Workforce
Dr Rhonda
Jolly
It is acknowledged that health system
reform is unlikely to succeed without accompanying substantial
workforce reform and pronouncements made by the Rudd Government
have consistently implied it is supportive of such change. However,
this Budget, like its predecessors, appears to deviate only
marginally from conventional approaches to dealing with the
dilemmas of a shrinking workforce and an opposing growth in demand
for health workers. At the same time, it should be noted that while
there is little real reform to be seen in the Budget, there remains
the potential for some budget measures to be its
precursors.
In recent months a number of workforce initiatives have been
announced progressively, and the funding for these has been
included as budget measures. Overwhelmingly, these measures focus
on medical practitioners, with over $600 million allocated to
increasing numbers over the next decade. Individual measures
include doubling the number of general practice training places and
expansion of the Prevocational General Practice Placement Training
Program to enable more junior doctors to experience general
practice.[1]
Not surprisingly, increasing the numbers of doctors has been
well received by the medical profession. The Royal Australian
College of General Practitioners (RACGP) considers the
Government’s investment in medical practitioners reaffirms
the central role of general practice in the health system.[2] A supplementary measure
to invest over $390 million to expand and restructure a general
practice nurse initiative has also been generally well
accepted.[3] The
Australian General Practice Network believes the nursing initiative
will alleviate workforce problems, and there is clear evidence that
the initiative to date has indeed improved patient
outcomes.[4]
Questions can be raised, however, about whether this initiative
will deliver where it is most needed. There appears, for example,
to be no guarantee that solo practices, which could gain great
benefits from the services of a practice nurse, will be eligible
for funding under the measure. Similarly, it could be asked if it
would be more appropriate to encourage nurses into aged care,
rather than general practice. This is particularly so given the
increases in medical practitioner numbers that will be realised,
albeit not for a decade or so, as a result of government
initiatives. Because this initiative focuses on supporting the
traditional, medico-oriented perspective of health teams, it could
be seen as a backwards step to realising a more cooperative and
collaborative health workforce in the future.
Similar questions arise about how the investment
in medical practitioner training, despite there being an emphasis
on placements in rural areas, will benefit people in the
bush.[5] There is no
certainty this will be the case, as fully qualified Australian
trained doctors cannot be forced to practice in a particular
location.[6] It is
therefore easy to understand the disappointment expressed by the
Rural Doctors Association of Australia (RDAA) that there is not
enough focus in this Budget on attracting doctors to rural
areas.[7] The RDAA
and the AMA insist that a rural rescue package is needed, but
rural-specific measures are limited to an increase in an allied
clinical placements scheme and the establishment of two locum
programs for allied health workers and nurses.[8] These reflect assessment by the
NHHRC that an integrated workforce package should apply across all
health disciplines.[9]
The specific circumstances of rural Australia aside, it can be
argued that the recent increase in medical training places, in
conjunction with earlier complementary increases in university
places for nursing and clinical training places for doctors, nurses
and allied health professionals, is a significant step in the
Government’s overall plan for the health system. Certainly,
this is how it has been promoted in budget documents. The rationale
in this argument is that increasing the numbers of health
professionals in the community can provide the means by which
health reform can look beyond care delivered in hospitals to a more
cost effective and efficient community-centred delivery of
services.[10]
However, it has been argued that such a strategy on its
own is essentially flawed.[11] Increasing the number of health workers of any
type, as a number of commentators have pointed out over time, will
not resolve workforce problems, unless it is accompanied by
complementary strategies.[12] Solving shortages and reforming the workforce to deal
more effectively with disease prevention and management of
persistent, long-term and recurrent conditions involves more
tangential thinking around a variety of issues. These include: task
allocation that provides for innovative and better uses of skill
sets, not simply conventional use of skills; persuasive
remuneration that draws practitioners to areas where their skills
are most needed; and exploration of workforce related issues and
patient involvement. These include, for example, consideration of
how patient self-management can complement professional health
service delivery and ways in which practitioners can be trained to
work better with patients to improve health outcomes in such an
environment.
From this perspective, health commentator and academic John
Dwyer is convinced that training dollars alone will not make
general practice the preferred career choice for medical graduates,
but complementary appropriate remuneration and job satisfaction may
achieve this ‘desired effect’.[13] The Budget takes a small step in this
direction by funding the two programs to provide locum placements
for rural nurses and allied health workers noted above. The
programs are clearly attempts to make rural practice more
attractive. But these programs appear to be more ad hoc responses,
rather than part of an integrated approach towards gaining a
desired effect, or effects.
Similarly, the provision of $18 million in seed funding to
explore models of practice which may promote the use of nurse
practitioners in the aged care sector has the potential to deliver
significant workforce reform in the future. But its success may be
dependent on the right combination of incentives and scope of
practice leeway being in place to achieve the elusive desired
effect.[14] The
Australian Medical Association has already reacted negatively to
the implication that nurse practitioners could have a role to play
in aged care.[15]
Given that the Government was forced to revise its only attempt at
task reallocation—allowing nurses and midwives access to
Medicare and the PBS—as a result of similar objections from
the medical profession, it is likely to be wary of sparking a
similar controversy. It would be easy to speculate that nothing
will eventuate from this investigation because conventional numbers
only and traditional task allocation strategies are less divisive
and easier to ‘sell’ than contentious and potentially
divisive reforms.
In essence, the Government’s enthusiasm for reform in
other areas of the health portfolio is perhaps not matched in the
workforce area. While previous budgets hinted there might be
underlying enthusiasm to explore multiple options for workforce
change, this Budget appears to have embraced a more traditional
solution.
[1]. The Government has promised to deliver
1375 more general practitioners practising or in training by 2013
and 5500 new general practitioners or general practitioners in
training in the next decade ($345 million). It has also provided
for 975 places each year for junior doctors to experience a career
in general practice during their postgraduate training period ($150
million) and 680 more specialist doctors in the next decade ($145
million). Australian Government Budget, A national health and hospitals network for
Australia’s future: delivering better health and better
hospitals, Commonwealth of Australia, Canberra, 2010,
viewed 17May 2010,
http://www.health.gov.au/internet/yourhealth/publishing.nsf/Content/report-redbook/$File/HRT_report3.pdf.
[2]. Royal Australian College of General
Practitioners (RACGP), Federal Budget recognises the central
role of general practice, media release, 11 May 2010, viewed
13 May 2010, http://www.racgp.org.au/media2010/37442
[3]. S Dunlevy, ‘Doctors and
nurses’, Daily Telegraph, 10 May 2010, p. 1, viewed
12 May 2010,
http://parlinfo.aph.gov.au/parlInfo/download/media/pressclp/43NW6/upload_binary/43nw61.pdf;fileType=application%2Fpdf#search=%22media/pressclp/43NW6%22
[4]. Australian General Practice Network,
Budget delivers for Australia’s health care future,
media release, 11 May 2010, viewed 13 May 2010,
http://www.agpn.com.au/__data/assets/pdf_file/0004/24799/20100511_med_budgetreaction_final_short.pdf
and see R Jolly, Practice nursing in Australia, Research
paper, no. 10, 2007–08, Parliamentary Library, Canberra,
2007, http://www.aph.gov.au/library/pubs/rp/2007-08/08rp10.pdf.
[5]. W Snowden (Minister for Indigenous Health,
Rural and Regional Health and Regional Services), Rudd
Government continues to tackle the rural health challenge,
media release, 11 May 2010, viewed 13 May 2010,
http://www.health.gov.au/internet/ministers/publishing.nsf/Content/mr-yr10-ws-ws043.htm?OpenDocument
[6]. Civil conscription for medical
practitioners is prohibited under section 51 of the
Constitution.
[7]. Rural Doctors Association of Australia
(RDAA), With a severe lack of rural workforce measures, this
budget really needs a doctor, media release, 11 May 2010,
viewed 12 May 2010,
http://www.rdaa.com.au/uploaded_documents/Budget%20reaction%20--%20May%202010.pdf
[8]. K Rudd (Prime Minister), N Roxon (Minister
for Health and Ageing) and W Snowden, (Minister for Indigenous
Health, Rural and Regional Health and Regional Services Delivery),
Boost for allied health in rural and remote Australia,
media release, 6 April 2010, viewed 12 May 2010,
http://www.health.gov.au/internet/ministers/publishing.nsf/Content/mr-yr10-nr-nr061.htm
[9]. National Health and Hospitals Reform Commission,
A healthier future for all Australians: final report
Commonwealth of Australia, Canberra, June 2009, viewed 17
May 2010,
http://www.health.gov.au/internet/nhhrc/publishing.nsf/Content/nhhrc-report
[10]. A Rosen, R Gurr and P Fanning, ‘The
future of community-centred health services in Australia: lessons
from the mental health sector’, Australian Health
Review, vol. 34, no.1, May 2010,viewed 12 May 2010,
http://www.publish.csiro.au/view/journals/dsp_journal_fulltext.cfm?nid=270&f=AH09741
[11]. For example, S Duckett, ‘Health workforce design
for the 21st century’, Australian Health
Review, vol. 29, no.2, May 2005, viewed 12 May 2010,
http://parlinfo/parlInfo/download/library/jrnart/STHG6/upload_binary/sthg62.pdf;fileType=application%2Fpdf#search=%22Health%20workforce%20design%20for%20the%2021st%20century%22
[12]. Ibid.
[13]. J Dwyer, ‘Health plan needs a few dollars
more’, The Australian Financial Review’, 11
May 2010, p. 63, viewed 12 May 2010,
http://parlinfo/parlInfo/download/media/pressclp/LKNW6/upload_binary/lknw60.pdf;fileType%3Dapplication%2Fpdf
[14]. Australian Government, Portfolio budget statements
2010–11: budget related paper no.1.11: Health and Ageing
Portfolio, Commonwealth of Australia, Canberra, 2010, p.
377.
[15]. Australian Medical Association, Health Budget
2010–11: AMA welcomes substantial investment in health
and calls for careful implementation, media release, 11 May
2010, viewed 13 May, http://www.ama.com.au/node/5582