ARPA: The health workforce

Regardless of which political party wins the upcoming election, and whether the approach to healthcare reform is revolution, evolution or status quo, the new commonwealth government will be unable to ignore the looming health workforce crisis. The ageing of the population and the increase in chronic illnesses are placing increasing demands on an ageing health workforce that is already over-worked and poorly distributed. New entrants to the workforce are increasingly female and looking to work fewer hours in areas and specialties that will offer financial rewards to offset educational costs that may total over $200,000. The increasing push for a better focus on prevention, publicly-funded dental care, early intervention and a team care approach to the management of chronic illnesses will exacerbate the current shortages of doctors, nurses, dentists, pharmacists, midwives and allied health professionals. Unmet needs in rural obstetrics, Indigenous health and mental health cannot be addressed without more healthcare professionals who are willing to work outside of the leafy suburbs of Sydney and Melbourne. Neither can the demand for improved services in public hospitals and residential aged care.

THE DATA TELL THE STORY

Recent media headlines highlight the problems: ‘NSW town offers $500k to fill doctor shortage’ (ABC Radio 2007), ‘Inland dentist shortage hits third world levels’ (2006) and ‘Nurse shortage to hit 8,500’ (Dunn 2004). Data collected by expert and professional bodies underpin the news headlines. By current estimates, Australia will be short 800–1,300 general practitioners by 2013 (Australian Medical Workforce Advisory Committee 2005), 470 registered nurses a year by 2010 (Preston 2006), and 1,500 dental health providers, mostly dentists, by 2010 (Marshall & Spencer 2006). There is already a nationwide shortage of about 2,000 midwives (Australian Health Workforce Advisory Committee 2002) and a shortfall of at least 172 pathology positions over the levels recommended by the Australian Medical Workforce Advisory Committee (Royal College of Pathologists of Australasia 2005). A work force survey in 2003 revealed that a quarter of Australian obstetricians were now aged 60 or more (Bell 2003). And only 3 per cent of psychiatrists live and work in outer regional or remote areas where 12 per cent of the population lives (Thomas 2007). Department of Immigration and Citizenship figures obtained by The Australian newspaper (Hart 2007) show there are currently 4,500 overseas-trained doctors working in Australia on temporary visas and health services are increasingly dependent on these doctors. In rural and regional areas in the period 1995–96 to 2003–04, there was an 80 per cent increase in overseas-trained GPs (Arkles et al. 2007).

This workforce shortage is a global phenomenon, with a recent World Health Organisation Workforce Report estimating that there will be a global shortage of over four million doctors, nurses, midwives and other health workers over the next decade (World Health Organisation 2006). So our current dependence on overseas trained health workers, particularly doctors, is not sustainable, particularly as it deprives developing countries of an essential asset.

WHAT NEEDS TO BE DONE?

No politician doubts that there is a severe workforce shortage, but what needs to be done to address it?

Since 2004 the Howard Government and the Council of Australian Governments (COAG) have acknowledged that there are problems and have moved to tackle them. In June 2004, COAG agreed to commission a paper on health workforce issues, including supply and demand pressures over the next ten years. The subsequent report from the Productivity Commission (2006) made a series of recommendations around these issues:

However, the report’s recommendations, even those endorsed by COAG, remain unaddressed and to date the focus has been almost entirely on more university places for medical and nursing students—a necessary but insufficient step in building the workforce we need for the 21st century.

The next commonwealth government will need to move beyond the piles of reports and COAG communiqués and platoons of advisory committees and workgroups to take real actions and make the necessary long term investments. This will require concerted national leadership to construct partnerships across the health and education bureaucracies, federal and state and territory governments, and the private and public healthcare sectors. It will also mean taking on a range of vested professional interests more motivated by protecting territory than by finding new ways to work together to improve patient outcomes.

Reform of the healthcare workforce will require policy and action in the following areas:

Long term planning

To date Australia has not done well in aligning education and training programs with national healthcare workforce needs. This is not an easy task, particularly when training a doctor takes twelve years or more. Also a growing focus on family and lifestyle and the feminisation of the medical workforce means that an increase in the overall number of providers does not necessarily equate to an increase in services, and so planning must look beyond headcounts to work practices.

We need a more farsighted and committed approach, where the National Health Workforce Strategic Framework, first put in place by the Health Ministers in 2004 (Australian Health Ministers’ Conference 2004), really can inform the allocation of resources to education, training, recruitment, retention and reskilling across the full range of workforce needs.

Ideally this will require an authoritative mechanism that is located outside of the short term influence of the electoral cycle—an independent group of experts, agreed to by COAG, and charged with looking at least a decade ahead.

Better links between education and clinical training

The increase in university places for health professionals has not been accompanied by planning for clinical placements or increases in supervisor numbers. There is a need for better integration between universities, health departments and medical colleges to develop training programs that are based on competencies.

Clinical training programs need to focus more on team work and involve both public and private facilities. The use of alternative training sites such as dialysis units, dental hospitals, and community health centres can help broaden the training experience and simultaneously provide additional staff to facilitate greater patient access to services.

There are a number of specific training issues that need to be addressed. These include:

Reassessment of Districts of Workforce Shortage and Areas of Need

The ability of overseas-trained doctors and non-vocationally registered GPs to have access to Medicare is dependent upon them practicing in areas that are designated by the Commonwealth Department of Health and Ageing as Districts of Workforce Shortage. The states and territories administer their own different definitions of Areas of Need which govern where overseas-trained doctors can take up medical positions. Methods of defining Areas of Need differ between the states and territories and there is no concordance with the criteria used by the commonwealth to define Districts of Workforce Shortage.

It makes little sense for the commonwealth and the states and territories to administer two separate schemes. Decisions about what constitutes an area of workforce shortage and the initiatives that can be implemented to address that shortage should be based on data and agreed guidelines and made by a single body at the national level. Regardless of the system/s in place, there will always be boundaries and therefore anomalies, so the system needs some flexibility, with decisions on exceptions made without political influence. There should be strong links between the body which makes long term planning decisions and the body which makes determinations about workforce shortage. They could even be the same body, a role which the National Health Workforce Strategic Framework could fulfill. This would ensure that planning was based on recognised national needs.

National accreditation and registration

COAG has agreed to establish a single national registration scheme for health professionals and a single national accreditation scheme for health education and training by July 2008. The proposals have been met with suspicion and in some cases outright opposition by the various professional health bodies which are reluctant to cede control and concerned about task substitution (see Australian Medical Association 2007). Nevertheless, it is imperative that work on these two national schemes goes forward to ensure national standards, eliminate red tape and bureaucracy, and facilitate the movement and work of health professionals across state boundaries.

COAG also agreed that a national assessment system for overseas trained doctors would be implemented by December 2006. That deadline has passed and the wrangling continues. A report commissioned by the Howard Government but never released found that more than 3500 doctors enter Australia every year on temporary visas and are given jobs without their competency being assessed by the Australian Medical Council. (Hart 2007). Public hospitals and GP services in rural and remote areas are dependent on these doctors, but they are often in need of additional training and supervision.

New healthcare professionals

Increased demand for prevention and chronic illness care and support for team approaches to the delivery of healthcare have lead to proposals for extensions of the current roles of healthcare workers and the creation of new types of healthcare workers such as hospitalists (doctors who co-ordinate a patient’s hospital care), clinical assistants (non-doctors who work as surgical assistants, physician assistants and anaesthesia assistants), and prescribing nurse practitioners.

While some of these new health professionals are already in place and filling a valuable role, the issue of role delineation or task substitution has been seen as a threat rather than an opportunity by some medical bodies. Their concerns are couched in terms of safety and quality but probably go to the fact that the exclusivity of medical knowledge and skills is being broken down (Ellis et al. 2006).

It is clear that the health workforce and health workplace practices must be modernised to meet the demands of the 21st century. The ability to get beyond initial unfounded resistance to change has the potential to deliver benefits in professional morale and satisfaction, productivity dividends and patient outcomes.

Recruitment and retention incentives

Recruitment and retention incentives are important because they provide a means of addressing workforce shortages in the short term and ensuring that investments made in education and training pay-off in the long term.

The increasing educational costs faced by young people wishing to take up university places are a major disincentive for them to work in those professional and geographic areas where financial remuneration is low, and also serve to as a barrier to the entry of some students in the first place. A simple and practical solution would be to rebate HECS fees based on the time spent training and working in approved clinical and geographical areas.

Significant numbers of trained professionals such as nurses and psychologists do not work in healthcare, and in other areas such as aged care, poor wages and low morale have led to a steady exodus of staff. Reskilling programs and workplace reforms that acknowledge the need for flexible, family-friendly hours, provide benefits such as after-hours transport and childcare, and ensure career path options and commensurate salary benefits will help attract back these trained workers.

In rural areas the challenges involved in recruiting and retaining health workers are amplified by the lack of professional support, the difficulties involved in making time for continuing education and vacations, concerns about schooling for children and employment for partners, and social and cultural isolation. These factors, as much as economic security, govern decisions about where to live and work.

Currently 25 per cent of GPs practising in rural and remote locations are compelled to do so as a result of Medicare provider number requirements or bonding conditions, so it is important that they are offered assistance with integration so that this period in their professional life is viewed as an opportunity rather than a sentence. Many of these doctors are overseas-trained and need help with adapting to life in a country town.

We do know that students from rural areas, and those who have a good rural experience during their training, are more likely to stay and work in these areas, and health professionals who have a support network of their peers will stay longer in rural and remote areas. The value of networking extends to the family. Careful attention to the needs of the health professional as part of a family unit will increase the probability that they will be attracted to and stay in rural practice. While there is no shortage of successfully trailed projects addressing these needs (see Cheney et al. 2003), there is a dearth of sustained funding to ensure their continuation and growth.

CONCLUSION

Regardless of the health policies of the government that is elected in the forthcoming election, addressing the healthcare workforce crisis is the essential priority. This will require a multifaceted approach, simultaneously addressing long term planning, education, training, reskilling, recruitment, retention and the modernisation of the health workforce and the workplace. It will require strong national leadership to forge partnerships across the health and education bureaucracies at both state and federal levels. And it will require the ability to address genuine professional and public concerns and dismiss frivolous plays for jurisdictional power and the protection of professional bailiwicks.

The next government will be assessed on its vision for Australia, its ability to carry that through and its willingness to make the long term investments that may not pay off during its term. It will take all these attributes to deliver the healthcare workforce reforms that are needed.

REFERENCES

Arkles, R.S., Hill, P.S. & Jackson Pulver, L.R. 2007, ‘Overseas-trained doctors in Aboriginal and Torres Strait Islander health services: Many unanswered questions’, Medical Journal of Australia, vol. 186, no. 10, pp. 528–530.

Australian Broadcasting Corporation 2007, Transcript of interview, ‘NSW town offers $500k to fill doctor shortage’, The World Today, ABC Radio, 14 June [Online], Available: http://www.abc.net.au/worldtoday/content/2007/s1951677.htm [2007, Sep 7].

Australian Health Workforce Advisory Committee 2002, The Midwifery Workforce in Australia 2002–2012, Australian Health Workforce Advisory Committee Report 2002.1 [Online], Available: http://www.health.nsw.gov.au/amwac/pdf/midwifery_20022.pdf [2007, Sep 4].

Australian Medical Association 2007, AMA steps up campaign to have COAG National Registration Plan scrapped, Media release, 21 February [Online], Available: http://www.ama.com.au/web.nsf/doc/WEEN-6YM4LA [2007, Sep 4].

Australian Medical Workforce Advisory Committee 2005, The General Practice Workforce in Australia: Supply and Requirements to 2013, Australian Medical Workforce Advisory Committee Report 2005.2 [Online], Available: http://www.health.nsw.gov.au/amwac/pdf/gp_2005.pdf [2007, Sep 4].

Cheney, H., Wilson, E., & Campbell, S. 2003, Meeting the family support need of rural GPs via a rural community development approach, paper presented to the 7th National Rural Health Conference, Hobart [Online], Available: http://www.isf.uts.edu.au/publications/HC_EW_2003.pdf [2007, Sep 4].

Ellis, N., Robinson, L. & Brooks, P.M. 2006, ‘Task substitution: Where to from here?’, Medical Journal of Australia, vol. 185, no. 1, pp. 18–19.

Marshall, R.I. & Spencer, A.J. 2006, ‘Accessing oral health care in Australia’, Medical Journal of Australia, vol. 185 no. 2, pp. 59–60.

Royal College of Pathologists of Australasia 2005, Manpower crisis in pathology, Pathway, Royal College of Pathologists of Australasia, Spring 2005 [Online], Available: Available at http://www.rcpa.edu.au/pathway/pdf/PathWay_Spring05_A4.pdf [2007, Sep 4].

World Health Organisation 2006, The World Health Report 2006—Working Together for Health, World Health Organisation [Online], Available: http://www.who.int/whr/2006/en/ [2007, Sep 4].

Dr Lesley Russell is Menzies Foundation Fellow at the Menzies Centre for Health Policy at The University of Sydney and the Australian National University.

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Election 2007: The health workforce