicated they provided rural outreach services. Table B18: Metropolitan obstetricians and gynaecologists providing rural outreach services (%), by State/Territory, 1997 (n=72)

NSW

Vic

Qld

SA

WA

Tas

ACT

15.5

25.3

19.7

23.9

11.3

1.4

2.8

Source: RACOG/AMWAC survey Respondents gave the main reasons for providing rural outreach services as: rural lifestyle; rural demand for obstetrics and gynaecology services; committed to providing a rural service; adds variety to my work; maintain skills; opportunity to expand practice; remuneration; and, continue to work in rural areas because there is no replacement. Respondents indicated that the catchment population required to sustain a rural outreach obstetrics and gynaecology service ranged from 20,000 to 100,000 people. The average catchment population was 40,000. It was also noted that an appropriate infrastructure with necessary equipment and the availability of other specialists was necessary (please refer to Appendix B for further information on requirements). Respondents also indicated that ideally there should be a pool of about three specialists available for visiting posts so that issues concerning on call, study leave and holidays can be covered. More importantly this pool of specialists should remain the same so communities are not faced with new individuals at each visit. Women have repeatedly stressed the importance of receiving care during pregnancy and childbirth from the same care giver, or from a small group of caregivers with whom they can become familiar. Evidence from a controlled trial shows that women who had continuity of caregivers were less likely to use pharmacological analgesia or anaesthesia during

AMWAC 1998.6 106

labour and birth, to have labour augmented with oxytocin, to have a labour length of more than six hours. They were also more likely to feel well prepared for labour, perceive the labour staff as caring, feel in control during labour and feel well prepared for labour (Enkin et al, 1996). Table B18 summarises the requirements for providing a sustainable rural outreach obstetrics and gynaecology service, refer to Appendix B for further information on service requirements. Table B18: Basic requirements for providing a rural outreach obstetrics and gynaecology service

Local hospital facilities/equipment

In-patient bed, casualty Small surgical/limited equipment Telelink to consultants Appropriate consulting facilities Good hospital administration

Allied health professionals and ancillary staff

Midwives/nursing Physiotherapists Dieticians

General practitioners

The interest and support of local GPs was considered paramount by numerous respondents

Other specialist services

Anaesthetists Paediatricians Psychiatrists Psychologists Neonatologists

Other

Good transport to the area for both patients and specialist local accommodation for patients

Source: RACOG/AMWAC survey Metropolitan obstetrics and gynaecologists providing rural outreach services were asked to indicate their reasons for preferring to live in a capital city or urban centre the comments in order of frequency of comment are: children=s schooling, family considerations; lifestyle, friends, cultural interests; convenience/availability of professional facilities; always lived in an urban area; academic and research interests; dislike rural isolation; financial considerations; better work in the city. Resident Rural Obstetricians and Gynaecologists 94 respondents (18.8%) out of 501, indicated that they lived and worked outside a major urban centre. The main reasons for living and working in a rural area were given as: rural lifestyle; variety of work; good place to raise children; came from the country. The average number of years that obstetricians and gynaecologists practising in a rural

AMWAC 1998.6 107

area intend remaining in the country was 12 years (minimum 1 years and maximum 40 years, mode 20 years). The majority of rural respondents considered that a catchment population of 40,000-60,000 was required to sustain two specialists in a resident rural practice. Two specialists are required so that a viable obstetric and gynaecology service is offered to the community and covered for 24 hours. Respondents were asked to rank in order of priority the basic requirements for providing a good resident rural obstetrics and gynaecology services. These were: the availability of local hospital facilities and equipment; the availability of skilled nursing staff; the availability of other specialists (ie., specialists other than obstetricians and gynaecologists); the availability of sufficient similar specialists to provide 24 hour cover; the availability of allied health/ancillary staff; attributes/skills of referring GPs and finally the public hospital appointments. Other basic requirements included the need for holiday/study leave cover, access to locum services and good schools for children, spouse satisfaction with lifestyle, income parity with city specialists. Locum Service Requirements 54 of the 94 rural obstetricians and gynaecologists indicated that if a specialty locum scheme were established they would make use of it. The majority of those interested indicated a requirement for 5 weeks of locum support (minimum 2 weeks, maximum 24 weeks, mode 4 weeks). Professional Satisfaction Overall, 69.9% of respondents were satisfied with their work. Aspects of their work with which they were most satisfied were sufficient work to maintain competence, physical working conditions, and the opportunity to use your abilities. Aspects of their work with which they were most dissatisfied (in order of percentage of people expressing dissatisfaction) were industrial relations between management and workers in your health service, workload sufficient to maintain income, hours of work, and amount of work (Table B20). No difference was observed in overall level of satisfaction between urban practitioners and rural practitioners. No differences were observed based on location of primary practice and satisfaction with hours of work and amount of work. There also were no differences observed in level of satisfaction with hours worked and age or gender or with satisfaction with work hours and plans to reduce work hours.

AMWAC 1998.6 108

Table B20: Obstetrics and gynaecologists’ professional satisfaction (percentage), 1997 (n=485) Indicator

Satisfied

Uncommitted

Dissatisfied

No

response Overall satisfaction

69.9

14.6

11.8

3.8

Work environment - physical working conditions

66.9

17.8

11.2

4.2

- industrial relations

39.3

28.9

26.5

5.2

The work itself - opportunity to use your abilities

75.4

11.2

10.2

3.2

- workload sufficient to maintain competence

71.9

16.0

8.6

3.6

Workload - hours of work

43.9

29.9

22.6

3.6

- amount of work

48.7

24.8

22.4

4.2

Level of income - workload sufficient to maintain income

48.9

21.0

25.5

4.6

Support from other providers in your area - availability of similar specialists

69.1

16.2

10.2

4.6

- availability of other specialists

78.2

11.6

5.8

4.4

- support from primary care practitioners

63.7

21.6

10.2

4.6

- availability of skilled nursing staff

63.9

21.6

10.4

4.2

- availability of skilled allied health personnel

60.7

25.0

9.0

5.4

Source: RACOG/AMWAC survey Respondents indicated that rising medical insurance indemnity premiums will affect the way they practice with 83% (403) indicating that they would either cease practising obstetrics or retire early, 9% indicated that they would pass costs on to patients. Other changes indicated were: work solely in public sector; increase workload to cover costs; practice defensive medicine by providing more information to patients; change career; and take more detailed medical records on patient. Perceptions of the Factors Affecting Workforce Requirements Respondents were asked to indicate whether they believed particular factors would

AMWAC 1998.6 109

increase workforce requirements, decrease workforce requirements or whether requirements would stay the same (Table B21). Among the important issues that respondents considered would increase included: more defensive medicine, patients expectations and knowledge, advances in medical technology, and need for improved geographic distribution of specialists. Factors perceived as most likely to decrease workforce requirements were substitution of specialist services by other providers, requirements for procedural practice, and cost containment strategies. Table B21: Obstetrics and gynaecologists= perceptions of the factors that could affect the size of the obstetrics and gynaecology workforce over the next ten years (%), 1997 (n=476)

Factors affecting the size of the workforce

Increase

Decrease

Stay the

same

No

response Population trends Ageing of the population

42.7

8.0

44.1

5.2

Changing disease patterns

23.4

6.8

63.5

6.4

Lifestyle changes that improve population health

17.0

13.8

63.5

5.8

Patients expectations/knowledge

69.3

2.8

23.0

5.0

Clinical practice trends Requirements for safer procedural practice

66.1

26.9

0.8

6.2

Advances in medical technology

68.3

3.6

22.8

5.4

Multi-disciplinary team provision

45.3

6.0

41.3

7.4

More defensive medicine

73.1

1.4

20.2

5.4

Workforce trends Need for improved geographic distribution of specialists

54.5

5.2

33.3

7.0

Increasing doctor specialisation

46.3

9.8

37.7

6.2

Substitution of specialist services by other providers

16.0

31.7

43.9

8.4

Health care system trends Cost containment strategies

34.3

24.4

34.1

7.2

Reforms to increase efficiency

33.5

14.6

44.3

7.6

The introduction of coordinated care processes

25.7

17.2

46.5

10.6

Evidence-based medicine

33.9

6.2

49.7

10.2


AMWAC 1998.6 110

Medical Indemnity Insurance One of the issues confronting the obstetrics and gynaecology profession is the real and potential withdrawal of specialists from obstetrics, in part induced by the fear of being sued and high indemnity insurance premiums. Any trend has to be seen against the backdrop of the traditional career changes of obstetrics and gynaecology specialist away from obstetrics as they get older, and the effect on recruitment of trainees to the profession. Respondents to the RACOG/AMWAC survey indicated that rising medical indemnity insurance premiums will affect the way they practice with 83% (403) indicating that they would either cease practising obstetrics or retire early and 9% indicating that they would pass cost on to patients. Other comments included: to work solely in public sector; increase workload to cover costs; practice defensive medicine by providing more information to patients; change career; and take more detailed records on patients.

AMWAC 1998.6 111

APPENDIX C: AIHW NATIONAL MEDICAL LABOUR FORCE SURVEY 1995 The Medical Labour Force Survey does not differentiate between specialists and sub-specialists but examines the total workforce. In this report when reference is made to the AIHW survey this data includes both specialists and sub-specialists. Number of Practising Consultants in Obstetrics and Gynaecology The Medical Labour Force Survey, 1995, AIHW, identified 974 obstetrics and gynaecology specialists and sub-specialists indicating their main specialty of practice. The AIHW defined a specialist in obstetrics and gynaecology as a clinician in active practice who reported being a specialist with a qualification in obstetrics and gynaecology. In 1986 there were 833 obstetricians and gynaecologists who were identified as Medicare providers and a total of 968 in 1996, indicating a 16.2% increase in the workforce during this period., with the number per 100,000 population increasing slightly from 5.2 to 5.3. Geographic Distribution The geographic distribution by State/Territory was similar. State provision ranged from 5.1 per 100,000 population in New South Wales and Queensland to 6.2 in South Australia. The two Territories had a higher provision but this would be expected given a younger age structure and relatively more births and more women in the child rearing age groups. The distribution of obstetrics and gynaecology specialists was 83.8% had their primary practice in a major urban centre; 9.0% large rural centre; 4.3% in small rural centre, 2.3% in other rural centre and 0.6% in remote centre. The Medicare data indicate that metropolitan areas and large rural centres are well serviced with specialist obstetrics and gynaecology services, but rural and remote populations elsewhere have a much lower patient and service coverage. Gender Profile There were 115 (11.8%) female obstetrics and gynaecology specialists. Males made up 88.2% (859) of the specialty. Age Profile There were 14 (1.4%) obstetrics and gynaecology specialists aged less than 35 years (20.2% of which were females) and 21 (2.2%) males who were aged over 65 years of age. For females the largest age range was the 35 to 44 year age group representing 60 (52.2%), followed by 22 (19.1%) in the 45 to 54 year age group. There were no females aged 75 and over. For males the largest age range was the 45 to 54 year age group representing 325 (37.8%), followed by 234 (27.2%) in the 55 to 64 year age group. There were 21 (2.4%) male obstetrics and gynaecology specialists aged 75 years and over.

AMWAC 1998.6 112

The largest five year age cohort group was the 45 to 54 year age group with 347 specialists (35.6%), followed closely by the 35 to 44 years age group with 256 (26.3%) and 254 (26.1%) in the 55 to 64 year age group. Table C1: Age profile of obstetrics and gynaecology specialists, by State/Territory and gender, 1995, AIHW

Sex

<35 yrs

35-44 yrs

45-54 yrs

55-64 yrs

65-74 yrs

75+ yrs

Total

Males

11

197

325

234

71

21

859

Females

3

60

22

20

10

0

115

Persons

14

256

347

254

82

21

974

(Per cent)

Males

79.8

76.7

93.7

92.0

87.6

100.0

88.2

Females

20.2

23.3

6.3

8.0

12.4

0.0

11.8

Source: Medical Labour Force Survey, 1997, AIHW The 1995 AIHW data indicated that the average age of the both the specialists and sub-specialists was 51.1 years, with 103 (10.5%) aged 65 and over. Table C2: Age profile of obstetrics and gynaecology specialists and sub/specialists, by State/Territory and age, 1995

Age (years)

NSW

Vic

Qld

WA

SA

Tas

ACT

NT

Total

%

<35

4

2

6

2

0

0

0

0

14

1.5

35-44

84

74

42

20

20

5

12

0

256

26.3

45-54

121

85

62

35

34

6

12

4

347

35.6

55-64

67

68

42

25

30

11

7

4

254

26.1

65-74

26

23

14

5

7

1

2

4

82

8.4

75 +

8

6

0

3

0

2

3

0

21

2.1

Total

309

258

165

89

91

25

26

11

974

100.0

Average age

51.2

51.4

50.0

50.5

51.2

55.2

49.0

56.8

51.1

-

% aged 65 yrs +

10.8

11.2

8.3

8.8

7.2

13.1

18.4

36.5

10.5

-

Source: Medical Labour Force Survey, 1997, AIHW Hours worked AIHW data gave the total average hours per week as 55 hours (Table C3) with male specialist/sub-specialists averaging 55.7 hours and for females 49.3 hours (Table C3). Specialist/sub-specialists worked an average of 46.6 hours per week in the direct care

AMWAC 1998.6 113

of patients, with male specialist/sub-specialists averaging 47.3 hours and for females 41.2 hours. This varied from 68.3 hours in remote areas compared to 46.1 hours in major urban areas. Average Hours Worked - State/Territory It is estimated that specialist/sub-specialists worked a total of 2,457,400 hours in 1995 (of these 2,079,000 were in direct patient care). This equates to 33,678 hours per 100,000 population, with the provision of hours worked per 100,000 population significantly above the average for the Australian Capital Territory and below the average for Tasmania with 10,721. Table C3: Specialists and sub-specialists in obstetrics and gynaecology average hours provided per week, annual labour supply hours (a) and hours worked per 100,000 female population (>15 years) in obstetrics and gynaecology, direct care patient care hours worked, hours on call not worked, by State/Territory, 1995 State/Terr.

NSW

Vic

Qld

SA

WA

Tas

ACT

NT

Total

Total hours worked

Average

55.8

55.7

55.7

49.3

56.2

43.6

56.4

50.2

55.0

(hours >000)

792.3

660.0

423.4

202.0

235.3

50.7

67.1

26.5

2,457.4

Hrs worked per 100,000 female pop

31,906

35,765

32,369

33,700

34,264

26,905

55,003

42,361

33,678


Average

47.7

45.1

50.5

44.0

42.4

35.4

49.8

47.7

46.6

(hours >000)

677.3

534.4

383.9

180.3

177.5

41.2

59.3

25.1

2,079.0


27,275

28,959

29,349

30,080

25,847

21,864

48,610

40,123

28,493


Average

64.6

56.6

61.6

56.7

71.6

87.2

60.1

81.8

63.2

(hours >000)

608.0

367.5

281.8

149.7

232.6

77.6

57.2

28.7

1,803.2


24,484

19,915

21,544

24,975

33,871

41,180

46,888

45,877

24,712

Female pop > 15 years (>000)

2,483.2

1,845.4

1,308.0

599.4

686.7

188.4

121.9

62.6

7,296.6

Note: a - calculated as average hours multiplied by persons multiplied by 46 weeks per year Source: Medical Labour Force Survey, 1997, AIHW

AMWAC 1998.6 114

Average Hours Worked - Gender and Age Those under 55 years of age averaged 60 hours per week; this declined to 49.5 hours for 55 to 64 year olds, 31.7 hours for 65 to 74 year olds and 27.3 hours for those aged 75 or more (Table C4). The highest average hours worked per week were 54.0 hours by males aged 45 to 64 years. 132 specialists/sub-specialists (13.5%) worked less than 35 hours per week and 12.3% reported working 80 hours per week or more, more than double the proportion of other specialists. Table C4: Specialists and sub-specialists in obstetrics and gynaecology average hours and annual hours worked*, by sex and age, 1995 Sex.

25-34

yrs

35-44

yrs

45-54

yrs

55-64

yrs

65-74

yrs

75 yrs & over

Total

Total hours worked

Male

57.2

63.5

61.2

50.3

32.8

27.3

55.7

Female

65.0

53.7

49.0

38.9

21.2

0.0

49.3

Total

59.1

61.2

60.5

49.5

31.7

27.3

55.0

Annual hours worked (>000)

38.7

725.0

969.0

580.2

118.2

26.2

2,457.4


Male

50.0

53.9

51.1

41.9

29.3

27.8

47.3

Female

0.0

45.1

44.2

31.2

17.8

0.0

41.2

Total

50.0

51.8

50.7

41.0

28.2

27.8

46.6


26.5

617.7

817.2

485.1

105.7

26.9

2,079.0


Male

46.0

60.7

66.0

63.3

60.7

40.0

63.6

Female

70.0

59.4

53.8

87.6

19.5

0.0

59.0

Total

52.0

60.4

65.4

64.4

57.0

40.0

63.2


15.1

468.3

728.7

493.0

91.1

7.0

1,803.2

Total spec/sub-spec

14

256

347

254

82

21

974

* Calculated as average weekly hours multiplied by persons by 46 weeks per year. Source: Medical Labour Force Survey, 1997, AIHW Average Hours Worked - Location The results indicated that 63.6% reported on call hours worked. Hours on call not worked for these averaged 64.3 hours per week. The proportion on call and the number of hours on call rose with distance away from a metropolitan area, with remote area

AMWAC 1998.6 115

specialists/sub-specialists reporting 100% on call, an average of 75 hours per week worked and a further average of 93.7 hours on call not worked as is shown in Table C5. The average hours worked varied by region with the average hours in direct patient care in major urban areas at 46.1 hours a week compared to 68.3 hours a week in remote areas. Table C5: Specialists in obstetrics and gynaecology: average working hours and average age, by geographic location, 1995

Region of main job

Major urban centre

Large rural

Centre

Small rural

centre

Other rural area

Remote

Total

Total obstetrics and gynaecology workforce AIHW (1997) Total hours worked

54.8

58.4

59.0

39.9

75.0

55.0


46.1

51.5

53.2

41.5

68.3

46.9


64.3

59.1

66.1

70.5

93.0

64.3


62.0

63.9

79.3

81.3

100.0

63.6

Average age

51

50

50

58

48

51

Source: RACOG/AMWAC Survey 1997 and AIHW Practice Profiles In 1995, 84.7% of obstetricians and gynaecologists reported their main job or secondary job was located in private rooms, 49.5% in an acute care public hospital, 9.7% in acute care private hospital, and 16.1% in other settings. The proportion reporting employment in public hospitals was much higher in the Australian Capital Territory (79.8%) and lower (31.1%) in Western Australia. Private hospital employment was highest in the Australian Capital Territory (19.8%), New South Wales (17.2%) and Tasmania (11.9%).

AMWAC 1998.6 116

APPENDIX D: SERVICE PROVISION AND REQUIREMENTS OF OBSTETRICS AND GYNAECOLOGY

In compiling this report, the Working Party agreed that the Australian community should have available an adequate number of trained obstetric and gynaecology specialists appropriately distributed to provide the obstetrics and gynaecology services it requires. All Australian residents must have access to a good standard of obstetric and gynaecology services as well as sub-specialty services, irrespective of geography and economic status. The community is therefore best served when obstetric and gynaecology specialists and sub-specialists have high standards of qualification and work with a high level of ongoing experience. A RACOG specialists/sub-specialist in obstetric and gynaecology therefore should be able to provide the following services: deliver expert advice and treatment to maximise the safety and well-being of the

patient in a caring professional manner appropriate management of pregnancy; appropriate management of gynaecological diseases; appropriate service proficiency across all female age groups; appropriate level of information and explanation to patients; appropriate tests and treatment to patients; to arrange a further opinion if requested and practicable; to offer referral to another obstetrician/gynaecologist if unable to care for any reason; to provide appropriate professional cover for periods off duty or on leave; and to be available within 15 minutes travelling time from the nearest serviced hospital;

this also holds for rural and remote areas. Population Catchment The population catchment required for a capital city/major urban area has been identified as 1 per 20,000 total Australian population. In rural and remote areas it is recommended area there be two specialists covering a total Australian population catchment of 40,000-60,000. Two specialists are required so that a viable obstetric and gynaecology service is offered to the community and covered for 24 hours. Two specialists will be able to support emergencies, provide cover during travelling time of colleague, and provide on call hours support, relief during holidays, study and sick leave. In areas where there is outreach services provided to large remote areas such as Cairns, RACOG has recommended that there should ideally be at least four specialists which will allow appropriate cover for those specialists who are on call and/or are visiting remote areas. Other Specialist Services Required in Close Proximity

AMWAC 1998.6 117

In capital cities/major urban areas the following specialists are considered necessary in providing a good standard of obstetric and gynaecology service: anaesthetists

dieticians

midwives

physiotherapists

neonatal trained nurses

genetic counselling services

paediatricians

access to community mental health

psychiatrists neonatologists

ultrasound provided by individual with medical training

psychologists

availability of specialist physicians and specialist surgeons

for cross referral and consultation

In rural and remote areas the following specialists are considered necessary in providing a good standard of obstetric and gynaecology service: anaesthetists psychiatrists

availability of specialist physicians and specialist surgeons

for cross referral and consultation midwives genetic counselling services

the ability to transfer to other hospital to services such as

ICU paediatricians

visiting specialists such as urologists

radiology pathology

general practitioners and surgeons with training in

obstetrics psychologists

ultrasound provided by individual with medical training

Surgical Facilities Surgical facilities that are required to provide obstetrics and gynaecology services include: gynaecological equipment; sterilisation equipment. Colposcopy; ultrasound; office hysteroscopes need to be provided wherever the outreach specialist is consulting. Infrastructure The following infrastructure are required in capital cities /major urban areas to provide obstetrics and gynaecology services: a fully equipped theatre, intensive care unit, maternal fetal unit, ultrasound and radiology unit as well as appropriate medical and surgical backup. In rural and remote areas a level 2 nursery is necessary. Access to the following are also required: ante-natal care services, intensive care unit, maternal fetal unit, ultrasound and radiology unit, telelink to consultants and access to medical and surgical

AMWAC 1998.6 118

backup. The provision of accommodation for both obstetrics and gynaecology patients is also important as well as access to good transport to and from hospital for both patients and specialists. Requirements for the Indigenous Community The most important requirement in providing appropriate services to Indigenous communities is the education of doctors and staff in birthing facilities in appropriate attitudes and ethnic understanding. It is also essential that there is an increase in the number of Indigenous people working in the areas of women=s health care, nursing, midwifery and medicine. The provision of accommodation for both obstetrics and gynaecology patients and the extended family is considered necessary when dealing with the Indigenous communities and their culture. By the same token it is vital that services be provided by the same specialist rather than new specialists so that trust and communication is established with Indigenous patients. Basic Requirements for Providing a Rural Outreach Service In a rural outreach service it is important that there is an appropriate consulting facility with a dedicated nurse or health worker who monitors the practice and sets up appointment times and provides ante-natal care. There is also a need for the availability of appropriate hospital infrastructures for operative procedures; small surgical/limited equipment; access to allied health professionals and ancillary staff; access to other specialist services; and a telelink to other consultants. The interest and support of local GPs is also paramount in the success of maintaining a rural outreach service. Another incentive is the availability of good transport to the area for specialists.

AMWAC 1998.6 119

APPENDIX E: RACOG OBSTETRICS AND GYNAECOLOGY TRAINING PROGRAM

The following information on the obstetrics and gynaecology training program was provided by RACOG Eligibility Prospective trainees must hold medical registration approved by a relevant certifying authority. All trainees commencing the RACOG Training Program will be required to complete the requirements of the new FRACOG Training Program which includes a four year Integrated Training Program and a two year Elective Training Program. The Integrated Program consists of defined clinical and educational experience in training hospitals. This includes the MRACOG Distance Education Program and in-training assessment in the form of the In-Hospital Clinical Assessment modules. The terminal or exit assessment for the Integrated Program will be the MRACOG examination, which is designed to test core knowledge and skill. This examination will continue to consist of the MRACOG written (MCQ) examination and the MRACOG oral (OSCE) examination. Because it will be the terminal assessment for the Integrated Program, trainees are only able to attempt the MRACOG examination for the first time during Year 4 of the (the final year) of the Integrated Program. The Elective Program is completed in the remaining two years of the MRACOG/ FRACOG Training Program. This program is designed to offer Trainees an opportunity to pursue a special interest in a planned way. Trainees are required to submit a plan for a two-year program which is designed to meet their own educational needs. This plan must be prospectively approved. Some obvious options include further training in operative obstetrics and gynaecology, training in provincial posts, research leading to a postgraduate degree (eg. MD or MPH) and the commencement of sub-specialty training. The requirements for being granted the FRACOG will be satisfactory completion of both the Integrated Program (including passing the MRACOG examination) and the Elective Program. Integrated Program Essentials The following are Essentials for an Integrated Program. In other words, for a program to be accredited by the College, it must be able to offer the following: a planned rotation over a four year period which includes at least 12 months

experience in hospitals other than the home hospital and at least 12 months in a tertiary hospital;

a Program Coordinator with responsibility for coordinating that Integrated Program

AMWAC 1998.6 120

a tutorial program specifically designed for MRACOG trainees; and levels of clinical experience such that each Trainee can obtain the following

minimum levels of experience over the four years of the program. Figures for procedures refer to the number of procedures available to be performed, not assisted, by the Trainee. All figures refer to the minimum levels of experience which hospitals must agree to arrange for each Trainee over the four year period of the Integrated Program. However, they do not define absolute requirements that must be met by each Trainee. 100 normal deliveries (supervision and management) 100 Caesarean sections 100 operative vaginal deliveries (including multiple pregnancy, ventouse, breeches,

forceps) 100 major abdominal surgical procedures 50 major vaginal surgical procedures 200 laparoscopic examinations or procedures 100 hysteroscopic examinations or procedures 100 colposcopic examinations 50 hours of ultrasound 300 hours in gynaecology clinics (inc. specialist clinics in uro-gynaecology and

reproductive medicine) 300 hours in obstetrics clinics 3 months in an approved gynaecologic oncology unit (at least 50% of this time must

be spent in clinical work in gynaecologic oncology) In addition to these essentials, each Integrated Program is required to meet the standards already in place for approval of training posts as defined in the document Standards for the Accreditation of MRACOG/FRACOG Training Posts. However, it is not necessary for each of the training posts in the Integrated Program rotation to meet all of these standards (e.g. library requirements) as accreditation is based on the four year program rather than on any individual training post. All trainees who entered the Training Program after 1 January 1997 are required to spend at least six months in a provincial post at some stage of the MRACOG/FRACOG Training Program (i.e. as a component of either an Integrated Program or an Elective Program). Trainees are advised by the Program Coordinator/Training Supervisor of their planned rotation for the four year program, at the commencement of Year 1. Approval for training at a provincial training post will be based on the particular merits of that training post. Flexibility regarding the model for training supervision will be considered.

AMWAC 1998.6 121

Program Coordinators Each Integrated Program is coordinated by a Program Coordinator, appointed by the College for a minimum two year period. The Program Coordinator is responsible for planning the local Integrated Program and coordinating the progress of Trainees through the program. As such, the Program Coordinators role is similar to the Chairman of a State Training and Accreditation Committee in those states which already offer a statewide program or similar to the Senior Training Supervisor in major teaching hospitals which already offer a program involving rotation to other hospitals. The role of the Training Supervisor in the individual hospitals will continue with little change. Hospital-Based and State-Based Integrated Programs Because each Integrated Program is four years in duration and because it must involve at least two hospitals, each program must be offered cooperatively by at least two hospitals. This is, however, the only institutional requirement. An Integrated Program could thus be offered by: a tertiary hospital and a single peripheral hospital; a tertiary hospital and a number of peripheral hospitals; two or more tertiary hospitals; all of the teaching hospitals within an Australian state; two or more hospitals, at least one of which is a tertiary hospital, in different

Australian states; two or more hospitals, at least one of which is a tertiary hospital, in different

countries A program which included all of the teaching hospitals within a state (a state-based program) might, in effect, have no base hospital but instead be coordinated from the State Training and Accreditation Committee. However, it is expected that most programs are hospital-based in the sense that Trainees receive most of their training at a single base or home hospital and rotate out to other hospitals intermittently. Elective Programs While Integrated Programs are designed to standardise the clinical and educational experience available to Trainees in the core areas of obstetrics and gynaecology, Elective Programs may be individualised to meet the needs and interests of the Trainee. Each trainee is required to submit a learning plan for prospective approval by the State Training and Accreditation Committee. The Trainees Elective Program may focus on: extending expertise in general obstetrics and gynaecology; extending expertise in gynaecological surgery; developing expertise in provincial practice; developing research expertise; developing expertise in an area of special interest; commencing sub-specialty training or developing expertise in practice in the third world. The Elective Program is designed to be individualised and its aims will therefore vary from trainee to trainee. However, there are some aims which should be common to most Elective Programs, especially those pursued in the last two years of training.

AMWAC 1998.6 122

These include the development of confidence and competence in surgery; confidence and competence in patient management; career directions; leadership skills; teaching skills; financial management skills; and people management skills. While there is no intention to make any of these mandatory, it is expected that most individualised Elective Programs will focus on at least some of these areas. Resources Required for the Training of Specialists in Obstetrics and Gynaecology Whether a program receives accreditation is determined by the nature and content of the program in regard to its adequacy in: clinical exposure and >in-service= training; teaching sessions and seminars; instruction in pathology; instruction in medicine and surgery relevant to obstetrics and gynaecology; and library facilities which include obstetrics and gynaecology textbooks listed in the College recommended reading list, together with an adequate selection of general medical texts and journals as well as E-mail and Internet access. There also needs to be time for reading and study during normal working hours and arrangements to allow trainees to attend lectures and seminars within the hospital itself and at other institutions. For accreditation a program should have the following content: clinical obstetrics and gynaecology, it is expected that the majority of training will be

spent in clinical work with the trainee responsible, under supervision, for the care of patients in both the outpatients department and the wards;

pathology; medicine and surgery relevant to obstetrics and gynaecology. library with E-mail and Internet access and general reading (journals, preparation for

seminars and case presentations); regular teaching sessions/seminars and group discussions.

AMWAC 1998.6 123

APPENDIX F: GENERAL PRACTITIONERS PROVIDING OBSTETRICS AND GYNAECOLOGY SERVICES

One of the features of the obstetrics and gynaecology workforce is the scope for alternative providers to provide some of the services. The pattern of health care provision in obstetrics and gynaecology varies markedly by region, with specialist involvement much more likely in the capital cities and much less likely in regional areas. In rural and remote areas, GP and midwifery provision is predominant. These patterns have clear implications for specialist requirements and the need for provision of services. GENERAL PRACTITIONERS RACOG Diploma and Certificate Programs in Women=s Health Generally, GPs wishing to provide obstetrics and gynaecology services complete an additional training program in obstetrics and gynaecology. The training is overseen by the Joint Consultative Committee - RACOG and RACGP. GPs can qualify with either the Diploma of RACOG (DRACOG) and the Certificate of Satisfactory Completion of Training in Women’s Reproductive Health (CSCT). The aim of the DRACOG is to provide training to GP obstetricians who wish to be able to: perform normal deliveries, assisted deliveries and to a limited extent, breech

deliveries; perform basic gynaecological procedures; undertake shared ante and postnatal care with specialists obstetricians or a

specialist hospital; manage of the antenatal care of low to moderate risk to patients; and, provide family planning advice

The DRACOG is a time limited qualification and requires re-certification every three years. The aim of the CSCT is to provide training to GP obstetricians who wish to provide: shared ante and postnatal care with specialists obstetricians, GP obstetrician or a

specialist hospital; management of the antenatal care of low to moderate risk to patients; office gynaecology; and, family planning.

CSCT holders do not undergo re-certification, instead they are asked to declare their commitment to maintenance of standards by involvement in the RACGP quality assurance and continuing medical education program.

AMWAC 1998.6 124

The duration of training for the DRACOG is for a minimum period of six months and the CSCT is for a minimum period of three months. Currently there are 2,845 GPs who have the (DRACOG). Table F1 shows that Victoria has the highest number (35.1%) of qualified GPs in obstetrics and gynaecology. There are a further 161 DRACOG candidates who at the end of 1997 have applied to sit the written and oral examinations. Table F1: General practitioners qualified to practice in obstetrics and gynaecology and general practitioners candidates for the DRACOG, by gender and State/Territory 1997

Gender

NSW

Vic

Qld

WA

SA

Tas

ACT

NT

Total

Qualified DRACOG

Males

447

548

223

186

189

35

21

31

1,680

Females

263

451

123

101

135

31

25

36

1,165

Total %

710

25.0

999

35.1

346

12.2

287

10.1

324

11.4

66

2.3

46

1.6

67

2.3

2,845

100.0

DRACOG candidates

Males

21

28

17

10

9

1

0

5

91

Females

19

25

6

8

6

2

1

3

70

Total

40

53

23

18

15

3

1

8

161

Source: RACOG 1997 There are currently 27 GPs who have the CSCT qualification in Australia. There are a further 93 CSCT candidates who at the end of 1997 have applied to sit the written and oral examinations.

AMWAC 1998.6 125

Table F2: General practitioners qualified with the Certificate Satisfactory Completion of Training in women’s health and candidates, by gender and State/Territory 1997

Gender

NSW

Vic

Qld

WA

SA

Tas

ACT

NT

Total

Qualified CSCT

Males

0

4

2

0

1

0

0

0

7

Females

5

7

2

0

4

0

1

1

20

Total

5

11

4

0

5

0

1

1

27

CSCT candidates

Males

6

12

1

3

3

0

1

3

29

Females

12

29

5

5

12

0

1

0

64

Total

18

41

6

8

15

0

2

3

93

Source: RACOG 1997 Rural and Remote General Practitioners who Practice in Obstetrics and Gynaecology The Centre for Rural Health conducted a National Rural General Practitioner Survey in 1996. The survey collected information in regards to rural general practitioners working in obstetrics and gynaecology and this information is shown below in Table F3. Of the survey respondents, 541 indicated that they practice in obstetrics and gynaecology. All of these respondents were qualified in either DRACOG or CSCT. Table F3: Rural and remote general practitioners who practice in obstetrics and gynaecology, by State/Territory, 1997

NSW/ACT

Vic

Qld

WA

SA

Tas

NT

Total

GPs practising in obstetrics & gynaecology

138

123

96

105

61

10

8

541

%

25.5

22.7

17.7

19.4

11.3

1.9

1.5

100.0

Source: Centre for Rural Health, 1997 Female GPs represented 15.5% of the GPs who indicated they practice in obstetrics and gynaecology. Age Profile 50% of respondents who indicated that they were GPs who practice in obstetrics and gynaecology were aged 35 to 44 years, and 41.2% were aged over 45 years.

AMWAC 1998.6 126

Table F4: Age profile of rural and remote general practitioners who practice in obstetrics and gynaecology, by sex and age, 1997

Age (years)

Males

Females

Total

%

less than 35

30

18

48

8.9

35-44

220

50

270

50.0

45-54

138

17

155

28.7

55-64

45

4

49

9.1

65-74

16

1

17

3.1

75+

2

0

2

6.1

Total

451

90

541

100.0

%

83.4

16.6

100.0

100.0

Source: Centre for Rural Health, 1997 Geographic Location The majority of respondents providing obstetrics and gynaecology services were located in other rural areas (28.5% of the total female population) (59.9%); 15.2% of respondents were located in remote areas. Table F5 below shows the age and geographic distribution of GPs who practice in obstetrics and gynaecology in rural and remote areas of Australia. The highest age range is in the 36 to 40 year olds at 26.4% with the majority of this age group (62.9%) working in other rural areas. The highest proportion (30.9%) in remote areas are represented by the 41 to 45 year olds. Table F5: Age profile of rural and remote general practitioners who practice in obstetrics and gynaecology by geographic location, 1997

Age (years)

Small rural area

Other rural area

Remote centre

Remote other

<31

1

6

1

1

31-35

12

36

5

3

36-40

33

90

8

12

41-45

36

79

12

13

46-50

25

55

5

3

51-55

15

19

3

5

56-60

6

17

3

3

61-65

4

8

1

1

66-70

1

10

1

1

Total

133

320

39

42

%

24.9

59.9

7.3

7.9

Source: Centre for Rural Health, 1997

AMWAC 1998.6 127

Hours Worked The average hours worked by GPs who are practising in obstetrics and gynaecology in rural/remote areas of Australia is 1.06 hours (std. deviation ∀ 0.1) in obstetrics. Those aged 35 to 44 years of age indicated the highest average hours per week at 1.36 hours. Current Issues Regarding the Decline in GP Obstetricians Comprehensive national data is not available on the number of services provided by GP obstetricians and therefore the trend in service provision. This is a serious data deficiency when attempting to determine which practitioners are providing obstetrics and gynaecology services. Nevertheless, it is generally considered that there is a decline in the number of GPs providing birthing services. For example, the number of GPs who performed more than five private patient confinements (including Caesareans) annually declined by 37.2% in the period from 1988 to 1992 (AIHW). This does not give the complete picture as it is likely that GPs continue to provide at least the non-procedural components of birthing services quite extensively. Anecdotal evidence suggests that the likelihood that birthing services to public patients in public hospitals are provided by GPs more often in rural and remote areas and less often in provincial/urban areas. However, with the general decline in numbers of rural and remote birthing practitioners and the availability of local birthing services this may have an adverse effect upon patient safety. For example, women in rural areas prefer to give birth close to home which can lead them to choose to stay at home until it becomes too late to go anywhere except the local hospital. This can be because of personal preference, but more often, it can be because of financial necessity or the need for close family support. This is particularly the case for Aboriginal and Torres Strait Islander women. Alternatively, where a woman has a short labour, the same result can occur as an automatic consequence of labour. The delay in attending hospital, the possible lack of facilities and expert back-up close at hand, and the consequent emergency nature of the birth can compromise the safety of the birthing services. As the number of GPs providing procedural birthing services declines, the effect on the availability of local birthing services in rural and remote areas is likely to be more adverse because the majority of services in these areas have traditionally been provided by GPs rather than specialists. Various studies have been undertaken to examine the reasons GP obstetricians are discontinuing practice and these are summarised below. Lifestyle and Family Considerations A study of why GPs are ceasing obstetrics in Victoria was conducted by Dr Kathy Innes in 1996. The findings of this study confirm the hypothesis that reasons other than those related to Medical indemnity insurance premium increases and fear of litigation are

AMWAC 1998.6 128

important in a GPs decision to cease intrapartum obstetric practice. The study found that the other reasons are primarily to do with lifestyle and family. Medicolegal threat was chosen by a significant number of doctors as a secondary reason for ceasing obstetrics. The qualitative information gained from this study indicates that ceasing to provide obstetric care is a difficult decision for many family physicians and that a socially acceptable reason related to cost benefit or fear of litigation is easier to justify to oneself and ones community than the real reason which may be related to home and family. This is particularly true in small to medium size communities where loss of even one service provider is crucial and the family doctor is more likely to be held responsible for the loss of such a service. Analysis of the GPs most important reason for ceasing obstetrics shows that 36% (18) chose personal, family or interference with lifestyle as their number one reason for ceasing. 16% (8) chose rising insurance premiums. Concern regarding the management of unexpected emergencies and lack of remuneration were chosen by 10% (5) and 8% (4) respectively. Other reasons for ceasing obstetrics included: closure of local hospital; not doing enough deliveries to maintain skills and the stress of being constantly on call and the exhaustion of working night and day. Comparison between the reasons from rural GPs and urban or provincial GPs suggested that both groups consider personal, family and lifestyle issues as the most important 29% versus 40%. Urban/provincial GPs, however site lack of remuneration (12%) and interference with other clinical responsibilities (8%) as important. Rural GPs indicated that rising insurance premiums (25%) and concern regarding the management of unexpected emergencies (13%) were also very important to them. In an analysis of the doctors’ suggestions to keep GP’s practising obstetrics, 45% (24) of the GP respondent doctors felt that the most useful suggestion for retaining doctors in obstetrics involved increasing the fees. Comments were made that it takes 10 deliveries just to pay the medical defence premiums. Suggestions included: altering the on-call or after hours arrangements 19% (10) and altering the medical defence arrangements 11% (6). Medical Indemnity Another indicator for the decline in the number of GPs providing obstetric services is the increasing cost of medical indemnity. Indemnity insurance increases pose a problem for GP obstetricians who provide services in rural and remote areas where they need

AMWAC 1998.6 129

to undertake at least 20 deliveries a year under the sessional payment system to cover the extra medical indemnity required to do obstetrics. Specialists have been able in part to compensate the medical indemnity situation by an increase in incomes, as their patient caseload increased as an outcome of the trend for more women to seek specialist care irrespective of the complexity or risk to their birth. While this move to specialist care for all births including low risk births is an option in urban Australia, the same cannot be said for rural areas. It is difficult for specialists to gain what is perceived as adequate remuneration in small rural centres, simply because of the relatively small potential patient base upon which it is possible to draw and this is where the need for rural and remote GP obstetricians emerges. Studies have been undertaken to show that the medical insurance situation is a key reason for the declining numbers of GPs practising in obstetrics. One such study by Watts et al in 1997, found that South Australian GPs are leaving obstetrics at an alarming rate and that the most important reason for ceasing obstetrics was indemnity insurance (56.8%) followed by lifestyle issues (54.5%) and poor remuneration (34.1%), litigation fear (29.5%), declining deliveries (29.5%) and wanning skills (22.7%). The study also reported that the recent rise in obstetric (procedural) indemnity insurance has made rural obstetric practice financially nonviable and threatened the whole service. Most GPs felt that a full subsidy tied to accreditation, but not to the number of activities, is the best way to solve the crisis. GPs also favoured independent legal tribunals as a method to handle malpractice claims. Similarly a New South Wales survey conducted by Dr Mark Henschke in 1997 found that the continuation of GP obstetrics in major rural hospitals (sessional payment) is unlikely unless there is medical insurance intervention to assist GP obstetricians in small rural centres. The survey obtained a 90% (80) response rate and found that almost one in four had stopped providing obstetric services in the previous two years. 54% indicated that they were planning to stop in the next two years, and 17% indicated that they would be continuing with GP obstetrics beyond 1999. Of those GP obstetricians who had stopped in the previous three years, 70% cited the cost of medical indemnity insurance as the major factor and a further 20% indicated the stress associated with the obstetrics and the pressure of constantly being on call. When asked what would entice them back to GP obstetrics, 60% indicated that financial support, such as an Obstetrics Incentive Allowance, would make them reconsider their decision to abandon obstetrics. Other recommendations that would help were specialist support and a roster for Medicare patients.

AMWAC 1998.6 130

Other Reasons Why Rural Doctors Leave Their Communities General social, cultural and professional issues are acknowledged all of which are well documented. A summary of these reasons is presented below. Access to health care in much of rural Australia remains poor by urban standards. There are many rural and remote communities that have traditionally had difficulty in attracting and keeping doctors. While the interest in a rural career among medical students and recent graduates appears to be increasing, there is little evidence that recruitment and retention of rural doctors is dramatically improving. Studies have also been undertaken to examine why rural doctors leave their communities. One such study undertaken by Hays et al in 1997 examined rural and remote Queensland doctors during 1995 and found there were are series of issues such as: family, education and support, cultural deprivation, limited social amenities, lack of privacy, limited education and employment opportunities for family members and financial considerations that are raised. The study found that the initial sense of responsibility to the rural communities, enjoyment of the clinical variety, autonomy and family lifestyle, and appreciation of assimilation into the community were powerful influences to stay. However, enthusiasm waned in response to pressures to return to a larger centre. Overwork, awareness that family and friends were distant and appreciation of the educational and career limitations of staying too long contributed incrementally to a situation where there was no longer any perceived reason to stay. Another very basic factor such as the identification with the community also brought disadvantages. Rural medical families have little, if any, anonymity, contributing to the feeling that it is difficult not to be at work. The close and special relationship with the community can interfere with clinical work. Being an important part of a close community also tests other relationships. Personality clashes can develop with significant community leaders, such as senior nursing staff, other doctors, health managers and local government leaders. Small communities are difficult to live in when there are uncomfortable relationships with powerful but unavoidable individuals. In response to questions about measures that could entice a longer commitment the following suggestions were offered: improving housing quality; quality and access to locums for longer holidays, particularly for longer services; short term CME relief; the provision of more flexible delivery CME through the use of information technology; the provision of management training to be offered during vocational training; the development of educational packages for families, such that children are being supported locally. The study found that many urban background doctors will not stay more than three to five years in certain smaller communities. In the longer term, increased selection of

AMWAC 1998.6 131

students from a rural background should provide a higher proportion of graduates who will remain comfortable with rural community life. In Australia, and particularly rural Australia, where obstetric services are largely dependent upon GPs as service providers, access to obstetric care is threatened if the issues mentioned above are not addressed. Once a doctor has ceased obstetrics, the evidence would suggest that they do not resume and will not consider resuming except under the most urgent of clinical circumstances.

AMWAC 1998.6 132

APPENDIX G: AMWAC SURVEY OF DIVISIONS OF GENERAL PRACTICE METHODOLOGY To obtain information about the adequacy of the supply of specialist obstetric and gynaecology services throughout Australia, AMWAC administered a mailed survey of all Divisions of General Practice. Of a possible 122 Divisions, 77 responded (63.1%). RESULTS Distribution of Respondents Table G1 shows the distribution of responding Divisions to the AMWAC survey by State/Territory and by location. 37.6% of Divisions were from New South Wales, 26% from Victoria, 11.7% from Queensland, 10.4% from Western Australia and 7.8% from South Australia. With respect to location, 35.1% were located in a capital city, 13% in an other metropolitan area and 51.9% in a rural area. Table G1: Distribution of responding Divisions of General Practice, by State/Territory and geographic location, 1997

% DGP* by location

State/Terr.

Total

number of DGP*

% DGP*

by State/Terr.

Capital City

Other

metropolitan

Rural

Total

NSW

29

37.6

24.1

27.6

48.3

100.0

Victoria

20

26.0

40.0

0.0

60.0

100.0

Qld

9

11.7

33.3

22.2

44.4

100.0

South Aust.

6

7.8

16.6

0.0

83.3

100.0

West. Aust.

8

10.4

62.5

0.0

37.5

100.0

Tasmania

2

2.6

50.0

0.0

50.0

100.0

North. Terr.

2

2.6

50.0

0.0

50.0

100.0

ACT

1

1.3

100.0

0.0

0.0

100.0

Australia

77

100.0

35.1

13.0

51.9

100.0

*Number of Divisions of General Practice Source: AMWAC survey of Divisions of General Practice When the data from (Table G1) are compared with the distribution of all Divisions of General Practice (Table G2) it can be seen that among respondents to the AMWAC survey, New South Wales Divisions are over-represented, Queensland Divisions are under-represented and rural Divisions are over-represented.

AMWAC 1998.6 133

Table G2: Distribution of all Divisions of General Practice in Australia, by State/Territory and geographic location, 1997

% DGP* by location

State/Terr.

Total

number of DGP*

% DGP* by State/Terr.

Capital city

Other

metropolitan

Rural

Total

NSW/ACT

36

29.5

44.4

27.7

27.7

100.0

Victoria

32

26.2

53.1

12.5

34.4

100.0

Qld

20

16.4

40.0

35.0

25.0

100.0

South Aust.

14

11.5

35.7

7.1

57.1

100.0

West. Aust.

13

10.7

69.2

0.0

30.8

100.0

Tasmania

3

2.5

33.3

33.3

33.3

100.0

North. Terr.

4

3.4

25.0

0.0

75.0

100.0

Australia

122

100.0

46.7

18.9

34.4

100.0

*Number of Divisions of General Practice Source: AMWAC survey of Divisions of General Practice Triggers for General Practitioner Referral to a Specialist Obstetrician Gynaecologist Divisions of General Practice were asked to indicate the importance of eight Αtriggers≅ for referral to an obstetrician and gynaecologist and to identify any further important triggers. Table G3 indicates that the two most important triggers for a referral are condition unresponsive to treatment and severity of the condition followed by lack of experience within the practice regarding the condition and/or its treatment, the availability of appropriate back-up, rarity of the diagnosis and request of patient to be referred. The least important triggers for referral to an obstetrician and gynaecologist were the age and social circumstances of the patient. No differences were observed among responses to this question based on location (ie., metropolitan or rural).

AMWAC 1998.6 134

Table G3: Importance of eight triggers for general practitioner referral to an obstetrician and gynaecologist, 1997

Trigger

Not important

Very important

1

2

3

4

5

Condition unresponsive to treatment

0.0

1.8

12.5

41.1

44.6

Severity of the condition

0.1

1.2

15.6

57.1

26.0

Lack of experience

0.0

8.8

24.6

43.9

22.8

Availability of appropriate back-up

0.0

10.7

23.2

37.5

28.6

Rarity of the diagnosis

5.4

12.5

17.9

37.5

26.8

Request of patient to be referred

5.3

10.5

24.6

43.9

15.8

Age of patient

22.8

28.1

28.1

15.8

5.3

Social circumstances of the patient

36.8

33.3

19.6

10.5

0.0

Source: AMWAC survey of Divisions of General Practice Supply of Resident and Visiting Obstetricians and Gynaecologists Table G4 indicates that 22.2% (n=14) of Divisions of General Practice reported that there were no resident obstetrics and gynaecology specialists providing services in the area covered by their Division. Of these Divisions, 7 (50%) were from New South Wales, and all but one were from rural locations. Further analysis revealed that of the Divisions with no resident obstetrics and gynaecology specialists all but two had specialists visiting their area. Table G4: Percentage of Divisions with resident obstetricians and gynaecologists providing services in area, by State/Territory, 1997

Number of resident obstetricians and gynaecologists

State/ Terr.

None

One

Two

Three

Four

Five-Ten

11 or more

Total

NSW

28.0

20.0

4.0

20.0

8.0

8.0

12.0

100.0

Vic

15.4

7.7

15.4

46.2

0.0

15.4

0.0

100.0

Qld

28.6

0.0

0.0

14.3

14.3

42.9

0.0

100.0

SA

33.3

50.0

16.6

0.0

0.0

0.0

0.0

100.0

WA

12.5

37.5

0.0

12.5

0.0

25.0

12.5

100.0

Tas

0.0

0.0

0.0

0.0

50.0

50.0

0.0

100.0

NT

0.0

0.0

100.0

0.0

0.0

0.0

0.0

100.0

Aust

22.2

19.0

7.9

20.6

6.3

17.5

6.3

100.0

Source: AMWAC survey of Divisions of General Practice

AMWAC 1998.6 135

Adequacy of the Supply of Obstetricians and Gynaecologists 55.4% (n=43) of Divisions of General Practice considered that a shortage of obstetrics and gynaecology specialists existed in their area with the remaining predominantly of the opinion that supply was about right (Table G5). One Division in South Australia considered there was an oversupply. States/Territories with the greatest shortage of obstetrics and gynaecology specialists were New South Wales, Victoria and the Northern Territory. Significantly (p<0.05), a greater percentage of rural Divisions (61.5%) perceived the supply of obstetrics and gynaecology specialists to be inadequate than did Divisions located in capital cities (50%) or other urban areas (50%). Comments on the adequacy of services reflected the distribution of obstetrics and gynaecology specialists. For example, Divisions in well supplied areas commented that access is good, a specialist is always available and we have excellent access through the flying O&G service in Queensland. Divisions in poorly supplied areas commented that access is excellent in the town but poor in remote areas. Aboriginal women have to travel to town for ultrasounds, waiting time for specialists is three months, waiting times for public patients is too long, adequacy during weekends and nights is poor. Impending shortages were also commented on. For example Divisions indicated that some GPs are giving up obstetric practice because of the costs of indemnity insurance and that in some cases this is placing a heavy burden on other GPs. Suggestions for improving the supply of obstetrics and gynaecology services included training more specialists, specialists doing more visits to regional centres, allowing GPs and midwives to do antenatal care, opening the rural hospital, improved transport, training for small hospital GP antenatal services to Aboriginal women, shared care and improved financial incentives for GP confinements in rural areas with phone link with specialists. Table G5: Adequacy of the supply of specialist obstetricians and gynaecologists by State/Territory, 1997 State/Terr.

Shortage

About Right

Over supplied

Total

NSW

70.0

30.0

0.0

100.0

Victoria

66.7

33.3

0.0

100.0

Queensland

42.9

57.1

0.0

100.0

South Aust.

0.0

83.3

16.7

100.0

West. Aust.

42.9

57.1

0.0

100.0

Tasmania

50.0

50.0

0.0

100.0

NT

100.0

0.0

0.0

100.0

Australia

55.4

42.9

1.7

100.0

Source: AMWAC survey of Divisions of General Practice

AMWAC 1998.6 136

Requirement for Additional Resident and Visiting Obstetricians and Gynaecologists In response to the question ΑIf a shortage for obstetrics and gynaecology specialists exists in your area, please indicate the number of resident and visiting specialists required≅, Divisions with shortages indicated a need for 82 resident specialists and 26 visiting specialists. Resident specialists are required in New South Wales (26), Victoria (22), Queensland (6), Western Australia (5), the Northern Territory (9) and Tasmania (4). Capital city located Divisions perceived a requirement for 44 resident obstetrics and gynaecology specialists while rural Divisions required 31 and other metropolitan Divisions required 7. Visiting specialists are required in Victoria (13), New South Wales (8), Queensland (3), Western Australia (1) and the Northern Territory (1). Capital city located Divisions perceived a requirement for 17 visiting specialists and rural Divisions required nine. Availability of General Practitioners with Qualifications in Obstetrics and Gynaecology Over 72.7% (n=56) of Divisions responded to the question about the number of resident general practitioners providing services in their area with qualifications in obstetrics and gynaecology. Of these, all but three Divisions indicated that there was one or more resident general practitioner providing services in their area with qualifications in obstetrics and gynaecology. Significantly, over 80% of rural Divisions indicated that they had one or more resident qualified general practitioners in their area while the comparative figures for other metropolitan areas and capital city areas were 70% and 48.1% respectively (Table G6). Only five Divisions reported having general practitioners visiting their area with qualifications in obstetrics and gynaecology and all were located in capital cities. Table G6: Number of Divisions with resident general practitioners with qualifications in obstetrics and gynaecology providing services in area, by State/Territory, 1997

Number of resident GPs with qualifications in obstetrics and gynaecology

Location of DGP*

None

One

Two

Three

Four

Five-Ten

11 or more

Total

Capital City

2

2

1

0

0

2

8

15

Other Urban

0

0

0

3

1

1

2

7

Rural

1

3

3

3

0

11

13

34

Total

3

5

4

6

1

14

23

56

* DGP - Divisions of General Practice Source: AMWAC survey of Divisions of General Practice Satisfaction with the Diploma of Obstetrics offered by RACOG

AMWAC 1998.6 137

Divisions indicated strong support for the Diploma of Obstetrics offered by the Royal Australian College of Obstetrics and Gynaecology. Ninety three percent of Divisions answered in the affirmative to the question ΑDo you consider the Diploma of Obstetrics offered by RACOG the preferred qualification by general practitioners in Australia?≅ Comments as to how the program could be improved included a need to develop more hands-on skills to equip rural GPs and the need for a definite rural component. Summary The findings arising from this survey of Divisions of General Practice indicate an overall shortage of obstetrics and gynaecology specialists. However, this shortage is greater in some State/Territories than others and is particularly pronounced in some rural and remote areas. Divisions of General Practice have indicated a need for an additional 82 resident obstetrics and gynaecology specialists and 26 visiting specialists. There is strong support among Divisions for the RACOG Diploma of Obstetrics and at least 43% of Divisions of General Practice throughout Australia have general practitioners with qualifications in obstetrics and gynaecology providing services to patients in their area.

AMWAC 1998.6 138

APPENDIX H: DATA ON MIDWIVES Definition ΑA midwife is a person who, having been regularly admitted to a midwifery educational program, duly recognised in the country in which it is located, has successfully completed the prescribed course of studies in midwifery and has acquired the requisite qualifications to be registered and/or legally licensed to practice midwifery. She must be able to give the necessary supervision, care and advice to women during pregnancy labour and the postpartum period, to conduct deliveries on her own responsibility and to care for the newborn and the infant. This care includes preventative measures, the detection of abnormal conditions in mother and child, the procurement of medical assistance and the execution of emergency measures in the absence of medical help. She has an important task in health counselling and education, not only for the women, but also within the family and the community. The work should involve antenatal education and preparation for parenthood and extends to certain areas of gynaecology, family planning and child care. She may practice in hospitals, clinics, health units, domiciliary conditions or in any other service. (Jointly developed by the International Confederation of Midwives and the International Federation of Gynaecology and Obstetrics. Adopted by the International Confederation of Midwives Council 1972. Adopted by the International Federation of Gynaecology and Obstetrics 1973. Later adopted by the World Health Organization. Amended by the International Confederation of Midwives Council, Kobe October 1990. Amendment ratified by the International Federation of Gynaecology and Obstetrics 1991 and the World Health Organisation 1992.) Main Characteristics of the Midwifery Workforce Number of Nurses Employed as Clinicians in Midwifery, Obstetrics and Gynaecology The AIHW Nursing Labour Force Survey indicated that, in 1995, there were 13,913 registered and enrolled nurses employed in midwifery and 1,540 employed in obstetrics and gynaecology. Table H1 below shows that New South Wales has 31.1% of midwives where the Northern Territory has 1.4% of the total workforce. Table H1: Registered and enrolled nurses in midwifery, obstetrics and gynaecology, by State/Territory, 1995

Type of nurse clinician

NSW

Vic

Qld

WA

SA

Tas

ACT

NT

Total

Midwifery

4,325

3,803

2,323

1,152

1,366

399

344

201

13,913

Obstetrics and gynaecology

505

351

284

212

109

39

32

8

1,540

Total

4,830

4,154

2,607

1,364

1,475

438

376

209

15,453

% midwives

31.3

26.9

16.9

8.8

9.5

2.8

2.4

1.4

100.0

% female population

34.0

25.3

17.9

9.4

8.2

2.6

1.7

0.9

100.0

Source: Nursing Labour Force, AIHW 1997 and ABS

AMWAC 1998.6 139

In 1995, there were 195,692 nurses, nurses in midwifery and obstetrics and gynaecology represented 7.9% of the nursing workforce. In 1993 there were 13,759 registered and enrolled nurses in midwifery, obstetrics and gynaecology, a 12.3% increase in the period 1993 to 1995. In 1995 there were 85.6 registered nurses per 100,000 population in midwifery, obstetrics. This consisted of 82.2 registered nurses per 100,000 population and 3.4 enrolled nurses per 100,000 population. Gender Profile In 1995, 99.0% of the midwifery workforce were females. Age Distribution Table H2 shows the age distribution of midwives in Australia in 1995 and indicates that the majority of midwives are aged 35 to 39 years (25.0%) and that 65.5% of midwives are aged over 35 years. 69.2% of nurses employed as clinicians in obstetrics and gynaecology are aged over 35 years. Table H2: Nurses employed as clinicians in midwifery and obstetrics and gynaecology, by age group, 1995

Age (years)

Midwives

% Midwives

Obstetrics & gynaecology

% Obstetrics &

gynaecology Less than 25

133

1.0

58

3.8

25-29

1,494

1.7

145

9.4

30-34

3,176

22.8

271

17.6

35-39

3,482

25.0

293

19.0

40-44

2,547

18.3

294

19.1

45-49

1,569

11.3

229

14.9

50-54

898

6.5

151

9.8

55-59

463

3.3

76

4.9

60-64

132

0.9

19

1.2

65 and over

18

0.1

5

0.3

Total

13,913

100.0

1,540

100.0

Source: Nursing Labour Force, AIHW 1997

AMWAC 1998.6 140

Geographic Location The geographic location of nurses employed as clinicians in midwifery, obstetrics and gynaecology in 1995 indicated that the majority (74.1%) were based in capital cities/metropolitan centres, 23.9% were located in rural areas and 1.9% were in remote areas (Table H3).

Table H3: Nurses employed as clinicians in midwifery and obstetrics and gynaecology, by geographic location, 1995

Geographic location

%

Capital city

66.2

Other metropolitan centre

7.9

large rural centre

11.3

Small rural centre

6.9

Other rural area

5.7

Remote centre

1.2

Other remote area

0.9

Source: Nursing Labour Force, AIHW 1997 Hours Worked The average hours worked by nurses employed as clinicians in midwifery, obstetrics and gynaecology in 1995 was 32.3 hours. Those working part time (<35 hours) represented 53.0% and those working full time (35 hours+) was 47.0%. Work Setting Table H4 shows that 76.2% of nurses employed as clinicians in midwifery, obstetrics and gynaecology worked in the public sector and 23.8% worked in the private sector. Table H4: Nurses employed as clinicians in midwifery and obstetrics and gynaecology, by work setting of main job, 1995 Work setting

Hospital

Community

Agency

Other

Total

Public

72.3

0.8

0.9

2.2

76.2

Private

21.0

1.0*

0.6

1.3

23.8

* Medical (doctors rooms) Source: Nursing Labour Force, AIHW 1997 Current Supply of Midwives Each State/Territory health department was requested to provide recent data on nurses employed as clinicians in midwifery and information on known shortages or oversupply of midwives. There was an overall difficulty experienced by all State/Territories in

AMWAC 1998.6 141

providing baseline data on midwifery staff. It was not possible for Victoria, Queensland and South Australia to provide a response. Of those States/Territories that were able to provide information, all indicated there was an undersupply of midwives. New South Wales The Nurses Registration Board of New South Wales indicated that as of 30 December 1997, there were approximately 10,400 qualified nurses in midwifery/mothercraft of which 3,044 were currently working in midwifery. This leaves a potential pool of recruits of over 7,000 recruits. Of the 3,044 currently working midwives the largest age group is the 35 to 39 year olds at 26.2%. 63.7% of practising midwives were located in capital city/metropolitan areas, 20.7% were located in provincial city/rural areas and 0.2% were located in remote areas, 15.4% gave no response. A 1996 report conducted by the New South Wales Health Department, Workforce Planning Study for Maternity Service Nurses, Adult Critical & Intensive Care and Operating Room Nurses estimated that there is a shortage of maternity service nurses in New South Wales. This conclusion was based on an examination of various trends including demographic, utilisation patterns of hospital maternity services and trends in service delivery patterns in maternity services. It also found that; there has been a trend towards greater numbers of mothers planning to give birth in

a birthing centre from 723 in 1990 to 3,404 in 1994; there are significant differences between rural and metropolitan maternity services

with the segmentation of midwifery practice into large maternity units and a general under utilisation of midwifery skills in smaller hospitals, particularly in rural hospitals; and,

there is a need to enhance parenting education services and maternity services for women with special needs.

The report recommended that to address the gap between requirements of midwives and supply of services there is a need to: increase the number of nurses in the maternity services workforce; reduce the current wastage rate; maintain the current midwifery student numbers (320 per year); and ensure full employment of midwifery students.

Western Australia The Labour Force Survey Western Australia 1997 report which contributes to the AIHW National Labour Force collections indicated that there were 2,814 registered midwives, 2350 actually working and 931 working in midwifery. Midwives represented 16% of the nursing population.

AMWAC 1998.6 142

In Western Australia, the average age of midwife respondents have risen every year for which records are available, from 37.8 years in 1989 to 42.7 years in 1997. A greater proportion of midwives than would be expected of the total nursing population reported that their main job was in rural Western Australia (32% compared to 27% nationally) and fewer midwife respondents worked in the private sector for their main job than was observed for nurses as a whole (27% compared to 30% nationally). Total entrants to the nursing workforce are also decreasing, so it could be expected that fewer nurses will be available to go into midwifery in the future. Western Australia’s projected needs for midwives based on the 1995 Nurse Workforce Planning Project are for 70 new midwives Αproduced in Western Australia≅ to join the workforce per year. Currently, Western Australia does not reach this figure as many students switch from full time to part time, and others do midwifery so they can go on to child health. In December 1996, for example, there were 26 metropolitan and 40 rural midwifery vacancies. The number of agency staff used to temporarily cover midwifery positions was 369 in the metropolitan area and 20 in the rural area, all at considerable expense, and sometimes for considerable durations. 23% of surveyed sites predicted midwifery shortages during 1997 (Nursing Vacancies Survey Report Western Australia: June to December 1996). Western Australia indicated that there is an ongoing shortage of skilled midwives available to practice in rural and remote areas. Some towns had ceased obstetric services because midwives could not be provided. A pilot Rural Midwifery Course between King Edward Memorial Hospital and the rural Health Service Units is underway, with the first cohort of four students commencing the course in October 1997 with a second group of six expected to commence in March 1998. The students are required to give a commitment to return to a rural area as a midwife on completion of the course. South Australia A report produced for the South Australian Health Commission on the South Australian Midwifery Training Requirements 1997-2002 indicated that between May 1994 to September 1996 South Australian midwifery requirements declined from 1,288.4 to 1,112.7 FTEs. However, midwifery requirements are unlikely to decline further, particularly as the birth rate in South Australia is likely to remain steady at a little below 20,000 over the period 1997-2001. It was suggested that at least 109 midwives should be trained each year. Training numbers in South Australia have been historically low, for example, about 60 midwives in total were trained in the three years up to and including 1996. These low training numbers already appear to have had significant impact on the age profile of the

AMWAC 1998.6 143

midwifery workforce. The current age distribution shows less than 7% of working midwives are under the age of 30 years, while 45% are aged between 35 and 45 years. The current age distribution, which indicates 53% of the midwife workforce is aged over 40, lends considerable weight to the argument that training numbers should considerably exceed the levels of the past three years if the midwifery workforce size remains anywhere near its current level. The recommendations by the report were: that universities be notified of the future requirements; midwifery training numbers should be at least 109 per annum over the period 1997 to 2001; and a review be done in 1998-99. Tasmania Tasmania has 1,863 licensed midwives. 50.7% (942) of midwives are aged over 45 years. A 1996 survey by the Nursing Board of Tasmania found that 31.4% (604) of respondents practised midwifery or used their skills in a practice setting which is not exclusively midwifery (ie. family child health nurse, family planning nurse). Those working directly in midwifery totalled 357 (18.5%). Of nurses working directly in midwifery 165 worked in the Southern Region, 116 in the Northern Region and 76 worked the Northwest Region. The survey also found that 554 (47.8%) of licensed midwives had not utilised their skills for in excess of five years. With the implementation of the Board=s new Competence to Practice Policy on 1 July 1998, it is hypothesised that the number of licensed midwives will drop by anywhere between 50% and 70%, giving approximate numbers of licensed midwives from 1 September 1998 to between 930 and 560. The number of graduates in midwifery during 1992 to 1997 was 158 graduates. With hospital based training in Tasmania ceased in 1997 the future training of midwives has raised concerns for the future midwifery workforce. It has been estimated that Tasmania will require at least 20 midwife graduates per year. Arrangements have begun to be formulated with Flinders University in South Australia to provide the necessary training to those students who wish to take up midwifery and practice in Tasmania. Northern Territory Table H5 represents the actual and establishment requirement for midwives in the Northern Territory and indicates there is a definite shortage of community midwives in the Northern Territory. A major problem with attracting and maintaining midwives in the Northern Territory is the professional and personal isolation experienced by the midwives. Another factor that may contribute to the high turnover rates is that a majority of midwives are from interstate and are working their way across Australia.

AMWAC 1998.6 144

The Northern Territory Health Services also holds a 14 day cultural experience rotation for community nurses which tries to address cultural issues that are relevant to the large Aboriginal population in the Northern Territory. Table H5: Midwives in the Northern Territory, by type of employment category (FTE), December 1997 Area of employment

Actual (FTE)

Requirement(FTE)

Public hospital - Darwin

44

44

Public hospital - rural and remote

77

74

Community urban

8

15

Community remote

15

48

Flight nurses (with double certificate)

15

15

Specialised women=s health service

4

4

Educators

4

4

Source: Northern Territory Health Services Issues Anecdotally, midwives are reluctant to participate in the workforce in a midwifery capacity for several reasons, including legal and ethical issues, remuneration, recognition of qualifications, opportunities to apply and maintain specialist skills, the impact of the staffing arrangements offered in terms of compatibility with family responsibilities and financial security offered by limited shift patterns. The modes of health care delivery also have not encouraged team work and mutual recognition of skills between medical and midwifery staff, with an atmosphere of demarcation existing in some instances. It is anticipated that a move toward models in which continuity of care and a team approach is used may improve this situation, as well as the overall quality of care for the patient. While the figures show that a only a low percentage of those registered as midwives are actually practising in midwifery, there are a number of related nursing fields in which a midwifery qualification is of great utility, such as neo-natal intensive care, child health, and community nursing, as well as geographic factors which, while precluding the formal practice of midwifery in small and remote locations, continues to render the possession of midwifery qualifications desirable in at least one staff member, in case of emergency. Midwifery qualifications and registration may also have been a valuable part of achieving a management or administrative position, but return to midwifery practice is unlikely.

AMWAC 1998.6 145

Analysis is yet to be undertaken to determine to what level these factors would raise the proportion of midwifery registrants who use their midwifery qualifications or perceive them to be necessary to their current employment. In short, the proportion of midwifery registrants who are actively employed in midwifery does not comprehensively depict the application of midwifery skills in Australia, nor does it mean that those midwives not currently employed in midwifery are or would be available to move into that field. There is also a range of education issues that are currently under discussion which are outside the concerns of this review but may affect the future midwifery workforce. This includes: The transfer of midwifery education to the higher education sector has been

accepted as a positive way forward by the midwifery profession in Australia and the need for universities to be more flexible with practice based courses as well as the need for close collaboration between service providers and universities to achieve success of midwifery education programs.

Midwifery is currently considered under legislation as a specialty of nursing in all

States, however, there is currently a debate as to whether potential candidates for midwifery can enroll directly into a midwifery degree without having to first undertake a general nursing training degree and therefore not prolong the training period, and making the midwifery qualification subject to HECS rather than a full fee paying status. While this decision is being disputed, the current situation is considered to pose a threat to enrollment, as does the lack of recognition for the additional skills and qualifications gained.

Furthermore, a prospective midwifery student can choose to remain in a nursing

position and be rewarded for years of experience with no further requirement for formal study other than professional updating. Midwifery does not result in any special allowance despite the nature of the increased responsibility and accountability that is expected of the practitioner.

With the move towards the evolving models of care the role of a midwife is expected

to change. This will require new skills/education, increased responsibility and therefore increased autonomy by midwives. It is anticipated that industrial and other implications may arise with the new roles associated with new service models.

AMWAC 1998.6 145

APPENDIX I: AIHW NATIONAL HOSPITAL MORBIDITY DATA Obstetrics and Gynaecology National Hospital Morbidity Data Source Data relating to obstetrics and gynaecology procedures were extracted from the AIHW National Hospital Morbidity Database. The National Hospital Morbidity Database is a compilation of electronic summary records collected in public and private hospitals. Almost all hospitals in Australia are included. The exceptions are public hospitals not within the jurisdiction of a State or Territory health authority or the Department of Veterans= Affairs (that is, hospitals operated by the Department of Defence, for example, and hospitals located in off-shore Territories). In addition, data were not able to be supplied for the one private hospital in the Northern Territory, the private free-standing day hospital facilities in the Australian Capital Territory, the public psychiatric hospitals in Queensland and some private Victorian separations in 1993-94 and 1994-95. For 1995-96, a further expansion of the scope has occurred, with morbidity data for public psychiatric hospitals included for all but Queensland. Definitions Procedures Procedures are reported according to the ICD-9-CM codes (at the 3-digit level). The ICD-9-CM classification encompasses the National Health Data Dictionary definition whereby a procedure is one that is surgical in nature, carries a procedural risk, carries an anaesthetic risk, requires specialised training, or requires special facilities or equipment only available in an acute setting. The ICD-9-CM classification also includes non-surgical investigative and therapeutic procedures such as x-rays and chemotherapy. Obstetrical procedures Obstetrical procedures are defined as in the ICD-9-CM chapter of the same name. Gynaecological procedures Gynaecological procedures are defined as in the ICD-9-CM chapter Operations on the female genital organs. Private patient Either a patient who is eligible for Medicare who elects to be a private patient or a patient who is not eligible for Medicare. Public patient A patient who is eligible for Medicare who does receives treatment free of charge ie charges are paid through the Medicare Agreements, by the Department of Veterans’ Affairs or, less commonly, by other arrangements such as compensation, Defence Force entitlements or common law arrangements.

AMWAC 1998.6 146

Limitations of the Data Although the National Health Data Dictionary definitions form the basis of the definitions of the database, the actual definitions used may have varied among the data providers and from one year to another. In addition, fine details of the scope of the data collections may vary from one jurisdiction to another. Comparisons between years and sectors should therefore be made with caution. Comparison between years in this exercise has been limited by incomplete reporting of the private or public status of patients in 1993-94 and 1994-95.

AMWAC 1998.6 147

Table I1: Gynaecological procedures (ICD-9-CM groupings) undertaken on public and private patients (a), Australia, 1995−96

Unknown

Public

Private

patient

Procedure

patient

patient

status

Total

650

Oophorotomy

589

306

0

895

651

Diagnostic procedures on ovaries

429

536

0

965

652

Local excision or destruction of ovarian lesion or tissue

4,054

4,740

2

8,796

653

Unilateral oophorectomy

1,378

1,176

0

2,554

654

Unilateral salpingo-oophorectomy

2,522

2,384

1

4,907

655

Bilateral oophorectomy

507

500

0

1,007

656

Bilateral salpingo-oophorectomy

4,915

4,857

1

9,773

657

Repair of ovary

181

110

0

291

658

Lysis of adhesions of ovary and fallopian tube

2,285

2,546

1

4,832

659

Other operations on ovary

3,322

14,142

0

17,464

660

Salpingotomy and salpingostomy

1,095

574

0

1,669

661

Diagnostic procedures on fallopian tubes

77

437

0

514

662

Bilateral endoscopic destruction or occlusion of fallopian tubes

12,691

7,289

0

19,980

663

Other bilateral destruction or occlusion of fallopian tubes

3,384

1,728

0

5,112

664

Total unilateral salpingectomy

470

431

0

901

665

Total bilateral salpingectomy

446

303

0

749

666

Other salpingectomy

2,118

1,214

2

3,334

667

Repair of fallopian tube

1,008

672

0

1,680

668

Insufflation of fallopian tube

5,002

7,289

0

12,291

669

Other operations on fallopian tubes

509

5,331

0

5,840

670

Dilation of cervical canal

554

731

0

1,285

671

Diagnostic procedures on cervix

6,558

3,836

1

10,395

672

Conization of cervix

2,850

1,830

0

4,680

673

Other excision or destruction of lesion or tissue of cervix

17,767

15,267

5

33,039

674

Amputation of cervix

159

178

0

337

675

Repair of internal cervical os

431

437

0

868

676

Other repair of cervix

204

104

0

308

680

Hysterotomy

47

18

0

65

681

Diagnostic procedures on uterus and supporting structures

29,723

37,024

12

66,759

682

Excision or destruction of lesion or tissue of uterus

4,741

7,310

2

12,053

683

Subtotal abdominal hysterectomy

249

185

0

434

684

Total abdominal hysterectomy

9,935

9,433

3

19,371

685

Vaginal hysterectomy

7,076

7,494

2

14,572

686

Radical abdominal hysterectomy

307

309

0

616

687

Radical vaginal hysterectomy

17

13

0

30

688

Pelvic evisceration

42

26

0

68

689

Other and unspecified hysterectomy

248

257

0

505

690

Dilation and curettage of uterus

70,465

61,121

19

131,605

691

Excision or destruction of lesion or tissue of uterus and supporting structures

1,883

2,366

0

4,249

692

Repair of uterus supporting structures

708

594

1

1,303

693

Paracervical uterine denervation

59

169

0

228

694

Uterine repair

63

44

0

107

695

Aspiration curettage of uterus

25,895

26,530

6

52,431

696

Menstrual extraction or regulation

2

2

0

4

697

Insertion of intrauterine contraceptive device

1,108

842

1

1,951

699

Other operations on uterus, cervix, and supporting structures

588

4,369

0

4,957

700

Culdocentesis

248

524

0

772

701

Incision of vagina and cul-de-sac

970

10,876

0

11,846

AMWAC 1998.6 148

702 Diagnostic procedures on vagina and cul-de-sac 11,149 6,105 3 17,257 703

Local excision or destruction of vagina and cul-de-sac

2,263

2,950

0

5,213

704

Obliteration and total excision of vagina

40

45

0

85

705

Repair of cystocele and rectocele

8,300

9,062

0

17,362

706

Vaginal construction and reconstruction

15

63

0

78

707

Other repair of vagina

1,897

2,142

0

4,039

708

Obliteration of vaginal vault

134

145

0

279

709

Other operations on vagina and cul-de-sac

798

1,023

1

1,822

710

Incision of vulva and perineum

710

589

0

1,299

711

Diagnostic procedures on vulva

815

605

0

1,420

712

Operations on Bartholin's gland

1,796

1,235

1

3,032

713

Other local excision or destruction of vulva and perineum

2,677

2,417

3

5,097

714

Operations on clitoris

25

17

0

42

715

Radical vulvectomy

62

31

0

93

716

Other vulvectomy

120

100

0

220

717

Repair of vulva and perineum

495

433

0

928

718

Other operations on vulva

62

63

0

125

719

Other operations on female genital organs

103

64

0

167

Total

261,340

275,543

67

536,950

Source: AIHW National Hospital Morbidity Database (a) Private and public patients have been classified according to the 'patient accommodation status' data field. This field is defined in accordance with the National Health Data Dictionary. Private patients in this table comprise 'eligible private patients' and 'ineligible patients', public patients comprise 'eligible public patients', 'eligible DVA patients' and 'eligible other patients'. Table I2: Obstetrical procedures (ICD-9-CM groupings) undertaken on public and private patients(a), Australia, 1995−96

Unknown

Public

Private

patient

Procedure

patient

patient

status

Total

720

Low forceps operation

534

538

2

1,074

721

Low forceps operation with episiotomy

2,888

2,272

2

5,162

722

Mid forceps operation

5,920

5,729

0

11,649

723

High forceps operation

140

146

0

286

724

Forceps rotation of fetal head

1,686

1,702

1

3,389

725

Breech extraction

1,042

406

1

1,449

726

Forceps application to aftercoming head

62

30

0

92

727

Vacuum extraction

6,023

4,004

1

10,028

728

Other specified instrumental delivery

13

18

0

31

729

Unspecified instrumental delivery

46

31

0

77

730

Artificial rupture of membranes

50,146

25,413

5

75,564

731

Other surgical induction of labour

226

121

0

347

732

Internal and combined version and extraction

76

33

0

109

733

Failed forceps

477

298

0

775

734

Medical induction of labour

29,705

17,835

4

47,544

735

Manually assisted labour

10,814

3,884

1

14,699

736

Episiotomy

16,052

10,152

0

26,204

738

Operations on fetus to facilitate delivery

76

69

0

145

739

Other operations assisting delivery

353

62

0

415

740

Classical caesarian section

210

142

0

352

741

Low cervical caesarian section

27,643

19,476

4

47,123

742

Extraperitoneal caesarian section

3

3

0

6

743

Removal of extratubal ectopic pregnancy

51

31

0

82

744

Caesarian section of other specified type

11

5

0

16

749

Caesarian section of unspecified type

30

22

0

52

AMWAC 1998.6 149

750 Intra-amniotic injection for abortion 35 19 0 54 751

Diagnostic amniocentesis

380

81

2

463

752

Intrauterine transfusion

82

20

0

102

753

Other intrauterine operations on fetus and amnion

22,695

4,015

13

26,723

754

Manual removal of retained placenta

3,783

1,607

3

5,393

755

Repair of current obstetric laceration of uterus

225

66

0

291

756

Repair of other current obstetric laceration

49,173

25,568

8

74,749

757

Manual exploration of uterine cavity, postpartum

195

69

0

264

758

Obstetric tamponade of uterus or vagina

26

13

0

39

759

Other obstetric operations

174

117

0

291

Total

230,995

123,997

47

355,039

Source: AIHW National Hospital Morbidity Database

(a) Private and public patients have been classified according to the 'patient accommodation status' data field. This field is defined in accordance with the National Health Data Dictionary. Private patients in this table comprise 'eligible private patients' and 'ineligible patients', public patients comprise 'eligible public patients', 'eligible DVA patients' and eligible other patients'. Table I3: Percentages of obstetrical procedures (ICD-9-CM groupings) undertaken on public patients (a,b) in given age categories, Australia, 1995−96 in given age

(per cent)

Age (years)

Procedures

0−14

15−24

25−34

35−44

45−54

55−64

Total

720


0.0

31.5

56.2

12.2

0.2

0.0

100.0

721


0.1

33.2

57.6

9.0

0.1

0.0

100.0

722


0.1

32.0

58.5

9.4

0.1

0.0

100.0

723


0.0

31.4

60.0

8.6

0.0

0.0

100.0

724


0.1

31.7

57.8

10.1

0.3

0.0

100.0

725

Breech extraction

0.0

25.0

58.7

16.0

0.2

0.0

100.0

726


0.0

22.6

67.7

9.7

0.0

0.0

100.0

727

Vacuum extraction

0.2

32.0

58.2

9.6

0.1

0.0

100.0

728


0.0

23.1

69.2

7.7

0.0

0.0

100.0

729


0.0

32.6

56.5

10.9

0.0

0.0

100.0

730


0.1

35.8

55.0

9.1

0.0

0.0

100.0

731


0.0

37.6

52.7

9.7

0.0

0.0

100.0

732


0.0

31.6

52.6

14.5

1.3

0.0

100.0

733

Failed forceps

0.2

31.2

58.9

9.6

0.0

0.0

100.0

734


0.1

33.7

56.1

10.1

0.1

0.0

100.0

735


0.0

34.9

54.9

10.2

0.0

0.0

100.0

736

Episiotomy

0.1

34.2

56.3

9.4

0.0

0.0

100.0

738


0.0

28.9

51.3

19.7

0.0

0.0

100.0

739


0.0

24.9

61.8

13.3

0.0

0.0

100.0

740


0.5

21.0

57.6

20.5

0.5

0.0

100.0

741


0.1

24.5

60.1

15.2

0.1

0.0

100.0

742


0.0

33.3

66.7

0.0

0.0

0.0

100.0

743


0.0

29.4

52.9

17.6

0.0

0.0

100.0

744


0.0

27.3

63.6

9.1

0.0

0.0

100.0

749


0.0

16.7

70.0

13.3

0.0

0.0

100.0

750

Intra-amniotic injection for abortion

0.0

42.9

42.9

14.3

0.0

0.0

100.0

751


0.0

17.9

44.7

36.8

0.5

0.0

100.0

752


1.2

14.6

58.5

25.6

0.0

0.0

100.0

753


0.1

37.6

52.2

10.0

0.1

0.0

100.0

754


0.1

28.4

57.4

13.9

0.1

0.0

100.0

755


0.0

30.2

48.9

20.9

0.0

0.0

100.0

AMWAC 1998.6 150

756 Repair of other current obstetric laceration 0.1 31.1 58.3 10.5 0.0 0.0 100.0 757


0.5

32.3

52.3

14.9

0.0

0.0

100.0

758


0.0

34.6

46.2

19.2

0.0

0.0

100.0

759


1.1

28.7

52.9

14.9

1.7

0.6

100.0

Total

0.1

32.7

56.5

10.7

0.1

0.0

100.0


(a) Private and public patients have been classified according to the 'patient accommodation status' data field. This field is defined in accordance with the National Health Data Dictionary. Private patients in this table comprise 'eligible private patients' and 'ineligible patients', public patients comprise 'eligible public patients', 'eligible DVA patients' and 'eligible other patients'. (b) 47 patients were of unknown accommodation status - these are included in the total tables (Tables 17 and 18) but not in this public patient table nor in the private patient table.

AMWAC 1998.6 151

Table I4: Percentages of obstetrical procedures (ICD-9-CM groupings) undertaken on private patients (a,b) in given age categories, Australia, 1995−96

(per cent) Age (years)

Procedure

0−14 15−24

25−34

35−44

45−54

55−64

75+

Unkn.

Total

720


0.0

7.4

72.1

20.4

0.0

0.0

0.0

0.0

100.0

721


0.0

7.7

75.7

16.5

0.0

0.0

0.0

0.0

100.0

722


0.0

8.5

75.3

16.2

0.0

0.0

0.0

0.0

100.0

723


0.0

6.8

77.4

15.8

0.0

0.0

0.0

0.0

100.0

724


0.0

7.2

75.1

17.6

0.1

0.0

0.0

0.0

100.0

725

Breech extraction

0.2

3.2

75.1

21.4

0.0

0.0

0.0

0.0

100.0

726


0.0

0.0

76.7

23.3

0.0

0.0

0.0

0.0

100.0

727

Vacuum extraction

0.0

7.5

74.6

17.9

0.1

0.0

0.0

0.0

100.0

728


0.0

5.6

77.8

16.7

0.0

0.0

0.0

0.0

100.0

729


0.0

6.5

83.9

9.7

0.0

0.0

0.0

0.0

100.0

730


0.0

8.2

74.3

17.4

0.1

0.0

0.0

0.0

100.0

731


0.0

10.7

65.3

23.1

0.0

0.8

0.0

0.0

100.0

732


3.0

3.0

60.6

33.3

0.0

0.0

0.0

0.0

100.0

733

Failed forceps

0.0

9.7

74.2

16.1

0.0

0.0

0.0

0.0

100.0

734


0.0

8.0

73.6

18.3

0.1

0.0

0.0

0.0

100.0

735


0.0

6.9

73.1

19.8

0.2

0.0

0.0

0.0

100.0

736

Episiotomy

0.0

7.5

75.5

16.9

0.0

0.0

0.0

0.0

100.0

738


1.4

37.7

37.7

21.7

1.4

0.0

0.0

0.0

100.0

739


0.0

1.6

72.6

25.8

0.0

0.0

0.0

0.0

100.0

740


0.0

4.2

59.9

35.9

0.0

0.0

0.0

0.0

100.0

741


0.0

5.3

70.1

24.4

0.2

0.0

0.0

0.0

100.0

742


0.0

0.0

100.0

0.0

0.0

0.0

0.0

0.0

100.0

743


0.0

9.7

74.2

16.1

0.0

0.0

0.0

0.0

100.0

744

Ceasarian section of other specified type

0.0

0.0

100.0

0.0

0.0

0.0

0.0

0.0

100.0

749


0.0

0.0

63.6

31.8

4.5

0.0

0.0

0.0

100.0

750


0.0

21.1

57.9

21.1

0.0

0.0

0.0

0.0

100.0

751


0.0

2.5

35.8

61.7

0.0

0.0

0.0

0.0

100.0

752


0.0

0.0

50.0

50.0

0.0

0.0

0.0

0.0

100.0

753


0.0

8.2

70.2

21.5

0.1

0.0

0.0

0.0

100.0

754


0.0

4.8

70.9

24.0

0.2

0.0

0.0

0.0

100.0

755


0.0

6.1

72.7

21.2

0.0

0.0

0.0

0.0

100.0

756


0.0

6.8

74.1

19.0

0.0

0.0

0.0

0.0

100.0

757


0.0

1.4

78.3

20.3

0.0

0.0

0.0

0.0

100.0

758


0.0

30.8

53.8

15.4

0.0

0.0

0.0

0.0

100.0

759


0.0

7.7

72.6

17.1

0.9

0.9

0.9

0.0

100.0

Total

0.0

7.3

73.4

19.3

0.1

0.0

0.0

0.0

100.0


(a) Private and public patients have been classified according to the 'patient accommodation status' data field. This field is defined in accordance with the National Health Data Dictionary. Private patients in this table comprise 'eligible private patients' and 'ineligible patients', public patients comprise 'eligible public patients', 'eligible DVA patients' and 'eligible other patients'. (b) 47 patients were of unknown accommodation status - these are included in the total tables (Tables 17 and 18) but not in this private patient table nor in the public patient table.

AMWAC 1998.6 152

Table I5: Percentages of gynaecological procedures (ICD-9-CM groupings) undertaken on patients (both public and private) in given age categories, Australia, 1995−96

Age (years)

Procedure

0−14

15−24

25−34

35−44

45−54

55−64

65−74

75+

Unkn

.

Total

650

Oophorotomy

0.4

18.7

36.3

32.1

10.5

1.0

0.4

0.6

0.0

100.0

651


1.5

15.9

31.2

26.7

15.1

4.0

3.0

2.6

0.0

100.0

652


1.1

19.0

38.7

27.9

9.7

1.5

1.4

0.8

0.0

100.0

653


0.6

5.0

18.8

34.7

22.4

7.6

6.1

4.9

0.0

100.0

654


0.5

3.8

16.4

41.8

26.9

4.6

4.3

1.7

0.0

100.0

655


0.3

0.5

8.5

23.7

35.4

14.8

10.3

6.5

0.0

100.0

656


0.1

0.2

3.7

18.1

43.1

17.1

11.7

6.0

0.0

100.0

657

Repair of ovary

2.4

17.9

39.5

33.0

5.8

0.7

0.3

0.3

0.0

100.0

658


0.2

11.4

41.3

33.0

11.1

2.2

0.5

0.3

0.0

100.0

659


0.3

9.4

46.4

38.5

4.5

0.5

0.3

0.1

0.0

100.0

660


0.1

18.7

58.7

20.3

1.7

0.2

0.1

0.1

0.0

100.0

661


0.6

7.0

58.8

30.0

2.1

0.6

0.4

0.6

0.0

100.0

662


0.0

3.5

45.6

47.8

3.2

0.0

0.0

0.0

0.0

100.0

663


0.0

4.7

55.1

38.7

1.4

0.0

0.0

0.0

0.0

100.0

664


0.3

5.8

25.7

42.6

18.9

2.9

2.9

0.9

0.0

100.0

665


0.0

2.0

24.6

42.5

20.2

6.0

3.6

1.2

0.0

100.0

666

Other salpingectomy

0.6

16.6

48.8

26.8

5.6

1.2

0.4

0.2

0.0

100.0

667


0.0

4.2

52.8

41.5

1.4

0.1

0.0

0.0

0.0

100.0

668


0.0

13.8

59.8

25.5

0.8

0.0

0.0

0.0

0.0

100.0

669


0.1

6.2

53.9

37.6

1.9

0.2

0.0

0.0

0.0

100.0

670


0.7

17.7

31.1

26.2

13.5

5.7

3.5

1.6

0.0

100.0

671


0.1

21.6

30.9

22.4

13.9

5.7

3.5

1.9

0.0

100.0

672


0.0

10.8

28.3

29.7

17.1

8.3

4.6

1.2

0.0

100.0

673


0.0

20.2

31.7

24.2

15.6

5.5

2.3

0.6

0.0

100.0

674


0.3

1.2

6.5

19.9

19.6

19.0

19.0

14.5

0.0

100.0

675


0.0

12.3

59.1

27.6

0.6

0.2

0.1

0.0

0.0

100.0

676


0.0

15.9

37.0

29.2

12.7

2.3

2.6

0.3

0.0

100.0

680

Hysterotomy

1.5

15.4

26.2

16.9

16.9

6.2

7.7

9.2

0.0

100.0

681


0.1

6.8

22.0

28.2

26.6

9.8

4.8

1.8

0.0

100.0

682


0.0

5.6

20.3

35.1

25.7

8.2

3.8

1.3

0.0

100.0

683


0.0

1.6

9.4

39.2

35.3

6.2

5.8

2.5

0.0

100.0

684


0.0

0.3

9.5

37.2

37.1

8.0

5.2

2.6

0.0

100.0

685


0.0

0.3

9.1

31.9

27.0

11.7

13.1

7.1

0.0

100.0

686


0.0

0.3

9.9

24.4

19.8

18.3

17.2

10.1

0.0

100.0

687


0.0

0.0

6.7

30.0

23.3

20.0

16.7

3.3

0.0

100.0

688

Pelvic evisceration

0.0

0.0

14.7

11.8

14.7

22.1

20.6

16.2

0.0

100.0

689


0.0

1.0

11.5

36.8

32.9

9.1

4.4

4.4

0.0

100.0

690


0.1

13.3

31.3

27.3

17.5

6.2

3.1

1.2

0.0

100.0

691


0.3

23.7

40.5

26.6

7.3

0.8

0.6

0.2

0.0

100.0

692


0.0

9.5

28.1

19.5

11.8

10.9

13.4

6.8

0.0

100.0

693


0.9

33.3

38.2

23.7

3.9

0.0

0.0

0.0

0.0

100.0

694

Uterine repair

0.0

19.6

43.9

22.4

5.6

2.8

3.7

1.9

0.0

100.0

695


0.3

37.2

43.1

18.7

0.7

0.1

0.0

0.0

0.0

100.0

AMWAC 1998.6 153

696


0.0

75.0

0.0

25.0

0.0

0.0

0.0

0.0

0.0

100.0

697


0.1

14.0

41.0

35.8

9.1

0.1

0.0

0.0

0.0

100.0

699


0.1

3.3

49.3

42.3

2.5

1.0

1.1

0.5

0.0

100.0

700

Culdocentesis

1.2

27.8

36.4

24.5

7.3

1.7

0.8

0.4

0.0

100.0

701


0.4

4.6

48.6

41.6

2.6

0.9

0.7

0.5

0.0

100.0

702

Diagnostic procedures on vagina and cul-de-sac

1.2

22.9

31.4

21.6

11.9

5.2

3.6

2.1

0.0

100.0

703


1.2

25.9

31.1

21.3

10.6

5.2

3.1

1.5

0.0

100.0

704


3.5

0.0

5.9

14.1

20.0

16.5

28.2

11.8

0.0

100.0

705


0.0

0.2

4.2

15.6

23.7

21.0

23.7

11.5

0.0

100.0

706


6.4

14.1

17.9

21.8

15.4

7.7

11.5

5.1

0.0

100.0

707


1.7

3.4

7.9

17.1

24.5

19.1

18.6

7.6

0.0

100.0

708


0.0

0.0

3.6

9.0

16.1

20.4

27.6

23.3

0.0

100.0

709


0.3

1.0

4.6

11.6

21.7

19.2

26.6

15.0

0.0

100.0

710


10.6

19.6

30.6

15.6

10.3

6.7

4.1

2.5

0.0

100.0

711


1.5

8.8

13.9

17.2

16.1

13.8

17.2

11.5

0.0

100.0

712


0.2

17.4

32.2

28.9

15.9

3.4

1.6

0.5

0.0

100.0

713


1.3

32.1

24.1

16.8

11.9

5.8

4.9

3.1

0.0

100.0

714


45.2

7.1

11.9

9.5

4.8

4.8

4.8

11.9

0.0

100.0

715

Radical vulvectomy

1.1

0.0

2.2

5.4

14.0

15.1

26.9

35.5

0.0

100.0

716

Other vulvectomy

2.3

7.3

10.5

14.5

15.5

14.5

20.5

15.0

0.0

100.0

717


14.0

14.1

26.3

14.4

11.0

8.2

7.0

4.8

0.1

100.0

718


10.4

32.0

22.4

19.2

7.2

4.8

2.4

1.6

0.0

100.0

719


2.4

25.1

35.9

22.8

8.4

1.8

0.6

3.0

0.0

100.0

Total

0.3

13.3

30.9

27.9

15.8

6.0

4.0

1.8

0.0

100.0


Table I6: Percentages of obstetrical procedures (ICD-9-CM groupings) undertaken on patients (both public and private) in given age categories, Australia, 1995−96

Age (years) Per cent Procedure

0−14

15−24

25−34

35−44

45−54

55−64

75+

Unkn.

Total

720


0.0

19.4

64.1

16.5

0.1

0.0

0.0

0.0

100.0

721


0.1

22.0

65.6

12.3

0.1

0.0

0.0

0.0

100.0

722


0.0

20.4

66.8

12.7

0.1

0.0

0.0

0.0

100.0

723


0.0

18.9

68.9

12.2

0.0

0.0

0.0

0.0

100.0

724


0.0

19.4

66.5

13.9

0.2

0.0

0.0

0.0

100.0

725

Breech extraction

0.1

18.9

63.4

17.5

0.1

0.0

0.0

0.0

100.0

726


0.0

15.2

70.7

14.1

0.0

0.0

0.0

0.0

100.0

727

Vacuum extraction

0.1

22.2

64.8

12.9

0.1

0.0

0.0

0.0

100.0

728


0.0

12.9

74.2

12.9

0.0

0.0

0.0

0.0

100.0

729


0.0

22.1

67.5

10.4

0.0

0.0

0.0

0.0

100.0

730


0.1

26.5

61.5

11.9

0.0

0.0

0.0

0.0

100.0

731


0.0

28.2

57.1

14.4

0.0

0.3

0.0

0.0

100.0

732


0.9

22.9

55.0

20.2

0.9

0.0

0.0

0.0

100.0

733

Failed forceps

0.1

23.0

64.8

12.1

0.0

0.0

0.0

0.0

100.0

734


0.0

24.1

62.6

13.2

0.1

0.0

0.0

0.0

100.0

735


0.0

27.5

59.7

12.7

0.1

0.0

0.0

0.0

100.0

736

Episiotomy

0.1

23.8

63.7

12.3

0.0

0.0

0.0

0.0

100.0

738


0.7

33.1

44.8

20.7

0.7

0.0

0.0

0.0

100.0

AMWAC 1998.6 154

739 Other operations assisting delivery 0.0 21.4 63.4 15.2 0.0 0.0 0.0 0.0 100.0 740


0.3

14.2

58.5

26.7

0.3

0.0

0.0

0.0

100.0

741


0.0

16.6

64.2

19.0

0.1

0.0

0.0

0.0

100.0

742


0.0

16.7

83.3

0.0

0.0

0.0

0.0

0.0

100.0

743


0.0

22.0

61.0

17.1

0.0

0.0

0.0

0.0

100.0

744


0.0

18.8

75.0

6.3

0.0

0.0

0.0

0.0

100.0

749


0.0

9.6

67.3

21.2

1.9

0.0

0.0

0.0

100.0

750


0.0

35.2

48.1

16.7

0.0

0.0

0.0

0.0

100.0

751


0.0

15.6

43.0

41.0

0.4

0.0

0.0

0.0

100.0

752


1.0

11.8

56.9

30.4

0.0

0.0

0.0

0.0

100.0

753


0.1

33.2

54.9

11.8

0.1

0.0

0.0

0.0

100.0

754


0.1

21.4

61.5

16.9

0.1

0.0

0.0

0.0

100.0

755


0.0

24.7

54.3

21.0

0.0

0.0

0.0

0.0

100.0

756


0.0

22.8

63.7

13.4

0.0

0.0

0.0

0.0

100.0

757


0.4

24.2

59.1

16.3

0.0

0.0

0.0

0.0

100.0

758


0.0

33.3

48.7

17.9

0.0

0.0

0.0

0.0

100.0

759


0.7

20.3

60.8

15.8

1.4

0.7

0.3

0.0

100.0

Total

0.1

23.8

62.4

13.7

0.1

0.0

0.0

0.0

100.0


Table I7: Gynaecological procedures (ICD-9-CM groupings) undertaken on private patients as a percentage of total gynaecological procedures undertaken in given age categories, Australia, 1995−96

Age (years) Per cent

Procedure

0−14 15−24

25−34

35−44

45−54

55−64

65−74

75+

Unkn.

Total

650 Oophorotomy

0.0

22.2

33.2

42.5

34.0

55.6

25.0

20.0

n.a.

34.2

651


57.1

43.8

60.1

58.1

64.4

46.2

37.9

28.0

n.a.

55.5

652


54.1

41.2

53.9

58.8

61.8

68.4

56.3

52.9

n.a.

53.9

653


12.5

34.6

38.4

45.7

56.6

51.0

47.4

36.3

n.a.

46.0

654


26.9

28.5

35.2

49.0

58.7

54.2

46.2

48.8

n.a.

48.6

655


66.7

60.0

31.4

40.6

57.0

59.7

45.2

49.2

n.a.

49.7

656


40.0

33.3

39.1

45.7

53.5

54.0

44.1

39.9

n.a.

49.7

657

Repair of ovary

14.3

26.9

32.2

44.8

76.5

100.0

0.0

0.0

n.a.

37.8

658


25.0

42.2

50.6

57.2

56.6

60.7

46.2

57.1

n.a.

52.7

659


38.5

53.5

84.0

86.9

64.1

64.4

43.6

58.3

n.a.

81.0

660


0.0

13.8

35.1

50.7

44.8

25.0

100.0

0.0

n.a.

34.4

661


33.3

63.9

88.1

89.6

72.7

33.3

0.0

0.0

n.a.

85.0

662


n.a.

11.3

27.9

45.1

57.9

100.0

n.a.

n.a.

n.a.

36.5

663


50.0

12.0

27.9

43.5

70.0

100.0

n.a.

n.a.

n.a.

33.8

664


33.3

23.1

35.8

48.7

65.3

65.4

61.5

50.0

n.a.

47.8

665


n.a.

20.0

32.6

42.8

47.7

40.0

48.1

11.1

n.a.

40.5

666

Other salpingectomy

52.6

22.8

33.5

44.3

59.1

57.5

33.3

16.7

n.a.

36.4

667


n.a.

24.3

33.1

49.6

62.5

0.0

n.a.

n.a.

n.a.

40.0

668


100.0

41.1

60.5

66.0

67.3

0.0

50.0

100.0

n.a.

59.3

669


75.0

86.5

92.0

92.1

76.1

44.4

100.0

0.0

n.a.

91.3

670


33.3

42.1

55.3

66.2

69.4

53.4

46.7

40.0

n.a.

56.9

671


16.7

27.2

34.0

42.9

49.7

39.9

31.7

31.0

n.a.

36.9

672


0.0

25.4

33.7

42.1

50.1

45.6

32.9

37.9

100.0

39.1

AMWAC 1998.6 155

673 Other excision or destruction of lesion or tissue of cervix 28.6 34.1 42.4 52.5 57.2 55.1 45.9 39.4 n.a. 46.2 674


0.0

50.0

40.9

59.7

56.1

50.0

46.9

57.1

n.a.

52.8

675


n.a.

15.0

51.7

63.3

60.0

0.0

100.0

n.a.

n.a.

50.3

676


n.a.

20.4

28.1

46.7

41.0

28.6

25.0

0.0

n.a.

33.8

680

Hysterotomy

0.0

20.0

11.8

45.5

27.3

50.0

20.0

50.0

n.a.

27.7

681


59.2

44.6

56.7

56.7

58.1

55.9

47.8

41.0

100.0

55.5

682


100.0

52.5

60.1

62.1

64.3

59.3

48.8

35.0

n.a.

60.6

683


n.a.

57.1

34.1

41.8

51.0

25.9

32.0

27.3

n.a.

42.6

684


50.0

23.4

32.3

47.7

55.2

51.3

42.8

37.6

n.a.

48.7

685


n.a.

29.3

36.4

50.2

60.0

54.6

47.3

47.0

n.a.

51.4

686


n.a.

0.0

26.2

38.0

57.4

59.3

57.5

61.3

n.a.

50.2

687


n.a.

n.a.

50.0

11.1

57.1

66.7

60.0

0.0

n.a.

43.3

688

Pelvic evisceration

n.a.

n.a.

40.0

62.5

40.0

53.3

28.6

9.1

n.a.

38.2

689


n.a.

60.0

39.7

50.0

54.2

67.4

36.4

40.9

n.a.

50.9

690


35.8

30.5

43.5

50.5

55.2

54.1

46.4

41.0

100.0

46.4

691


30.8

44.0

57.3

62.3

64.4

36.4

51.9

25.0

100.0

55.7

692


n.a.

22.6

39.9

52.8

49.4

54.2

51.1

49.4

n.a.

45.6

693


50.0

73.7

70.1

77.8

100.0

n.a.

n.a.

n.a.

n.a.

74.1

694

Uterine repair

n.a.

14.3

40.4

58.3

66.7

66.7

25.0

50.0

n.a.

41.1

695


52.2

49.3

50.1

54.5

48.6

25.0

28.6

10.0

58.3

50.6

696


n.a.

66.7

n.a.

0.0

n.a.

n.a.

n.a.

n.a.

n.a.

50.0

697


0.0

26.3

37.9

50.1

65.0

100.0

n.a.

n.a.

n.a.

43.2

699


25.0

56.2

89.1

92.9

81.0

36.5

35.8

56.5

n.a.

88.1

700

Culdocentesis

44.4

53.0

72.2

79.9

66.1

84.6

50.0

33.3

n.a.

67.9

701


32.0

80.7

93.7

94.1

74.0

61.0

55.7

67.2

n.a.

91.8

702


31.6

26.5

33.8

40.5

45.6

40.9

33.4

36.8

100.0

35.4

703


47.5

45.6

58.8

62.1

63.8

63.7

60.1

46.2

100.0

56.6

704


66.7

n.a.

40.0

33.3

58.8

57.1

58.3

50.0

n.a.

52.9

705


100.0

27.5

38.8

53.4

58.8

54.2

48.1

47.0

n.a.

52.2

706


40.0

63.6

85.7

94.1

83.3

100.0

88.9

50.0

n.a.

80.8

707


26.5

34.8

43.7

53.0

58.1

57.6

52.5

50.3

n.a.

53.0

708


n.a.

n.a.

40.0

36.0

75.6

61.4

44.2

44.6

n.a.

52.0

709


66.7

52.6

60.2

55.0

65.2

58.2

52.5

46.7

n.a.

56.1

710


37.7

34.6

47.2

47.3

58.2

51.7

52.8

43.8

n.a.

45.3

711


22.7

45.6

45.2

50.0

49.8

42.9

34.0

31.3

n.a.

42.6

712


16.7

26.6

37.5

44.8

54.6

47.6

38.3

40.0

n.a.

40.7

713


40.9

40.8

47.7

50.4

58.6

54.6

45.2

47.2

n.a.

47.4

714


31.6

0.0

60.0

25.0

100.0

50.0

0.0

80.0

n.a.

40.5

715

Radical vulvectomy

0.0

n.a.

0.0

0.0

30.8

35.7

40.0

36.4

n.a.

33.3

716

Other vulvectomy

20.0

50.0

39.1

71.9

41.2

46.9

42.2

33.3

n.a.

45.5

717


26.9

28.2

49.6

56.7

65.7

61.8

44.6

44.4

100.0

46.7

718


30.8

35.0

67.9

66.7

66.7

66.7

0.0

0.0

n.a.

50.4

719


0.0

40.5

38.3

42.1

35.7

66.7

0.0

20.0

n.a.

38.3

Total

38.2

39.0

50.4

55.9

56.8

54.0

46.4

43.0

82.1

51.3


AMWAC 1998.6 156

Table I8: Obstetrical procedures (ICD-9-CM groupings) undertaken on private patients as a percentage of total Obstetrical procedures undertaken in given age categories, Australia, 1995−96

Age (years) Per cent

Procedure

0−14

15−24

25−34

35−44

45−54

55−64

75+

Unkn.

Total

720


n.a.

19.2

56.4

62.1

0.0

n.a.

n.a.

n.a.

50.1

721


0.0

15.5

50.8

59.0

25.0

n.a.

n.a.

n.a.

44.0

722


0.0

20.5

55.5

62.6

33.3

n.a.

n.a.

n.a.

49.2

723


n.a.

18.5

57.4

65.7

n.a.

n.a.

n.a.

n.a.

51.0

724


0.0

18.7

56.7

63.7

16.7

n.a.

n.a.

n.a.

50.2

725

Breech extraction

100.0

4.7

33.2

34.3

0.0

n.a.

n.a.

n.a.

28.0

726


n.a.

0.0

35.4

53.8

n.a.

n.a.

n.a.

n.a.

32.6

727

Vacuum extraction

0.0

13.4

46.0

55.3

42.9

n.a.

n.a.

n.a.

39.9

728


n.a.

25.0

60.9

75.0

n.a.

n.a.

n.a.

n.a.

58.1

729


n.a.

11.8

50.0

37.5

n.a.

n.a.

n.a.

n.a.

40.3

730


7.0

10.4

40.6

49.2

46.7

0.0

n.a.

n.a.

33.6

731


n.a.

13.3

39.9

56.0

n.a.

100.0

n.a.

n.a.

34.9

732


100.0

4.0

33.3

50.0

0.0

n.a.

n.a.

n.a.

30.3

733

Failed forceps

0.0

16.3

44.0

51.1

n.a.

n.a.

n.a.

n.a.

38.5

734


9.1

12.5

44.1

52.2

50.0

n.a.

n.a.

n.a.

37.5

735


0.0

6.6

32.4

41.2

66.7

n.a.

n.a.

n.a.

26.4

736

Episiotomy

0.0

12.2

45.9

53.2

62.5

100.0

n.a.

n.a.

38.7

738


100.0

54.2

40.0

50.0

100.0

n.a.

n.a.

n.a.

47.6

739


n.a.

1.1

17.1

25.4

n.a.

n.a.

n.a.

n.a.

14.9

740


0.0

12.0

41.3

54.3

0.0

n.a.

n.a.

n.a.

40.3

741


9.1

13.3

45.1

53.0

49.2

0.0

n.a.

n.a.

41.3

742


n.a.

0.0

60.0

n.a.

n.a.

n.a.

n.a.

n.a.

50.0

743


n.a.

16.7

46.0

35.7

n.a.

n.a.

n.a.

n.a.

37.8

744


n.a.

0.0

41.7

0.0

n.a.

n.a.

n.a.

n.a.

31.3

749


n.a.

0.0

40.0

63.6

100.0

n.a.

n.a.

n.a.

42.3

750


n.a.

21.1

42.3

44.4

n.a.

n.a.

n.a.

n.a.

35.2

751


n.a.

2.8

14.6

26.3

0.0

n.a.

n.a.

n.a.

17.5

752


0.0

0.0

17.2

32.3

n.a.

n.a.

n.a.

n.a.

19.6

753


0.0

3.7

19.2

27.5

13.6

n.a.

n.a.

n.a.

15.0

754


0.0

6.7

34.4

42.3

57.1

n.a.

n.a.

n.a.

29.8

755


n.a.

5.6

30.4

23.0

n.a.

n.a.

n.a.

n.a.

22.7

756


2.8

10.2

39.8

48.5

30.8

n.a.

100.0

100.0

34.2

757


0.0

1.6

34.6

32.6

n.a.

n.a.

n.a.

n.a.

26.1

758


n.a.

30.8

36.8

28.6

n.a.

n.a.

n.a.

n.a.

33.3

759


0.0

15.3

48.0

43.5

25.0

50.0

100.0

n.a.

40.2

Total

5.7

10.6

41.1

49.2

41.6

50.0

100.0

100.0

34.9


AMWAC 1998.6 157

Table I9: Relative growth in gynaecological procedures (ICD-9-CM groupings), Australia, 1993−94 to 1995−96

Procedure

1993−94

%

1994−95

%

1995−96

%

% increase 1993−94 to

1995−96 709


136

180

1,822

1239.7

689


179

314

505

182.1

696


2

2

4

100.0

661


281

373

514

82.9

706


46

68

78

69.6

693


139

201

228

64.0

660


1,203

1,577

1,669

38.7

687


22

19

30

36.4

691


3,297

3,716

4,249

28.9

702


13,420

17,754

17,257

28.6

717


730

849

928

27.1

681


52,663

66,317

66,759

26.8

671


8,341

11,444

10,395

24.6

669


4,713

5,261

5,840

23.9

703


4,212

4,712

5,213

23.8

707


3,339

3,657

4,039

21.0

673


27,722

35,941

33,039

19.2

650

Oophorotomy

757

932

895

18.2

714


36

60

42

16.7

670


1,106

1,672

1,285

16.2

699


4,280

4,641

4,957

15.8

659


15,149

16,398

17,464

15.3

710


1,135

1,170

1,299

14.4

701


10,386

11,366

11,846

14.1

685


12,814

14,235

14,572

13.7

652


7,760

8,564

8,796

13.4

676


272

341

308

13.2

695


46,620

50,981

52,431

12.5

657

Repair of ovary

260

289

291

11.9

716

Other vulvectomy

199

271

220

10.6

658


4,392

4,598

4,832

10.0

656


8,900

9,959

9,773

9.8

705


15,925

16,990

17,362

9.0

664


829

850

901

8.7

682


11,109

11,781

12,053

8.5

Total

498,590

548,047

536,950

7.7

718 Other operations on vulva

117

135

125

6.8

680

Hysterotomy

61

50

65

6.6

654


4,648

4,978

4,907

5.6

668


11,757

11,935

12,291

4.5

655


964

1,043

1,007

4.5

666

Other salpingectomy

3,211

3,298

3,334

3.8

712


2,928

3,143

3,032

3.6

713


4,968

5,006

5,097

2.6

683


424

463

434

2.4

653


2,520

2,575

2,554

1.3

AMWAC 1998.6 158

715 Radical vulvectomy 92 96 93 1.1 711


1,420

1,555

1,420

0.0

651


981

1,199

965

-1.6

663


5,217

5,262

5,112

-2.0

688

Pelvic evisceration

70

75

68

-2.9

665


772

767

749

-3.0

662


20,896

19,919

19,980

-4.4

694

Uterine repair

112

103

107

-4.5

690


138,511

141,859

131,605

-5.0

686


653

686

616

-5.7

684


20,910

21,028

19,371

-7.4

675


948

876

868

-8.4

672


5,113

5,937

4,680

-8.5

697


2,148

1,923

1,951

-9.2

692


1,485

1,463

1,303

-12.3

674


387

402

337

-12.9

667


1,973

1,745

1,680

-14.9

700

Culdocentesis

1,083

953

772

-28.7

719


256

240

167

-34.8

704


142

158

85

-40.1

708


1,449

1,692

279

-80.7


Table I10: Relative growth in obstetrical procedures (ICD-9-CM groupings) , Australia, 1993−94 to 1995−96

Procedure

1993−94

%

1994−95

%

1995−96

%

% increase 1993−94 to

1995−96 738


7

11

145

1971.4

753


11,512

20,822

26,723

132.1

758


17

33

39

129.4

734


28,768

33,670

47,544

65.3

739


275

335

415

50.9

757


176

230

264

50.0

752


74

128

102

37.8

759


246

279

291

18.3

727

Vacuum extraction

8,540

9,559

10,028

17.4

755


253

281

291

15.0

Total

317,522

345,036

355,039

11.8

733 Failed forceps

697

745

775

11.2

730


68,454

74,396

75,564

10.4

751


430

419

463

7.7

756


70,750

75,603

74,749

5.7

735


14,624

16,932

14,699

0.5

742


6

6

6

0.0

732


111

138

109

-1.8

754


5,497

5,854

5,393

-1.9

741


48,057

48,575

47,123

-1.9

744


17

25

16

-5.9

724


3,625

3,484

3,389

-6.5

725

Breech extraction

1,597

1,672

1,449

-9.3

AMWAC 1998.6 159

721 Low forceps operation with episiotomy 5,818 5,376 5,162 -11.3 740


400

477

352

-12.0

736

Episiotomy

29,778

28,828

26,204

-12.0

722


13,568

13,168

11,649

-14.1

720


1,296

1,281

1,074

-17.1

723


347

310

286

-17.6

750


107

78

54

-49.5

729


212

129

77

-63.7

726


268

162

92

-65.7

743


310

164

82

-73.5

731


1,315

1,677

347

-73.6

749


207

85

52

-74.9

728


163

104

31

-81.0


Table I11: Percentage of gynaecological procedures (ICD-9-CM groupings) undertaken on private patients (a) sorted by extent of private involvement, Australia 1995−96 Procedure

% of

procedures on private

patients

Total

procedures (public&

private patients) (no.)

701


91.8

11,846

669


91.3

5,840

699


88.1

4,957

661


85.0

514

659


81.0

17,464

706


80.8

78

693


74.1

228

700

Culdocentesis

67.9

772

682


60.6

12,053

668


59.3

12,291

670


56.9

1,285

703


56.6

5,213

709


56.1

1,822

691


55.7

4,249

651


55.5

965

681


55.5

66,759

652


53.9

8,796

707


53.0

4,039

704


52.9

85

674


52.8

337

658


52.7

4,832

705


52.2

17,362

708


52.0

279

685


51.4

14,572

Total

51.3

536,950

689 Other and unspecified hysterectomy

50.9

505

695


50.6

52,431

718


50.4

125

675


50.3

868

686


50.2

616

AMWAC 1998.6 160

696 Menstrual extraction or regulation 50.0 4 655


49.7

1,007

656


49.7

9,773

684


48.7

19,371

654


48.6

4,907

664


47.8

901

713


47.4

5,097

717


46.7

928

690


46.4

131,605

673


46.2

33,039

653


46.0

2,554

692


45.6

1,303

716

Other vulvectomy

45.5

220

710


45.3

1,299

687


43.3

30

697


43.2

1,951

683


42.6

434

711


42.6

1,420

694

Uterine repair

41.1

107

712


40.7

3,032

665


40.5

749

714


40.5

42

667


40.0

1,680

672


39.1

4,680

719


38.3

167

688

Pelvic evisceration

38.2

68

657

Repair of ovary

37.8

291

671


36.9

10,395

662


36.5

19,980

666

Other salpingectomy

36.4

3,334

702


35.4

17,257

660


34.4

1,669

650

Oophorotomy

34.2

895

663


33.8

5,112

676


33.8

308

715

Radical vulvectomy

33.3

93

680

Hysterotomy

27.7

65


(a) Private and public patients have been classifed according to the 'patient accommodation status' data field. This field is defined in accordance with the National Health Data Dictionary. Private patients in this table comprise 'eligible private patients' and 'ineligible patients', public patients comprise 'eligible public patients', 'eligible DVA patients' and eligible other patients'.

AMWAC 1998.6 161

Table I12: Percentage of obstetrical procedures (ICD-9-CM groupings) undertaken on private patients (a) sorted by extent of private involvement, Australia 1995−96 Procedure

% of procedures on private

patients

Total procedures (public&

private patients) (no.) 728


58.1

31

723


51.0

286

724


50.2

3,389

720


50.1

1,074

742


50.0

6

722


49.2

11,649

738


47.6

145

721


44.0

5,162

749


42.3

52

741


41.3

47,123

729


40.3

77

740


40.3

352

759


40.2

291

727

Vacuum extraction

39.9

10,028

736

Episiotomy

38.7

26,204

733

Failed forceps

38.5

775

743


37.8

82

734


37.5

47,544

750


35.2

54

731


34.9

347

Tot

Total

34.9

355,039

756 Repair of other current obstetric laceration

34.2

74,749

730


33.6

75,564

758


33.3

39

726


32.6

92

744


31.3

16

732


30.3

109

754


29.8

5,393

725

Breech extraction

28.0

1,449

735


26.4

14,699

757


26.1

264

755


22.7

291

752


19.6

102

751


17.5

463

753


15.0

26,723

739


14.9

415

Source: AIHW National Hospital Morbidity Database (a) Private and public patients have been classified according to the 'patient accommodation status' data field. This field is defined in accordance with the National Health Data Dictionary. Private patients in this table comprise 'eligible private patients' and 'ineligible patients', public patients comprise 'eligible public patients', 'eligible DVA patients' and eligible other patients'.

AMWAC 1998.6 162

Table I13: Projected (a) gynaecological procedures (ICD-9-CM groupings) for 1998 and 2018, Australia

1998

2018

Forecast growth

Procedure

forecast

(no.)

forecast

(no.)

1998 to 2018

(per cent) 715

Radical vulvectomy

98

147

49.6

708


294

438

49.0

709


1,915

2,776

44.9

705


18,274

26,200

43.4

688

Pelvic evisceration

71

102

42.3

704


89

126

42.0

674


355

495

39.4

707


4,240

5,828

37.5

716

Other vulvectomy

230

314

36.7

686


647

878

35.7

656


10,404

14,034

34.9

687


32

42

34.3

711


1,481

1,965

32.7

655


1,067

1,395

30.7

685


15,359

19,703

28.3

692


1,350

1,684

24.8

706


81

98

21.8

689


534

647

21.2

684


20,527

24,831

21.0

680

Hysterotomy

67

81

20.4

683


459

549

19.6

681


69,947

83,619

19.5

653


2,676

3,186

19.0

717


956

1,131

18.3

682


12,636

14,813

17.2

714


43

50

16.5

672


4,860

5,638

16.0

713


5,221

6,032

15.5

654


5,153

5,935

15.2

710


1,334

1,525

14.3

Total

556,291

633,907

14.0

665 Total bilateral salpingectomy

784

891

13.7

690


136,472

155,104

13.7

671


10,711

12,171

13.6

670


1,326

1,499

13.0

702


17,742

20,051

13.0

673


34,091

38,302

12.4

703


5,346

6,004

12.3

651


998

1,120

12.2

718


128

142

11.5

664


939

1,040

10.7

712


3,133

3,449

10.1

694

Uterine repair

110

120

9.1

676


317

345

8.8

719


171

185

8.1

652


9,038

9,682

7.1

700

Culdocentesis

789

842

6.7

AMWAC 1998.6 163

696


4

4

6.7

658


4,990

5,323

6.7

650

Oophorotomy

921

978

6.2

691

Excision or destruction of lesion or tissue of uterus and supporting struct

4,346

4,584

5.5

666

Other salpingectomy

3,417

3,575

4.6

657

Repair of ovary

298

312

4.6

693


232

242

4.2

697


2,009

2,094

4.2

695


53,008

54,961

3.7

699


5,111

5,284

3.4

659


17,970

18,557

3.3

701


12,206

12,597

3.2

661


528

542

2.7

660


1,702

1,747

2.7

662


20,620

21,013

1.9

675


888

904

1.9

668


12,557

12,787

1.8

669


6,003

6,112

1.8

667


1,729

1,754

1.4

663


5,257

5,331

1.4

Sources: AIHW National Hospital Morbidity Database and ABS population data.

(a) The projections have been based on morbidity data for 1995Β96.

Table I14: Projected (a) obstetrical procedures (ICD-9-CM groupings) for 1998 and 2018, Australia

1998

2018

Forecast growth

Procedure

forecast

(no.)

forecast

(no.)

1998 to 2018

(per cent) 738


147

152

3.3

750


55

56

3.2

759


296

305

3.1

758


39

41

3.1

753


27,012

27,822

3.0

731


352

362

2.8

735


14,893

15,270

2.5

732


111

114

2.5

730


76,574

78,438

2.4

755


296

303

2.4

757


268

274

2.3

734


48,237

49,326

2.3

Total

360,290

368,366

2.2

736 Episiotomy

26,583

27,173

2.2

756


75,875

77,504

2.1

733

Failed forceps

786

803

2.1

743


83

85

2.1

754


5,482

5,597

2.1

727

Vacuum extraction

10,181

10,394

2.1

721


5,240

5,349

2.1

751


474

484

2.1

739


422

430

2.0

729


78

80

2.0

722


11,834

12,064

1.9

AMWAC 1998.6 164

720 Low forceps operation 1,092 1,113 1.9 725

Breech extraction

1,474

1,503

1.9

724


3,445

3,511

1.9

723


291

296

1.8

741


48,005

48,842

1.7

740


360

366

1.7

744


16

17

1.7

749


53

54

1.7

726


94

95

1.5

752


104

106

1.5

742


6

6

1.4

728


32

32

1.3

Sources: AIHW National Hospital Morbidity Database and ABS population data. (a) The projections have been based on morbidity data for 1995−96.

AMWAC 1998.6 165

REFERENCES Australian Bureau of Statistics (1994), Projections of the Populations of Australia, States and Territories: 1993 to 2041, Catalogue no. 3222.0, Canberra Australian Bureau of Statistics (1997), Australian Demographic Situation, June Quarter 1997, Catalogue no. 3101.0, Canberra Australian Institute of Health and Welfare (1996), Australia's Health 1994, Canberra Australian Institute of Health and Welfare (1997), Medical Health Labour Force 1995, unpublished data collection Australian Institute of Health and Welfare (1997), Obstetrics and Gynaecology Labour Force Profile, 1994, unpublished data collection Australian Medical Workforce Advisory Committee & Australian Institute of Health and Welfare (1996), Australian Medical Workforce Benchmarks, AMWAC Report 1996.1, Sydney Australian Medical Workforce Advisory Committee & Australian Institute of Health and Welfare (1997), Female Participation In The Australian Medical Workforce, AMWAC Report 1997.7, Sydney Australian Society for Obstetrics and Gynaecology (1997), Position Statement Obstetrics and Gynaecology Services in General Hospitals, Australian Journal on Ageing, 15:2 British Obstetrics and Gynaecology Society (1994), For Health in Old Age, Guidelines: Policy Statement and Statement of Good Practice Cancer in Australia 1991-1994 (with Projections to 1999), Australian Institute of Health Welfare 1998 Department of Health, Housing, Local Government and Community Services, Aged and Community Care Division (1993), National Survey of Hospital Obstetrics and Gynaecology Services - A Study of Hospital-Based Obstetrics and Gynaecology Services in Australia, Canberra, February 1993 Department of Primary Industries and Energy and Department of Human Services and Health (1994), Rural, Remote and Metropolitan Areas Classification, Canberra

AMWAC 1998.6 166

Enkin M, Keirse M, Renfrew M, Neilson J, (1996) Guide to Effective Care in Pregnancy and Childbirth, New York Eagly A H, (1987) Sex differences in social behaviour: A social-role interpretation, Lawrence Erlbaum: New Jersey Fondren L, Ricketts,T, The north Carolina Obstetrics Access and Professional Liability Study: A Rural/Urban Analysis, The Journal of Rural Health 1993:129-37 Greenberg, D, Hochheiser, L, Family Practice Resident=s Decision making Regarding Future Practice of Obstetrics, Journal American Board of Family Practice, January-February 7: 25-30, 1994. Greer, T, Baldwin, L, Wu, R, Hart, G, Rosenblatt, R,.ΑCan Physicians Be Induced To Resume Obstetric Practice? Journal of American Board of Family Practice July-August 5:4 407-412 1992 Hays, R, Veitch, C, Cheers, B, Crossland L, Why Doctors Leave Rural Practice, Australian Journal of Rural Health (1997) 5, 198-203 Innes K, Why are GP’s Ceasing Obstetrics? A Study of Victorian General Practitioners who have Ceased Obstetric Practice 1989 - 1996, 1996. Nesbitt, T, Arevalo, J, Tanji, J, Morgan, W, Aved, B, Will Family Physicians Really Return to Obstetrics If Malpractice Insurance Premiums Decline? Journal of American Board of Family Practice July-August 5:4 413-418 1992 Nesbitt, T, Baldwin, L, Access to Obstetric Care, Primary Care, 20:3, September 1993 509-522 Health and Community Services, Birthing Issues - A Rural Perspective, Background Paper, Prepared by Review of Professional Indemnity Arrangements for Health Care Professionals. Department of Health, Housing, Local Government and Community Services, December 1993. Watts, R, Marley, K, Beilby, R, Doughty, M, Doughty, S, Training, Skills and Approach to High-risk obstetrics in Rural GP Obstetricians, Australian and New Zealand Journal of Obstetrics and Gynaecology (1997) 37:4:424-426 Woollard, L, Hays, R, Rural Obstetrics in NSW, Australian New Zealand Journal Obstetrics and Gynaecology 33:3, 240-242, 1993

AMWAC 1998.6 167

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The Obstetrics and Gynaecology Workforce in Australia

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