Jennifer Phillips, Social Policy
A robust health workforce is essential for maintaining the health care of Australians now and into the future. As the population continues to grow and health needs change, the health workforce will need to continually adapt to ensure the best outcomes for both health workers and the patients they treat, particularly in regional, rural and remote areas.
Overview of the health workforce
Australia’s healthcare system is underpinned by a large and diverse health workforce, comprised of skilled professionals employed in a number of occupations and across a variety of settings. The health workforce includes over 700,000 registered (see Box 1) medical practitioners, nurses, midwives, dentists and allied health professionals (such as physiotherapists); a large number of non-registered health practitioners such as dieticians, social workers and speech therapists; as well as managers, administrators, clerical workers and support staff.
While the overall number of health practitioners continues to grow, so too does the demand on the health system due to an ageing population, an increase in chronic disease burden and complex care, changing patterns of healthcare, and new health technologies. Ensuring that the health workforce is sufficient to meet community needs has been an ongoing concern for governments and policy makers for over 20 years, and it is likely to remain an area of interest for the 46th Parliament.
Box 1: Registered health practitioners
| In 2008, the Council of Australia Governments (COAG) agreed to establish a single national scheme for registered health practitioners, the National Registration and Accreditation Scheme (NRAS). The NRAS ‘ensures that all regulated health professionals are registered against consistent, high quality, national professional standards and can practise across state and territory boarders without having to re-register in each jurisdiction’. The NRAS has been in operation since 2010 and currently covers 15 health professions practicing under protected titles. The NRAS is administered by the Australian Health Practitioner Regulation Agency (AHPRA). As at December 2018, there were: 114,575 registered medical practitioners; 403,084 people registered as a nurse, midwife or both; 23,714 registered dentists and 181,089 registered allied health professionals in Australia (sum of 12 occupations).
Who is responsible for the health workforce?
As outlined in the Review of Australian Government Health Workforce Programs (the Mason Review, 2013) health workforce arrangements in Australia are complex and interdependent, with responsibilities shared between the Australian and state and territory governments. In addition, private sector and non-government agencies, such as universities, vocational education and training providers, specialist medical colleges and employers can influence the training and employment pathways of health professionals.
The states and territories are largely responsible for recruitment and retention of staff in public hospitals, as well as the provision of clinical training placements. States and territories are also responsible for identifying areas of need—locations where there is a lack of medical practitioners; and for providing funding and delivering programs to address supply and demand issues at the state level.
The Australian Government can influence the health workforce in a number of ways, including:
- Placing restrictions on Medicare provider numbers to influence the distribution of the workforce. For example, Section 19AB the Health Insurance Act 1973, restricts overseas trained doctors (OTDs) and foreign graduates of accredited medical schools (FGAMS) from receiving Medicare benefits for a period of 10 years following their Australian medical registration, unless they work in specified locations, called districts of workforce shortage.
- Funding programs and providing incentive payments to improve the supply of medical professionals in rural, regional and remote areas, such as the Workforce Incentive Program.
- Increasing or restricting the number of OTDs through the immigration portfolio. In the 2018–19 Budget, the Turnbull Government announced that the number of visas for overseas OTDs, who provide a significant proportion of Medicare-funded services in rural areas, will be capped at 2,100 per year from January 2019.
- Funding for Commonwealth supported places for university students to study medicine.
What are the key issues?
Issues relating to the number of health practitioners, supply and demand for health services and health professionals in different regions and settings, medical education and training, and the future of Australia’s health workforce have been explored in a number of reports. These include, a Productivity Commission review of ‘Australia’s Health Workforce’ (2006), Health Workforce Australia 2025 Volumes 1–3 (2012), the Mason Review (2013) and the Australia’s Future Health Workforce reports (2014–2018) covering a number of health specialities.
One major issue that has persisted, despite successive Government attempts to address it, is the shortage of medical practitioners and specialists in rural, regional and remote areas. While Australia currently has an adequate supply of doctors at the national level, with 3.6 doctors per 1,000 people (2016) compared to the OECD average of 3.4 per 1,000 people (2015), the geographic distribution of these doctors is uneven. In 2014, there were 437 Full-time equivalent (FTE) medical practitioners per 100,000 population in major cities, decreasing to 272 in outer regional areas and 264 in remote and very remote areas. This unequal distribution also exists for medical specialists, dental practitioners and allied health professionals (p.57).
The regional, rural and remote health workforce
People living in rural and remote areas of Australia experience poorer health outcomes, higher rates of chronic disease and lower life expectancy than those living in metropolitan areas. These issues are exacerbated by the uneven distribution of workforce, which results in poorer access and lower usage of some health services.
The reasons for this uneven distribution were examined by the Senate Community Affairs References Committee in 2012, which found that the barriers for health professionals to enter and stay in rural and remote locations are both professional and personal. They include limited opportunities for training and professional development, income, longer work hours and a lack of opportunities for spouses and children. The AIHW and the Australian Medical Association (AMA) have also found that low population density, limited infrastructure, isolation and a lack of flexible working arrangements impact on decisions to enter the rural workforce. Further, while the number of medical graduates is increasing, many are choosing to become specialists rather than general practitioners (GPs). Between 2008 and 2012 the increase in the number of specialists was 67 per cent, much higher than the growth in GPs of 33 per cent (p.13). As specialists are more likely to work in major cities, this has implications for the rural health workforce.
Addressing the shortage of health workers in rural, regional and remote health workforce was a focus of the 45th Parliament, with a number of reforms and initiatives announced.
In 2017, following an election commitment, the Turnbull Government announced the appointment of a National Rural Health Commissioner. The role of the Commissioner is to work with communities, the health sector and governments to improve rural health policies. The Commissioner was also tasked with developing and defining a new National Rural Generalist Pathway (NRGP). The NRGP seeks to provide rural training for general practice, emergency and additional skills in a single training program with the aim of increasing the number of practitioners working in rural areas. The Commissioner provided advice on this issue in December 2018, and the recommendations are currently being progressed. In the 2019–20 Budget the Morrison Government announced funding for the NRGP program (p.89).
In January 2019, the Minister for Regional Services requested that the Commissioner provide advice on rural allied health workforce reform by 1 October 2019, including policy options within the Commonwealth’s remit to ‘improve the quality, accessibility and distribution of allied health services in regional, rural and remote Australia’.
The Commissioner is a temporary position until 1 July 2020, appointed under Part VA of the Health Insurance Act 1973. The Health Minister must consider by 1 July 2019 whether the office of the Commissioner should be extended beyond this date.
As part of the 2018–19 Budget, the Government announced A Stronger Rural Health Strategypackage with the aim of building a ‘sustainable, high quality health workforce that is distributed across the country according to community need particularly in rural and remote communities’. The strategy aims to provide 3,000 more doctors, and more than 3,000 nurses into rural and regional areas over the next 10 years and includes a range of measures such as:
Stakeholders have been broadly supportive of the recent reforms, in particular the NRGP, with the Rural Doctors Association of Australia (RDAA) the National Rural Health Alliance and the AMA welcoming the strategy. However, during and after the recent election stakeholders noted that a number of these reforms will take time to come into effect and proposed additional options to address the workforce shortage sooner. For example the RDAA suggested rural Medicare loadings and supports for rural hospitals and rural birthing units; Allied Health Professionals Australia has called for Medicare rebates to be extended to telehealth consultations by allied health professionals, and the RDAA and AMA have called for infrastructure grants.
Mental health was another area of focus during the 45th Parliament. There is a shortage of mental health workers and services in regional, rural and remote areas of Australia. In 2016, for example, there were 16 FTE psychiatrists per 100,000 population in major cities, compared to 6.1 per 100,000 in inner regional areas and 4.0 in very remote areas. The trend is similar for mental health nurses and psychologists.
A 2018 inquiry by the Senate Community Affairs Committee into the Accessibility and quality of mental health services in rural and remote Australia, found that while people living in rural and remote communities are impacted by mental health disorders at the same rate as people living in major cities, they face greater barriers to seeking care. In 2016–17 people living in remote areas accessed Medicare-subsidised mental health services at a rate three times less than people living in major cities (p.57). The report made 18 recommendations, the majority of which were supported by the Government. As the Government response was tabled in April 2019, work on these recommendations is likely to commence or continue during the 46th Parliament.
Recent strategies to address access to mental health services in regional, rural and remote areas include the expansion in November 2017 of the Better Access Initiative to include telehealth consultations for people located in rural and remote areas who have a Mental Health Treatment Plan; and funding for the Royal Flying Doctors Service to deliver mental health services.
Where to from here?
In March 2019, COAG announced the development of a National Medical Workforce Strategy. The aim of the strategy is to guide long-term, collaborative medical workforce planning across Australia to ensure all Australians receive high quality health care no matter where they live. According to the Department of Health the strategy will ‘set a ten year vision and identify a five year action and implementation plan’. The strategy is intended to be finalised by mid to late 2020, following two periods of consultation.
Many reforms affecting the health workforce, particularly in rural, regional and remote areas are already underway. It will be important for the Australian and state and territory governments to monitor progress and evaluate whether the recently announced measures are achieving their aims. The health workforce is likely to remain an issue for the 46th Parliament.
A Biggs, Rural health workforce, Budget review 2018–2019, Research paper series, 2017–18, Parliamentary Library, Canberra, May 2018.
A Biggs and P Pyburne, Health Insurance Amendment (National Rural Health Commissioner) Bill 2017,
Bills digest, 71, 2016–17, Parliamentary Library, Canberra, 2017.
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