Pearls and Irritations

Medicare funds the established system of health care delivery, a system that has not seen major changes since Medicare was established 56 years ago. It needs serious reform and particularly in the way the health workforce is structured.  The pandemic has revealed serious weaknesses.

In the blue-collar area, there has been substantial workforce reform and improvements that have helped transform the Australian economy. They began under the Hawke/Keating governments.

But the health sector, the largest and fastest-growing in the economy, has not been seriously reformed. I ‘guesstimate’ a potential productivity dividend of at least 40% in health workforce reform over the next decade is possible. That 40% may be on the low side.

Reform of the health workforce structure, work practices, multi-skilling, teamwork and flexible training are the key micro-reform issues we face. 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. And many obstetricians charge excessively.

Health is Australia’s largest industry, at about 10% of GDP. 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.

But the workforce is ageing. By 2030, there will be an expected shortage of 123,000 nurses.

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.

My experience and observations tell me many things about inefficiencies and inequity in our health workforce.

We have boxes everywhere, junior doctors, specialists, clinicians, nurses, allied staff, managers, colleges, universities. There is not a thesis or plan that draws it all together.

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.

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 upskilled 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.

Professor Stephen Duckett has suggested some health workforce reforms in Australia. 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 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 other professionals. 

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 as 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 the 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.

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.

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.

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 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.

The 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.

Waterfront reform was a minor issue by comparison. Health workforce reform doesn’t require dogs and security guards with balaclavas, but political determination.

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.

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