Time to revolutionise hospital workforces

by Stephen Duckett

Published by The Australian Financial Review, Tuesday 15 April

Australian hospitals are under pressure. Waiting lists are growing and hospitals need more staff to meet increasing demand but budgets are being squeezed.

The pool from which universities draw students to undertake health professional training is shrinking. There may be shortages in the future, and experienced professionals are exiting the hospital workforce in droves.

All this calls for a rethink of how we use the workforce skills we have.

But much needed reform is being stymied by management timidity, and rules left over from demarcation decisions made 50 years ago, or even earlier, about who in hospitals can do what. The good news is there are answers to these problems, ones that will free up substantial amounts of money to meet future demand.

The Grattan Institute’s new report, Unlocking skills in hospitals: better jobs, more care, estimates public hospitals can save $430 million every year if they realign the roles of doctors, nurses, physiotherapists and assistants.

The proposed changes won’t reduce the high-quality care that Australians expect. What they are likely to do is make health professionals more satisfied at work.

A key change affects nurses, the largest professional group in hospitals. Nurses’ roles need to change. They need to spend more time using the skills they spent three years at university to acquire, then consolidated with years of on the job experience. As much as 15 per cent of nurses’ time is spent on work that can be done safely by staff without those years of training and experience. Grattan’s report argues the hospital care workforce should be rebalanced. Instead of a hospital system that relies almost entirely on university graduate nurses, as is the case today.

About 15 per cent of the workforce should be assistants. The change should occur without reducing the number of nurses employed in hospitals. Instead, it should be a way to meet growing demand.

This change alone would save an estimated $360 million a year.


While assistants relieve them of some basic tasks, nurses have the preparation to do much more than they do now. With additional training, they can undertake advanced roles such as carrying out “scopes”; using endoscopes to look inside the body. Nurses in Britain and the United States have long performed such roles as part of clinical teams, with both patient satisfaction and clinical safety maintained.

Pilot programs of “nurse endoscopists” have started in Victoria and Queensland but they need to move into routine practice. Nurses could also perform low-risk anaesthesia. “Sedation nurses” are being employed in Australia, building on successful experience overseas. But like nurse endoscopists, they remain rare.

If these two specialist nurse roles were more widespread in Australia, $28 million could be saved each year. Another change the report proposes is employing more assistants to free up physiotherapists and occupational therapists for more advanced roles.

Changes such as these won’t happen if we just sit on our hands and wait.

There will be opposition that will dress itself up as selfless protection of patient care but is, in fact, designed to protect existing roles. The changes we propose have been tried and proven in other countries, and sometimes even as demonstration projects in Australia.

To overcome inertia, rules and regulations need to be changed centrally to allow hospitals to act.

Industrial negotiations are needed to overcome union and professional association opposition.

Hospitals need to have time-limited subsidies to help with the transition.

Revised workforce roles will benefit both staff and patients. Staff will do more of the things they were trained for and that only they can do. They will be happier at work, while patients will continue to get good care. The changes would reduce the risk of waiting times spiralling as workforce shortages get worse.

With $430 million freed up, it could mean as many as 85,000 more patients treated every year. At a time when the sustainability of the health system is being questioned, the sector has no choice but to use all the skills it has.