What the strengthening Medicare Taskforce: Must do to modernise the primary health care workforce

Aug 19, 2022
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The first of the five focus areas identified by the Strengthening Medicare Taskforce is to have a reliable training and development pipeline, to build a strong and vibrant primary health care workforce. This is a logical and critical first step, but it is a well-known maxim that form must follow function.

To have a reliable training and development pipeline…

In order for us to know what our workforce is to look like, we need to be clear about the future work for PHC professionals. This will then inform curriculum design and how many of each PHC professional we need in the pipeline.

Primary health care is, to paraphrase Taskforce member, Stephen Duckett, so much more than simply primary medical care. The largest workforce in primary healthcare is the ~89,000-strong nursing workforce, yet they are neither quantified nor prioritised when it comes to education and training. Similarly, allied health plays a huge role in keeping people functional, independent and pain free, but neither have they been adequately considered, or planned for, in the PHC workforce.

So, if we are serious about our real PHC workforce, we need to plan. We need to plan what healthcare we want to happen in the community and then determine what our workforce needs to look like. Previously, workforce research and planning was carried out by Health Workforce Australia (HWA) but this unit was disbanded by the Abbott government in 2014. This has significantly reduced the Commonwealth’s ability to plan for a sustainable health workforce. Currently, Australia only has medical workforce strategy which was completed late in 2021. The largest workforces (nursing and allied health) do not have strategies and while steps are being taken to address this, there are no timeframes for completion.

The Dept. of Health and Ageing officials charged with developing plans for these workforces, the Chief Nursing and Midwifery Officer (CNMO) and Chief Allied Health Officer (CAHO) are at different stages. It’s worth acknowledging the structural challenges in the CNMO and CAHO offices, which are under-resourced compared to the Chief Medical Officer (CMO) and arguably do not have access to appropriate data or capacity to engage across the Department and support comprehensive strategies in the same way as the office of the CMO.

Currently, the CNMO is developing a Nursing and Nurse Practitioner strategy, neither of which has a clear completion date. The CAHO is working on a gap analysis that may provide the foundations for a strategy. It will be important that the Taskforce takes into account how their recommendations will interact with these workforce strategies.

A range of activities will be required to achieve the capability and capacity envisaged by the Taskforce. These include:

  • Increasing resources to the CNMO and the CAHO roles so that they can:
    • Make these workforces visible through ongoing collection and analysis of workforce data;
    • Prioritise and adequately resource the completion of the nursing and allied health workforce strategies; and
    • Proactively work within the Department and with stakeholders to address workforce issues.
  • Funding research into the whole of the PHC workforce requirements;
  • Strengthening the place of PHC in the undergraduate curriculum;
  • Funding PHC student placements to provide valuable experience for the next generation of PHC health professionals; and
  • Broadening successful programs such as the John Flynn Scholarship and Medicare funding for supervising GP registrars to nurses and allied health professionals.

Some of this is not new work, much of it can be done by revisiting earlier reviews that have largely been ignored. For example, only 4 recommendations from the Educating the Nurse of the Future Report were accepted by the government.

to build a strong and vibrant primary health care workforce.

The second half of the focus area sets a high bar. It’s one thing to train and attract a workforce, it’s another to retain it.

Bodenheimer’s Quadruple Aim for health care provides guidance on this, making it clear that not only must we aim to improve the patient experience and outcomes, reduce per capita costs and improve the health of the community, we must also seeking to increase ’joy in work’ to ensure that the careers of those working in healthcare are satisfying. In the context of primary health care, value-based care is best delivered by health care professionals working to their top of scope delivering multidisciplinary care in teams. This generally results in better patient outcomes and generally results in more satisfied health care professionals. This is particularly needed in general practice as well as rural health settings where it’s essential that we spread the load.

We know that many General Practitioners (GPs) are overwhelmed by the demands on them and underwhelmed by their levels of remuneration. We know that they often have minimal time off and are diminishing in number. We also know that ~45% of PHC nurses have consistently reported that they are rarely or never used to their full scope of practice. On top of this, around 1 in 4 nurses plan to leave the profession in 2-5 years. There’s time to prevent this.

We need to teach GPs and practice managers to utilise the nursing and allied health workforce better (and to remove incentive payments if they don’t). This can be turbo-charged by reviewing funding models and Medicare item descriptors and increasing accountability for workforce incentive payments. Doing this will tap into the latent capacity in the two largest workforces in primary health care, increase the number of patients seen in general practice (and primary healthcare more broadly) while reducing the load on GPs. It will also reduce many of the frustrations within the nursing, allied health and medical workforce.

A fundamental shift in the use of Nurse Practitioners (NPs) in primary health care is also required. The under-utilisation of this highly skilled workforce is an ugly stain on Australian health policy. Despite their extensive skill set and training, this group has faced ongoing exclusion from primary health care funding and restrictions on their autonomy. We cannot expect nurses to undertake post-graduate study to become NPs without having a real possibility that they will be able to use their skills (and receive commensurate pay) at the end of it. The underutilisation of NPs must end in order to improve the health of Australia. The same could be said of many other specialised PHC nurses, particularly Australia’s highly trained mental health nurses.

These changes alone could release significant capacity of the health workforce while providing more satisfaction in their career so that they can be retained in the long term. It is also important to acknowledge that to work in primary health care, all primary health care professionals take a cut in pay. Unlike their hospital counterparts, provisions such as long service leave are not portable. We need to improve this in order to ensure primary health care is an attractive career destination.

A range of changes could provide the new functions that are envisaged. These include:

  • Defunding models that unnecessarily restrict scope of practice
  • Increasing accountability around incentive payments to ensure full value and the original intent is achieved including enabling full scope of practice eg PIP QI and Workforce Incentive Payments (WIP)
  • Enable all PHC professionals to work to full scope and funding them to do so;
  • Fund team-based education to encourage team-based care;
  • Invest in proven transition to practice programs to assist retention of newly graduated and experienced health care professionals transitioning into PHC from other health care sectors. The APNA TPP program delivers 91% nurse retention after 12 months (APNA 2021); and
  • Ensure that remuneration is commensurate with equivalent professionals in hospital settings

These suggestions will enable a flexible workforce that can meets the needs of consumers at the right place and the right time. As is so often the case, the Taskforce can revisit earlier reviews that have largely been ignored.

For example, all 14 of the recommendations from the Nurse Practitioner Reference Group of the MBS Review (MBSR) were rejected by the MBSR in 2019. The fourteen recommendations were designed to improve the accessibility and availability of quality health care for Australian people, especially those in underserved and marginalised communities. This not only reduced provision of care to Australian’s but also demotivated and marginalised the nursing profession by ignoring considered advice.

Acting on any and all of these suggestions requires no more (or less) than proper respect and recognition for the contribution of the total PHC workforce.

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