Breast Cancer Network Australia (BCNA):
Submission to the Productivity Commission Health Workforce research study

May 2005

Breast Cancer Network Australia (BCNA) is the peak national breast cancer consumer organisation, representing 117 member groups and more than 12,000 individuals in each state and territory.  Its role is to empower, inform, represent and link together Australians personally affected by breast cancer.  It is driven by women who have themselves experienced breast cancer.  It influences key decision makers to ensure that the needs and issues of people affected by breast cancer are raised and addressed.

BCNA welcomes the opportunity to provide a submission to the Productivity Commission Health Workforce research study.

Summary

In recent years, understanding of the complexity of illness and the requirements of healthcare services to deal with illness has changed substantially.  In the area of breast-cancer care in particular, through the efforts of the National Breast Cancer Centre (NBCC), there has been a focus on the development of clinical practice guidelines.  Development of these guidelines has resulted in a shift in our understanding of what constitutes best-practice care in the management of breast cancer.  In order to implement these guidelines as the standard of breast cancer care across the county, changes in the healthcare workforce will be required.

In addition, the work done to develop guidelines for the management of breast cancer has and will continue to influence work in other areas.  This is evidenced by the way in which development of the Psychosocial clinical practice guidelines: providing information support and counselling for women with breast cancer influenced development of the more broadly applicable Clinical practice guidelines for the psychosocial care of adults with cancer. This will result in the requirements for workforce change to flow through the entire healthcare system.

Some areas of workforce change that Breast Cancer Network Australia envisages will be required over the next decade are outlined in this submission.  In summary they include:

•	Alteration in the current composition of the healthcare workforce.  Practitioners that were previously viewed as having a smaller or more targeted role in healthcare will now have a role to play in the management of larger groups of patients.  Examples of this are the roles of psychologists and psychiatrists.  In the past, these clinicians might have been considered to work predominantly in the area of mental health.  However, as the understanding of psychosocial morbidity in a whole range of other illnesses, such as cancer, increases, the demand for the services of these clinicians will increase.  The current numbers of these clinicians will not be sufficient to meet this increased demand and more will be required.

•	Increased flexibility of the health care workforce.  A focus on treating people as whole beings rather than as collections of diagnoses requires health professionals to think outside their traditional boundaries.  Best-practice healthcare now requires health workers to be involved with the person as a whole rather than dividing them up into parts, each bit to be managed by a different medical specialty.   In order to deliver best-practice care in areas such as cancer care, healthcare workers must now work as part of a team, consulting with colleagues whom they might traditionally have seen as being on “the other team” rather than on “the same team” ie the patient’s team.

•	Introduction of new members to the healthcare workforce.  With an increasing reliance on information technology and other new technologies in the delivery of best-practice care, particularly over large distances, information technology specialists will be required to become part of the front-line medical team.  Their role might be to coordinate multidisciplinary case conferences via video-link or to ensure precious digital images are safely transferred between isolated rural centres and metropolitan tertiary treatment centres.  Whilst this will facilitate the provision of best-practice care in isolated areas, the recruitment and training of these specialists will be vital in ensuring this happens effectively.

•	A focus on retention of members of the healthcare workforce.  Recognition that members of the healthcare workforce may also be healthcare consumers or carers of healthcare consumers is essential.  Providing workplace flexibility to accommodate the conflicting demands on these workers may be instrumental in ensuring greater retention rates of healthcare workers in the workforce.

BCNA believes this productivity commission review of the healthcare workforce is timely in addressing these and other challenging issues in healthcare.  Without an adequately structured and educated health workforce, it will be impossible to deliver best-practice healthcare to every Australian, regardless of where they live, over the coming decade and beyond.  

Health workforce issues that effect breast-cancer care for women

A number of the issues that have been referred to in the terms of reference of this productivity commission review have also been identified by BCNA as being significant in ensuring that standardised, best-practice healthcare is available for all Australian women with breast cancer.  Some of these issues are outlined in this section of the submission.

1.	Structure and distribution of the health workforce

Regional, remote and indigenous issues

There is growing evidence that health consumers living in rural areas can suffer a greater burden as a result of being diagnosed with illnesses such as cancer, than those living in metropolitan areas.  In its recent submission to the Senate inquiry into services and treatment options for persons with cancer, the Rural Doctors Association of Australia expressed their alarm at research showing that “people in country areas who are diagnosed with cancer are 35% more likely to die within five years than cancer sufferers in the city”.  

Rural patients frequently have to travel long distances to access standard treatment such as radiotherapy.  Continuity of care and follow-up for these patients can be poorer than for their city counterparts.  The financial burden of having to travel to access treatment and of having to pay for accommodation near metropolitan treatment centres has an enormous impact on many of BCNA’s rural members.  In addition, support services in rural areas are not always as available as they are to women in metropolitan centres.  This can lead to isolation and, potentially, an increased risk of psychosocial morbidity.  A challenge for the next decade will be to ensure that an adequate healthcare workforce exists to provide best-practice cancer care to those living in rural and remote locations.

Discrepancies in funding and distribution of the health workforce between the public and private sectors

Women who receive their breast cancer care in private hospitals are less likely to have access to a breast care nurse than women in the public sector.  In addition, multidisciplinary care, which is now viewed as best-practice care in the management of breast cancer is more difficult to deliver under the current private sector funding arrangements than in the public sector.  While shifting the burden of health care from the public to the private sector may be viewed as a fiscally responsible action by government, this cannot be at the expense of best-practice care.  Governments must ensure that private hospitals and all public hospitals offer the equivalent standard of care to that offered by public teaching hospitals.  This includes ensuring that the most appropriate workforce mix operates in every healthcare facility.

2.	Education and training

Workforce preparation and training

The effectiveness of current workforce preparation in training healthcare practitioners to work with healthcare consumers is of concern to BCNA.  BCNA believes a consumer focus should be adopted in the training of all health professionals.  Each year, BCNA provides trained and supported consumer representatives to address undergraduate medical students at The University of Melbourne as well as medical, nursing and allied health students in a number of other universities around Australia.  This program has been highly successful in raising awareness of the consumer perspective among medical, nursing and allied health students.  BCNA would like to see this model funded and implemented nationally so that all Australian healthcare trainees have access to this experience.  

3.	Workforce planning

Increasing flexibility of professional roles and permeability of professional boundaries

In the past, specialist practitioners could focus exclusively on their area of expertise.  There was a lower expectation that healthcare workers would view the patient as a whole person rather than focus on a diseased body part or diagnosis.  However, our growing understanding of the complexity of disease and the impact of disease on mental health now demands a broader approach to patient management by medical practitioners and other health workers.  

BCNA believes that in areas such as psychosocial care, all health professionals should have the skills to be able to competently identify and appropriately refer individuals at risk of psychosocial morbidity.  Healthcare training must equip the workforce for dealing competently with patients as physical, emotional, psychological, sexual and spiritual beings.

Deployment of the health workforce and the responsiveness of the workforce and the system as a whole to changing needs

Prior to the NBCC releasing the Psychosocial clinical practice guidelines: providing information support and counselling for women with breast cancer and the Clinical practice guidelines for the psychosocial care of adults with cancer, the level of psychosocial morbidity amongst cancer sufferers was underestimated.  It is now known that up to one in three cancer patients experiences significant psychosocial morbidity as a result of their diagnosis of cancer.  

Availability of adequate psychological support and specialist psycho-oncology services, where required, is now regarded as best-practice in the provision of cancer care.  This new situation is already impacting on the demand for specialised, psycho-oncology services and will continue to do so over the next decade.  A priority workforce issue will be ensuring that adequate numbers of these specialist professionals are trained and ready to meet this increasing demand.   

In addition, BCNA recommends that palliative care services should be accessible and available to all women with breast cancer as they are needed.  Over the coming years, palliative care will increasingly be viewed as care of people with a terminal illness rather than care of people who are dying.  With the advent of new pharmaceuticals, people with terminal illnesses will live for longer periods of time and may require access to palliative care practitioners over many years.  This will have significant workforce implications over the coming decade and beyond.

Coordinators of care

Implementation of multidisciplinary care, whilst demonstrating better healthcare outcomes, leads to a need for greater coordination of clinical management and information exchange between patients, families and the range of clinicians involved in care.  In the area of breast cancer, the evolution of the breast care nurse role has been effective in filling this need.  As the breast cancer model of care spreads to the management of other cancers, there will be an increasing need for coordinators of care.  This model may also flow through to other areas of healthcare.

Application of new technologies

With the growing use of Sentinel Node Biopsy as a surgical technique for managing some women with early breast cancer and the widespread encouragement of women to access screening mammography services there will be a requirement for increasing numbers of radiologists, radiation oncologists and nuclear technicians.  A priority workforce issue will be ensuring that adequate numbers of these specialist professionals are recruited, trained and ready to meet this increasing demand.   

Collection of adequate data for the facilitation of workforce planning

Currently, data is collected on the diagnosis of new cancers as well as cancer mortalities.  However, data on the incidence of metastatic breast and other cancers is not routinely collected.  In order for workforce and other resource allocation and management issues to be adequately addressed, BCNA recommends that mechanisms for the collection of statistics on the diagnosis of recurrent and metastatic breast cancer be implemented.  In addition, women diagnosed with DCIS should be included uniformly in the cancer statistics of all states so that allocation of resources to cancer services can be accurately determined.

4.	Regulation of the health care workforce

Ensuring implementation of clinical practice guidelines

Currently, there is a high degree of regulation of many areas of the mainstream health workforce.  For members of a number of professions, maintenance of annual registration or membership of professional organisations is dependent on participation in ongoing professional education and development.  Because health care is an area of constant change and technological advancement, BCNA supports this level of regulation of the health care workforce.  However, it is important that this should occur in accordance with best-practice and be guided, where possible, by clinical practice guidelines.

Regulation of complementary health practitioners

In addition, consumers are increasingly looking to non-traditional healthcare providers and complementary therapists to meet some of their healthcare needs.  This highlights the issue that in most Australian states there is no statutory regulation of the majority of complementary health disciplines.   BCNA supports recommendation 28 of the Recommendations of the Expert Committee on Complementary Medicines in the Australian Health System report that “Health Ministers review the findings of the current New South Wales and Victorian reviews concerning regulation of complementary healthcare practitioners and move quickly to implement statutory regulation where appropriate”.  This recommendation was noted but not accepted in the Government response to the complementary therapy report, released in March 2005.

Accreditation and credentialing

In an increasingly complex healthcare environment, the requirement of consumers to have knowledge and information about their healthcare treatments and the options available to them continues to grow.  It is no longer considered acceptable for clinicians to make decisions about patient management without providing the patient and their family with the opportunity to be involved in that decision-making process.  This new approach to clinician/consumer communication places an increasing burden on clinicians to be effective communicators and it is appropriate that they are supported in obtaining the level of communication skills required to achieve this.  BCNA believes clinicians should be supported in their attainment of appropriate communication skills and that accreditation and credentialing criteria should include measures of effectiveness of clinicians’ communication skills and other skills required for the delivery of best-practice care as outlined in the clinical practice guidelines.  

5.	Workforce participation

According to Cancer Council statistics breast cancer will affect one in eleven Australian women during their lifetime.  Many of these women will be at the peak of their working lives and many will be members of Australia’s healthcare workforce when they are affected by breast cancer. Others will require care from relatives who are members of Australia’s healthcare workforce.  In order to reduce the rate of attrition in particular health professions, workplaces must become more flexible in order to accommodate the needs of healthcare workers who are also healthcare consumers or who are carers of healthcare consumers.  Without in-built mechanisms for accommodating the health, personal and family needs of the workforce, there is a great risk of losing health professionals in whom society has already invested significant resources.

6.	Productivity

Recent projects like the Commonwealth funded Strengthening support for women with breast cancer program have demonstrated the potential of E-health to benefit people with health needs living in rural communities. In Victoria, a number of E-health projects were initiated under this program.  They were aimed at improving supportive care for rural women with breast cancer.  These projects included launching of web sites, videoconferencing of multidisciplinary review meetings and supporting IT training to improve health professionals’ capacity to access E-technology.  

A number of issues were highlighted as a result of this program, one of these being that IT support is critical for the effective use of E-health.  With advances in technology, IT workers must increasingly be viewed as members of the healthcare team.  Specialist health IT workers must therefore be trained and recruited in health systems around the country.

In addition, as diagnostic, treatment and communication equipment becomes increasingly technology based, members of the healthcare workforce who have traditionally not been required to have high levels of technical skills (as opposed to clinical skills) must be supported to increase their skills in the use of information, digital and other new technologies.

Conclusion

In its 2004 Still Making a Difference report from Australia’s Second National Breast Cancer Conference for Women, Breast Cancer Network Australia identified a number of priority areas that it believes are essential in order for Australian women to have access to best-practice breast-cancer care.  These include:

•	Standardisation of the delivery of breast cancer services across Australia
•	National implementation of the National Breast Cancer Centre clinical practice guidelines and evaluation of the extent of implementation
•	Consumer input into all aspects of service improvement including breast cancer research

BCNA believes that addressing the workforce issues raised in this submission is important in addressing these priority areas.

We look forward to the results of this study and request that we be informed of and where appropriate, involved in any future stages of consultation.

Please note that BCNA’s Still Making a Difference Report outlining the above priority areas and a range of other recommendations for improving breast cancer care for Australian women is attached as an accompaniment to this submission.

Lyn Swinburne
Chief Executive Officer
Breast Cancer Network Australia