More bang for each health care buck

The recent Productivity Commission Report on Australia’s Health Workforce (‘the report’) comes at an opportune time as health systems around the nation reel against the ever increasing demands placed upon them. There is currently a world shortage of skilled health workers and whether we like it or not, it is not going to improve for sometime.

We need to do things differently; to ask whether the work of one health care professional can be done as well or more cost effectively by another. We need to also ask whether tasks can be performed in different and more efficient ways without task substitution.

This is not simply about saving money — it is about making the whole health system more efficient and delivering more services at a lower incremental rise in health care costs. We need to get more bang for each health care buck.

The report clearly outlines the complex background to the Australian health care system and calls for review of the amount of bureaucracy. Health workers at all levels complain about the paper work — surely we can do better!

Thanks to Scratch!

It is hoped that the report will be endorsed by the Council of Australian Governments (CoAG) at its next meeting and then its implementation can follow. There were four major recommendations in the report.

The first recommendation calls for the establishment of an Advisory Health Workforce Improvement Agency to evaluate opportunities for national workforce innovation, particularly those that cross existing professional boundaries. This is particularly important because of the silo-mentality that exists in the workforce and delivery of service. Such a mentality is ridiculous and unacceptable given that most of a patient’s health problems get managed by a ‘team’ of health professionals anyway.

Unless we have a group that can drive these innovations (and that will require this Agency to have some fiscal, bureaucratic and political clout), each separate group will continue to undermine reform (note the comments from the AMA this week), protecting their professional group over the interests of the community at large.

The second recommendation calls for the establishment of an Advisory Council on Health Workforce Education and Training to provide for a systematic and integrated review of training and education models. We need to assess how clinical training is provided and funded and develop a more transparent and contestable system.

This may mean that other groups, including universities and private providers, deliver programs that up until now have been the exclusive purview of the professional colleges.

The third recommendation calls for the establishment of a single, consolidated national accreditation and registration system entailing overarching statutory national accreditation and registration boards. Rationalising the ninety existing health professional registration boards would surely present cost savings and efficiencies. But if you think health professional bodies are self serving, watch this space because the health boards are worse. Have you ever heard of a registration board asking to dissolve itself? On a more serious note, this would significantly increase the efficiency, standardisation and portability of practice. It would also assist in the registration and accreditation of new types of health professionals particularly those that may have multidisciplinary skills.

The fourth recommendation calls for the establishment of an Independent Review Committee to advise on the services that should be covered by the Medical Benefits Schedule (MBS), as well as referral and prescribing rules. This is about achieving workforce change through funding incentives. It is important to remember that the system of funding is pretty perverse — it rewards procedures (including investigations) far in excess of cognitive opinion.

It is much easier to order a test than to spend time taking a proper history and carrying out a good physical examination – the ultimate ‘investigation’. Perverse outcomes are also produced by incentives created by the reimbursement for the various ‘-oscopies’ (e.g. gastroscopy, colonoscopy) and many other surgical procedures.

This Committee would act a little like the PBAC (Pharmaceutical Benefits Advisory Committee) which has thus far acted in the interests of the Australian community in relation to the provision of and access to effective drugs at reasonable cost. Importantly, it makes its decisions based on evidence and cost-effectiveness. 

Financial incentives are beginning to significantly influence the system. Health profession graduates are looking towards the areas that produce better remuneration — private practice and the interventional specialties. No wonder we have had a problem recruiting to general practice and to academic health practice. If we have no health academics then how do we train the next generation and how do we develop ideas to the advance the health system as a whole?

This is arguably the most important proposal and the one that must be driven hard by governments. However its implementation will not be easy — successive Governments have done nothing to reign in the earning capacity of health professionals. Why should this change now? A starting point for moving this forward is the Relative Values Study (‘RVS’), which was exhaustively carried out by the Department of Health and Ageing and reported in 2001. The RVS recommendations were never implemented, but volumes of useful data were collected which could be used during the implementation phase of the Independent Review Committee.

The report also recommends that efforts be made to develop better-focused and more streamlined projections of future workforce requirements. This has proven to be very difficult to do in the past. The difficulty results from important factors changing — the population;, old diseases change and new ones appear.

Equity was also an issue in the report, with recommendations calling for improved outcomes in rural and remote areas and for groups with special needs. These are important given the increasing chasm between the ‘haves and have nots’ in our community. However, given some of the reactions to this report, one wonders how committed elements of the health profession are to being the ‘caring society’ that we think we are.

What we have here is a real challenge for governments. The report contains sensible and well argued recommendations but their implementation will mean that some of the most powerful institutions in the country — the Australian Medical Association (AMA) and the Colleges — need to participate in the debate and be willing to collaborate with governments and the community to achieve a health system that is both patient focused and health provider friendly.

What an opportunity we all have. Let’s see how creative we can be!

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