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Interventions to facilitate health workforce restructure

Interventions to facilitate health workforce restructure There are recognised shortages in most health professions in Australia. This is evidence that previous attempts at health workforce planning have failed. This paper argues that one reason for such failure is the lack of appropriate structures for health workforce planning. It also suggests that Australia needs to move beyond planning for particular professions and that health workforce planning needs to be based on identifying skill shortages as much as shortages in particular named professionals. The paper proposes specific policy suggestions to facilitate workforce flexibility and health workforce planning in Australia. www.who.int/hrh/whr06_consultation/en/. Although the Background Health workforce reform is clearly on the agenda of health headline problem is usually couched in terms of work- policy makers in Australia. It has been the focus of discus- force supply, problems in flexibility of the workforce and sion at the Council of Australian Governments which workforce planning also confront policymakers. requested the Commonwealth to initiate further research in this area, operationalised by the Treasurer commission- The focus on workforce flexibility is in part a response to ing the current research study by the Productivity Com- perceived overspecialisation of the health workforce. Spe- mission http://www.pc.gov.au/study/healthworkforce/ cialisation, which in part was seen to be associated with index.html. There are a number of immediate causative higher quality, is now seen as possibly detracting from factors for this heightened policy attention, most notably continuity of care and hence may have a deleterious contemporary perceived shortages of most categories of impact on quality, especially in the context of the health professionals. Increasingly, health policy makers increased salience of chronic diseases in the health sector. and health service managers are also recognising that the Although all the benefits of specialisation should not be current structure of the health workforce is probably not lost, the current assignment of roles for health profession- st suitable for 21 century healthcare delivery. [1] als is perceived to be inefficient either because more staff are employed than would be required in an efficient Australia is not unique in facing workforce shortages organisation of roles, or staff at higher pay classifications [2,3], nor in recognising the inadequacy of current work- being used to perform tasks which could be performed by force structures [4]; the World Health Organisation is staff at lower pay levels. The inflexibility of contemporary highlighting workforce issues internationally by making workforce structure also inhibits service delivery because them the focus of its 2006 World Health Report http:// of shortages of staff to perform key roles. Policy attention Page 1 of 6 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:14 http://www.anzhealthpolicy.com/content/2/1/14 Table 1: Examples of potential (or current) task substitutions Task* Traditional professional Substitute professional/assistant Anaesthesia Anaesthetist Nurse anaesthetist Clerking of new hospital patients Hospital medical officer Nurse Closure of wound Surgeon Nurse Foot care Podiatrist Foot care assistant Foot surgery Orthopaedic surgeon Podiatric surgeon Laryngoscopy/Naso-endoscopy ENT surgeon Speech pathologist/Nurse Maternity care Obstetrician Midwife or GP Mobilisation assistance Physiotherapist Physiotherapy assistant Patient management Medical practitioner Nurse practitioner Plain X-ray Medical imaging technologist X-ray assistant Refraction Optometrist Orthoptist Reporting pathology Pathologist Scientist Reporting X-rays Radiologist Medical imaging technologist * Performance of the substituted tasks will generally require additional training and clear protocols, and will also depend on the complexity of the condition and the comorbities of the patient is therefore being directed towards strategies about work- challenges to our contemporary conception of the defini- force substitution [5] and to develop skills "escalators", tion and place of a "nurse" or "physiotherapist". This will that is to make it easy for existing health professionals to not be an issue for members of health care teams who acquire additional skills to enable them to perform addi- work closely or regularly with team members working in tional tasks. extended roles, but transient team members (such as agency staff or staff with only irregular or peripheral con- Table 1 shows some of the task substitutions which could tact with the team) may not be fully aware of the team's potentially take place in Australia. In some cases the sub- skill mix and may make inappropriate referrals or consult- stitution is already occurring and the potential is for ative decisions. Consumers may also have different expec- expansion of this practice. In other cases, substitution will tations of the treating team membership, and this too will require: need to be addressed. • Identification and clarification of the precise range of The importance of addressing workforce flexibility and tasks to be substituted; the associated issue of workforce substitution cannot be underestimated, particularly as predictions of future  Protocols to identify the types of patients for whom the workforce requirements need to make some assumptions substitute professional or assistant is relevant; about the mix of tasks that will be performed in the future by the health professionals under review [7,8]. If the tasks  Clarification of the nature of supervision, and reporting undertaken by physiotherapists, for example, are and regulatory arrangements (if any); expanded, then more physiotherapists will be required, but if tasks currently undertaken by physiotherapists are  Negotiation of payment/salary arrangements. able to be delegated to other categories of the health work- force, then the number of physiotherapists required in the Obviously new substitution arrangements need to be care- future will be reduced. For this reason, the term 'skills fully planned and monitored, but over time as health shortage' is preferred to 'workforce shortage' to describe agencies (and patients) become more confident and the contemporary problem. The latter term focuses on familiar with substitution, expanded roles and task substi- particular professions, thus channelling policy attention tution will become a recognised and routine part of serv- into traditional professional structures, rather than recog- ice delivery. nising workforce flexibility and the potential for changed skill mix. The possible substitution examples outlined above mostly involve changing the scope of practice of existing profes- A second cluster of problems relates to health workforce sionals. Substitution can also occur through creation of planning. The legal aphorism, res ipsa loquitur, is relevant new categories of professionals or assistants. [6] The more here. The existence of skills shortages damns current prevalent substitution becomes, the more there will be workforce planning efforts. Although there are technical Page 2 of 6 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:14 http://www.anzhealthpolicy.com/content/2/1/14 The mechanisms for a health agency or a State Health Department to influence the admission or curriculum Commonwealth Commonwealth decisions of universities are very indirect, typically Health Dept. Education Dept. progressing up and down the chain, mediated by the Commonwealth Departments. The longer the links in an implementation chain, the more the policies are likely to State be attenuated or distorted. [9] The mechanisms for imple- State Health menting health workforce decisions are very indirect and Education Universities Dept. Dept. this could be predicted to be relatively ineffectual, which they are. Proposals for reform Faculties of Health agency The incentives on health services and universities are very Health Sciences different. The nature of accountability of the two sectors does not automatically guarantee that the two sectors would see the problems of the health workforce in a sim- ilar way, nor that they would accord the same priority to Org sectors Figure 1 anisational relationships between health and education different solutions. Organisational relationships between health and education sectors. These differences, coupled with the indirect mechanisms of influence highlighted in the figure, mean that the per- ceived problems of the health workforce may not be easily resolved. Faculties of Health Sciences within universities are not autonomous, and even if they identify with the problems faced by the health sector, they may not have problems with workforce and demand projections, a crit- sufficient internal power within universities to effect ical inhibiting factor is the lack of effective formal struc- change. University management may not recognise or tural links between the health and education sectors. accept a need to change university priorities or respond to Figure 1 shows the current relationships. the perceived problems of the health sector. A health agency, for example, relates most closely in There are similar problems of alignment in terms of facil- organisational terms to the State Health Department. The itating workforce flexibility. The structure of Australia's State Health Department has an overview of the needs of Medicare benefits arrangements militate against propos- the health agencies within a State and State Health Minis- als for medical practitioners to promote substitution ters may be politically exposed to shortages in particular strategies. health professions which lead to problems of service delivery. These problems suggest that new strategies are necessary to change incentives to facilitate workforce reform; such State Health Departments have two sets of relationships strategies can be initiated by individual players in the which are of relevance here. One is to the Commonwealth health workforce policy area which would facilitate Health Department structured through organisational improvements in flexibility and in workforce planning. arrangements such as the Australian Health Ministers' Conference and the Australian Health Ministers' Advisory Workforce flexibility Council. The other is to the parallel State Education In terms of workforce flexibility, one of the critical barriers Department. Relationships between state health and edu- to reform is the lack of financial incentives on the medical cation departments are not always close and rarely involve profession to engage in significant restructure of work structured joint planning arrangements. These somewhat roles. The Australian Medicare scheme places financial looser relationships are indicated by dotted lines in the incentives on medical practitioners to provide services figure. The Commonwealth Health Department has links themselves because, in general, only services provided by to the Commonwealth Education Department, which in the medical practitioner attract a rebate under the Medical turn has links to State Education Departments and to uni- Benefits Schedule. However, this is not universally true, versities. At the bottom of the figure we note that health and there are a number of items on the Schedule which do agencies have direct relationships with Faculties of Health not require "personal provision" by the medical practi- Sciences within universities, for example, in terms of tioner (see Section 12.1.1 of the Medicare Schedule, http:/ placement arrangements. /www7.health.gov.au/pubs/mbs/mbsnov04/index.html). Page 3 of 6 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:14 http://www.anzhealthpolicy.com/content/2/1/14 A typical item that does not require personal provision is Thirdly, the Medical Benefits and Pharmaceutical Benefits a pathology test, where the test if performed by a medical arrangements (and associated state regulatory controls) scientist with the medical practitioner not necessarily could be changed to give other professionals access to test being present, or even seeing the test result before it is ordering or prescribing authority. This is already occurring issued. through expanding nurse practitioner access to MBS and PBS arrangements, but it could also apply to podiatrists, One strategy to encourage flexibility in the workforce optometrists, physiotherapists and other health would be to increase the range of items which do not professionals. require personal provision by, for example, designating all procedural items in this category. In this way, for exam- These flexibility arrangements should be accompanied by ple, an anaesthetist would be able to bill for the work of a parallel educational reforms to facilitate upskilling and nurse anaesthetist using the anaesthetic items of the reskilling of health professionals. In this regard, increased Schedule. Assuming salary costs for the substitute profes- graduate entry programs for health professionals, sional are lower than the medical specialist, this would whereby graduates from other disciplines are able to then put a financial incentive on medical practitioners to undertake shortened courses to gain professional recogni- utilise other health professionals for service delivery. It tion, should be encouraged. Shortened courses for profes- may also be appropriate to allow some consultation items sionals to acquire some of the key skills beyond their to be billed without personal provision, eg. if provided by normal range should also be developed (eg. nurses to be a nurse practitioner/advanced practice nurse. This change trained in foot care). Similarly, universities should be could be undertaken by the Commonwealth Department encouraged to provide modular and multiple pathways of Health unilaterally. A change to the 'personal provi- for developing health professionals. For example, there sion' rules of the Schedule can be undertaken without should be expanded arrangements for dental therapists to affecting contemporary fee relativities. However, proce- upgrade to become dentists. Similarly, there should be dural items are often claimed to be over valued relative to multiple pathways for training of psychiatric nurses, pro- non-procedural items, and a change in the personal pro- viding structured courses for people with an initial nurs- vision rules could also involve some realignment of the ing background and for people with an initial psychology Schedule to facilitate a greater recognition of the cogni- background. tively complex components of patient care which will remain the preserve of medically qualified practitioners. Not all skill upgrades will need to involve university pro- grams. Health agencies (and professional registration Medical practitioners are rightly concerned at their place bodies) may cooperate to develop work-based programs in the health care system. The political voices of the med- to address skill gaps. Such programs should be conducted ical profession thus generally oppose structural changes with a recognised qualification framework to ensure port- which reduce medical autonomy or might increase com- ability. The Vocational Education and Training sector may petition and impact on medical incomes. A change to the have a role here, possibly in collaboration with Medicare Benefits Schedule of the kind proposed would universities. ameliorate these concerns and might thus enable the medical professional to support such changes without any Changes to structures The changes to facilitate flexibility outlined above can be threat to their roles and income. It should be noted, how- ever, that delegation from medical practitioners is not and undertaken unilaterally by States changing registration should not be the only possible source of income to sup- Board legislation or by the Commonwealth changing the port new or expanded roles. MBS arrangements. However, in the long term there needs to be reform to funding and management structures to A parallel change could be to introduce powers of delega- improve health workforce planning in Australia. The Nel- tion within health professional registration Acts. A power son changes to higher education have improved the of delegation would facilitate professionals delegating accountability of universities though closer monitoring of tasks by extending the reach of a health professional reg- the course mix within universities. But this monitoring is istration board to cover the work of any person to whom still undertaken at a very broad level and cannot be a professional registered with that board has delegated expected to go into the detail of particular health profes- tasks (see, for example, http://www.cpso.on.ca/Policies/ sions. Further, previous experience suggests that, although delegation.htm. [10] Such a power of delegation would the Department of Education will have an initial flush of establish a regulatory framework for health professionals' enthusiasm for close monitoring, this enthusiasm abates delegating to other professionals or assistants, and would and the relationships between the Commonwealth allow professionals to delegate tasks, knowing they were Department of Education and universities become more doing so within an accepted regulatory framework. laissez faire over time. [10] Page 4 of 6 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:14 http://www.anzhealthpolicy.com/content/2/1/14 The situation in Australia for funding universities for change in funding source could be undertaken unilater- health professional education contrasts with that in the ally by the Commonwealth Government. United Kingdom where, for most health professions, there is a direct contractual relationship between the State health authorities could also exercise influence over health sector and universities. For example, although universities. In many States, the State health authority degree-level education for nursing is funded through provides subsidies to universities either directly or indi- standard education sector funding for universities, rectly for professorial appointments. Many clinical Chairs diploma-level training, which represents the overwhelm- in medicine, nursing and other disciplines, are funded by ing majority of university-based nursing education in the the State health authority (or health agencies). Similarly, United Kingdom, is funded in universities through a health professional education would not be viable were it direct contract between the university and the National not for the access to State-funded health agencies for clin- Health Service. This helps to ensure that universities are ical education. Controlling this access could thus give more accountable to the health sector to provide relevant State health authorities some levers over universities. and appropriate health professional education graduating Given these levers, State health authorities could take a adequate numbers of professionals. Such contracts are much more direct role in negotiating with universities comprehensive, providing for an ongoing relationship about health professional education than they have hith- between the health service and the university, and are not erto. This change could be undertaken unilaterally by any simply based on selection of the cheapest provider. It also State, regardless of any changes in Commonwealth provides a framework for experimentation and respon- responsibilities. siveness in terms of preparing new types of health work- ers. The potential of these arrangements has not been fully Finally, it would be better if the actions of the Common- realised, although there are pockets of innovation (see wealth and the States were brought together into a coher- http://www.content.modern.nhs.uk/cmsWISE/Work ent policy approach. This could be done informally force+Themes/Using_Task_Skills_Effectively/roleredegIn through arrangements for joint Commonwealth/State oduction/Introduction.htm). In the early years of NHS negotiations with universities. A stronger policy could be purchasing of professional education, the NHS tended to to establish a single funding pool to which both the Com- underestimate demand for health professionals from monwealth and the States contribute, which would facili- non-NHS agencies [7], highlighting the need for compre- tate direct negotiations between the Commonwealth and hensive skills planning. State Governments on one hand, and universities on the other. A single funding pool could be administered by a There are lessons for Australia here, and more direct links jointly established health workforce funding agency in between the health sector and universities could improve each State which would have the full purchasing responsi- responsiveness of universities to emerging needs. The first bility for health professional education. These arrange- stage of such a closer relationship could occur if the Com- ments would, of course, be more complex to implement monwealth assigned responsibility for health professional but would be much more powerful mechanisms for education to the Department of Health and Ageing rather reform. Coordination of state and Commonwealth activ- than the Department of Education, Science and Technol- ity would also facilitate engagement with the private sec- ogy. Universities already face multiple sources of funding, tor. Given the different roles of the public and private and a shift of responsibility for health professional educa- sectors in health delivery, it is important to develop struc- tion to the Department of Health and Ageing would give tures to engage the private sector more directly in educat- that Department a direct involvement in setting priorities ing the future health workforce which will be employed in for the future health workforce and funding universities that sector. Involvement of the private sector in the skills accordingly. In contrast to the Department of Education, planning process would also help to ensure that demand Science and Training, the Department of Health and Age- from that sector is taken into account in supply decisions, ing is much more likely to have an ongoing and continu- overcoming one of the early weaknesses experienced in ing interest in ensuring adequate numbers of health the similar arrangements in the United Kingdom. professionals and the competencies attained by new grad- uates. Similarly, many reports commissioned by the Universities might benefit from more systematic planning Department of Health lament the adequacy of the curric- arrangements for health professional education. At ulum of universities in a range of areas, but there have present universities often have problems negotiating clin- been few levers over universities to effect relevant changes. ical education arrangements with health agencies, where A shift of responsibility would reduce the number of links there are few incentives on agencies to assume responsi- in the chain between health agencies and universities in bility for education of the next generation of health pro- terms of responsiveness and skills planning. Such a fessionals. A quid pro quo for increased university accountability to State or Commonwealth health Page 5 of 6 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:14 http://www.anzhealthpolicy.com/content/2/1/14 3. Simoens S, Villeneuve M, Hurst J: Tackling nurse shortages in OECD departments would be an increased responsibility on countries 2005 [http://www.oecd.org/dataoecd/11/10/34571365.pdf]. either the Commonwealth or the State governments (or OECD Health Working Papers (19): Paris both) to ensure the adequacy of clinical education 4. Buchan J, Calman L: Skill-mix and policy change in the health workforce: Nurses in advanced roles 2004 [http://www.oecd.org/dataoecd/30/28/ arrangements for universities. A direct relationship would 33857785.pdf]. OECD Health Working Papers (17): Paris also make it more likely that skills upgrading would 5. Laurant M, Reeves D, Hemens R, Braspenning J, Grol R, Sibbald B: 'Substitution of doctors by nurses in primary care (Review)'. remain within the purview of universities rather than The Cochrane Library 2005 [http://www.thecochranelibrary.com]. bypassing them. Finally, distinct education funding 6. Sibbald B, Shen J, McBride A: 'Changing the skill-mix of the arrangements for the health sector would mean that gov- health care workforce'. J Health Serv Res Policy 2004, 9(S1):28-38. 7. Buchan J, Edwards N: 'Nursing numbers in Britain: the argu- ernment could allocate more funding per health student ment for workforce planning'. BMJ 2000, 320:1067-1070. without creating a precedent for increases in other 8. Reinhardt UE: Physician productivity and the demand for health manpower disciplines. Ballinger Publishing Company: Cambridge, Mass; 1975. 9. Pressman J, Wildavsky A: Implementation: How great expectations in Washington are dashed in Oakland California University Press; 1973. Conclusion 10. de Bie J, Cuperus-Bosma JM, Gevers JKM, van der Wal G: 'Reserved procedures in Dutch hospitals: knowledge, experiences and There are a number of contemporary problems of health views of physicians and nurses'. Health Policy 2004, 68:373-384. professional education. Many of these problems have 11. Marginson S: 'Steering from a distance: Power relations in been identified for decades, but there have been few Australian higher education'. Higher Education 1997, 34:63-80. incentives to achieve change and/or the structural mecha- nisms for change have hitherto not been present. Past opportunities have been missed, eg. in the negotiation of the 2003–2008 Australian Health Care Agreement. The current heightened policy awareness of the need for work- force reform provides a new opportunity for change. Dis- cussion, planning and experimentation should commence now to provide a sounder conceptual and evi- dence base to ensure that opportunities are not missed to incorporate reform proposals in the 2008–2013 Austral- ian Health Care Agreement. In this paper I have outlined incremental steps that could be used to facilitate change in health workforce policy in Australia. The general tenor of the changes are that they provide for increased accountability of universities. But the costs of these changes do not fall only on universities. Introducing new mechanisms to hold universities accountable for adequacy of health professional educa- tion in turn means that governments themselves are more clearly accountable for the adequacy of health profes- sional education, and shortages in any discipline would be more clearly seen to be as a result of government deci- sions. Governments (both Commonwealth and State) benefit from the ability to blame shift to other partici- pants in the health workforce policy arena. New structures for the health workforce and for health Publish with Bio Med Central and every workforce planning are clearly necessary in Australia. In scientist can read your work free of charge this paper I have outlined a possible win/win scenario for "BioMed Central will be the most significant development for policy reform to address these needs. disseminating the results of biomedical researc h in our lifetime." Sir Paul Nurse, Cancer Research UK References Your research papers will be: 1. Duckett SJ: 'Health workforce design in the 21st century'. Aust Health Rev 2005, 29(2201-210 [http://www.aushealthreview.com.au/ available free of charge to the entire biomedical community publications/articles/issues/ahr_29_2_0505/ahr_29_2_201-210.asp]. peer reviewed and published immediately upon acceptance 2. Simoens S, Hurst J: Matching supply with demand for the services of phy- sicians and nurses 2004 [http://www.oecd.org/document/58/ cited in PubMed and archived on PubMed Central 0,2340,en_2649_201185_31786874_1_1_1_1,00.html]. Towards yours — you keep the copyright high-performing health systems, The OECD Health Project: Paris BioMedcentral Submit your manuscript here: http://www.biomedcentral.com/info/publishing_adv.asp Page 6 of 6 (page number not for citation purposes) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Australia and New Zealand Health Policy Springer Journals

Interventions to facilitate health workforce restructure

Duckett, SJ
Australia and New Zealand Health Policy , Volume 2 (1) – Jun 29, 2005
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Springer Journals
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Copyright © 2005 by Duckett; licensee BioMed Central Ltd.
Subject
Medicine & Public Health; Public Health; Social Policy
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1743-8462
DOI
10.1186/1743-8462-2-14
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15987520
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Abstract

There are recognised shortages in most health professions in Australia. This is evidence that previous attempts at health workforce planning have failed. This paper argues that one reason for such failure is the lack of appropriate structures for health workforce planning. It also suggests that Australia needs to move beyond planning for particular professions and that health workforce planning needs to be based on identifying skill shortages as much as shortages in particular named professionals. The paper proposes specific policy suggestions to facilitate workforce flexibility and health workforce planning in Australia. www.who.int/hrh/whr06_consultation/en/. Although the Background Health workforce reform is clearly on the agenda of health headline problem is usually couched in terms of work- policy makers in Australia. It has been the focus of discus- force supply, problems in flexibility of the workforce and sion at the Council of Australian Governments which workforce planning also confront policymakers. requested the Commonwealth to initiate further research in this area, operationalised by the Treasurer commission- The focus on workforce flexibility is in part a response to ing the current research study by the Productivity Com- perceived overspecialisation of the health workforce. Spe- mission http://www.pc.gov.au/study/healthworkforce/ cialisation, which in part was seen to be associated with index.html. There are a number of immediate causative higher quality, is now seen as possibly detracting from factors for this heightened policy attention, most notably continuity of care and hence may have a deleterious contemporary perceived shortages of most categories of impact on quality, especially in the context of the health professionals. Increasingly, health policy makers increased salience of chronic diseases in the health sector. and health service managers are also recognising that the Although all the benefits of specialisation should not be current structure of the health workforce is probably not lost, the current assignment of roles for health profession- st suitable for 21 century healthcare delivery. [1] als is perceived to be inefficient either because more staff are employed than would be required in an efficient Australia is not unique in facing workforce shortages organisation of roles, or staff at higher pay classifications [2,3], nor in recognising the inadequacy of current work- being used to perform tasks which could be performed by force structures [4]; the World Health Organisation is staff at lower pay levels. The inflexibility of contemporary highlighting workforce issues internationally by making workforce structure also inhibits service delivery because them the focus of its 2006 World Health Report http:// of shortages of staff to perform key roles. Policy attention Page 1 of 6 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:14 http://www.anzhealthpolicy.com/content/2/1/14 Table 1: Examples of potential (or current) task substitutions Task* Traditional professional Substitute professional/assistant Anaesthesia Anaesthetist Nurse anaesthetist Clerking of new hospital patients Hospital medical officer Nurse Closure of wound Surgeon Nurse Foot care Podiatrist Foot care assistant Foot surgery Orthopaedic surgeon Podiatric surgeon Laryngoscopy/Naso-endoscopy ENT surgeon Speech pathologist/Nurse Maternity care Obstetrician Midwife or GP Mobilisation assistance Physiotherapist Physiotherapy assistant Patient management Medical practitioner Nurse practitioner Plain X-ray Medical imaging technologist X-ray assistant Refraction Optometrist Orthoptist Reporting pathology Pathologist Scientist Reporting X-rays Radiologist Medical imaging technologist * Performance of the substituted tasks will generally require additional training and clear protocols, and will also depend on the complexity of the condition and the comorbities of the patient is therefore being directed towards strategies about work- challenges to our contemporary conception of the defini- force substitution [5] and to develop skills "escalators", tion and place of a "nurse" or "physiotherapist". This will that is to make it easy for existing health professionals to not be an issue for members of health care teams who acquire additional skills to enable them to perform addi- work closely or regularly with team members working in tional tasks. extended roles, but transient team members (such as agency staff or staff with only irregular or peripheral con- Table 1 shows some of the task substitutions which could tact with the team) may not be fully aware of the team's potentially take place in Australia. In some cases the sub- skill mix and may make inappropriate referrals or consult- stitution is already occurring and the potential is for ative decisions. Consumers may also have different expec- expansion of this practice. In other cases, substitution will tations of the treating team membership, and this too will require: need to be addressed. • Identification and clarification of the precise range of The importance of addressing workforce flexibility and tasks to be substituted; the associated issue of workforce substitution cannot be underestimated, particularly as predictions of future  Protocols to identify the types of patients for whom the workforce requirements need to make some assumptions substitute professional or assistant is relevant; about the mix of tasks that will be performed in the future by the health professionals under review [7,8]. If the tasks  Clarification of the nature of supervision, and reporting undertaken by physiotherapists, for example, are and regulatory arrangements (if any); expanded, then more physiotherapists will be required, but if tasks currently undertaken by physiotherapists are  Negotiation of payment/salary arrangements. able to be delegated to other categories of the health work- force, then the number of physiotherapists required in the Obviously new substitution arrangements need to be care- future will be reduced. For this reason, the term 'skills fully planned and monitored, but over time as health shortage' is preferred to 'workforce shortage' to describe agencies (and patients) become more confident and the contemporary problem. The latter term focuses on familiar with substitution, expanded roles and task substi- particular professions, thus channelling policy attention tution will become a recognised and routine part of serv- into traditional professional structures, rather than recog- ice delivery. nising workforce flexibility and the potential for changed skill mix. The possible substitution examples outlined above mostly involve changing the scope of practice of existing profes- A second cluster of problems relates to health workforce sionals. Substitution can also occur through creation of planning. The legal aphorism, res ipsa loquitur, is relevant new categories of professionals or assistants. [6] The more here. The existence of skills shortages damns current prevalent substitution becomes, the more there will be workforce planning efforts. Although there are technical Page 2 of 6 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:14 http://www.anzhealthpolicy.com/content/2/1/14 The mechanisms for a health agency or a State Health Department to influence the admission or curriculum Commonwealth Commonwealth decisions of universities are very indirect, typically Health Dept. Education Dept. progressing up and down the chain, mediated by the Commonwealth Departments. The longer the links in an implementation chain, the more the policies are likely to State be attenuated or distorted. [9] The mechanisms for imple- State Health menting health workforce decisions are very indirect and Education Universities Dept. Dept. this could be predicted to be relatively ineffectual, which they are. Proposals for reform Faculties of Health agency The incentives on health services and universities are very Health Sciences different. The nature of accountability of the two sectors does not automatically guarantee that the two sectors would see the problems of the health workforce in a sim- ilar way, nor that they would accord the same priority to Org sectors Figure 1 anisational relationships between health and education different solutions. Organisational relationships between health and education sectors. These differences, coupled with the indirect mechanisms of influence highlighted in the figure, mean that the per- ceived problems of the health workforce may not be easily resolved. Faculties of Health Sciences within universities are not autonomous, and even if they identify with the problems faced by the health sector, they may not have problems with workforce and demand projections, a crit- sufficient internal power within universities to effect ical inhibiting factor is the lack of effective formal struc- change. University management may not recognise or tural links between the health and education sectors. accept a need to change university priorities or respond to Figure 1 shows the current relationships. the perceived problems of the health sector. A health agency, for example, relates most closely in There are similar problems of alignment in terms of facil- organisational terms to the State Health Department. The itating workforce flexibility. The structure of Australia's State Health Department has an overview of the needs of Medicare benefits arrangements militate against propos- the health agencies within a State and State Health Minis- als for medical practitioners to promote substitution ters may be politically exposed to shortages in particular strategies. health professions which lead to problems of service delivery. These problems suggest that new strategies are necessary to change incentives to facilitate workforce reform; such State Health Departments have two sets of relationships strategies can be initiated by individual players in the which are of relevance here. One is to the Commonwealth health workforce policy area which would facilitate Health Department structured through organisational improvements in flexibility and in workforce planning. arrangements such as the Australian Health Ministers' Conference and the Australian Health Ministers' Advisory Workforce flexibility Council. The other is to the parallel State Education In terms of workforce flexibility, one of the critical barriers Department. Relationships between state health and edu- to reform is the lack of financial incentives on the medical cation departments are not always close and rarely involve profession to engage in significant restructure of work structured joint planning arrangements. These somewhat roles. The Australian Medicare scheme places financial looser relationships are indicated by dotted lines in the incentives on medical practitioners to provide services figure. The Commonwealth Health Department has links themselves because, in general, only services provided by to the Commonwealth Education Department, which in the medical practitioner attract a rebate under the Medical turn has links to State Education Departments and to uni- Benefits Schedule. However, this is not universally true, versities. At the bottom of the figure we note that health and there are a number of items on the Schedule which do agencies have direct relationships with Faculties of Health not require "personal provision" by the medical practi- Sciences within universities, for example, in terms of tioner (see Section 12.1.1 of the Medicare Schedule, http:/ placement arrangements. /www7.health.gov.au/pubs/mbs/mbsnov04/index.html). Page 3 of 6 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:14 http://www.anzhealthpolicy.com/content/2/1/14 A typical item that does not require personal provision is Thirdly, the Medical Benefits and Pharmaceutical Benefits a pathology test, where the test if performed by a medical arrangements (and associated state regulatory controls) scientist with the medical practitioner not necessarily could be changed to give other professionals access to test being present, or even seeing the test result before it is ordering or prescribing authority. This is already occurring issued. through expanding nurse practitioner access to MBS and PBS arrangements, but it could also apply to podiatrists, One strategy to encourage flexibility in the workforce optometrists, physiotherapists and other health would be to increase the range of items which do not professionals. require personal provision by, for example, designating all procedural items in this category. In this way, for exam- These flexibility arrangements should be accompanied by ple, an anaesthetist would be able to bill for the work of a parallel educational reforms to facilitate upskilling and nurse anaesthetist using the anaesthetic items of the reskilling of health professionals. In this regard, increased Schedule. Assuming salary costs for the substitute profes- graduate entry programs for health professionals, sional are lower than the medical specialist, this would whereby graduates from other disciplines are able to then put a financial incentive on medical practitioners to undertake shortened courses to gain professional recogni- utilise other health professionals for service delivery. It tion, should be encouraged. Shortened courses for profes- may also be appropriate to allow some consultation items sionals to acquire some of the key skills beyond their to be billed without personal provision, eg. if provided by normal range should also be developed (eg. nurses to be a nurse practitioner/advanced practice nurse. This change trained in foot care). Similarly, universities should be could be undertaken by the Commonwealth Department encouraged to provide modular and multiple pathways of Health unilaterally. A change to the 'personal provi- for developing health professionals. For example, there sion' rules of the Schedule can be undertaken without should be expanded arrangements for dental therapists to affecting contemporary fee relativities. However, proce- upgrade to become dentists. Similarly, there should be dural items are often claimed to be over valued relative to multiple pathways for training of psychiatric nurses, pro- non-procedural items, and a change in the personal pro- viding structured courses for people with an initial nurs- vision rules could also involve some realignment of the ing background and for people with an initial psychology Schedule to facilitate a greater recognition of the cogni- background. tively complex components of patient care which will remain the preserve of medically qualified practitioners. Not all skill upgrades will need to involve university pro- grams. Health agencies (and professional registration Medical practitioners are rightly concerned at their place bodies) may cooperate to develop work-based programs in the health care system. The political voices of the med- to address skill gaps. Such programs should be conducted ical profession thus generally oppose structural changes with a recognised qualification framework to ensure port- which reduce medical autonomy or might increase com- ability. The Vocational Education and Training sector may petition and impact on medical incomes. A change to the have a role here, possibly in collaboration with Medicare Benefits Schedule of the kind proposed would universities. ameliorate these concerns and might thus enable the medical professional to support such changes without any Changes to structures The changes to facilitate flexibility outlined above can be threat to their roles and income. It should be noted, how- ever, that delegation from medical practitioners is not and undertaken unilaterally by States changing registration should not be the only possible source of income to sup- Board legislation or by the Commonwealth changing the port new or expanded roles. MBS arrangements. However, in the long term there needs to be reform to funding and management structures to A parallel change could be to introduce powers of delega- improve health workforce planning in Australia. The Nel- tion within health professional registration Acts. A power son changes to higher education have improved the of delegation would facilitate professionals delegating accountability of universities though closer monitoring of tasks by extending the reach of a health professional reg- the course mix within universities. But this monitoring is istration board to cover the work of any person to whom still undertaken at a very broad level and cannot be a professional registered with that board has delegated expected to go into the detail of particular health profes- tasks (see, for example, http://www.cpso.on.ca/Policies/ sions. Further, previous experience suggests that, although delegation.htm. [10] Such a power of delegation would the Department of Education will have an initial flush of establish a regulatory framework for health professionals' enthusiasm for close monitoring, this enthusiasm abates delegating to other professionals or assistants, and would and the relationships between the Commonwealth allow professionals to delegate tasks, knowing they were Department of Education and universities become more doing so within an accepted regulatory framework. laissez faire over time. [10] Page 4 of 6 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:14 http://www.anzhealthpolicy.com/content/2/1/14 The situation in Australia for funding universities for change in funding source could be undertaken unilater- health professional education contrasts with that in the ally by the Commonwealth Government. United Kingdom where, for most health professions, there is a direct contractual relationship between the State health authorities could also exercise influence over health sector and universities. For example, although universities. In many States, the State health authority degree-level education for nursing is funded through provides subsidies to universities either directly or indi- standard education sector funding for universities, rectly for professorial appointments. Many clinical Chairs diploma-level training, which represents the overwhelm- in medicine, nursing and other disciplines, are funded by ing majority of university-based nursing education in the the State health authority (or health agencies). Similarly, United Kingdom, is funded in universities through a health professional education would not be viable were it direct contract between the university and the National not for the access to State-funded health agencies for clin- Health Service. This helps to ensure that universities are ical education. Controlling this access could thus give more accountable to the health sector to provide relevant State health authorities some levers over universities. and appropriate health professional education graduating Given these levers, State health authorities could take a adequate numbers of professionals. Such contracts are much more direct role in negotiating with universities comprehensive, providing for an ongoing relationship about health professional education than they have hith- between the health service and the university, and are not erto. This change could be undertaken unilaterally by any simply based on selection of the cheapest provider. It also State, regardless of any changes in Commonwealth provides a framework for experimentation and respon- responsibilities. siveness in terms of preparing new types of health work- ers. The potential of these arrangements has not been fully Finally, it would be better if the actions of the Common- realised, although there are pockets of innovation (see wealth and the States were brought together into a coher- http://www.content.modern.nhs.uk/cmsWISE/Work ent policy approach. This could be done informally force+Themes/Using_Task_Skills_Effectively/roleredegIn through arrangements for joint Commonwealth/State oduction/Introduction.htm). In the early years of NHS negotiations with universities. A stronger policy could be purchasing of professional education, the NHS tended to to establish a single funding pool to which both the Com- underestimate demand for health professionals from monwealth and the States contribute, which would facili- non-NHS agencies [7], highlighting the need for compre- tate direct negotiations between the Commonwealth and hensive skills planning. State Governments on one hand, and universities on the other. A single funding pool could be administered by a There are lessons for Australia here, and more direct links jointly established health workforce funding agency in between the health sector and universities could improve each State which would have the full purchasing responsi- responsiveness of universities to emerging needs. The first bility for health professional education. These arrange- stage of such a closer relationship could occur if the Com- ments would, of course, be more complex to implement monwealth assigned responsibility for health professional but would be much more powerful mechanisms for education to the Department of Health and Ageing rather reform. Coordination of state and Commonwealth activ- than the Department of Education, Science and Technol- ity would also facilitate engagement with the private sec- ogy. Universities already face multiple sources of funding, tor. Given the different roles of the public and private and a shift of responsibility for health professional educa- sectors in health delivery, it is important to develop struc- tion to the Department of Health and Ageing would give tures to engage the private sector more directly in educat- that Department a direct involvement in setting priorities ing the future health workforce which will be employed in for the future health workforce and funding universities that sector. Involvement of the private sector in the skills accordingly. In contrast to the Department of Education, planning process would also help to ensure that demand Science and Training, the Department of Health and Age- from that sector is taken into account in supply decisions, ing is much more likely to have an ongoing and continu- overcoming one of the early weaknesses experienced in ing interest in ensuring adequate numbers of health the similar arrangements in the United Kingdom. professionals and the competencies attained by new grad- uates. Similarly, many reports commissioned by the Universities might benefit from more systematic planning Department of Health lament the adequacy of the curric- arrangements for health professional education. At ulum of universities in a range of areas, but there have present universities often have problems negotiating clin- been few levers over universities to effect relevant changes. ical education arrangements with health agencies, where A shift of responsibility would reduce the number of links there are few incentives on agencies to assume responsi- in the chain between health agencies and universities in bility for education of the next generation of health pro- terms of responsiveness and skills planning. Such a fessionals. A quid pro quo for increased university accountability to State or Commonwealth health Page 5 of 6 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:14 http://www.anzhealthpolicy.com/content/2/1/14 3. Simoens S, Villeneuve M, Hurst J: Tackling nurse shortages in OECD departments would be an increased responsibility on countries 2005 [http://www.oecd.org/dataoecd/11/10/34571365.pdf]. either the Commonwealth or the State governments (or OECD Health Working Papers (19): Paris both) to ensure the adequacy of clinical education 4. Buchan J, Calman L: Skill-mix and policy change in the health workforce: Nurses in advanced roles 2004 [http://www.oecd.org/dataoecd/30/28/ arrangements for universities. A direct relationship would 33857785.pdf]. OECD Health Working Papers (17): Paris also make it more likely that skills upgrading would 5. Laurant M, Reeves D, Hemens R, Braspenning J, Grol R, Sibbald B: 'Substitution of doctors by nurses in primary care (Review)'. remain within the purview of universities rather than The Cochrane Library 2005 [http://www.thecochranelibrary.com]. bypassing them. Finally, distinct education funding 6. Sibbald B, Shen J, McBride A: 'Changing the skill-mix of the arrangements for the health sector would mean that gov- health care workforce'. J Health Serv Res Policy 2004, 9(S1):28-38. 7. Buchan J, Edwards N: 'Nursing numbers in Britain: the argu- ernment could allocate more funding per health student ment for workforce planning'. BMJ 2000, 320:1067-1070. without creating a precedent for increases in other 8. Reinhardt UE: Physician productivity and the demand for health manpower disciplines. Ballinger Publishing Company: Cambridge, Mass; 1975. 9. Pressman J, Wildavsky A: Implementation: How great expectations in Washington are dashed in Oakland California University Press; 1973. Conclusion 10. de Bie J, Cuperus-Bosma JM, Gevers JKM, van der Wal G: 'Reserved procedures in Dutch hospitals: knowledge, experiences and There are a number of contemporary problems of health views of physicians and nurses'. Health Policy 2004, 68:373-384. professional education. Many of these problems have 11. Marginson S: 'Steering from a distance: Power relations in been identified for decades, but there have been few Australian higher education'. Higher Education 1997, 34:63-80. incentives to achieve change and/or the structural mecha- nisms for change have hitherto not been present. Past opportunities have been missed, eg. in the negotiation of the 2003–2008 Australian Health Care Agreement. The current heightened policy awareness of the need for work- force reform provides a new opportunity for change. Dis- cussion, planning and experimentation should commence now to provide a sounder conceptual and evi- dence base to ensure that opportunities are not missed to incorporate reform proposals in the 2008–2013 Austral- ian Health Care Agreement. In this paper I have outlined incremental steps that could be used to facilitate change in health workforce policy in Australia. The general tenor of the changes are that they provide for increased accountability of universities. But the costs of these changes do not fall only on universities. Introducing new mechanisms to hold universities accountable for adequacy of health professional educa- tion in turn means that governments themselves are more clearly accountable for the adequacy of health profes- sional education, and shortages in any discipline would be more clearly seen to be as a result of government deci- sions. Governments (both Commonwealth and State) benefit from the ability to blame shift to other partici- pants in the health workforce policy arena. New structures for the health workforce and for health Publish with Bio Med Central and every workforce planning are clearly necessary in Australia. In scientist can read your work free of charge this paper I have outlined a possible win/win scenario for "BioMed Central will be the most significant development for policy reform to address these needs. disseminating the results of biomedical researc h in our lifetime." Sir Paul Nurse, Cancer Research UK References Your research papers will be: 1. Duckett SJ: 'Health workforce design in the 21st century'. Aust Health Rev 2005, 29(2201-210 [http://www.aushealthreview.com.au/ available free of charge to the entire biomedical community publications/articles/issues/ahr_29_2_0505/ahr_29_2_201-210.asp]. peer reviewed and published immediately upon acceptance 2. Simoens S, Hurst J: Matching supply with demand for the services of phy- sicians and nurses 2004 [http://www.oecd.org/document/58/ cited in PubMed and archived on PubMed Central 0,2340,en_2649_201185_31786874_1_1_1_1,00.html]. Towards yours — you keep the copyright high-performing health systems, The OECD Health Project: Paris BioMedcentral Submit your manuscript here: http://www.biomedcentral.com/info/publishing_adv.asp Page 6 of 6 (page number not for citation purposes)

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Australia and New Zealand Health Policy – Springer Journals

Published: Jun 29, 2005

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