Pearls and Irritations

Conservative commentators and the Business Council of Australia speak endlessly about the need for industrial and 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 30 years. It was begun under the Hawke/Keating governments and continued under the Howard governments.

But the health sector has scarcely 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. The Productivity Commission estimated a few years ago that a 10% efficiency improvement in health would deliver an $8 b dividend at that time.

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% In NZ it is 90%.  The reason why Australia is so far behind the field is opposition by obstetricians who want to protect their market share and high incomes. They are highly favoured through the Medical Benefits Scheme.

Health is Australia’s largest industry, and employs about 7% of the civilian workforce.  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. Above all else it requires political courage to face down the special and entrenched interests that dominate the health sector.

Several years ago, an emeritus professor at University of Sydney, Professor Kerry Goulston described the problems he saw as follows.

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.

We clearly need to dramatically reshape our health workforce. The Productivity Commission made the first serious attempt to address the problem. But progress has been very slow.

My own view is that the financial lever of the Medical Benefits Scheme is the best way to promote reform. Nicola Roxon made a few changes in this regard but it was quite minor.

We need concerted and strong political and administrative action to break down  the old historic workforce boundaries and boxes and  establish new ways of working – teams 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 need for example to consider 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.

Professor Peter Brooks  has drawn attention to the 60,000 physician assistants in the United States who grew out of the ‘medics’ in Vietnam. They are trained for about two years in 100 professional programs across the United States, concentrating on science and clinical aspects.

Clearly nurses, allied health, ambulance officers and community health workers could undertake more skilled work except for the barriers erected by other professionals.  Pharmacists need to employ their professional skills in primary care with less of their time spent as shop keepers.

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.

Failure to tackle these major workforce problem results in 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. Excuse me dropping names but 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 at the end of its design life. The whole health system is built around provider demarcations. It must be efficiently built around patients’ needs.

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