Surgical Workforce Projection to Volume 2 The New Zealand Workforce

Transcription

1 Surgical Workforce Projection to 2025 Volume 2 The New Zealand Workforce

2 Royal Australasian College of Surgeons ROYAL AUSTRALASIAN COLLEGE OF SURGEONS Department of Workforce Assessment College of Surgeons Gardens Spring Street EAST MELBOURNEE VIC 3002 Telephone: Facsimile: workforce@surgeons.org Internet: Suggested citation: RACS 2013: New Zealand Surgical Workforce Projection to

3 Glossary APC CAR CPD FTE FRACS GAC GEN IMG MOPS MCNZ NEU NTP NZ ORT OTO PAE PLA RACS SET URO VAS Annual Practicing Certificate Cardiothoracic Surgery Continuing Professional Development Full Time Equivalent Fellow of the Royal Australasian College of Surgeons Governance and Advocacy Committee General Surgery International Medical Graduate Maintenance of Professional Standards Medical Council of New Zealand Neurosurgery National Training Plan New Zealand Orthopaedic Surgery Otolaryngology, Head and Neck Surgery Paediatric Surgery Plastic and Reconstructive Surgery Royal Australasian College of Surgeons Surgical Education and Training Urology Surgery Vascular Surgery 3

4 Executive Summary The Royal Australasian College of Surgeons Workforce projections suggests that the present level of training and retention of surgeons will be sufficient to replace those retiring, permit some change in the work-lifestyle imbalance and address the increased health requirements of an ageing population. The modelling presented in the Surgical Workforce to 2025, Volume 2: New Zealand shows that an average of 27 surgeons have entered the workforce each year since This matches very closely the predicted requirement to replace those retiring and to permit some change in the worklifestyle imbalance Furthermore, a combination of growth in surgical training, increased productivity, and attraction of overseas trained surgeons will deliver a margin of surgeons additional to the minimal replacement requirements to meet the increasing demands of the ageing population. Below are some of the key drivers considered in this report: Between 2010 and 2025 the demand for surgical services, as a consequence of changing population demographics, can be expected to increase by approximately 40%. Modelling indicates that the number of New Zealand surgeons currently being trained will not be sufficient to meet the needs of the community during the next 15 years under the existing model of care. The anticipated significant increase in demand for surgical services in a fiscally constrained environment will drive changes in the way care is provided. Retention of surgeons in the workforce beyond the currently accepted age of retirement would effectively expand the available workforce. If surgeon retention is combined with increased efficiency in the use of resources and measures to improve the productivity of surgeons then it is anticipated that the projected workforce will be adequate in 2025 if the current rate of training is continued. These findings reflect the consideration of the impact of a number of factors upon the planning for future workforce requirements. These factors include 1. Changing population demographics. The New Zealand population is expected to increase by 13% by The population cohort aged 65 years and over will increase greatly. As those aged over 50 years (and particularly those aged over 65 years) place the greatest demand on surgical services, this significant ageing of the population will have a major influence on the future workforce. 2. Changing work patterns and structure of the workforce. Surgeons currently work an average of 50 hours/week (excluding on call). Based upon the recognised trends and surgeons expressed desires to have a better work-life balance it is considered likely that by 2025 surgeons will work fewer hours (RACS Workforce Census 2011). While the College acknowledges that the overall numbers are still relatively low, the percentage of women working in the surgical workforce has increased by 25% over the past 5 years and this increase is likely to continue as women now comprise the greater proportion of students entering medical schools. 4

5 A further factor is that an increasing percentage of medical students are older at the time of their entry into medical school and therefore their length of contribution to the surgical workforce following training is reduced. 3. Retirement. Currently the majority of surgeons substantially reduce their contribution to active patient care at about age 65 years. If that trend continues there will be the loss of 317 currently active surgeons during the next 15 years. With the community having a longer life expectancy, it has been strongly advocated that doctors should work for longer (a third age beyond the current accepted retirement age). If over the next 15 years 50% of surgeons worked until age 70 years there would be the retention of 159 of those 317 surgeons in the workforce for an additional 5 years. 4. RACS surgical training. During the period an average of 24 RACS trained surgeons entered the New Zealand workforce each year. In that same period there was a large increase in the number commencing training, with an average of 47 entering the SET programs each year in New Zealand. The majority of trainees complete their training and achieve independent specialist status. Unfortunately some are lost to the workforce as they subsequently secure long term employment outside New Zealand. 5. Overseas Trained Surgeons. New Zealand has been reliant upon the recruitment of overseas trained surgeons to meet its needs. Between 2005 and 2012 there is an average annual increase of 5 overseas trained surgeons on the vocational register. 6. Changes in community health. If the health of the community was to be improved this would reduce the need for healthcare support and surgery in particular. Reduction in the incidence of obesity would result in significant reductions in the development of type 2 diabetes, cancers and degenerative arthritis. Higher levels of activity within the community would assist the maintenance of muscle and bone, balance and independent living and reduce the incidence of osteoporotic fractures. Reduction of alcohol consumption would significantly reduce injury and illness. Unfortunately such societal change occurs only slowly and this is thought unlikely to have any significant impact over the time interval under review. 7. Health care funding limitation. Government has indicated clearly that funding for health care cannot be sustained at the previous levels and is likely to decrease in relative terms. This requires a re-evaluation of the way in which health care is provided. 8. Increased productivity. A 10% improvement in productivity as a consequence of greater efficiency in work process and altered models of care over the next 15 years has the potential to contribute the equivalent of 70 additional surgeons to the workforce. Whilst this report is based on the best information currently available, it is the College s view that given the rapidly changing health care environment workforce projections should be refined every three years. 5

6 Introduction The Royal Australasian College of Surgeons is a Fellowship based organisation serving nine surgical specialties. These are Cardiothoracic Surgery, General Surgery, Neurosurgery, Orthopaedic Surgery, Otolaryngology, Head and Neck Surgery, Plastic and Reconstructive Surgery, Paediatric Surgery, Urology and Vascular Surgery. Although the College currently has members from the professions of Ophthalmology and Obstetrics and Gynaecology, these specialties are not analysed in this report as they are represented by separate Colleges. Medical workforce numbers have become a growing area of concern for governments around the world. In the 1970s and 1980s, opinion alternated between the view that we had too few medical practitioners and then too many. In 2005 the College commissioned the Surgical Needs Analysis Project for New Zealand (Projections of Surgical Need: An analysis of the future need for surgery in New Zealand 2006: Raymont and Simpson). The report, prepared by the Health Services Research Centre at the Victoria University of Wellington, estimated the number of surgeons needed to meet the community demand to It was stated that there would be the necessity to increase surgeon numbers by up to 59% by 2026 (22% as a consequence of expected population increase, 33% as a consequence of population aging). At the time of publication it was estimated that the unmet need in most of the surgical specialties was 25%. In common with our population we have an aging workforce and a relatively large number of Fellows will retire from active practice over the next 15 years. However, the number of surgeons is just one factor that influences the provision of surgical services. Other factors include the availability of infrastructure, namely operating theatres, pre- and postoperative hospital beds, and appropriate equipment. Surgery is heavily dependent upon the availability of support staff, such as anaesthetists, radiologists, pathologists, nurses and allied health workers. Finally it has been increasingly recognised that in the hospital setting productivity is vitally dependent upon efficient work practices. More recently it has been stated by Government that funding of the public health services cannot be sustained at the previous levels. The time of continuing expansion of health services has ended, but it is important to plan for a 40% increase in demand for services over the next years with little likelihood of any associated increase in funding. Professor Des Gorman, Chair Health Workforce New Zealand, has repeatedly stated the absolute necessity to seek alternative models of care. The College s Australian report is complete (Surgical Workforce Projection to 2025, Volume One: Australia) and, along with this report, will form the basis of the College s ongoing efforts to better inform and influence decision makers in the ten governments and health departments/ministries across Australia and New Zealand. Using this comprehensive current information the College hopes to support the development of a properly resourced and sustainable surgical workforce in each country. 6

7 Background In this workforce review, any surgeon utilising their skill, knowledge and training as a health care professional in any capacity is considered an active surgeon. There is currently no differentiation between the different types of activity undertaken by surgeons. All doctors practising medicine in New Zealand are registered with the Medical Council of New Zealand and hold a current practice certificate issued under the Health Practitioners Competence Assurance Act (2003). For those with vocational registration participation in continuing professional development is a mandated requirement for annual re-certification. The College also mandates continuing professional development and uses this as one factor in the categorisation of a Fellow as active. An active status includes clinical and operative practice, medico-legal services, and other specialist non-procedural and non-clinical work such as surgical administration and education where surgical knowledge is engaged. The retirement age of the New Zealand population is approximately 65 years. While a number of surgeons continue to practise into their 70s and even 80s, surgeons typically reduce their hours worked at about 65 years of age. Their practice shifts from procedural work to encompass roles in consulting, medico legal reporting, education and management. Tables in this report detail Fellows of the College who are active, active and under the age of 65, and active and under the age of 70. Data from Statistics New Zealand, Projected Population of New Zealand, by Age and Sex, 2009 (base) to 2061 data series 5 (as at July 2011) was utilised. This data series assumes medium fertility, medium mortality and long run annual net migration of 10,000. Statistics New Zealand regularly reviews the New Zealand population data and its forward projections. In some surgical specialties, trainees move through rotations in both New Zealand and Australia. In these specialties most of the NZ trainees spend their final years in rotations in Australia and are frequently appointed to consultant positions in that country. This represents a loss to New Zealand. Following admission to Fellowship and the establishment of practice, the flow of surgeons between New Zealand and Australia decreases. The Medical Board of Australia requires overseas trained surgeons to be assessed by the Royal Australasian College of Surgeons as being of a standard comparable to a locally trained surgeon if they are to practise unsupervised, and almost all become fellows of the College. In contrast, the Medical Council of New Zealand in assessing International Medical Graduates (IMGs) for vocational registration requires confirmation that their qualifications, training and experience are comparable to or as satisfactory as those of a local graduate on the relevant vocational register. It explicitly states that IMGs are not required to be fellows of the Royal Australasian College of Surgeons in order to be vocationally registered in New Zealand. Consequently, a significant number of vocationally registered surgeons (approximately 10%) practising in New Zealand are not fellows of the College. However, for the purpose of this report s workforce scenario and projection calculations, the assumption is made that New Zealand surgeons who are fellows of the College and vocationally registered IMGs are considered to be comparable in their contribution to the surgical workforce. 7

8 Methodology Many factors influence the demand for health services and the health professional workforce required to meet those needs. These include: Changing technology; Increasing knowledge; Changing disease profiles; Changing population demographics; Changing work practices; Availability of hospital resources; and Funding availability, either through government or private health insurance. Data utilised in preparing this report is derived from previously published College surgical workforce reports. These reports include the Annual Activities Report (2005 to 2012) and Surgical Workforce Census (2005 and 2011). The reports are based on the College database, activities facilitated by the College and information supplied by its Fellows. The baseline data includes information in respect to active and retired surgeons, specialty, gender, age and hours worked. Statistics New Zealand data from the catalogue Projected Population of New Zealand, by Age and Sex, 2009 (base) 2061 at 20 March 2012 was also used in the development of this report. The Medical Council of New Zealand (MCNZ) Medical Workforce in 2011 is also referred to. This report utilises trends analysis over the period 2005 to The planning models in this report have been based upon the current ratio of surgeon to population. Using Statistics New Zealand projections for population change, ratios are developed to provide an informed estimate of future surgical workforce requirements to accommodate a number of possible scenarios. There is some variance in the data recorded by RACS and MCNZ. The number of surgeons recorded as active on the RACS database fails to match those recorded by MCNZ as having Vocational Registration. In 2012 the total number of surgeons with vocational registration, who held an annual practicing certificate and were also Fellows of the College, was 746 (Table 1). However, 713 Fellows of the College were recorded as residing in New Zealand with vocational registration by the Medical Council of New Zealand (Table 9). This may be explained in part by the timing of the data review (MCNZ register as of October and RACS database as of the end of December each year) allied with the timing of new graduates gaining vocational registration. The RACS database does not record the significant number of overseas trained doctors who have vocational registration but are not fellows of RACS. Recognising these difficulties, and the necessity for accurate data, Chapter 1 covers the data specific to RACS fellows. In subsequent chapters the data has been aligned (as accurately as possible) and also includes non-racs surgeons. Construction of mathematical models for analysis and projection modelling has been based upon a number of assumptions. These are outlined in the following section. 8

9 CHAPTER ONE: RACS SURGEONS CHARACTERISTICS AND DEMOGRAPHICS This chapter is based solely upon data in respect to RACS surgeons working in New Zealand. Age distribution In New Zealand there are 746 surgeons who are registered as active Fellows of the Royal Australasian College of Surgeons (Table 1). 85% are under the age of 65 (Table 2). Almost 10% of New Zealand RACS Fellows are female, similar to the proportion of Australian female RACS Fellows. Table 1. Characteristics of active RACS surgeons by specialty Specialty No. of surgeons % Female Average Age # % Under 55 % Under 65 CAR GEN NEU ORT OTO PAE PLA URO VAS Total Source: RACS Annual Activities Reports 2012 # Internal RACS data College data indicate that a small proportion of surgeons continue to practise beyond the age of 70 years (47 surgeons, or 6%). The majority of New Zealand Fellows are aged between 40 to 59 years. Table 2 shows that surgeons work well into their sixties, and makes up almost a quarter of the surgical workforce. Table 2. Characteristics of active RACS surgeons by specialty and age cohort Age group CAR GEN NEU ORT OTO PAE PLA URO VAS Total < Source: RACS Annual Activities Report

10 It is difficult to determine the amount of work undertaken by Fellows aged over 65 years who are still self determined to be active in procedural work. In this workforce assessment, it is assumed that by 2025 most surgeons currently aged 55 or more will be retired from procedural and consulting work. That is approximately 279 active Fellows (as of Dec 2012) who are expected to retire or significantly reduce their workload by Most of the remaining 467 Fellows are expected to still be active in Figure 1: Age group of active RACS surgeons by speciality Percentage of RACS surgeons per specialty CAR ( n=23) GEN ( n=229) NEU ( n=20) ORT ( n=256) OTO ( n=77) PAE ( n=16) PLA ( n=56) URO ( n=52) VAS ( n=17) Source: RACS Annual Activities Report yrs yrs yrs yrs 70+ yrs The number of active New Zealand Fellows continues to increase steadily. In the seven years since 2005 there has been an increase of 29%, or 167 Fellows (Table 3). Table 3. Active RACS surgeons by specialty and year Year CAR GEN NEU ORT OTO PAE PLA URO VAS TOTAL Source: RACS Annual Activities Reports

11 Trainee Intake During the past eight years, an average of 47 Trainees entered the SET programs in New Zealand each year (Table 4). Recognising that the SET programs are bi national for five of the smaller specialties some of those commencing training in New Zealand may be Australian. This is unlikely to represent a large number of trainees. There has also been a trend for trainees to spend longer in training programmes reflecting time committed to research. Notwithstanding these recent changes, the great majority of trainees go on to complete training and are elected to Fellowship. Unfortunately we lack information concerning the number that subsequently secure long term employment outside New Zealand. Table 4. Total number of first year trainees by specialty and year in New Zealand Year CAR GEN NEU ORT OTO PAE PLA URO VAS Total Source: RACS Annual Activities Reports Table 4 illustrates the fluctuations in the number of SET1 trainees between 2005 and The 2008 peak is attributed to the Basic Surgical Training program and Specialty Surgical Training program being reformed into the Surgical Education and Training Program. This resulted in a much higher than usual intake of trainees for the 2008 training year. The public sector has almost reached capacity in terms of availability of suitable surgical training posts. Currently approximately 50% of elective surgery undertaken in New Zealand hospitals is carried out in the private sector. To adequately meet the demands for surgical training (both increasing numbers and breadth of experience) now and into the future, surgical training must be extended into the private sector. This involves confronting issues of workload, remuneration and compensation, the sharing of responsibility between supervisor and trainee operating on private patients, government funding, patient consent, and trainee employment issues. 11

12 New Surgeons Although the Annual Activities Reports provides data regarding new Fellows commencing practice, they do not differentiate between those who gain fellowship through the SET program and the International Medical Graduates (IMGs) who are awarded fellowship based upon assessment (Table 5). The number of new RACS Fellows appears low when compared to the trainee intake the relevant number of years prior, but this is due to the data collection process. New Fellows are counted according to the country / state in which they reside when their Fellowship is awarded. When the administrative process for the award of Fellowship is completed, a number of New Zealand s new Fellows have already moved to post fellowship education positions in Australia or further afield. They are recorded as new surgeons in one of the Australian states or overseas. Table 5. The number of surgeons obtaining RACS Fellowship by specialty and year (includes International Medical Graduates) Year CAR GEN NEU ORT OTO PAE PLA URO VAS Total Source: RACS Annual Activities Reports The 2012 Annual Activities Report differentiates between new surgeons gaining Fellowship through the SET program and the IMG pathway as detailed in Table 6. Table 6. The number of new surgeons by specialty and pathway in 2012 CAR GEN NEU ORT OTO PAE PLA URO VAS Total Set program IMG pathway Source: RACS Annual Activities Report

13 Retirement Data from the 2011 RACS Surgical Workforce Census found that 30% of New Zealand Fellows aged years no longer worked in public practice and almost 50% intended to cease public practice within 3 years. Table 7 shows the number of active RACS surgeons likely to retire in each five year interval until 2026 where 65 is the age of retirement. Table 7. Number lost to each specialty if RACS surgeons retire at 65 years age: Year & Specialty CAR GEN NEU ORT OTO PAE PLA URO VAS TOTAL Retiring within 5 years ( ) Retiring within 10 years ( ) Retiring within 15 years ( ) Source: RACS Annual Activities Report 2012 Table 8 shows the number of active RACS surgeons likely to retire in each five year interval until 2026 where 70 is the age of retirement. Table 8. Number lost to each specialty if RACS surgeons retire at 70 years age: Year & Specialty CAR GEN NEU ORT OTO PAE PLA URO VAS TOTAL Retiring within 5 years ( ) Retiring within 10 years ( ) Retiring within 15 years ( ) Source: RACS Annual Activities Report

14 CHAPTER TWO: ALIGNING WORKFORCE DATA Scope of Practice Registration The Medical Council of New Zealand (MCNZ) registers all doctors practicing medicine in New Zealand. Registration is usually confirmed annually with the issuing of an Annual Practicing Certificate (APC), but may be interim or short term. To practise independently as a surgeon vocational registration is required. A further category comprises surgeons with general registration employed by District Health Boards and who are required to work under collegial support. This small group of surgeons has not been included in the subsequent workforce analysis. Table 9 represents the number of surgeons with Vocational Registration who hold an Annual Practicing Certificate. It shows the number of surgeons, by specialty, with and without RACS fellowship. Table 9. Vocationally Registered surgeons by specialty and FRACS status FRACS Surgeons Year CAR GEN NEU ORT OTO PAE PLA URO VAS TOTAL Non FRACS surgeons % Non FRACS surgeons Source: Medical Council of New Zealand Register for Month of October Table 10 shows the specialty distribution of non FRACS surgeons Otolaryngology, Head & Neck has a disproportionately large percentage of non FRACS surgeons. In the period the number of non FRACS surgeons with vocational registration in New Zealand increased by approximately 5 surgeons per year. If this trend continues, then by 2025 an additional 60 non FRACS surgeons would have vocational registration (This is not the same as the number of international medical graduates gaining vocational registration each year. That number is greater. Some IMGs utilise the Fellowship by Assessment pathway and become RACS Fellows (refer to Table 6). At that time they are included in the FRACS Surgeons numbers.) Table 10. Vocationally Registered (APC) non FRACS surgeons by specialty Year CAR GEN NEU ORT OTO PAE PLA URO VAS TOTAL Source: Medical Council of New Zealand Register for Month of October

15 Table 11 details the ratio of surgeons who do and who not have a FRACS, but are vocationally registered, by specialty. Table 11. The ratio of non-fracs to FRACS Vocationally Registered surgeons in 2012 CAR GEN NEU ORT OTO PAE PLA URO VAS TOTAL 1:8 1:13 1:10 1:9 1:4 1:14 1:13 1:8 1:3 1:8 Source: Medical Council of New Zealand Register for Month of October 2012 New Zealand Surgical Workforce 2012 MCNZ information pertaining to age, gender, and hours worked of the non FRACS New Zealand surgeons is restricted due to privacy. This restriction prevents detailed modelling for work-life balance and retirement for this segment of the workforce. However it has been assumed that their profile is comparable to that of the FRACS workforce. Where there is variance between RACS and MCNZ data, MCNZ data has been used as the reference except for vascular surgery where some dual specialty registration occurs. Unless otherwise indicated, for the remainder of this report the combined sum of vocationally registered and APC certified surgeons is used in modelling calculations. Table 12. Total number of Vocationally registered FRACS surgeons and non FRACS surgeons working in New Zealand (2012) Vocationally registered FRACS CAR GEN NEU ORT OTO PAE PLA URO VAS TOTAL Non-FRACS TOTAL Source: Medical Council of New Zealand Annual Practicing Certification Report for Month of October Assuming the age distribution of non-fracs surgeons follows a similar pattern as RACS Fellows in Table 2, we have extrapolated the age distribution of vocationally registered surgeons below (Table 13). Table 13. Extrapolation of age groups of vocational and APC surgeons based on age distribution of RACS surgeons. Projected distribution of vocational Age group No. of RACS surgeons FRACS and non-fracs surgeons < TOTAL * *Does not add up to 798 due to rounding. 15

16 CHAPTER THREE: CHANGING DEMOGRAPHICS Population Characteristics and Demographics The New Zealand population is expected to grow by 13% over the next 15 years (Statistics New Zealand, Projected Population 2009 (base) to 2061). Like many other countries the New Zealand population is aging and the number of people aged 65 years and over is expected to increase disproportionately compared to the other age groups (Table 14). These changes are of particular importance because the increasing number of hospital admissions is strongly driven by the population over the age of 65 years (Appendix 4). The number of surgeons required in the future will be strongly influenced by the changing age profile of our community. The 65 years and over cohort is likely to require increasing surgical intervention and will place a greater demand on health services. In addition, this age group is predicted to swell greatly over the next 12 years with an increase of over 400,000 people. Conversely the 0 14 year age cohort is predicted to increase by only 3% (30,000). Table 14. New Zealand population age profiles Age Profile 2006 population 2012 population % population increase ( ) 2026 population projection % population increase ( ) Total Pop 4140,300 4,441, ,004, Pop , , , Pop ,751,680 2,932, ,115, Pop , , , Source: Statistics New Zealand (Projected Population of New Zealand, by Age and Sex, 201 (base) 2061), National Population Estimates: September 2012 quarter. Effect of age on workforce It is recognised that increased life expectancy in New Zealand will lead to an increase in the retirement age and time spent in the workforce. If surgeons worked for longer in some capacity then this has the potential to reduce the number of additional surgeons required to meet service demands. RACS data indicate that 15% of active Fellows are aged 65 years or older, and a modest number of surgeons aged 70 years or older are still active in the workforce (2012 RACS Activities Report). Data from the 2011 RACS Surgical Workforce Census found that 37% of New Zealand Fellows surveyed aged years old were no longer employed in public practice, and another 12% were retiring within the next year. In the private sector, 31% of Fellows surveyed were no longer engaged in private practice, and another 6% were retiring within the next year. In order to allow for this reduction in the volume of work from the age 65 years the model assumes a 50% workload (or 0.5 FTE) compared to their younger colleagues. The relatively smaller contribution made by the small number of surgeons aged 70 years and older is excluded from the model as most of these surgeons will have ceased procedural work. Table 15: Estimated number of active surgeons by age group (FRACS and Non FRACS) Status & Specialty CAR GEN NEU ORT OTO PAE PLA URO VAS TOTAL Total active surgeons (2012) Active surgeons aged yrs Active surgeons aged yrs Active surgeons Source: RACS 2012 Annual Activities Report: Medical Council of New Zealand Workforce Report

17 CHAPTER FOUR: DEMAND MODELLING Retirement The timing of retirement is an important factor in the maintenance of a workforce adequate to meet service demands. Early retirement for any reason results in a loss of productive capacity. Conversely, where competence and performance is maintained and retirement is delayed this represents a valuable additional contribution. To maintain the existing level of surgical services an increasing number of surgeons will be needed to replace those who are expected to reduce their work at 65 years of age and retire at 70 years. Model 1: Surgeons 65 years and older reducing their active status Data from the 2011 RACS Workforce Census indicates that 40% of Fellows aged between years work less than 40 hours per week. For the purpose of this review it has been estimated that surgeons aged years currently make a 0.5 FTE contribution to patient care and this results in FTE surgical positions (Table 16). This effectively reduces the current workforce estimates by 84.0 FTE.. Table 16: Effect of earlier retirement Active surgeons aged <65 yrs (assume 1.0 FTE per surgeon) Active surgeons aged yrs (assume 0.5FTE per surgeons) FTE CAR GEN NEU ORT OTO PAE PLA URO VAS Total FTE Total FTE Based on Table 15 Total active surgeons Based on our workforce age cohort data, if surgeons retired from procedural work at age 65 years there would be a loss to the workforce of 317 surgeons (Table 17). This translates as a loss of approximately 21 surgeons from the workforce each year. Table 17: Annual loss of surgeons through retirement at 65 years Retirement period Loss through retirement Average loss /year Retirement between Retirement between Retirement between Total retirement

18 Model 2: Surgeons maintaining active status until age 70 years If most surgeons were to continue an active role in the direct provision of patient care until the age 70 years this has a significant impact upon the workforce. If we change the age model to increase the retirement age by five years, 69 additional surgeons will be retained in the workforce compared to Model 1. There would be a reduction of 4 surgeons required to replace those retiring each year (Table 18 summary). This has a significant impact upon the number of new surgeons required to maintain the current level of service in Table 18: Annual loss of surgeons through retirement at 70 years Retirement year Loss through retirement Average loss/year Retirement between Retirement between Retirement between Total retirement Summary: Effect of Retirement age Change Average change/year Retirement at 65 years Retirement at 70 years Government and the College should work together on models for retaining surgeons in the workforce until 70 years of age as the number of new Fellows entering the workforce exceeds the projected losses of Fellows through retirement in Model 2. This will ensure a surgical workforce which can continue to safely service the New Zealand population under this scenario. 18

19 Model 3: Population ratio and increased demand on surgical services It has been recognised that the population aged 50 years and over, and particularly those aged 65 years and older, place the greatest demand on health services. Consequently, in planning for the future workforce it is essential that the significant increase in the proportion of older people in our community is acknowledged. Planning which accommodates this specific requirement will result in more appropriate recommendations than simply looking at the distribution on a national per capita basis. Table 19 shows the number of surgeons required to maintain the same ratios in 2026 as those of 2012 for the projected population. Table 19: Predicted number of surgeons required in 2026 to maintain existing population ratios NZ FTE 2026 total 2026 population Specialty positions 2012 population aged yrs CAR population aged 65 yrs GEN NEU ORT OTO PAE N/A N/A PLA URO VAS TOTAL Source: RACS 2012 Annual Activities Report; Statistics New Zealand (Projected Population of New Zealand, by Age and Sex, 2009 (base) 2061) at 18 March 2013: Medical Council New Zealand Workforce Report 2012 It has been assumed that paediatric surgeons provide care for two thirds of the paediatric population (0 14 years age) and general surgeons care for the remainder. It is also assumed that vascular surgeons provide little care for the paediatric age group and this group has been excluded from the general population calculations for that specialty. If the current surgeon to population ratio is to be maintained, 806 surgeons will be required in 2025 (Table 20). To maintain the existing population ratio for those 65 years and older 1122 surgeons will be required in For paediatric surgeons the small growth in the less than 15 years of age group requires an increase to 15 surgeons in 2025 (from 14 currently active in 2010). Table 20. Change in number of surgeons to maintain current population ratios at 2026 for older age cohorts 2026 Total 2026 Population 2026 Population 2012 Population Aged Aged 65 Total surgeons Increase cf Number / year Maintaining a surgical workforce that can safely service the New Zealand population clearly presents the greatest challenges from a workforce planning perspective. Under this scenario, somewhere between 6 and 26 additional surgeons would need to be trained and enter the workforce per annum. This would present a significant challenge to both government and the College. The College recommends that government consult the profession closely so that contingency planning can be undertaken to address the outcomes modelled in this scenario. 19

20 Work-life balance The most recent College census indicates that surgeons work an average of 50 hours per week, excluding on-call hours (2011 Surgical Workforce Census Report). However, concerns about safe working hours and the desire for a better work-life balance may in the future result in surgeons choosing to work fewer hours and this would result in the need for more surgeons. The increasing number of female surgeons has become a feature of the medical workforce over the past three decades. The proportion of female New Zealand surgical Fellows has grown significantly from 6% in 2005 to 9% in 2012 (RACS 2012 Annual Activities Report). In % of New Zealand surgical graduates were female (RACS 2012 Annual Activities Report). During the comparable period 52% of medical graduates undergoing vocational training were female (The New Zealand Medical Workforce in 2011 Report). Consequently, there will be a continued increase in the proportion of women within the surgical workforce in the future. This has implications for workforce planning given that women across all medical workforce fields currently work on average approximately seven hours fewer per week (MCNZ Workforce report 2010). Based on the clearly expressed desire of both male and female surgical trainees and younger surgeons to better address work-life balance, it is more appropriate to consider work-life balance as an issue for all surgeons rather than those of a particular gender. To accommodate reduced hours of work while maintaining a surgical workforce that can meet the needs of the New Zealand community, a greater number of surgeons will be needed (Table 21 summary). If surgeons were on average to work 5 hours less each week there would be the requirement for an additional 81 surgeons to meet the existing workload. A decrease of 10 hours per week per surgeon would require an additional 181 surgeons. Table 21. Number of surgeons required by specialty to sustain current service level where hours worked per week decreases Specialty Working 50hrs/wk Working 45hrs/wk Working 40 hrs/wk CAR GEN NEU ORT OTO PAE PLA URO VAS Total Source: RACS 2012 Annual Activities Report; Statistics New Zealand (Projected Population of New Zealand, by Age and Sex, 2009 (base) 2061). Medical Council New Zealand Workforce Report 2012 Summary: Additional surgeons required if weekly work hours are reduced by 5 10 hours per week by 2025 Working 50hrs/wk Working 45hrs/wk Working 40hrs/wk Number Change Number/year ( ) This increase in the number of surgeons may be better considered as the additional surgeons to be employed annually to meet service needs. A reduction in surgeon working time from 50 to 45 hours per week is a realistic scenario as medical specialists as a group have reduced their working time by three hours over the past 10 years (2010 MCNZ Medical Workforce). As with the models addressing retirement age, the lower of these two projections would be met through the natural growth in the training program over the forecast period. 20

21 Changing Models of Care: Increased efficiency and productivity It has been recognised for some time that we must change the way in which care is delivered if we are to maintain our present high standards in an environment of increasing demand but relatively diminishing funding (Professor Des Gorman has been emphasising this fact during the past two years). In almost all operating theatre process there is scope for improvement in efficiency. Despite the substantial monetary and personal costs involved in the training of surgeons, this high level expertise is frequently under utilised. Considerable time is spent in dealing with increasing administrative demands, poorly organised meetings which fail to produce outcomes, assessing and counselling patients where there is little or no likelihood of surgical intervention and providing surgery in situations which confer only marginal benefit for patients. Change to practice where time and skill is used more effectively has the potential to significantly increase the productivity of surgeons, thereby reducing the need to so significantly increase the size of the workforce. Using a conservative suggestion, that surgeon s productivity could be increased by 10% over the next 15 years, this would represent the addition of 70 surgeons to the workforce over this time (based on the 2010 number of surgeons). This represents approximately 5 each year. A 20% improvement in productivity over the same period would effectively contribute almost 10 surgeons annually. Summary: Contribution through 10% increase in Productivity Maintaining the existing surgeon:population ratio to 2025 with a 10% increase in productivity would effectively increase the surgical workforce by 70 surgeons (4.7/year). 21

22 Conclusions The net effect of the factors discussed on the preceding pages, together with their likely effect upon surgeon numbers are summarised in Table 23. Table 23. Summary of influence of different factors upon the number of additional surgeons required to meet projected population needs at 2025 Factor Retirement Total additional surgeons required over 15 years Additional surgeons required each year 1 Retirement at 65 years Retirement at 70 years % surgeons working to age 70 years Population ratios 4 Maintenance of existing total surgeon:population ratio Maintenance of surgeon:population ratio for > 65 years population Productivity 6 Reduction of hours worked per week, from 50 to hours. 7 10% increase in surgeon productivity In considering the factors listed in Table 23, item 6 is highly likely as there is evidence of a trend in this direction already. Item 3 is a realistic assumption as this would mirror changes within society and the work environment where working at an older age is increasingly encouraged. Projecting forward to 2025 these changes are likely to occur and together will require the recruitment of approximately 17 surgeons annually. If the existing surgeon to population ratios are to be maintained through the same period then an additional 6 surgeons will be required annually to meet the projected population growth of 13%. This conservative estimate suggests that 31 replacement surgeons are required annually to merely ensure the status quo (Items 3, 4 and 6). Item 5 represent a significant change in the concept of surgeon to population ratios, whereby this is related to the high user segment of the population rather than the total. This is clearly more meaningful when the population structure is undergoing a very rapid change. The significant constraint on taxation funding of health care has resulted in a closer examination of all aspects of efficiency and productivity in health. It has become obvious that the maintenance of the existing levels of service provision and standards will be increasingly difficult recognising the greatly increased need for health care as the population ages. Alternative models of health care with higher levels of efficiency will be required if the present standards are to be maintained despite a relatively smaller per capita funding. It is realistic to believe that there could be at least a 10% improvement in productivity over this 15 year period and this is equivalent to adding 70 surgeons to the workforce (Item 7). A further factor which has the potential to impact upon these workforce projections is the loss of some New Zealand and Australian trained surgeons to positions outside New Zealand. The New Zealand Association of Salaried Medical Specialists has repeatedly warned of the risk this poses to the maintenance of an adequate specialist workforce in New Zealand. While this loss may be compensated for by the employment of surgeons trained in other environments (if they can be persuaded to accept working conditions being rejected by some New Zealand surgeons) there is the 22

23 additional cost associated with their acquaintance with and assimilation into the New Zealand health care environment and culture. Since 2005 on average 25 RACS trained surgeons have entered the workforce each year. In addition 5 non-racs trained surgeons have joined the workforce annually (Table 10). Thus over the past five years there has been a gain of 30 additional surgeons each year and this matches very closely the numbers predicted to replace those retiring and to permit some change in the worklifestyle imbalance (Table 21). During the period an average of 47 young surgeons commenced RACS surgery training programs in New Zealand each year. Allowing approximately 7 years from the commencement of training until appointment to a specialist surgical position, the first of this significantly increased number being trained will be available for appointment from A small number of these trainees will be Australian (recognising five of the nine programs are bi-national) and there is presently an unknown loss as some are appointed to long-term consultant positions outside New Zealand. In effect as few as may be available to fill positions in New Zealand. If overseas trained surgeons continue to enter New Zealand at the present rate of approximately 5 each year this increases the number available to approximately annually. Based upon these estimations there appears to be a margin of surgeons additional to the minimal replacement requirements to meet the increasing needs of the future. Gains in productivity can potentially add at least 5 surgeons annually. Overall, this suggests that if the present level of training and retention of surgeons can be maintained, there may potentially be surgeons annually to meet the increasing demands of the ageing population. 23

24 APPENDICES Appendix 1 New Zealand Hospital Statistics Publicly funded hospital casemix discharges Table 1: Publicly funded hospital casemix discharges, 2001/02 to 2006/07 Day patient discharges as percentage of total discharges Age standardised hospitalisation rate Average length of stay (days) Total Inpatient Day patient Year discharges discharges discharges 2001/02 504, , , , /03 501, , , , /04 512, , , , /05 516, , , , /06 528, , , , /07 544, , , , Source: New Zealand National Minimum Dataset Note: The age standardised rate is the rate per 100,000 population, age standardised to World Health Organization (WHO) world population (see Appendix D: WHO world standard population). Please note that in previous editions of this publication, age standardised rates were calculated using SEGI population figures so rates in this publication are not comparable with previous editions. Mean populations for the year ended 31 December were sourced from Statistics New Zealand (2002, 2003, 2004, 2005, 2006, 2007). Source: Ministry of Health Publicly Funded Hospital Casemix Events 1 July 2006 to 30 June Wellington: Ministry of Health. Page 3 Appendix 2 New Zealand Hospital Statistics Number of publicly funded procedures performed in casemix events by age Table 2: Number of procedures performed in casemix events in publicly funded hospitals for selected procedures by age group, 2006/07 Procedure Total Cataracts 10, ,697 8,143 Grommets 6,437 6, Hernia 5,614 1, ,574 1,649 Coronary angioplasties 4, ,091 2,090 Total hip replacements 4, ,332 2,874 Total knee replacements 3, ,482 Coronary artery bypass grafts 3, ,305 1,717 Closed prostatectomies 1, ,474 Source: Ministry of Health Publicly Funded Hospital Casemix Events 1 July 2006 to 30 June Wellington: Ministry of Health. Page 8 24

25 Append dix 3 New Zealand Hospital Statistics Age specificc casemix hospitalisation rates by gender Figure funded 1: Age specific casemix hospitalisation rates per 100, 000 population in publicly hospitals by age and sex, 2006/077 Rate per 100,000 population Malee Female Source: Ministry of Health Publicly Funded Hospitall Casemix Events 1 July 2006 to 30 June Wellington: Ministry of Health. Page 4 25

26 Append dix 4 New Zealand Hospital Statistics Age specific case mix hospitalisation rates by ethnicity Age specific casemix hospitalisation rates in publicly funded hospitalss by age ethnicity, 2006/07 Rate per 100,000 population and Māori Pacific Non- Māori non- P ifi Source: Ministry of Health Publicly Funded Hospital Casemixx Events 1 July 2006 to 30 June Wellington: Ministry of Health. Page 5 26