Australia needs a radical rethink of the way it delivers and resources its health services. Robert Fogel (Nobel Laureate in Economics) predicted that the economies of developed nations would be ‘driven’ by health by the mid 2020s, expending between 20 and 25 percent of GDP in that area. A recent report for the US predicts a doubling of spending on health by 2016 to $4.1 trillion dollars USD – and that nation currently devotes over 16% of its GDP to health. Australia’s health economy is heading in a similar direction, yet despite this expansion numerous reports over the last ten years have indicated an increasing inability of the Australian health care system to deliver appropriate and timely care to Australians. This is reflected by the continuing concern about waiting lists for surgical procedures and specialist consultations in public hospitals, long waiting times in the private sector for particular specialties and increasing disparities between the delivery of care in major centres and in the rural sector. The increased demands on the health system are being generated by a number of factors which include the ageing population, an increasing burden of chronic disease, a more demanding population in terms of provision of health advice and services and a health workforce, that along with the workforce in general, is somewhat less committed to providing the 24/7 service of yesteryear.
Our inability to deliver appropriate health services to Australians is dictated by a number of factors which demand reform. These include inefficiencies with the multiplicity of organisations (Commonwealth, State and professional) that administer and fund the health sector, outdated industrial practices which protect the health professional ‘silos’ and a lack of willingness on the part of any of these groups to address reorganisation and the productivity gains that might flow from this.
It should be acknowledged that this is a worldwide phenomenon with the most recent World Health Organisation Health Workforce Report estimating that there would be a global shortage of over four million doctors, nurses, midwives and other health workers over the next decade. As a nation we have become far too dependent on international health graduates (medical in particular) and have become (somewhat unwittingly) part of the international trade in health workers which often deprives developing countries of one of their most important ‘assets’ – health workers.
Concern in relation to the health workforce led the Australian Government to request the Productivity Commission to develop a report on Australian’s health workforce (which was handed down in December 2005). A summary of the Commission’s proposals is shown in the table below.
Productivity Commission Recommendations, 2005
|Enhancing the National Health Workforce Strategic Framework as a reference
point for future reform and importantly a vehicle for promoting coordination across the policy areas that impact on the health workforce.
|Facilitating workplace innovation through the establishment of an Advisory Health Workforce Improvement Agency that would provide an independent assessment of the benefits and costs of workforce innovation opportunities, identify implications for education and training, accreditation and registration and the funding through both the public and private sectors.|
|More responsive education and training requirements to better align the numbers of tertiary health training places with the health needs of the community and the workforce requirements of the service providers. There is also a need to ensure the clinical training capacity in many areas and to encourage new providers of health training through a range of organisations.|
|Develop a consolidated national accreditation regime that would facilitate timely uptake of workplace innovations emerging from the proposed workforce improvement agency and interdisciplinary learning. This would also provide a platform for uniform national standards on which to base registration and to facilitate the development of a national approach for the assessment of the qualifications of overseas trained health workers.|
|Develop a consolidated national registration agency to promote a national uniform approach to the regulation of health workers and reduce barriers to the movement of health professionals within Australia.|
|Provide improved funding related incentives for workplace change which might include an expansion of MBS (Medical Benefit Schedule) items including the development of delegated care models.|
|Develop a more streamlined and focused approach to projecting future workforce requirements. This might be achieved by better use of resources available to undertake the projections and more transparency in relation to the impact of policy settings on future workforce requirements.|
|A more effective approach to improving outcomes in rural and remote Australia.|
In any implementation of the Productivity Commission’s findings it is important to ensure that certain groups in the community are not marginalised and that efficiency gains are used to create a more patient-focused health system. It was disappointing that the Council of Australian Governments meeting (June 2006) which considered the report did not accept the majority of the recommendations, but the document remains a significant blueprint for innovation and change in the health system.
Australia still has one of the best health systems in the world and it is underpinned by general practice. General practice has been under threat in this country for some years as the incentives (work organisation and remuneration) for engaging in specialist practice rather than in general practice are significant. There is some evidence to suggest that general practice is undergoing a minor ‘renaissance’ with numbers enrolling in the General Practice Education and Training Australia (AGPT) program increasing steadily over the last few years. General practice and primary care should continue to underpin the Australian health care system and incentives need to be created to ensure that graduating medical students are drawn to this discipline. Incentives should be created to fund general practitioners appropriately and reduce the ‘earnings gap’ between general practice and the specialties. The disciplines of general practice and health promotion need to be expanded and incentives provided to encourage general practitioners to work in rural areas as well as in the city. One issue that needs to be addressed is that of the isolated practitioner whether he or she be in a rural centre or in a city. Professional isolation leads to diminishing job satisfaction and may have a significant effect on quality and safety issues relating to service delivery. Technology now provides many ways for health professionals to maintain contact over quite significant distances whether this is a simple telephone line, video conferencing, exchange of data (x-rays, pathology tests) over the internet or other mechanism. Teleconsulting could be expanded to provide remote access to specialist’s consultation – the technology is available yet little incentive (provision of MBS telemedicine item numbers) has been provided by the Government.
Health Promotion/Public Health/Primary Health Care
Less than 10% of the health budget is directed to health promotion and disease prevention. In fact, we have an ‘illth’ system not a health system. Australia has one of the fastest growing epidemics of obesity in the world and this will lead to a significant burden of diabetes, heart disease, arthritis and other associated conditions over the next century. As with global warming, we have taken some time to acknowledge that this epidemic of obesity is a reality and that we need to do something about it. This can be best achieved by concerted intersectoral and community effort. Public health education should be strengthened at all levels. We should, for example, provide school children with a good health curriculum – teaching them about the most important asset they have (their own body) and how to look after it both physically and psychologically. This will need cooperation between health and education jurisdictions at all levels of government. The community needs to be far better informed and engaged in decision making about issues such as advertising of ‘junk food’, substance abuse and stress. This is not about creating a ‘nanny’ society, it is about establishing a society in which our children can grow up to be healthy and look forward to the same longevity as we have. It should be remembered that there is evidence that our children may be the first generation on this planet to have a shorter lifespan than their parents. The primary health care workforce should be increased with new models of ‘carers’ and lower level multiskilled health workers who can contribute to team care of the chronically ill and aged.
The health workforce currently makes up just over 11% of the total workforce in Australia and it has been suggested that we need a significant increase in this number to around 20% if we are to maintain the delivery of health services that we currently have. This expansion will be driven by the increased funding. To date four options for meeting this increased demand have been identified:
- Extending the role of existing health professionals (nurses, allied health professionals).
- Creating new types of health workers e.g. clinical assistants, physician assistants, surgical assistants, carers
- Improving efficiency by using information technology more effectively in the health industry.
- Placing more emphasis on prevention and health promotion.
Role redesign can involve the creation of new autonomous roles – ‘nurse practitioners’ for example – or roles in which non medical practitioners work under the supervision of someone else (usually a medical practitioner) – the delegated care model. Supervision of the person providing delegated care may be face to face or remote using video or other communication links for medical supervision.
This type of model has been accepted in the United States for some thirty years (physician assistants) and has been more recently trialled in the United Kingdom, parts of Europe and in Canada. We will need to look at some of the models that have been developed in these countries and to examine them rigorously in an Australian context. Underpinning task substitution is the notion of generic descriptions of health competencies that cross professional boundaries. The ‘skills escalator’ that has been developed for the National Health Service (NHS) in Britain is a useful example of this. The skills escalator is a nine-level career framework that starts with supporting roles and then moves to assistants and senior assistants, assistant practitioners, qualified practitioners, senior or specialist practitioners, advanced practitioners, consultant practitioners and finally more senior posts as seen in Figure 1. It provides a wide variety of entry points into health care careers, encourages and recognises life-long learning and acquisition of new skills and is used in an environment that seeks both job satisfaction and service efficiencies by delegating roles, work and responsibilities up and down the escalator where appropriate.
Underpinning many of these concepts is the idea of the health professional as part of a health care team. This is very important for the management of complex chronic disease, and it emphasises (using the skills escalator) the importance of training ‘generalists’ who have a clearly defined set of generic health competencies and who can rapidly assess multiple system disease, manage chronic cases and be involved to a certain extent in health promotion and disease prevention. The World Health Organisation recently identified five core competencies required for delivering effective health care for chronic conditions:
- Patient centred care
- Partnering (linking patients, providers and communities)
- Quality improvement
- Knowledge of information and communication technology
- Understanding the public health perspective moving from individual to whole of community care.
There are many situations where already existing health workers might be retrained to take on tasks that they have not previously undertaken. This could include radiographers taking on a role in reporting x-rays, ultrasounds and other images, pathology technicians becoming involved in the reporting of routine pathology (an extension of the PAP smear and other screening programs) and nurses taking on a role in minor procedures such as endoscopy and minor surgery. Podiatrists might be involved more in foot surgery and optometrists in cataract extraction. Ambulance officers can play a significant role as primary care providers in rural areas and programs are already being developed to expand their role.
Increasing efficiencies of current health workers
Health workers at all levels complain about the amount of paperwork that they now have to engage with in the health system. This can be anything from obtaining authority for Pharmaceutical Benefit Scheme (PBS) items, obtaining geriatric assessments, or accessing practice incentive payments. Significant efficiencies must be attainable in hospitals where doctors and other health workers are weighed-down by their administrative burdens. Options should be investigated for increasing the use of electronic ordering and improving the ‘flow’ of patients and paperwork, particularly in areas such as accident and emergency and hospital admissions. For example, how many times does a patient being admitted to a major hospital have her history taken from the time she arrives in the Accident and Emergency Department to the time she is finally in a bed in the ward?
The situation in geriatrics/aged care is a case in point. To access home care, each agency providing services generally conducts an assessment at admission. This is repetitive and frustrating for the clientele. This problem could be resolved, at least in part, by aggregating service providers into one organisation. Separate assessments are only necessary for specialist aspects of assessment and care planning. In hospital care, there is often duplication of assessment procedures among professional groups. Although each professional group is trained to perform ‘holistic’ assessments, there is often repetition in both the interview and documentation process. Parallel duplication also occurs throughout the course of a hospital admission, for patients with complex needs. Admission assessments are conducted by the medical, nursing and allied health staff, then nurse discharge planners, then geriatric consultation services and the ACAT services. With each contact, there is a repeated patient interview, and telephone phone calls to relatives, who are surprised at the poor communication and coordination between hospital staff.
Far more flexibility could be introduced in the workplace with timing and duration of shifts, job sharing and distribution of workloads.
Increasing efficiencies of training medical specialists
Training of doctors involves at least three different ‘agencies’ – universities, postgraduate medical committees (an arm of State health departments) and the Royal colleges. There are currently few formal links between these organisations and little attempt to look at the vertical integration of curricula. We need to be asking ourselves whether it should really take five to ten years to train medical specialists from the time of graduation to independent practice when in an increasing number of situations that independent practice is going to be in a relatively defined area of medicine (endoscopy, arthroscopy, cataract extraction, coronary angiography to name but a few). Training of doctors and other health professionals is still time-based to a large extent rather than competency based, and the training programs do not have the flexibility that is present in many other industries. There is an urgent need for universities, health departments and medical colleges to engage in a meaningful dialogue about how vertical integration of curricula can be achieved and to create some practical examples. Flexible, online postgraduate and continuing education programs with competency based assessment and recertification are the way of the future. This could enhance workforce training and job satisfaction as well as the implementation of research through knowledge transfer.
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The health system is naturally driven by the acute care hospital sector and there is still poor coordination between out of hospital services (primary care and general practice) and hospitals. Australia does not have a coordinated primary care policy, with medical practice managed by the Commonwealth with little provision for allied health and other services. The recent expansion of the MBS to allow non-medical access should be extended. Physiotherapists could be involved in screening musculoskeletal injury and ordering radiology; pharmacists could at least handle repeat prescriptions in patients with chronic disease or carry out medication reviews. States and territories tend not to have well developed primary care policies and programs which leads to a lack of coordination between hospitals and primary care in the community. At a regional level role delineation and clinical service networking is still poor (particularly between hospitals), although this is being addressed in some jurisdictions. The transparency of funding streams for health remains a challenge but could be improved by clear lines of responsibility and communication. This is particularly true in relation to Commonwealth and State responsibilities.
Significant improvements in health could be made by:
1. Increasing the proportion of the health budget dedicated to public health activities – specifically designed to improve the health literacy of the population as a whole and ‘at-risk’ groups in particular:
- Community public health campaigns
- Increased training of health promotion advocates (cross sectoral, including school teachers)
- Increased emphasis on disease prevention in health professional education programs
- Development of individual and community incentives to maintain health
2. Improving productivity by reviewing the structure of health delivery systems (National, State and Local) to address inefficiency, duplication and waste:
- Review and implement where appropriate the Productivity Commission Report into Australia’s health workforce.
3. Developing new types of health workers including:
- Physician Assistants;
- Health ‘trainers’ (coordinators of care particularly for chronic disease);
4. Reviewing incentives for the provision of health services to disadvantaged groups (rural and remote, Indigenous, disabled etc). This should include the development of funding incentives to attract health workers to train and work in rural and remote Australia and with these groups. It would also include a review of the use of and funding for technology to improve access (telehealth, telemonitoring etc.) for both patient and provider.
This paper has attempted to identify some of the elements of health workforce reform. It should not be viewed as a panacea but as the start of a long journey to improve the health system. There is little doubt that we will not be able to provide the health service which will be demanded by Australians in the future unless we redesign the health system and restructure the health workforce. These are significant challenges and there is no one or easy ‘fix.’ The health workforce currently makes up about 11.3% of the total workforce in Australia and this may have to increase to around 20% of total workforce by 2020 if we are to maintain the level of health service provision that the community has become accustomed to. Our challenge is to ensure that this expanded workforce is flexible, able to deliver patient-centred care, can partner and work as part of a health care team, uses information and communication technology and is dedicated to a public health perspective and quality improvement. This is our challenge – why don’t we rise to it?