Pearls and Irritations

Following the outcome of this year’s Federal Election, Health Minister Mark Butler convened the Strengthening Medicare Taskforce (SMT).

At its first meeting, the SMT established five focus areas to guide its recommendations to the Australian Minister of Health and Aged Care.

The fifth aim of the SMT, set out in its first communiqué, is to “[provide] universal health care and access for all through health care that is inclusive and reduces disadvantage.”

Providing universal healthcare means every person needs to be equal at the front door of the health system. While Australians are proud of their healthcare system, it is well established that that “where you live, how much you earn, whether you have a disability, your access to services and many other factors can affect your health”.

These issues are compounded by issues related to funding models, workforce capacity and workforce distribution. As if sensing these issues, the Minister for Health’s most recent communiqué stated that the November meeting would “discuss opportunities in multidisciplinary care and in harnessing the full skills of the primary care sector (emphasis added).” This is absolutely essential if we are to provide “access for all through health care that is inclusive and reduces disadvantage”.

Achieving excellent care

The provision of excellent care requires:

• Multidisciplinary teams: In the current GP-centric model of care, these tend to work optimally with one GP and three supporting clinicians who work together, supported by additional clinicians who are called in as needed. The make-up of these teams may vary based on community need (eg older populations may require more physiotherapists and pharmacists. Low socio-economic communities may require community health workers and behavioural support workers).

Other models of care that are nurse or nurse or practitioner-led, or allied health professional-led also exist and need to be considered as part of the mix, particularly when the GP workforce is concentrated around cities and increasingly their patient lists are being closed.

For almost a decade, the Commonwealth Department of Health has been funding the development of nurse-led, team-based clinic models through the Australian Primary Health Care Nurses Association (APNA). The positive benefits of these clinics include improved patient health outcomes, better access to care, and decreased rates of hospital admission.

• Supportive funding models: Funding models must ensure sustainable businesses to provide care. They also must enable the clinicians who deliver it. Currently, Medicare ties care to a specific clinician (generally the general practitioner) who does the bulk of the work with minimal delegation. It also restricts nurses and nurse practitioners, allied health professionals, pharmacists and indigenous health workers from working to their full scope of practice. With a contemporary funding model, the capacity of general practitioners can be greatly increased with multidisciplinary teams sharing the clinical load and increasing the effectiveness and efficiency of care delivery.

Supportive funding models should take a broad view as to how care can be provided. This means not limiting care solely to a general practice, particularly in areas of market failure, where a general practice may not exist.

Crucially, supportive funding models will also remove the barrier of cost to providing excellent care to all Australians, ensuring that they are able to access high quality care, from the right professional at the right time.

• Change management: Lessons from previous Australian trials of different care models such as Health Care Homes showed that, without change management, new models of care tend to be unsuccessful. Changing Australia’s focus on a traditional GP care model requires support for GPs and the broader general practice team to alter their ways of working. But it will also require education of the public who will need to understand the benefits of the new model of care and why they may not always see a doctor. Without this change management, the benefits of multidisciplinary care will be hard to achieve.

• Workforce Planning: Developing and funding new models can only be done with a clear view of the workforce available. Since the abolition of Health Workforce Australia, the health systems has been lacking strong workforce planning. A Medical Workforce Strategy was completed late 2021 but it is unclear how it will be operationalised. Meanwhile nursing, the largest health care workforce and the allied health professions do not have a strategy at all.

Achieving universal health care

Planning true universal health care requires recognition of the health issues facing our most marginalised members of society.

The Australian Institute of Health and Welfare (AIHW) states that:

Overall, Aboriginal and Torres Strait Islander people, people from areas of socioeconomic disadvantage, people in rural and remote locations, and people with disability experience more health disadvantages than other Australians. These disadvantages can include higher rates of illness and shorter life expectancy.

Further, the AIHW reports that:

While many aspects of Indigenous health have improved, challenges still exist. Indigenous Australians have a shorter life expectancy than non-Indigenous Australians and are at least twice as likely to rate their health as fair or poor.

Compared with non-Indigenous Australians, Indigenous Australians are also:

• 2.9 times as likely to have long-term ear or hearing problems among children
• 2.7 times as likely to smoke
• 2.7 times as likely to experience high or very high levels of psychological distress
• 2.1 times as likely to die before their fifth birthday
• 1.9 times as likely to be born with low birthweight
• 1.7 times as likely to have a disability or restrictive long-term health condition”.

It is critical that we establish an environment where indigenous Australians feel able to access culturally safe and appropriate health care. This requires increasing the numbers of indigenous students undertaking health related programs, which in turn requires educational environments that are culturally safe and appropriate. The Aboriginal and Torres Strait islander Health Performance Framework (HFP) data demonstrate that:

In the Higher Education Student Statistics collection for 2018, there were 1,310 commencements and 597 completions for health-related courses for Indigenous students.

Between 2001 and 2018, enrolment rates for Indigenous students in health-related courses have significantly increased from 27 to 61 per 10,000, and completion rates have significantly increased from 5 to 11 per 10,000 population. Over this period, the enrolment rates for Indigenous students increased at a faster rate than the completion rates (157% compared with 134%). There was also a significant increase in enrolment and completion rates for non-Indigenous students in health-related courses, widening the enrolment gap between Indigenous and non-Indigenous students (a gap of 17 per 10,000 in 2001 and a gap of 21 per 10,000 in 2018). The completion rate for Indigenous students studying health-related courses in 2018 was 81% compared with 92% for non-Indigenous students.

In relation to people living in rural and remote locations, the Modified Monash Model classifies metropolitan, regional, rural and remote areas according to geographical remoteness, as defined by the Australian Bureau of Statistics (ABS), and town size. MM1 refers to metropolitan communities, MM2 regional centres and this goes through to MM6 being remote communities and MM7 being very remote communities. The model can then be used to identify the accessible health workforce for these areas. Such information is critical to universal health care, as it enables us to understand who is servicing rural and remote communities and in what numbers. Importantly, this data must be accurate and up-to-date if health policy is to respond in a timely way to this.

At the Australian College of Nurse Practitioners (ACNP) conference earlier this month, Dr Ruth Stewart, the Rural Health Commissioner, presented the 2021 data on nurse practitioners per head of population using the Modified Monash Model classification. Whilst it is traditionally acknowledged that the majority of NPs are working in metropolitan areas, the argument that NPs service the underserved is confirmed when examined in this way. The FTE of NPs per 100,00 head of population is 5.9 for MM1, 7.1 for MM2, 7.0 for MM6 and 15.7 for MM7. Such an understanding is central to future workforce planning and vital for the increase and optimisation of the NP workforce to be able to continue to service these groups.

One in 6 (4.4 million Australians) live with a disability. It is often the allied health workforce that provides ongoing support to optimise their independence. We also know that coordinating this care with primary health care teams can make a big impact to health outcomes.

The August 2022 report from National Disability Services has found that, across Australia, there are significant allied health staff shortages and rapid turnover rates. It believes that these shortages lead to underuse of NDIS funds, due to lack of access to the allied health care required. The data revealed that, while the permanent employment rate of disability support workers remained unchanged at 53 per cent, there was a decline in the allied health worker rate, from 83 per cent to 78 per cent. There needs to be an emphasis on recruitment and retention of allied health staff into disability services as they are critically important for optimisation of well-being and lifestyle.

There are, of course many other members of our society that warrant further exploration including the homeless, those who are incarcerated and those with significant mental health issues.

If the Health Minister’s Taskforce is to truly strengthen Medicare, its recommendations must recognise and understand the true needs of the most marginalised members of our society and ensure that when they reach the front door of Australia’s health system, it will always be open.

The first four articles in this series can be found here:

Article 1: What the strengthening Medicare Taskforce: Must do to modernise the primary health care workforce

Article 2: The strengthening medicare taskforce: All healthcare workers are on the front line. Let’s get them on the front foot

Article 3: The Strengthening Medicare Taskforce: Commonwealth must resist lobbyists and embed team-based care

Article 4: The Strengthening Medicare Taskforce: No panacea, but great promise in technology driven care

Read the Communiques from the Strengthening Medicare Taskforce.