At the recent announcement of the changes to the Single Service Chiefs of the Australian Defence Force, the Minister for Defence, The Hon Joel Fitzgibbon MP made the following comments:
“… the single biggest challenge facing the Australian Defence Force in the future is our people and skills shortage. … [E]ach service chief will be directly responsible for ensuring that sufficient trained and skilled personnel are available. … It is a tough challenge in the face of almost full employment, and a booming mining industry. However, there is no choice but to succeed. The best available military equipment is of little use without sufficient high quality personnel to operate and sustain it.”1
There are many areas in the skilled and technical trades and professions where the Defence Force is currently under-recruited, and although the size and perceived importance of the health professionals to Defence is small, shortages remain significant. The 2004 Stevens’ Review reported that in most of the health professional groups in the ADF the separation rates remain high and consequently the numbers under training will not meet future needs.2
The dilemma
Clements in “A View from the Front” – Retention of senior medical officers: Time for a rethink on career progression? – reflects on the career choice dilemma that faces all medical officers as they move from junior to more senior ranks.3
This dilemma is one faced by all medical officers who join the Defence Force in the early stages of their medical career, and particularly those who join as medical students – before they have perhaps decided where they want to take their medical career.
Defence recruiters have been notorious in promising anything and everything to medical students to get them to sign on the dotted line. The reality then hits at various points: some don’t like it right from the start as they have not understood the culture of a disciplined service (or just wanted the money) while some come to the realisation that the clinical career they want to pursue cannot be done from the Permanent Forces.
There is a group who do actually decide that they are attuned to management or public health or occupational medicine so that a long term Permanent Forces career is a practical course. But this group is in the minority, and there remains a considerable attrition rate across the services.
Impacts of past reforms
The challenges of recruitment and retention have been impacted by some of the reforms that have occurred in Defence, with the focus on outsourcing and commercialisation of non-combat activities. Some of these reforms may have had benefits – for instance, the provision of “garrison” care with its focus on the mundane of routine medical examinations by civilian contractors leaving the uniformed medical officer to focus on more challenging operational training and deployment.
Many of the changes, however, could be argued to have been detrimental to retention. Even the outsourcing of garrison care had the consequences of removing opportunities for general practice work, and by reducing the numbers of medical officer positions in the support areas increasing the proportion of operational postings and therefore time deployed required. The Stevens Review reported that this strategy is not sustainable in the longer term as the consequential multiple deployments adversely affect family relations, the taking of recreational leave and the undertaking of professional development.4
Other consequences, some of which have, in part, been forced on Defence through lack of health professionals, include the outsourcing of some health support to combat-like operations, such as in Bougainville. While this does reduce the operational deployment requirement, it also reduces the ability of uniformed medical officers to experience the clinical challenge of providing high-level health support in a difficult environment, activities which provide great professional satisfaction.
Past strategies
A number of strategies have been tried over the years to resolve the problem of recruitment and retention of medical officers.
Many of these have focussed on remuneration or retention bonuses, and in some circumstances Services have individually case managed medical officers through clinical specialist training.
The most recent strategies include the competency based pay scales and the Medical Officer Specialist Training Scheme (MOSTS). However, each of these has reportedly met with criticism, with the pay scales being criticised as favouring those who go into management or public health specialties over those in general practice, and MOSTS being subject to antipathy by at least one of the services and disenchanting a number of medical officers who joined because of the opportunities it was meant to provide but which presumably have failed to materialise.5
The evidence in relation to staffing levels and recruitment would tend to suggest that none of these recent approaches has been particularly successful.
Factors determining retention
The Australian Medical Workforce Advisory Council (AMWAC) in a 2005 survey of medical practitioners identified key intrinsic and extrinsic factors that were involved in determining the individual’s choice of discipline.6
Three intrinsic factors were assessed as the the most influential factors in choice of specialty – appraisal of own skills/aptitudes, interest in helping people and intellectual content of the specialty. Influential extrinsic factors were discipline-related work cultures and working conditions.
The report noted that these factors were experienced throughout medical school and early postgraduate years. Given that most doctors choose their specialty during these years, the importance of Defence identifying and developing strategies aimed at junior medical officers to encourage and support retention is clear.
In the case of women (an increasing proportion of the medical workforce), the AMWAC report observed that they give greater consideration to extrinsic factors when choosing a specialty than do men.7
For Defence, the challenges to recruitment are complex but, in reflecting the AMWAC findings, likely include (a) differential remuneration; (b) lack of clinical career opportunities; (c) routine tasks that are perceived to lack professional satisfaction; and (d) the requirement for operational deployment at short notice.
While remuneration is important, it is not necessarily the key to retention. The more important issue is likely to be career and professional development and progression.
Defence must recognise that amongst a cohort of new entry medical students the vast majority will want to become clinical specialists (including general practice). Only a small proportion will be interested in management, public health or occupational health – areas that can be accommodated from within a Permanent Forces career as evidenced by previous experience in these fields where medical officers have completed training and achieved Fellowship while serving in the Permanent Forces.
In the past, Defence has seemed to accept that it will lose those wanting to train as clinical specialists, hoping that some will join the Reserves and perhaps providing some operational support in the future.
The Defence health environment
The ADF provides health support to its Permanent Forces only. This means that the total dependency of the Defence Health Services is relatively small – and widely dispersed across the country and overseas on operations.
Maintaining and supporting full-time clinical specialists just to support this dependency is therefore not practicable. Dependent care – often touted as one solution to this – creates the problems of prioritisation of effort, and in the US has apparently led to situations where operational training and non-combat deployments take second place to dependent care.
Defence, to its credit, has recognised that its personnel are entitled to be cared for in the operational environment by clinicians with the same skill sets, experience and qualifications as members of the general community. This therefore demands that these clinical specialists be available for operational deployments.
Defence has relied on the Reserves to provide this pool of Specialist personnel and this has generally been satisfactory although is dependent upon the willingness of these clinicians to leave their civilian/private practices at short notice. The Stevens Review has highlighted the personal, professional and financial consequences of deployment on the Reserve medical officer as well as the relatively high age of current Reservists (less than 40% under the age of 45).8 These issues raise concerns as to whether continued reliance on Reservists to support the current tempo of operations will be viable in the long-term.
A future strategy
A Defence Health Service focussed on the provision of support to combat operations provides limited career opportunities for medical officers, and opportunities that do not fit with the broader aspirations of young doctors to stay in the clinical (specialist) fields.
These problems of retention can be fixed, but they need radical solutions that will require considerable investments in time, organisation and money.
Defence needs to establish, as part of a legitimate and structured career pathway, processes that actively support medical officers to pursue clinical specialist training whilst (at their option) either remaining in the Permanent Forces or transferring to the Reserves.
It is not the purpose of this piece to define how this would be done, however the focus needs to be on a structured career pathway supported by a structured and funded establishment.
Opportunities for the funding or shared-funding of training posts in the public and private health sectors should be pursued. It is well recognised that a shortage of training posts is one of the key barriers to increasing the number of qualified specialists in Australia and this approach should be welcomed by the broader health community.
Similarly, opportunities for the shared funding of specialist positions in the civilian sector should be pursued, and given the challenges to funding specialist services this should again be welcomed.
There will need to be innovative solutions and a level of shared responsibility for these positions, including an acceptance by the civilian sector that these specialists will be available for relatively short-notice deployments, but these factors should be able to be overcome. Defence will need to accept a flexible remuneration system to ensure that the military specialists have an income that is commensurate with their civilian counterparts so as to avoid the pay differentials that have apparently occurred in the UK model of embedding military units in National Health Service hospitals and have resulted in uniformed personnel leaving to do the same work as civilians.
These concerns and the potential solutions do not solely concern the medical profession in Defence, but are relevant to all the health professions. Regardless of the solution, continuing along the current pathway places at risk the ability of the Defence Health Services to provide the proper health support to the military community when it is at its most vulnerable – on deployed operations
Please specify the URL of your file
