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the multiplicity of organisations (Commonwealth, State and professional) that administer and fund the health sector, outdated industrial practices which protect the health professional ‘silos’ and a lack of willingness on the part of any of these groups to address reorganisation and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

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.

General Practice

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.

Role Delineation

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.

Figure 1

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.

Thanks to sxc

‘System issues’

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.

Policy Issues

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:

• Carers;
• Physician Assistants;
• Health ‘trainers’ (coordinators of care particularly for chronic disease);
• Hospitalists.

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.

Conclusion

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?

In this new paper Jill Iliffe argues that any serious attempt to improve Australia’s health policy must address the capacity, efficiency and flexibility of our health workforce.

Download the paper, ‘A New Approach to Australia’s Heatlh Workforce‘ (pdf)

The health workforce comprises around 5% of the total workforce in Australia, and absorbs around two thirds of Australia’s total health spending. Health spending itself is about 9.7% of GDP.

Australia employs similar ratios of health professionals to the OECD average; however the rate of employment growth in the health system, concentrated among allied health and complementary health professionals, is now twice our rate of population growth.

Health workers are highly diverse, ranging from entry level workers educated at a Certificate II or III level, to highly qualified professionals with Bachelor, Masters or PhD qualifications. It is this specialisation that makes evidence based workforce policy and management essential.

Why do we need to reform health workforce policy?

• The ageing demographics of both health care consumers and the health workforce;
• The need to shift the focus of health service delivery towards prevention, early intervention and self-management;
• The need to evolve existing workforce roles to match these new modes of health servicing;
• Inherently conflicting service, educational and funding interests between the commonwealth, state and territory governments;
• An uncoordinated health education regime, whereby system demand and supply are poorly measured and matched;
• Fragmented clinical training – no central funding, measurement or profiling of the clinical training resources and outcomes within the system;
• The need to practicably integrate relevant innovation and technology into clinical and administrative practice;
• The need for work/family balance among health workers in a long-lived, double-income society;
• Poor distribution and utilisation of the health workforce relative to requirements;
• Workforce shortages and erosion, as a consequence of the unsustainable structures within this changing health environment; and
• Australia’s resulting reliance on permanent or temporary migration of health workers;

‘A New Approach to Australia’s Heatlh Workforce‘ recommends:

That the National Health Workforce Strategic Framework be properly executed by all Australian governments, to:

• collaboratively involve all health stakeholders in policy development;
• produce evidence-based health workforce policy and planning, linked to the broader health system;
• ensure and sustain supply;
• distribute workforce to optimise health care access and meet the needs of all Australians;
• use skills and knowledge to the optimum, and foster workforce adaptability;
• ensure that the health workforce is always skilled and competent; and
• produce health environments where people want to work.

A change in policy is essential for Australia’s health care system to be sustainable, and the following should proceed immediately:

• introduce an independent health reform commission to examine the best model of health funding, and the best ways to utilise the Australian health workforce;
• establish and strengthen community health centres across the nation, staffed by primary health care teams that include existing general medical practitioners; and
• conduct comprehensive national workforce planning, linking education places to workplace needs.

The media today is full of workforce reform, particularly in the blue-collar area where there has already been very substantial reform and improvement. Changes in the Australian workforce have helped transform the Australian economy in the last 20 years. It was begun under the Hawke/Keating governments and continued under the Howard governments.

But the health sector has not been touched. I ‘guesstimate’ that there is a potential productivity dividend of at least 40% in health workforce reform over the next decade. That 40% may be on the low side. I am less familiar with the community services sector, but I would be surprised if the story is much different.

Reform of the health workforce structure, work practices, multi skilling, teamwork, and flexible training, are the key micro-reform issues that we face. The most obvious example of restrictive practices in health is in obstetrics and midwifery. In Australia, less than 10% of normal births are managed by midwives. In the Netherlands it is over 70% and in the UK over 50%. The reason why Australia is so far behind the field is obstruction by obstetricians who want to protect their market share and are highly favoured through the medical benefits scheme.

Health is Australia’s largest industry, $80 b per annum or 9% of GDP. About 70% of every health dollar of expenditure is in labour costs. Such a large area of expenditure cannot be excluded from workforce reform. It is more important than any other workforce issue. Health workforce reform will not be easy but it is essential.

Four years ago I surveyed the inefficiencies and inequity of the health workforce in NSW. I would like to share with you some of the comments I received. It is the same in other states and the same today as it was four years ago.

I was told by senior clinicians, academics and executives that ‘NSW health has an archaic work structure’. …’It is quite incoherent’ …’we have boxes everywhere, junior doctors, specialists, clinicians, nurses, allieds, managers, colleges, universities, but there is not a thesis or plan that draws it all together.’

I was told consistently that no one owns workforce issues – ‘workforce planning is reactive’. .. ‘Improvements in people management occur in spite of the system’ …’the workforce is structured on a medical model, not a health model’ …’there is extremely poor human resources and people management skills across the workforce’.

I was told about the lack of coordination between workforce issues, service delivery, finance and infrastructure. The example often given was opening more hospital beds without the nursing staff to service them. As one clinician put it to me ‘there is a hit and miss linkage between the workforce, budget and service delivery.’

I was told that there was not enough understanding and research about the extent of the workforce problems. ‘Many tasks should be thoroughly re-engineered’ …’work practices are a major problem, they are quite ad hoc’ …’the medical boundaries must be invaded’ …’there is not a workforce shortage. The issue is how we use the workforce.’

I was told that education and training is supply driven and not really linked to the demands of a rapidly changing health system. I was told that education and training entrenches the boundaries within the system. ‘There is no genuine health training. Almost all the training is in separate streams. Core training is incidental.’

I was told that the health workforce is inward looking with many people working their whole professional lives within the same system. ‘Health is introspective, new people and new ideas are essential.’

In the last issue of online magazine New Matilda, emeritus professor at University of Sydney, Professor Kerry Goulston said
Our medical workforce management in hospitals is rigid and antiquated. Job sharing is rare. …Most hospitals are staffed on the front line at nights and weekends by junior medical staff, often without onsite supervision. …The traditional roles of doctor, nurse and allied health personnel have to be redesigned around the patients’ needs.Many procedures carried out by doctors could be done by non-doctors. Many medical duties could be done by other health professionals. In places where it has proven impossible to recruit doctors, nursing staff have been upskilled to provide a higher level of clinical care. It is clearly possible to extend this model for use in public hospitals where better supervision is available, but would require a reduction in the strict demarcation of clinical roles. …The morale of our hospital workforce is low. Disengagement and loss of commitment is a real issue.

I won’t go on. I rest my case. We recognise the problem but little is done.

Solving the problem

We clearly need to dramatically reshape our health workforce.

The UK NHS is piloting a new generic ‘health care practitioner’ as a broadly banded job description. The role of a health care practitioner in an acute hospital would include roles presently performed by junior doctors, senior nurses, professions allied to medicine and speech and language therapy. Such a health care practitioner in an acute hospital would assess a patient’s condition, make a physical examination and arrange diagnostic tests, establish a treatment plan, implement the plan, ensure ongoing assessment and management and be responsible for admission and discharge. What a reformation that would be.

In primary care, the health care practitioner role would take up to 40% of the GP workload, with significant overlaps between the roles of nurse practitioners, general practitioners and practice nurses. Such a health care practitioner would be charged to manage a case load in a wide range of conditions – patient assessment, patient history, physical examination, diagnosis and development and implementation of treatment plans. In primary care, the health care practitioner would treat the following conditions – asthma, diabetes, hypertension, hormone replacement therapy, minor acute and wound management, self-limiting conditions, paediatric surveillance, immunisation and vaccination.

In the NHS, they are also looking at widely banded roles for health care assistants as well as health care practitioners.

These proposals are really a breaking down of the old historic workforce boundaries to establish new ways of working – team working across professional and organisational boundaries; flexible working to make the best use of the range of skills and knowledge of staff; streamlined workforce planning and development which stems from the needs of patients not of professionals; maximising the contribution of all staff to patient care, doing away with barriers which say only doctors or nurses can provide particular types of care; modernising education and training to ensure that staff are equipped with the skills they need to work in a complex, changing health system; developing new, more flexible careers for staff in all professions; expanding the workforce to meet future demands and more flexible deployment of staff to maximise the use of their skills and abilities. We highlighted these new ways of working in the Generational Health Review in SA 2003 (p126).

Professor Stephen Duckett has suggested some more limited health workforce reforms in Australia. They include nurses undertaking greater responsibility for prescribing, diagnosis and triage in hospitals; nurse anaesthetists complementing and substituting for medically qualified anaesthetists; enrolled nurses taking on some of the tasks currently done by registered nurses; midwives substituting for obstetricians; new allied health assistants supporting allied health workers to increase their capacity to treat more patients; practice nurses undertaking some of the work currently performed by GPs, including some prescribing, screening and triage.

Clearly nurses, allied health and community health workers could undertake more skilled work except for the barriers erected by other professionals.

An example of the barriers are the restrictions on nurse practitioners. Despite all the rhetoric, very little progress has been made in building the professionalism and career opportunities of senior nurses. I believed that a lot of the opposition came from doctors who didn’t want their territory invaded, often in the name of quality and safety, but invariably to the detriment of people in need of care, particularly in country areas. But I think there is more to it than that. My clear impression after chairing two health enquiries is that the nurses’ federations have not been doing much heavy lifting on this issue. If they have, there is not much evidence of it. They are clearly wary of ‘elite’ nurses. It is a pity that senior nurses are not better supported because they really hold the Australian health system together, but are denied real advancement. Large numbers leave nursing for other industries, particularly hospitality. The best that stay in the industry go into academia or health administration.

The great problem is that our health and community services workforce is trained and works in boxes – ‘there are boxes everywhere’. We need dramatic change, up-skilling, multi-skilling, broad banding and teamwork.

No one is really tackling this major workforce problem despite the clear loss of morale and high staff turnover across the health and community sector. We see the problems like the tip of the iceberg, only when they are revealed before a court or medical board. The powerful sectional interests still call the shots and resist change. If they had blue collars, rather than white coats, the story would be different.

What is lacking is courage and determination to address the problem. In the late 1980s, I attended a round table discussion with UK Prime Minister, Maggie Thatcher in Sydney. She was asked ‘now that you have reformed the work practices of the printers and coal miners in the UK, what do you propose to do about the restrictive practices of doctors and lawyers?’ She replied, ‘It is a very serious problem, but if you don’t mind I will leave it until my last term’. The coal miners and printers were fair game, but not the doctors and lawyers who were put in the ‘too hard’ basket.

The health and community workforce structure is clearly at the end of its design life. The whole health system is built around provider demarcations. It is certainly not built around patients’ needs. What will cause a breakthrough – a staff crisis, sinking morale, unbearable workloads or escalating costs? It takes courage to take on the powerful interests involved in health. It hasn’t happened yet. The soft option is invariably more money to get the issue off the front page of the Daily Telegraph or its interstate equivalent.

The success or otherwise of workforce reform comes down to the courage of health ministers, governments and senior officials to face down the powerful vested interests that oppose reform of the workforce and want to protect their privileged positions. Ministers, governments and officials must win the case for change and drive the process. Waterfront reform was a minor issue compared with this one. Health workforce reform doesn’t require dogs and security guards with balaclavas, but it does require determination.

This article is based on a speech John delivered to the CS & H Industry Skills Conference on 7 June 2005. He also spoke on Primary Care and Wellbeing .