The Hospital Skills Program: a professional development program for non-specialist doctors in New South Wales

The Hospital Skills Program (HSP) is a flexible training and professional development program for New South Wales career medical officer (CMO)-equivalent medical practitioners with needs that are not met by prevocational and specialist college training programs. The 510 enrolled doctors work in a range of public health services across NSW and provide vital support to specialists in numerous clinical areas. In many situations, they practise as independent expert clinicians without specialist back-up. The HSP supports their heterogeneous skills and circumstances and recognises their contribution to service delivery in NSW public hospitals.

The HSP is governed by the medical directorate of the NSW Health Education and Training Institute (HETI; formerly the NSW Clinical Education and Training Institute). The key components of the HSP are summarised in Box 1. Its aim is to ensure participants have the knowledge and skills to safely fulfil their roles in alignment with the goals of their workplace clinical service, the needs of the local patient community, and the aims of NSW Health. Integral to this is the provision of lifelong support and guidance sufficient to satisfy the career advancement needs of each participant. Fundamentally different to selective college training programs, the HSP does not exclude participants nor does it provide a final qualification, in preference supporting the continuous attainment of further skills. The HSP identifies an individual’s current level of competence and operates to satisfy his or her learning needs to attain a progressively higher level of competence. Using valid and reliable workplace-based assessment processes, it will define a practitioner as working at one of three clinical levels within each clinical domain. These levels equate to trainee Postgraduate Year 3 and beyond, senior practitioner under supervision, and independent practitioner (Box 2).

Before the HSP, there was little organised clinical oversight or support in NSW for the professional development of doctors at Postgraduate Year 3 level and beyond, who were not in a specialist training scheme. Their training, up-skilling and education were dependent on a combination of what was convenient and available in the workplace, and the individual doctors’ efforts towards their own training. There was no universal structured education and training program that described what these doctors should know and the skills they should have, and that provided an actual attainment pathway. As a result, it has not been possible for workforce services to fully understand the competency of the workforce and to have confidence in the safe staffing of hospital and community services. This is particularly relevant to the staffing of emergency departments after hours, where historically there have been few onsite supervising emergency specialists. In 2005, an Institute of Medical Education and Training review found that there were significant numbers of doctors working in NSW emergency departments who were not Fellows of the Australasian College of Emergency Medicine or a part of the College’s training program.2 For example, of the 145 hospitals with an emergency department, only 40 had College Fellows on their staff, and only 31 were accredited for Fellowship training in NSW.

By addressing the training, supervision and professional development needs of this previously neglected group, the HSP will provide for public confidence in the safe staffing of NSW Health medical services. In the final report of the Special Commission of Inquiry into acute care services in NSW public hospitals, Commissioner Peter Garling SC recognised the potential of the HSP when he said:

There are an estimated 1000 “non-specialist” doctors working in publicly funded hospitals and health services across NSW employed under a variety of industrial agreements and locum arrangements, including the multiskilled medical officer and visiting medical officer agreements, and the medical officer, CMO and staff specialist awards. Box 3 summarises the demographics of the doctors currently enrolled in the HSP. With the pending influx of new graduates and a less than proportional growth in specialty training places, their number will increase. Some have skills across several medical disciplines equivalent to general practitioners of hospital and community services, whereas others fill niche, and often expert roles, within one service. Finding one name to describe this eclectic group is problematic. We suggest hospital generalist, or hospitalist, as more accurate and less pejorative than non-specialist, but these terms do not encompass doctors who work in community-based facilities or those with a subset of skills applicable to one discipline.

Non-specialist roles in our hospital system have evolved out of necessity rather than by design. There is growing recognition of how vital these roles are to the proper functioning of our hospital systems. Some have developed because of gaps in service provision by specialist services that are focused, by necessity, on efficient outpatient and short-stay management of single-system disease, often at the expense of the complex multisystem patients who increasingly populate inpatient beds. Non-specialists are integral to clinical service delivery in emergency departments, mental health, drug and alcohol services, aged care, Justice Health and a variety of other medical services.

Examples of non-specialist roles in NSW hospitals include:

• the CMO who fills the role of expert clinician and supervisor during the after-hours shifts in the emergency department;

• the multiskilled medical officer who works in a regional hospital as the senior medical officer in charge after hours, covering the combined role of medical and surgical admitting officer, intensive care unit consultant, leader of the arrest team, procedural expert and neonatal resuscitator;

• the CMO hospitalist (or hospital generalist) who, because of deep system knowledge, leadership skills and working relationships with providers across all disciplines, is called upon to solve the dilemma of a patient whose illness spans several subspecialty services;

• the CMO who works as a non-accredited training registrar as a long-term career option in orthopaedics, surgery, intensive care or emergency medicine;

• the CMO providing general practice services for Justice Health;

• the rural GP visiting medical officer providing emergency services at the local hospital on an on-call or permanent part-time basis; and

• the senior medical officer called upon to provide clinical leadership and training across several services too small to attract appropriate specialty services.

Most HSP doctors have made a positive choice to pursue these career options. They are not default options arising from the popular misconception that these doctors are unable to meet college entry requirements, cannot obtain a job in a teaching hospital, or have substandard ability.

There are many reasons to support the presence of a reliable and well trained generalist workforce in public hospitals and community services. Although not always recognised as such, many of our hospital non-specialists already represent the face of hospitalists, increasingly seen worldwide as integral to the coordination of specialist services.4 Specialty services, by the nature of their training role, expend large amounts of time and effort orientating registrars on rotation and developing systems to cover the risk of loss of system knowledge when trainees depart the service. Long-term generalist doctors, who are tasked with both patient care at a senior registrar level and overseeing the function of the service as a whole, are useful for minimising this risk to patient safety. Generalist doctors who may work part-time in the private sector in such fields as surgical assistance and general practice also bring knowledge and networking skills that ensure the safer transition of patients between private and public, and inpatient and outpatient, services.

By adding additional skills in leadership, teaching, management, patient safety and quality to the already extensive system and clinical experience of our hospital non-specialists, we can enhance their effectiveness and multiply their benefit to the system. For example, many health goals identified by specialist colleges and bodies such as the National Institute of Clinical Studies, NSW Clinical Excellence Commission, National Stroke Foundation, coroner’s courts, and patient advocacy groups encompass actions across a variety of clinical settings. Effective management of acute coronary syndrome requires interventions and improvements in primary care, ambulance response, emergency, cardiology and rehabilitation services. Such coordination of care is beyond the means of any one organisation to effect and is not within the purview of any specialist role. There is an exigency to support our non-specialist colleagues, as some may have the experience and skills to work across our clinical silos to help address these challenges. Further examples include thrombolysis in stroke, preventing thromboembolic disease, infection control, and Closing the Gap in Indigenous health. The HSP consults with peak health organisations to identify training needs and enhance HSP curricula to facilitate the implementation of system-wide programs to improve, for example, the management of sepsis, the deteriorating patient, and compliance with infection control measures.

The HSP gives its doctors the recognition and continuing professional development they deserve. Many provide care outside normal business hours and are the reason their specialist colleagues can rest and sleep. Further, by their continuous service at the sharp end of our hospital services, they understand the workarounds and provide the patient advocacy needed to make things happen in an increasingly subspecialised and complex health system. By supporting this previously neglected cohort of NSW doctors, the HSP aims to improve the safety, efficiency and efficacy of patient care. By highlighting the value of non-specialist medical roles, it will provide a catalyst for the definition of useful career paths to satisfy the influx of new graduates and the current and future needs of our health services.