Pearls and Irritations

Our eighteenth century health workforce structure needs a root and branch overhaul. But governments are too frightened to tackle health providers like doctors and pharmacists. Blue collar workers however are easy prey.

In the blue-collar area, there has been substantial workforce reform and improvements that have helped transform the Australian economy. Not surprisingly the Productivity Commission has recently called for a further overhaul of restrictive work practices at our ports.

But work force reform has not really touched the services sector and health care in particular. That is where large improvements in productivity and service are possible.

We are regularly told that our economic productivity has slumped from about 1.7% to about 1.1% a year. What we are not often told is that this slump is due largely to the change in industry structure from manufacturing to services where about 80% of our workforce is employed. And our two biggest services industries are health and education. So, for economic as well as the improvement in delivery of health services for patients and improved opportunities for nurses and other health workers, there are also urgent reasons for reform.

Our finance, legal and accounting sectors also have bloated structures. How much do some of them really add value? But that is a matter for another day.

Reform of the health workforce structure, work practices, multi-skilling, teamwork and flexible training are key micro-reform issues. That has been clear for decades.

An obvious example of restrictive practices and workforce inefficiency is in obstetrics and midwifery. In Australia, less than 10% of normal births are managed by midwives. In the Netherlands, it is more than 70% and in the UK more than 50%. The reason Australia is so far behind the field is obstruction by obstetricians, who want to protect their market share and are highly favoured through the medical benefits scheme. Many obstetricians charge excessively.

Health is Australia’s largest industry, at about 10% of GDP. There are almost 700,000 health professionals. The number is increasing by about 4% a year and will need to increase even faster. The health care and social assistance industries represent 14% of Australia’s total workforce and is expected to increase to 15% in the next four years.

About 70% of every health dollar of expenditure is in labour costs. Workforce reform cannot exclude such a large area of expenditure. It is more important than any other workforce issue. Health workforce reform will not be easy but it is essential.

We have employment silos everywhere, junior doctors, specialists, clinicians, nurses, allied staff, managers, colleges, universities, pharmacists and ambulance officers. There is not a thesis or plan that draws it all together. Health care is not integrated. And patients suffer.

It is not clear who owns workforce issues. Workforce planning is reactive. Improvements in people management occur in spite of the system. The workforce is structured on a medical model, not a health model. There is extremely poor human resources and people management skills across the workforce.

There is a lack of coordination between workforce issues, service delivery, finance and infrastructure. The numbers of hospital beds are increased without the nursing staff to service them. There is little understanding and research about the extent of the workforce problems.

Medical boundaries must be invaded.

There is not so much a workforce shortage. The issue is more often how we use the workforce.

We have a surplus of doctors but they are in the wrong places. We don’t have enough rural doctors. Young doctors are leaving general practice for higher remuneration as specialists. The three occupations with the highest taxable income in Australia are medical specialists-surgeons, anaethetists and medicine specialists. Whenever I am asked by my doctor if I have any allergies I always respond, ‘Yes, specialists fees’.

It is estimated that about a half of GPs are now employed by corporations. This is occurring by stealth. This corporatisation is having a dramatic effect; the loss of personal care, the shifting of patients between doctors and excessive referral to specialists.

Education and training are supply driven and not really linked to the demands of a rapidly changing health system. Education and training entrenches the boundaries within the system. There is no genuine ‘health’ training. Almost all the training is in separate streams. Core training is incidental.

The health workforce is inward looking with many people working their whole professional lives within the same system.

Emeritus professor at University of Sydney, Professor Kerry Goulston, has described the problem 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 up-skilled 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 need to break down the historic workforce boundaries and establish new ways of working – team 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 that say only doctors or nurses can provide particular types of care; modernising education and training to ensure staff are equipped with the skills 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.

Health workforce reforms in Australia could include 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 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 performed by GPs, including some prescribing, screening and triage.

Clearly, nurses, allied health and community health workers could undertake more skilled work if it weren’t for the barriers erected by the AMA. 

An example of the barriers are the restrictions on nurse practitioners. Despite all the rhetoric, very little progress has been made in building the professionalism and career opportunities of senior nurses. There has been very little progress outside hospitals, particularly in country areas.

Senior nurses need to be supported. They hold the health system together, but they are denied adequate advancement. Large numbers leave nursing for other industries, particularly hospitality. The best that stay in the industry go into academia or health administration.

Pharmacists are the most underused health professionals in the country. The Australian Pharmacy Guild desperately lobbies to corral pharmacists as shopkeepers rather than encourage their wider employment as health professionals. The 5,000 and more pharmacies on our high streets are a very visible and a better-accessed resource than doctors’ consulting rooms. They should be actively involved in blood tests, injections, repeat prescriptions and a whole range of aches and pains.

As taxpayers, we pay for their training. We subsidise their income but the Guild ties them down as shopkeepers.

Selfishly the AMA, that represents only about 30% of doctors defends its turf. An AMA spokesperson recently told us on the ABC that suggesting that pharmacists should undertake more health care was like asking bus drivers to fly an aeroplane!!

There are more than 12,000 excellent ambulance and paramedics in Australia but they are kept locked away in a silo. In France, paramedics make home calls by motorbike on small car.

Dental health operates in a quite separate silo from other major health areas, yet we know poor dental health can have dire consequences for general health. And dental fees are often excessive.

No one is really tackling these major workforce problems despite the clear loss of morale and high staff turnover across the health and community sector. It is politically too hard to tackle the Australian Medical Association and the Pharmacy Guild.

The Rudd Government established Health Workforce Australia in 2010 with a brief to work directly with the Australian Health Ministers’ Conference (AHMC) and the health and higher education sectors on:

• authoritative, evidence-based health workforce planning, policy advice and analysis of future supply and demand scenarios affecting Australia’s health care system
• capacity building and targeted reform in clinical training to ensure that Australia is able to maintain and grow the clinical training requirements of the nation’s health professionals—to be achieved through programs of funding, development and reform in both the health and higher education sectors
• innovation and reform of Australia’s health workforce to encourage an inter-professional approach to service delivery, flexibility in deployment of scarce health professional resources and development of new health workforce models to respond to demand for health care
• international recruitment and retention programs for health professionals and
• general advice on a range of health workforce policy, planning and strategic matters for federal and state Health Ministers, the health sector and the higher education sector

But in the disastrous 2014 Budget the Abbott Government abolished HWA.

Successive governments have run away from health workforce reform. They are frightened of the providers and their lobbying power. Ministers for Health may be in office but they are not in power.

In the late 1980s, I attended a roundtable discussion with the 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 the doctors and lawyers were in the ‘too hard’ basket. We have the same problem in Australia.

Our eighteenth century health workforce structure is clearly at the end of its design life. The whole health system is built around provider demarcations, not patients’ needs.

Workforce reform requires, most of all, courage by health ministers, governments and senior officials to face down the powerful vested interests that oppose reform of the workforce and want to protect their privileged positions. Ministers, governments and officials must win the case for change and drive the process.

We are not using our existing workforce well. The losers are taxpayers, the community and particularly, the outstanding professional people who perform so admirably in very difficult circumstances.