22
Nov
2016

Three challenges facing health workforce reform

by Stephen Duckett


Published by Health Voices, Tuesday 22 November

Changing who does what

Too many health professionals squander their valuable skills on work that other people could do.

In most cases, it doesn’t take 15 years of post-school training to provide light sedation to a stable patient having a simple procedure. Nor does it take a three-year degree to help someone bathe or eat.

But tradition, professional culture and industrial agreements often dictate that highly trained health professionals spend their time doing straightforward work. This wastes money, makes professional jobs less rewarding and often does not improve care.

The Productivity Commission raised these concerns a decade ago. Grattan Institute has also issued reports on this topic. Progress is occurring, but it is slow. Nurses are now performing endoscopies, helping to reduce long waiting times. Physician assistants are used in Queensland to support doctors and ensure that doctors’ time is used to best effect.

These and similar changes to professional roles need to be rolled out extensively. Above all, we need to think about the appropriate workforce model for rural and remote Australia. It certainly isn’t our current Noah’s Ark model where we need to have two (or more) of every therapist, everywhere. For example, we need a new model for providing allied health services so that scarce therapist time is used for planning and prescribing what needs to be done, with allied health assistants implementing the treatment.

Changing the way doctors are paid

All of this brings us to the second problem – the way health professionals are paid. The problem has three aspects: fee-for-service, co-payments, and the requirement for personal provision.

General practitioners are primarily paid a separate fee for each service. This is fine when every problem – such as an injury or an infection – is separate and you don’t care too much about continuity. But that is not the world of general practice today. Most patients are people with a chronic disease, often more than one. Health systems around the globe are facing the same change in patient needs, and are implementing similar policy changes. The universal policy direction has two elements. The first is to increase the proportion of payment to general practitioners that rewards continuity of care; that might involve a fixed payment for three months of care. The second is to introduce reward payments to doctors for better outcomes, such as helping patients to maintain key clinical measures (blood sugar measurements for diabetes, for example). The Government’s ‘Health Care Homes’ initiative is a small first step on this path but more needs to be done.

Another aspect of the payment problem is who pays. Medicare was supposed to eliminate financial barriers to seeing a doctor but many patients – especially in rural and remote Australia – face hefty bills if they need to see a general practitioner. Although the growing numbers of medical practitioners may force costs to patients down over time, there is no guarantee this ‘trickle down’ policy will come soon enough to ease the financial burden on people who need care. Governments should ensure that care is available throughout Australia on the same basis. A person shouldn’t have to pay more to see a general practitioner just because he or she lives in a rural or regional area.

The third aspect of the payment problem is the so-called ‘personal provision’ rule. For most treatment services, medical practitioners can only bill for work they actually do, rather than work they supervise.

This means that doctors are being paid, at doctor pay rates, to do the work of nurses and clerical staff. This stifles innovation and drives up costs.

General practices should be able to use nurses to check up on patients with chronic conditions, see them if things aren’t working out well and get the doctor to see them too if that is needed. The general practice should be able to claim for this care, regardless of who provides it.

Fixing where doctors work

I have already touched on the third big workforce problem – where doctors work. Although the number of general practitioners per head of population is roughly equal across Australia – at least as measured and reported with the broad measures that are published – this probably hides significant problems in some areas. Very small towns and more remote areas face definite workforce shortages that are not apparent in the statistics. We need better – more refined – reporting of areas of shortage. We also need action to address these shortages using the surplus of medical graduates resulting from the massive expansion in medical training in Australia over the last decade.

Conclusion

Australia has a good health system, at least on average. We have a good training system for health professionals, which helps to ensure that the health professionals who treat us are well skilled. But the system of yesteryear is no longer the best for today. Change is required in many aspects of the health workforce, but especially in what they do, how they are paid and where they work.