Australians place great value on their health and their health system. They believe that, with some exceptions, the health system is ‘gold medal’ winner by world standards – on access, equity and quality. In its core values, it is a system of which we should all be proud. But, 40 years after the introduction of Medicare, we are now victims of our own success. Our long life expectancies, the miracles of modern medicine and the expectation that all should benefit, mean that it’s now under enormous strain.
This challenge is one we share with others globally and its one we’ve seen coming for quite a long time. As signalled in the first Intergenerational Report in 2002, the sustainability of the Commonwealth’s underpinning of the health budget would be a rapidly growing challenge. In 2007, Prime Minister Rudd declared the system to be in crisis and led a review that ended up focusing principally on funding public hospitals.
In 2023, the Albanese Government is focused on the increasing costs not simply to the Commonwealth but to ordinary Australian families of accessing health care assessments and essential medicines.
Hence, it has focused in the 2023 budget on improving access to primary care (notably general practitioners) and reducing the costs of medicines. Further, Minister Butler has established a workforce scope of practice review entitled Unleashing the Potential of our Health Workforce.
The Review will focus on primary care, which is much broader than just supporting family doctors. It is an area which is absolutely fundamental to the sustainability of any 21st Century health system. It needs not only to provide easy access to assessment but ongoing coordination and delivery of care for chronic and disabling disorders. This latest review follows quickly on from the 2022 release by previous Health Minister Greg Hunt: ‘Future focused primary health care: Australia’s primary health care 10 year plan: 2022-2032’.
When functioning well, high quality primary care means different health care practitioners with varying levels of expertise working together to provide, best practice and often more complex forms of ongoing care. Care delivered by the right person, with the right training at the right time, close to home and at an affordable price, both for funders and patients. It is supported by new technologies and smart systems. It enables people and their carers to be very active partners in their own health care.
The harsh reality is that such systems cannot function without highly skilled, and well-trained workforces, capable of using new systems and working collaboratively to meet complex needs. So, this is going to be an especially important Review. Together with the 2022 report it will likely chart the direction of Australian primary care for the next 20 years. But will it be enough?
Is it not also an opportunity to identify other areas in the health system that are ripe for major structural (and financing) reforms? The Terms of Reference of the workforce review are narrow and focussed very much in terms of health professionals working together, with each working to the top of their scope of practice. The fundamental concept of health professionals working in teams is not new. It happens in hospitals every day. We know that how well the team works together is fundamental to achieving good outcomes. In fact, one might posit that those health professionals wishing to practice ‘independently ‘, outside of team environments, should not really be supported by Medicare.
While primary care is the major focus of the review, it does not exist in a vacuum. It can only function effectively when it is closely intertwined with specialist and other support services, alongside ready access to the secondary and tertiary heath sectors (which are largely operated by the states and private providers). Health workforces need to be intimately linked, philosophically, organisationally and technologically. The training of doctors, nurses, and the range of other key health professionals (i.e. physiotherapists, pharmacists, OTs, psychologists, speech pathologists, social workers etc) must promote student learning and then working together. There are already useful examples of this kind of multidisciplinary training.
A major driver of the ‘crisis’ in primary care is the fact that the number of graduating doctors opting to train in general practice has dropped rapidly from around 50% of medical graduates in the early 2000s to around 15% now. The vast majority of medical graduates now opt for specialist training, and they are also choosing to work part time. So although Australia has one of the higher numbers of doctors globally affordable access to medical practitioners is rapidly declining.
Interestingly the only health professionals mentioned in the Review’s Terms of reference under “Primary care practitioners” are those already designated by the Australian Health Professional Regulation Agency (AHPRA). There is no mention of Physician Assistants, Medical Assistants, Care Navigators or Digital Navigators, yet these professionals exist in other places around the world and some, such as Care Navigators and Medical Assistants are currently being trained in Australia. The predictions of the most recent update of the Intergenerational Report are that the population of those over the age of 65 will double and those over 85 will treble over the next 40 years. We also know that currently those over the age of 65 account for 16% of the population and 40 % of healthcare costs. Given the time lag to train health professionals, we urgently require an expansive workforce policy, that not only broadens the scope of practice but challenges many of the existing modes of care delivery and funding.
Health workforce reform has always been difficult, given the political power of the health professions and their tendency to focus on greater investment in systems that are already failing. But, as NSW Premier Jack Lang said, “Always back the horse named self-interest, son. It’ll be the only one trying.”
Remember the fight when Minister Roxon tried to have reimbursement for cataract surgery reduced or more recently the reaction of the Pharmacy Guild to providing two months of prescriptions rather than one.
None of the ideas raised in the workforce Review are revolutionary and most have been raised over the years by many commentators. They stand the test of time and are largely evidence-based – another critical foundation of our health system. Health systems are complex – we seem to make them so – and there are no single or quick fixes. Australia’s workforce challenges are mirrored in Canada, the US and in Britain and we should learn from their ideas as well.
This Review of the health workforce is extremely important and will set the direction of healthcare in this country for the next few decades. This is an opportunity to do things differently in health care for the benefit of all Australians. Could it not be broader in scope and look at what the major drivers preventing real health reform really are? They have been well articulated by commentators over the years but few better than in an excellent book by an English Health executive Professor Mark Britnell.
He has a wide experience in health systems both public (UK’s National Health Services) and the private sector, advising Governments in over 81 countries. He identifies “Ten large-scale changes to tackle the global health workforce crisis.”
Most of these issues have been raised previously, both in general and in specific reference to different challenging areas (e.g., mental health, chronic disease management, aged care, undue focus on procedural medicine, lack of real-time data to promote measurement-based care and lack of attention to prevention and self-care processes. Few have ever been seriously addressed in an Australian context:
1. Reframing the workforce debate to focus instead on promoting productivity, health and national wealth creation.
2. Entrepreneurial actions by Governments that expand health worker supply. Available measures include relaxing training limits, particularly given the likely impacts of artificial Intelligence on workforce development and real-time learning systems. Although this may result in a local ‘oversupply,’ there is a global demand for health workforces and workers will move regularly around the world. We must not simply think of importing health workers from low-income countries but rather we should provide training for international health workers in Australia and in their country of origin.
3. Encourage the rapid and large-scale adoption of new models of care. These models of care are all out there – sometimes most apparent in rural and regional sectors, or in lower income countries where necessity drives innovation. From a health system development perspective, much greater emphasis is needed on regional implementation, with ongoing evaluation, rather than rather artificial randomized controlled trials.
4. Engage patients in their own care – and perhaps even the care of others. A person with well controlled diabetes is often a good mentor for a newly diagnosed diabetic. Peer work force developments have been increasingly successful (though remain underdone) in specific health areas such as mental health and substance misuse, but can easily be incorporated into other domains. Most people, including aged persons, can now be assisted with a vast range of technology to manage their chronic conditions, supported by active monitoring by members of their health care team. Much greater control of the course of chronic conditions can be achieved without resort to regular attendance at specific clinics or admission to hospital.
5. Create healthy communities. Here there is a major emphasis on improving all aspects of health Literacy. Mobilizing the power of volunteers, families and other citizens needs to be acknowledged, as non-professional people will provide the bulk of ongoing care in our society.
6. Support health professionals to work to the upper limits of their training. This needs to be actively supported by health care regulators. To date, this is really the only one of Britnell’s major issues that the Review is addressing.
7. Create a new cadre of care assistants (multiskilled or focussed) who can integrate the linked issues of health and social care. For many chronic conditions and key areas such as mental health and aged care, around 50% of a person’s health needs are attributable to their social circumstances.
8. Embrace the digital revolution in healthcare. Finally in Australia there is some movement, but recent widespread adoption of telehealth is only the first step. Artificial Intelligence, with linked health care diagnostic, support and coordination systems all require attention to underpinning governance and privacy and issues, though even here, Australia is beginning to develop more robust linked datasets. While telehealth shifted the dial during the pandemic towards virtual care, there is some push back from clinic-based professionals and Government insurance systems. We do need to ensure that all health professionals, and their clients, are appropriately trained. The recent release of $5m in new NHMRC grants to develop enhanced telemedicine platforms for both patients and all Health professional staff is to be applauded.
9. Active engagement by larger health organisations with the digital revolution, particularly in the area of learning systems which will be able to educate, re-educate and support health workers to improve productivity and enhance worker well-being.
10. An active overhaul of leadership in the health care industry. Here we need to use well proven techniques to enhance performance and motivation of health workers, to construct a system built around capitalising on opportunities for systemic quality improvement.
We applaud the Minister for establishing this Review of the health workforce but would strongly advocate a bolder approach. For example, the Federal Government could provide critical new financial incentives under a suitably revised new national health and hospital funding agreement. These incentives could sponsor an environment more conducive to all governments engaging with Britnell’s priorities above.
We must use the Review as an opportunity to canvas for fundamental change in health care delivery that will provide a better roadmap for the health and productivity of all Australians.