Who is responsible for Australia’s specialist and surgeon bottlenecks?

New government modelling has exposed a widening disconnect between the number of graduates progressing through the medical system, the capacity of the specialist training pipeline and the distribution of clinicians required to meet community need.

The Royal Australasian College of Surgeons (RACS) has cautioned that the emerging imbalance should not be interpreted as a failure to produce sufficient doctors. Rather, it highlights a more complex problem where too few medical graduates are progressing through the specialist training pipeline at the pace and scale required to build the workforce communities need.

The government’s Whole of Medical Workforce Supply and Demand Study projects that by 2048 Australia will have 10,783 FTE more hospital prevocational doctors than modelled demand, while simultaneously confronting shortages of 3,885 FTE registrars and 12,812 FTE specialists.

RACS President Dr Phil Morreau said, “The paradox is that we can have more doctors coming through the early stages of the system while simultaneously facing a shortage further down the pipeline. That tells us the problem is not simply how many doctors we have, it is whether we have the right training pathways and capacity to develop the specialist workforce Australia needs.”

The capacity constraints extend beyond the remit of medical colleges. RACS said it cannot independently create funded training positions or provide the clinical capacity necessary to train surgeons. Governments and health services have a critical role in establishing the funded positions, clinical environments, operating capacity and supervision required to sustain specialist training at the scale and in the locations demanded by the population.

The issue has been recognised in broader health workforce reform efforts. The Special Commission of Inquiry into Healthcare Funding in NSW, led by the Hon. Justice Richard Beasley, examined the recruitment, retention, training and deployment of medical specialists, with particular attention to acute workforce shortages in regional areas and highly strained specialities including psychiatry, emergency medicine and obstetrics/gynaecology.

The inquiry recommended the establishment of a dedicated central workforce unit within NSW Health to address persistent staffing shortages, undertake longer-term capacity planning and improve the strategic deployment of public health staff.

The pressures generated by the current imbalance are already being borne by doctors working at the front end of the system. Commonwealth data shows hospital prevocational doctors worked an average of 46.8 hours a week in 2023, with 94% of their FTE in the public sector. The Commonwealth also identifies increased reliance on registrars to manage service delivery as one of the workforce issues arising from current imbalances.

“These doctors are not simply waiting to train,” Dr Morreau explained. “They are already contributing to our hospitals and patients. We need to recognise that contribution and give doctors greater clarity about pathways into specialist training.”

The College has identified elements of the surgical training pathway within its own remit that can be strengthened within its Surgical Pathways Strategy.

“We recognise that we can do better,” Dr Morreau stated. “That means clearer selection processes, more flexible pathways and training that reflects the surgical workforce Australia needs now and, in the future, including in regional and rural communities.”

Yet reforms to selection and training processes cannot, in themselves, resolve a capacity deficit that is embedded across the health system.

“We cannot create more training positions on our own,” added Dr Morreau. “A training position needs a funded job, appropriate supervision and sufficient clinical exposure to develop a competent surgeon. We need governments, health services and colleges working together to increase that capacity where it is needed.”

The underlying challenge, RACS argues, is therefore one of workforce architecture rather than simply workforce volume.

“The answer is not to lower surgical standards,” Dr Morreau said. “We should solve a specialist workforce shortage by building a better pathway to train the doctors Australia already has, and by making sure those training opportunities are available where communities need surgeons.”

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