Canberra Hospital’s obstetrics and gynaecology unit has not met five basic standards, and only partially met a sixth, according to an accreditation review report published by the Royal Australian and New Zealand College of Obstetrics and Gynaecologists (RANZCOG).

RANZCOG has given Canberra Hospital provisional accreditation for six months (the shortest limit of accreditation), and required them to supply evidence of workforce planning in September and a progress report in December. If Canberra Hospital fails to improve, loss of accreditation could be on the cards.

Health Minister Rachel Stephen-Smith states that work is already underway to address RANZCOG’s issues.

“I really want to reassure women and families who are looking to birth at Canberra Hospital that they will get the care that they need and deserve,” she said.

But the Canberra Liberals are concerned that Canberra Hospital will lose its training accreditation.

“The fact is that we are talking about the safety of Canberra mums,” Opposition Leader Elizabeth Lee said. “If the College of Obstetricians and Gynaecologists say that the ACT health system is not good for trainees, it is not good for Canberra mums. What we want to know, what the Canberra community deserve to know when they are about to give birth, is that they are going to be safe, that they are going to receive standard care that is befitting of the nation’s capital. At the moment, that is not happening.”

Report findings

The RANZCOG Accreditation Panel visited Canberra Hospital on Monday 5 June to assess how it was implementing its training program.

It found that training was insufficient: workplace culture had deteriorated to the point where it did not appear to prioritise training. Experience in subspeciality areas and domains other than obstetrics was not regularly available, due to staffing shortages, minimal workforce planning, and poor communication.

Training supervisors did not have enough time to carry out their additional duties due to staffing pressures and a high clinical workload; they were spread thinly, and sometimes only met trainees every three months.

The provision of structured education programs, teaching sessions, and learning opportunities was not met. There were minimal formal education sessions that trainees could attend, and training / teaching time was inadequate. (Three hours were allocated, but sessions were often interrupted by service needs, and only a few trainees could attend.)

Simulation training was poor, and opportunity for research was minimal. Trainees could not meet their training program requirements, or sign off their assessment of procedural and surgical skills, due to the service-focused nature of their roles, inadequate staffing at the trainee / unaccredited registrar level, and consultant turnover.

The hospital did not provide adequate clinical supervision or experience, and consultant involvement with and support for trainees was not met. The education program was neither consultant-led nor as comprehensive as would be expected from a home / base hospital. No designated consultant oversaw the education program, and no advanced trainees were onsite to fulfil this role. Consultants fulfilled very few training roles on a regular basis, due to high clinical workload (overwork), a perceived lack of executive and leadership level support, chronic understaffing, and resultant burnout.

Staffing was at a persistently critical level, and consultants’ ability to meet clinical needs was often impacted by unplanned leave, staff turnover, and increasing levels of burnout. Trainees sometimes had difficulty calling consultants in birth suites, or contacting them after hours. Trainees were sometimes advised to perform birthing procedures for which they were not formally credentialled, while a lack of accountability affected patient care.

Organisational culture was fractious (a clear divide between front-line medical staff and the hospital executive), highly reactive, and toxic; increased workloads led to frustration that made others feel unsafe. Junior staffing operated at between 40 and 50 per cent capacity: the hospital heavily relied on locums to meet service needs, or international medical graduates for registrars. Short staffing impacted trainees’ ability to meet training requirements.

The report lists 25 conditions that Canberra Hospital must meet to improve accreditation, and makes 31 recommendations.

ACT Government response

Health Minister Rachel Stephen-Smith and Canberra Health Services acknowledged the need to support training accreditation and to provide a better experience for trainees. CHS would work with RANZCOG to address any recommendations.

“Some of the issues can be fixed more quickly, such as better and earlier shift rostering for team members,” a CHS spokesperson said.

“Recent recruitment efforts have been successful in securing senior staff specialists who will join the unit from overseas to ensure that there is sufficient dedicated time to support trainees in a high-quality training experience. The busy clinical workload of our clinicians has meant that there is less time to dedicate to ongoing training of our obstetrics and gynaecology trainees. As a teaching and learning hospital, we know this is not acceptable.”

The last 18 months had been “particularly challenging” for the obstetrics and gynaecology team, Ms Stephen-Smith said, due to challenges around workforce recruitment and retention, and culture.

A lack of sufficient supports in place when critical incidents occurred contributed to staff feeling negative and burnt out, she said. This fed a cycle where staff leave or additional workforce pressures contributed to burnout, which in turn contributed to poor culture and to trainees not getting positive experiences. While supports had been put in place, the minister said they were not yet embedded in the way they should have been.

“I recognise that for many people, [the supports] won’t necessarily have flowed through to being seen on the front line, or that they will still be reflecting on the experiences that they might have had 12, 18 months ago,” Ms Stephen-Smith said.

“We’ve certainly heard the message that what we’ve done to date hasn’t been enough, and CHS is recommitting itself to ensuring that the voices of those staff are heard and that those issues are addressed.”

Ms Stephen-Smith said RANZCOG is committed to working with CHS to maintain the training accreditation.

“I have no expectation that our training accreditation is at risk,” she said.

“We know that training accreditation has been withdrawn at other units across the country, and it has happened before at Canberra Hospital. That’s not good for anyone. It’s not good for the trainees; it’s not good for the senior staff; it’s not good for the college; and it’s not good for the development of this specialisation across the country. So, the College has been very clear that their intention is to work with CHS to ensure that the recommendations that they have made are taken seriously and are addressed.”

RANZCOG was clear that workforce shortages were occurring across Australia, the minister said.

“The ACT is not alone in facing these issues. A number of obstetrics and gynaecology units across the country have faced challenges around their training environments and accreditation over the last year or so. The college has recognised that these are national issues, and that there is no quick fix at a national level.”

Canberra Liberals

Elizabeth Lee, however, worries that the Health Minister’s optimistic statements are ‘spin’ and “trying to downplay the very grave and serious failures that we see across the health system”. She noted that concerns had been raised since 2010.

“This minister will always talk about ‘ongoing challenges, but we’re dealing with it’,” she said. “How much longer does the Canberra community need to be told ‘Yep, we’re dealing with it’ with no outcome, no improvement, and no future planning? …

“I have no doubt that she firmly believes that she is going to work [with Canberra Health Services and RANZCOG] to make sure that the accreditation isn’t lost, but the facts speak for themselves. When you’ve got a health system that has had scathing report after scathing report going even further than a decade ago, and the report of the latest one talks about repeated issues that have been raised, then I don’t know how objectively anyone can look at that and say that accreditation loss is not a real risk.”

Ms Lee wants the government to implement all the recommendations of the report, and to accept the “serious failures” in the obstetrics and gynaecology unit in order to fix them.

“When you’ve got scathing remarks about the poor culture, about poor leadership, and about the fact that this is a tertiary hospital that is in danger of not being accredited, that speaks volumes, not only about the standard of care that patients are receiving but also about the health and wellbeing of the trainees themselves, the consultants and the trainers. But it also raises alarm bells about the long-term future.

“Because if the Canberra Hospital is not able to train these trainees, then the pipeline of trainees that we need to have, who are going to provide the critical obstetric services for Canberra mums, is going to be impacted. That is the reality. We need to make sure that as the nation’s capital, we are doing everything we can to attract train and retain the critical medical frontline services that we have and attract more, not making sure that we turn away these people. That is what we’re seeing with this Labor-Greens government.”