Doctors scared Maggie Thatcher. John Menadue

Excuse me for dropping names but at a round table discussion with Maggie Thatcher in the late 1980s that I attended in Sydney she was asked “Now that you have fixed the work practices of the miners and the printers in the United Kingdom what are you going to do about the restrictive work practices of the doctors?” She replied. “I will leave that to the last session in my last term as Prime Minister” She never got around to it. And neither have we in Australia.

The politically partisan Business Council of Australia has been campaigning for increased productivity through labour market reform. But it does not mention the health sector which has the most archaic work practices in the country.  They are a major economic burden and cost.  Based on Productivity Commission figures six years ago I estimated that workforce reform could save $3b per annum. I think that is a very conservative estimate.

The Health sector is rife with demarcations and restrictive work practices. The waterfront 20 years ago was a model of efficiency compared with the work practices today in the health sector. Health is our largest industry, with about 600,000 employees or 7% of our civilian workforce. About two thirds of health expenditure is labour cost. More efficient workforce practices are essential. The problems arise not because of individual failure, but because of unwillingness to address the structural inefficiencies. Archaic work practices deny career opportunities, particularly for nurses and allied health workers.

We need role-renewal and the creation of new types of health workers. We need up-skilling, multi-skilling, broad-banding and teamwork. Blue-collar workers have been fair game for workforce reform, but not professionals in health and the law. By comparison with countries like New Zealand, Canada, USA and the UK, we don’t have so much a shortage of doctors but a refusal of doctors to allow other qualified people to share their territory. The specialist colleges protect their territory in the name of quality of care. Only about 10% of normal births in Australia are delivered by midwives and 90% by obstetricians. In the UK midwives deliver 50% and in New Zealand it is 90%. We have only a few hundred nurse practitioners when we should have thousands. Many specialists treat public hospitals like a cottage industry in 19th Century England, coming and going at their convenience.

Former Health Minister Nicola Roxon has shown that the Medical Benefit Schedule can be a lever to promote workforce changes. She commendably pushed the door slightly open for midwives and nurse practitioners. But the opportunities for much wider reform are enormous, There is a whole range of necessary changes e.g. nurses undertaking greater responsibility for prescribing, diagnosis and triage in hospitals, nurse anaesthetist complementing and  substituting for medically qualified anaesthetists, assistants in almost all specialist disciplines, enrolled nurses taking on some of the tasks presently performed by registered nurses, midwives substituting for obstetricians, practise nurses undertaking some of the work currently performed by GP’s. Pharmacies should provide basic health care as well as being shop keepers dolling out drugs. What about a nurse practioners in many of our 5000 community pharmacies? What about assistant physicians?  The highly skilled and experienced ambulance officers should be fully integrated into health services and expand their role. Why can’t they make home visits as they do in France?

Many doctors but not all will resist in order protecting their territory. That resistance will be all in the name of patient safety

There have been numerous enquiries on workforce reform including by the Productivity Commission and COAG but little progress has been made.

There are enormous dividends in patient care and reduced costs in a thorough overhaul and change in work practices in health in Australia. The opposition will come from powerful providers as Maggie Thatcher knew very well.

John Menadue

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