Pearls and Irritations

Policy Series. 

With a federal election due in 13 months and the Coalition Government not travelling well enough to be confident of re-election, what should an incoming Health Minister focus on to ensure we have a highly skilled, professional and sustainable health workforce to care for the nation’s future health needs?

The answer is simple. It’s all about nurses.

Under current settings, in 10 years we will be experiencing an unprecedented shortage of nurses.

A shortfall of 85,000 nurses by 2025 will increase to 123,000 by 2030. This is about 25% of the total nursing workforce and rising!

By contrast, the doubling of medical school places since 2000 has meant that the supply of doctors will be approximately in balance – from a marginal oversupply now to a marginal undersupply of 2,500 doctors by 2025. In 2012 there were 91,504 doctors registered to practice medicine in Australia. The recent announcement of the Curtin University Medical School with 100 graduates each year will significantly address that shortfall and provide doctors for areas of greatest need.

Australia already has a doctor/population ratio well above the OECD average, and, reflecting recent medical school growth, between 2008 and 2012 Australia’s population grew by 7% while the number of doctors grew by 16.4%.

While doctors have their issues, they pale in significance alongside the challenges facing nursing.

Also, doctors have traditionally looked after their own very well and have the political power to ensure their issues are attended to. Nurses have not traditionally used their undoubted public support and power to the same effect.

The problems with nursing supply are easily identified:

• The attrition rate for nurses has historically been very high, especially for early career nurses. This suggests a disconnect between training and real working life experience. The high attrition rate should not come as a surprise. Over 40 years of research has consistently shown that nurses leave their profession because they do not feel that they can provide the level of care to their patients that they were trained and wish to provide, and they do not feel valued as part of the health care team.

Interestingly and significantly, since the Global Financial Crisis in 2008 the number of nurses leaving the profession has fallen dramatically. This is most probably caused by external economic factors, but does emphasise the importance of retention as the key strategy in achieving a sustainable nursing workforce.

• The attrition rate for nursing students nationally is a high 34%. For doctors it is almost zero.
• Over the last few years many thousands of graduating nurses have not been offered jobs by state government hospitals – squandering what will be a much needed resource in the future. (Can you imagine that happening to doctors?)
• Nurses are getting older. In 2009, 19.8% of nurses were aged over 55. In just three years, by 2012, this had increased to23.1%. While this validates recent improvements in retention, it also points to the looming nursing shortage when these mature nurses do retire.

How can we make nursing more attractive and retain these well-educated nurses?

One of the key elements of necessary overall health workforce reform is to enable all health professionals to practice at the top end of their licence. Simultaneously, an assistant workforce, supervised by the health professional, should be employed to take on the more routine and mundane tasks. This will free up the health professional to provide the higher level of care for which they were trained.

This is particularly apposite in the case of nursing, where the supply/demand gap will be impossible to close in the medium term by the traditional responses of increasing training and/or migration.

These changes are already occurring, but the pace is far too slow. We can also expect a continuation of conservative opposition. The AMA opposed the introduction of Nurse Practitioners (and they were wrong). The ANF is resisting the increased use of Assistants in Nursing.

This is all learned behaviour in a health system where everybody preciously guards their silo regardless of merit. In my view this change in skill mix is not optional if we are to have a sustainable health workforce able to meet the needs of the Australian population into the future.

Apart from these structural role changes, there is a lot that particularly hospitals can do to enhance the role of nurses and make them feel truly valued.

Ramsay Health Care were something of a model employer of nurses during my time as Health Minister in Western Australia and I am sure that government hospitals could still learn a lot from them, and others, today.

Briefly on doctors.

The problem is not aggregate supply, but distribution – both geographical and by speciality.

The large increase in medical school places, and consequentially newly graduating doctors, creates an opportunity to ensure that remote, regional and outer suburban areas are better serviced.

Provider numbers and the MBS are but two powerful tools that could be used to limit medical over servicing, at the taxpayer’s expense, for the more affluent inner urban populations, while simultaneously improving medical services in areas of greater need.

Similarly, the heightened demand for medical specialty training places presents an opportunity to ensure that the less popular (among doctors) specialties, or those with projected shortages, are more adequately filled.

Mental health professionals are, and will continue to be, in short supply. The creation of more training places for psychiatrists and mental health nurses must be a priority.

Also, the diagnostic specialties will be in short supply. The reason for this is simple – pathology and imaging are the precursors of almost all medical treatment.

The great Medicare principles of free, universal and equal medical treatment for all Australians would be enhanced by seizing the opportunities which are now presenting.

The third area of health workforce focus must be primary health care.

Keeping people well and out of hospital should be the aim of health care policy.

It’s not only about GP’s, although they must be at the centre of integrated primary health care delivery.

The inappropriately named Medicare Locals were an important development in caring for the primary health care needs of local populations. The 61 Medicare Locals throughout Australia identified gaps in local area health provision and either funded or directly provided the necessary services. They generally eased the patient journey between the various health care providers.

Former Health Minister Peter Dutton will be remembered, not for his contribution to better health, but for his Taliban like indiscriminate destruction of anything which was the legacy of the previous government. Despite a promise from the now Prime Minister, he abolished Medicare Locals along with many worthwhile health bodies created by the former Labor Government.

We can only hope that the Primary Health Networks, which are due to commence on July 1, 2015, will continue that good work.

Services to the most needy groups – people with mental illness, the aged, indigenous Australians, remote rural and outer suburban residents and low income earners – are best delivered by highly coordinated primary health care. The concern is that Primary Health Networks will be so large in the areas and populations they cover that they will merely replicate state health department bureaucracies and lose the responsiveness of smaller, more community focussed local groups.

But, back to the workforce needs of primary health care. It begins with training.

More General Practitioner training places is the first requirement and should not be all that difficult to achieve. In recent years the number of General Practitioner training places has grown, but at a slower rate than other medical specialties.

It is also the nature of that training – health professionals should be trained in teams to work in teams. When dealing with an ageing population, increased incidence of chronic disease and dramatically increasing levels of obesity, we need teamwork from our health professionals to a far greater degree than previously.

It should begin at pre-vocational level at university and then continue through higher degree and specialist training in the workplace.

The problems confronting Australia’s future health workforce are so great and important that the former Labor Government created a specialist agency – Health Workforce Australia – to deal with the issues.

The failure of the Commonwealth Department of Health and Ageing to respond to health workforce issues was a significant trigger in the formation of Health Workforce Australia.

It should not have taken a parliamentary enquiry into overseas trained doctors to tell us what we already knew – that they were lost in the labyrinth.

Policy makers did not know that we were facing a nursing shortage of the magnitude revealed by Health Workforce Australia in its landmark study “Health Workforce 2025” and its subsequent refinements.

Perhaps it is just too difficult for the Commonwealth Department of Health to be trusted by the myriad of health workforce stakeholders to accurately describe the nature of the problems and to be honest and forthright in pursuing an agenda of health workforce reform to meet them.

The Commonwealth’s own track record, funding role, relationship with the states and universities and political pressures all militate against the Commonwealth Department doing a good job in this area.

Post the next federal election, whichever party is in power, the fourth area of health workforce policy for consideration should be the re-establishment of Health Workforce Australia with two clear primary functions:

1. To provide the statistical evidence to enable informed decisions to be made about health workforce future policy, reform and funding.
2. To be responsible for driving health workforce reform – across doctors, nurses and the whole range of allied health professions.

The first of these functions, statistical analysis, was brilliantly done by HWA in its four years of existence until abolished by Dutton. The second, reform, was getting underway, but is now stillborn. Today there is no agency in Australia charged with driving much needed health workforce reform. And if no one is driving it, it simply won’t happen.

Australia’s government health systems have not been subject to the rigours of competition and efficiency demands experienced by most other sectors of the economy. For this reason, an agency dedicated to reform would be economically beneficial, as well as planning to meet our future health care needs.

Reform would include, but not be limited to, the scope of practice for all health professions and the assistant workforce; efficiency in the training pipeline and better integrating university training with employer and community needs; training funding to employers and universities to match supply and demand and to allow graduates to develop specialist skills, and the very important role that migration plays in meeting Australia’s health care needs.

For many years Australia’s Health Ministers have supported the principle that Australia should be self -sufficient in its supply of health professionals. However we remain one of the least self-sufficient OECD nations when it comes to training our own. We rely heavily on overseas trained doctors and to a lesser extent nurses to plug gaps in service provision.

While the growth in medical school places should take some pressure off the need to import doctors, the looming nursing shortage will have the opposite effect on nursing immigration.

And, of course, the ethical issue of a rich first world country taking trained health professionals from third world and developing countries is at best, problematic.

Australia’s health workforce issues have taken a back seat since the election of the Coalition Government. That does not mean that they are being adequately dealt with or are any less real. It simply means that health stakeholders are grappling with so many other government decisions in health – Medicare co-payment; tearing up the Commonwealth/State hospital funding agreement; abolition of primary health care agencies; threats to medical research funding; abolition of so many other important organizations, and more. Before long the reality of the workforce problems will take centre stage and will then require even stronger reforming action.

James McGinty held several ministerial portfolios in WA – Attorney-General; Housing, Construction, Services and Heritage; and Health. He was the Inaugural Chair of Health Workforce Australia 2010-2014.

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