NSW’s public dermatology services ‘unacceptable’

6 minute read

Nine LHDs have no public service. The dermatology college is taking a stand at a special inquiry into the state’s healthcare funding.

More than half of the local health districts in NSW do not have a public dermatology service, a situation branded “inequitable” and “unacceptable” by the Australasian College of Dermatologists.

According to NSW Health, there are 15 LHDs in the state – nine in the Sydney metropolitan region and nine covering rural and regional NSW.

The college said nine of these LHDs did not have a public dermatology service, and has welcomed a NSW government inquiry into healthcare funding, saying it remains one of the key barriers to service delivery and training in areas of need.

“Beyond inner metropolitan Sydney, public dermatology services are scarce and in some LHDs non-existent,” the college said in its submission to the Special Commission of Inquiry into Healthcare Funding.

According to the ACD’s submission there is no public dermatology service in the following LHDs: Far West, Mid North Coast, Murrumbidgee, Northern NSW, Southern NSW, Western NSW, Central Coast, Illawarra Shoalhaven and Nepean Blue Mountains.

“This inequitable access to specialist care is unacceptable and must be addressed,” the ACD said in its submission.

“The NSW Regional Health Strategic Plan is robust and should guide funding. However, in our experience of trying to secure investment to introduce or grow dermatology services and training in identified areas of need in NSW, there is a significant disconnect between government strategy and planning, and LHD funding and priorities.

“This maldistribution of specialist dermatology services exists not only in regional areas but, also in availability of public and private dermatologists in MM1 and MM2 designated outer metropolitan areas.”

The submission revealed activity-based funding models, focused on activity rather than outcomes, significantly disadvantaged outpatient services and primarily chronic disease specialties like dermatology.

“Cost-based decision-making by LHDs and public hospitals are hindering the introduction and growth of public outpatient clinics, consultant capacity and trainee positions in areas of need,” the ACD said.

“From a governance perspective, where health and service needs assessments identify a gap, the knowledge and resources of specialty medical colleges is not being sufficiently leveraged to identify potential on the ground workforce.

“End-to-end, place-based medical training has been clearly identified as an enabler to addressing maldistribution of the specialist workforce, yet opportunities for NSW funding for specialist training are not being leveraged to help drive place-based training and development of homegrown workforce in areas of need.

“All these factors need to be addressed so that the people of NSW can access the timely, safe, affordable and geographically convenient care they need now and into the future.”

A spokesperson for the college told TMR the ACD had requested and been authorised to appear at a hearing of the inquiry, although a date had not yet been advised.

“As a specialty, dermatology is in significant undersupply,” she said.

“What we need most from the NSW government (and other state, territory and federal governments) is investment in public hospital services, incorporating both dermatologists and trainees, and collaboration and investment in workforce initiatives that enable us to attract, support, select and train workforce in areas of need.”

She said ACD looked forward to continuing to work proactively with NSW Ministry of Health and LHDs.

“As a college, we have a strong track record in other states of acting as an effective nexus between key stakeholders [federal, state and territory, LHDs, public hospitals and private practice]) to build sustainable workforce and services in areas of unmet need,” she said.

The Special Commission of Inquiry was established in late August and has been tasked with conducting a holistic review of the funding of health services in NSW, and identifying opportunities to deliver higher quality, more timely, and more accessible patient-centred care.

According to its dedicated website, the Inquiry will examine:

  • The existing governance and accountability structure of NSW Health.
  • The way NSW health funds health services delivered in public hospitals and community settings.
  • Strategies available to address escalating costs, limit wastage and identify areas of improvement in financial management.

The inquiry is led by Richard Beasley SC, who was previously Senior Counsel Assisting the Special Commission of Inquiry into the Ruby Princess and also for the Murray Darling Basin Royal Commission. 

Submissions to the inquiry have closed, and as of 23 November, 166 submissions have been made, including the ACD’s.

The ACD’s submission sets out three key recommendations calling on the NSW Government to:

  • Examine and address cost/activity-based decision-making frameworks that constrain workforce growth in outpatient specialties and areas of need.
  • Invest in state-wide governance and funding arrangements that can respond flexibly to opportunities to build public specialist services in areas of need. For dermatology, this should start with NSW Health and Northern NSW LHD establishing a public dermatology service in Northern NSW LHD.
  • Implement a scheme for NSW-funded training positions in areas of need that enable selection and training from the area, in the area, for the area. For dermatology, this should start with SWSLHD funding two new registrar positions at Liverpool/Campbelltown Hospitals that require trainees to be selected having been educated at school and university in South Western Sydney, living in the area and being committed to working in the area.

The submission also paints a grim picture of Australia’s dermatology workforce as a whole, which will not be news to dermatologists.

“Despite Australia’s high rates of skin cancer and incidence of increasingly complex chronic skin disease, dermatology is one of the few medical specialties in national undersupply as most recently highlighted in the Australian Government’s National Medical Workforce Strategy 2021-203,” the submission said.

“There are only just over 600 dermatologists nationwide – or roughly two dermatologists per 100,000 Australians, a shortfall only set to worsen, and the workforce is maldistributed.

“This shortage is not due to a lack of doctors seeking to train as dermatologists, but to insufficient public investment in dermatology services and in the registrar and consultant supervisor positions needed to grow the dermatology workforce.”

The picture was consistent in NSW, the ACD said. ACD’s NSW Faculty, which provides specialist dermatology services across both NSW and the ACT, comprises 225 actively practicing Fellows (dermatologists) and 36 trainees and International Medical Graduates (IMGs) enrolled in the specialist dermatology training program.

The NSW Medical Workforce Modelling by Specialty 2015-2030 Summary identified dermatology as a specialty with substantial career opportunities needing an increase in trainee numbers of 25% to 150% in order to meet projected service demand by 2030.

“With 40% of the regional workforce aged 60 or older, maldistribution is expected to increase by 2030,” the college said in its submission.

“Despite this, there is a small cohort of dedicated Fellows who continue to provide outreach services. However, this outreach is inconsistent, unsustainable, costly and poses concerns to them regarding continuity of care which is being further exacerbated by the declining GP workforce. Outreach services are at best a ‘band-aid’ solution, improving the perception of care.”

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