Productivity Commission Health Workforce Study 
Initial Submission for Issues Paper

Please see individual sections for suggestions regarding additional issues which should be considered (in bold, red text).  A more detailed response will be submitted following the final publication of the Issues Paper
Health Workforce
Issues and Questions
Preliminary areas of interest

Workforce planning
Identification of, and planning for, future health workforce needs is a challenging task, especially in the context of: a mixed public-private system that seeks to provide universal access to quality health care; the involvement of both the Australian and State and Territory governments in funding and service delivery in the health and education and training sectors; and the role of various professional bodies in the training and accrediting of health care workers. Consequently, one early task will be to understand current arrangements, the roles of the key players, the interactions between them and any constraints or blockages that are preventing good outcomes.

•	What is the underlying rationale for workforce planning in the Australian context? 
•	Efficiency is more than just dollars:  what are the ramifications for health service provision if efficiency is equated solely with saving money? Is the economic rationalist view of health costs being provider-driven accurate?
•	Do current arrangements facilitate the identification of, and planning for, Australia’s health workforce priorities in the medium and long term as well as in the short term? 
•	What are the main problems with current planning arrangements? To what extent do they consider the structure or funding of the health system? Can they take adequate account of such matters as ageing and technological advances that are likely to change demand for, and the nature of, the health workforce in coming years? What provision is, or could be made, for potential future skill needs (eg for robotic technicians)? 
•	Are adequate data available to facilitate effective workforce planning? 
•	Is health workforce planning sufficiently well coordinated across services and jurisdictions? How well is it linked with the education and training of health care workers and the delivery of health care services? How might coordination and integration between each of these areas be improved? 
•	What lessons emerge from past attempts to improve health workforce planning? Have the high priority issues been targeted? Are there particular examples where planning has worked especially well? What can be learnt from workforce policies and outcomes in other countries and their efforts to improve planning arrangements?
•	How can workforce planning address the varying and individual needs of States in their ability to compete for a changing, restricted and highly mobile workforce?

Education and training

While much recent attention has focused on workforce planning, an effective and efficient education and training regime is central to providing a workforce capable of delivering the growing, and increasingly complex, array of health care services. In this context, it is not just the mainstream education sector that is relevant — the Colleges and other professional organisations, and the institutions involved in clinical training, are also influential. Indeed, concerns have been raised about the competitive implications of professional bodies having a central role in decisions about numbers of training positions.

•	How effective are current education and training arrangements (whether undergraduate, graduate, VET or clinical training)? 
o	Is there adequate coordination between the various entities involved in this area — governments, hospitals, educational institutions and professional groups — and agreement on common goals?
o	Is the balance in the numbers of training places in particular fields appropriate? If not, what is required to deliver a better balance in the future? 
o	Is education and training occurring in the best institutional settings and is it providing the skills and knowledge base required for effective delivery of health care services? Should medical workforce change be created to ensure that quality training occurs? Is the balance between public and private sector training appropriate? 
o	Is education and training responsive to changing health care needs? More specifically, is curriculum development responsive to changes in medical practice and technology? 
•	How effective are current arrangements that provide short-term retraining to allow health professionals to return to work, and training to those needing to upgrade their skills? 
•	What role do professional organisations play in the development and content of training courses? Are these arrangements delivering good outcomes?
•	Would it be feasible to use retired or semi-retired doctors as part of the medical education future workforce?  If so, what inducements would be required to involve this sector in education?

Linking of Educational Institutions/Committies, Workforce Planning
There are a number of groups looking at the issues being considered by the Productivity Commission, eg. University Committees (individual and national), State and National workforce planning and profession bodies.  How could communication regarding the ideas and work of these varying bodies be disseminated and linked?

Regulation of the health workforce

Regulations that specify who can provide particular services, and under what conditions or in what settings, will have a direct impact on outcomes for patients, the effectiveness of the health workforce and the efficiency of service delivery.
•	Are current regulatory arrangements broadly conducive to appropriate outcomes? To what extent do they increase the cost of and/or reduce access to services? 
•	What influence do registration procedures and professional rules have on workplace or professional mobility, or the ease of re-entry to the workforce after an absence? 
•	Would relaxing current restrictions in some areas improve the effectiveness, accessibility and financial sustainability of service delivery without endangering safety and quality objectives? Are there areas where more regulation would be desirable? How do Australia’s regulatory arrangements compare with those in other countries?
•	What is the impact of the increasing need to practice defensive medicine in an increasingly legalistic society?  How can this be best managed?

Workforce participation

Given further expected reductions in average working hours in some parts of the health care sector, measures to encourage workforce participation and more efficient use of the existing workforce could play a key role in helping to sustain future service delivery. Important amongst these will be initiatives to improve job design and job satisfaction.
•	To what extent is participation in the health workforce influenced by short term cyclical conditions in the economy rather than longer term structural factors? 
•	What are the key influences on workplace participation and job satisfaction? For example, how important are remuneration, conditions (including hours of work, job design and access to training), and workplace pressures?  What is the impact of shiftwork on the medical workforce?
•	What are the changing attitudes to work amongst medical graduates and how will these affect the future workforce?  How will the increasing age, gender profile and mobilty of graduates affect the workforce?
•	Apart from their impact on work satisfaction, do features of job design in the health care area detract in other ways from effective workplace outcomes — through, for example, inhibiting efficient work allocation and affecting the scope for mobility and re-entry? 
•	To what extent could initiatives to improve job design and working conditions increase the recruitment and retention of health professionals, and encourage the development of the required skills mix, over the next ten years? What new institutional arrangements would be required to support such initiatives? 
•	What other practical, financially-responsible, measures might reduce the rate of attrition in particular health professions and facilitate re-entry into the workforce?

Migration issues
Australia’s health workforce is part of a global labour market for health professionals. This has implications for workforce planning, education and training and regulatory requirements.
•	Should recruitment of overseas trained health care workers continue to supplement local health care resources? Should such recruitment mainly be used to address short term gaps, including in rural and remote areas, or is there scope to meet some ongoing needs in this way? Should ethical considerations limit the future role of overseas trained workers in the Australian health care system?  Should ethical considerations limit the future role in Australia for graduates who are Australian trained, but of international origin, especially those from developing countries with limited resources?
•	Do current regulatory and training arrangements facilitate the effective use of overseas trained health workers? 
•	What are the implications for the Australian workforce of competing demand from other countries also facing health workforce shortages? 

Productivity

Initiatives to improve the productivity of the health workforce would generate a dividend which could, at least partly, be used to improve service quality and access to health care services. Indeed, with labour being a large component of overall health care costs, this dividend could be very significant.
•	How should the productivity of the health workforce be measured? On currently available indicators, how does productivity in Australia compare to health workforces in other countries? Is there significant variation within Australia across jurisdictions and health fields, or between the public and private sectors? 
•	Should the roles and responsibilities of interns, registrars and VMO’s be redesigned to better reflect workforce needs and the changing allied professions? 
•	Would it be appropriate to redefine roles in the health professions?
•	Beyond the various avenues canvassed above, what options are available to improve the productivity of the health workforce? For example: 
o	What contribution can e–health make? 
o	Is there scope to reduce the total costs of service delivery by greater investment in labour saving technologies (such as robotics)? Are there any particular impediments to such investment and how might they be addressed? 
o	Would less restrictive delineation of work responsibilities within and between professional groups allow better use to be made of the health workforce? Are there particular regulations, education and training or workplace constraints that prevent or hinder this from happening now? 

Demand
While the Commission will not be undertaking detailed assessments of future demand for health services and thereby for particular health workers, it will be drawing out the implications for institutional and regulatory arrangements of growing demand for health care.

•	Are recent assessments of future demand for health care services and workers, and the specific impacts of factors such as ageing and advances in medical technology, broadly appropriate? 
•	Will future growth in demand have different implications for workforce needs and policies in particular health care fields and/or geographical areas? 
•	Are the benchmarks that are currently used in workforce planning to translate expected demand growth into specific training and deployment strategies appropriate? 

Regional, remote and Indigenous issues
Indigenous Australians, and people living in regional and remote areas, have some specific health care needs and can face particular difficulties in accessing necessary treatment. While system-wide initiatives to promote better health workforce outcomes may assist these groups, more targeted initiatives are also likely to be required.
•	What particular workforce issues arise in relation to the delivery of services to people living in regional and remote areas and to Indigenous Australians? Are there issues specific to Indigenous Australians living in urban areas? 
•	Are these issues mainly related to the attraction and retention of staff? Or are the appropriate mix of service providers and the skills that specific providers must have, different from those required by other groups? 
•	To what extent could system-wide initiatives to promote better workforce outcomes assist Indigenous Australians and those living in regional and remote areas? What more focused initiatives are required? What is the potential for telemedicine to improve services for these groups? 
•	Can rural and indigenous health consumers afford to wait for the undergradaute initiaitves to deliver an increase workforce? What other initiatives with mor eimmediate impact could be introduced now?

After hours GP services adjacent to acute care hospitals
Ensuring that there are high quality after hours medical services is a key component of health workforce policy in the broad. However, a more specific issue raised in the terms of reference relates to the interface between after hours GP services and ‘substitutable’ outpatient services available at acute care hospitals.
•	What factors determine the demand for and availability of after hours GP services? Has increased use of outpatient services at acute care hospitals significantly compromised hospitals’ capacity to provide ‘core’ services, or is much of the concern mainly about who pays for the services in question? 
•	What impact have recent initiatives — such as greater prioritisation of those presenting as outpatients at hospitals and government funding for the After Hours Primary Medical Care program — had on substitution between after hours GP services and outpatient hospital treatment? Are further initiatives required? 

Reference:

1.	Kingston M. Determining the professional attributes of a hospitalist: experience in one Australian metropolitan hospital. Internal Medicine Journal 2005; 35: 305-308.

Submitted on behalf of the University of Adelaide Medical School Curriculum Committee
Dr Ted Cleary, Associate Dean Curriculum
Dr Jonathan Newbury, Department of General Practice