Our C18th health workforce structure is riddled with demarcations, inefficiencies and antique work practices. (An edited repost)

Mar 1, 2021

 Casual workers are fair game but the government is not prepared to tackle the very serious workforce inefficiencies  in our large and growing health sector.

All political parties, are frightened of the political power of the health providers, especially doctors and pharmacists. Health Ministers may be in office but they are never in power. The providers have the real power.

We have before us now an appalling  example of how the powerful doctor lobby works to protect its own selfish interests at the expense of nurses and the community.

Professor Mary Chiarella and  Jane Currie put it this way on 17 December:

Published on 14 December 2020, the final report of the Medicare Benefits Schedule Review Taskforce endorsed none of the 14 recommendations of its own Nurse Practitioner Reference Group Report. Instead, the report proposed three unrelated recommendations that further restrict the practice of nurse practitioners who provide services subsidised by the MBS.

A decision not to endorse any of the 14 recommendations can only be viewed as a decision not to invest in nursing and the health of Australian communities.

Cowardly governments will attack vulnerable casual workers but will not lift a finger to challenge the abuse of power by the doctor lobby.

A perverse, offensive and oppressive rejection of nurses

In the blue-collar area there has been substantial workforce reform and improvements that have helped transform the Australian economy.

But the health sector, the largest and fastest growing in the economy, has not been seriously reformed. I ‘guesstimate’ that there is a potential productivity dividend of at least 40% in health workforce reform over the next decade. There are health ‘silos’ everywhere with historic demarcations and a lack of integration.

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 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.

Health is Australia’s largest industry, comprising about 10% of our GDP. The health care and social assistance industries represent almost 13 % of employed people in Australia. It is growing steadily. 

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. 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 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.

Professor Stephen Duckett has suggested some reforms. They 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 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; and
  • practice nurses undertaking some of the work currently performed by GPs, including some prescribing, screening and triage.

Clearly, nurses, allied health and community health workers could undertake more skilled work except for the barriers erected by other professionals. 

An example of the barriers are the restrictions on nurse practitioners that Mary Chiarella  and others have recently highlighted. Despite all the rhetoric, little progress has been made in building the professionalism and career opportunities of senior nurses. Much opposition comes from doctors who don’t want their territory invaded, often in the name of quality and safety, but invariably to the detriment of people in need of care, particularly in country areas. With some doctors I am sure there is professional snobbery as well.

It is a pity  senior nurses are not better supported because they hold the health system together, but are denied real 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 them as shopkeepers rather then encourage their wider employment as health professionals. The 5000 and more pharmacies on the high street are a  visible and 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. Perhaps the roll out of Covid vaccines through pharmacies will lead to an enhanced role for  pharmacists

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

Dental health operates in a quite separate silo to other major health areas, yet we know that poor dental health can have dire consequences for general health.

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.

No one is really tackling these major workforce problem despite the clear loss of morale and high staff turnover across the health and community sector. It is politically too hard to tackle the AMA and APG.

 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 tackle the problem. In the late 1980s, I attended a roundtable discussion in Sydney with UK Prime Minister, Maggie Thatcher. 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 workforce structure is at the end of its design life. The whole health system is built around provider demarcations. It is not built around patients’ needs. What will cause a breakthrough – a staff crisis, sinking morale, unbearable workloads or escalating costs? It takes courage to take on the powerful interests involved in health. It hasn’t happened yet. The soft option is invariably more money to get the issue off the tabloid front page. 

I am sure that 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.

There are specific skill shortages, but I am not persuaded that we have an overall shortage of health and community service workers. I am however persuaded that we are not using our existing workforce at all well. The losers are taxpayers, the community and particularly, the outstanding professional people who perform so admirably in very difficult circumstances.

Serving the underserved: nurse practitioners’ invaluable roles during Covid

So what can be done

Health Workforce Australia, which was abolished by the Abbott Government, should be re-established. It is necessary to promote an informed publish discussion and advise governments on the necessary reforms to our 18th-century workforce structure

The Fee for Service method of payment for specific consultations should be broadened to include bulk payments to those General Practices that develop ‘team medicine’ where the skills of a wide range of clinicians are employed eg nurses, physiotherapists and dieticians.

Access to the Medical Benefit Scheme must be widened to include all clinicians that are clinically qualified. The strangle hold by doctors must be broken.

Individual doctors must speak up on the need for workforce reform. After all only 30% of doctors are members of the AMA. Why are the 70% so quiet?

Individual pharmacists also need to speak up. Many pharmacists tell me that their professionalism is degraded by the Australian Pharmacy Guild  which treats it’s members as shop keepers and not professional health workers.

The Nurses and Midwives Association needs to project itself as not just  an industrial but also a professional organisation concerned with major health reform. The AMA is very much an industrial organisation but it hides it’s industrial role by seeming concern about the public interest in health.

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