FINAL VERSION

Response to Productivity Commission Position Paper

Australia’s Health Workforce

Faculty of Medicine, Nursing & Health Sciences
Monash University

The Faculty broadly supports the initiatives outlined in the Productivity Commission’s (PC’s) position paper. The Faculty endorses the view that both Australia’s health requirements and the workforce that meets those needs should be considered within a national framework. From the Faculty’s perspective many of the initiatives covered in the paper will begin to create the conditions which can assist in that process. However, there are a number of considerations that are vital to the efficient deployment of the health professions’ educational infrastructure and which the position paper does not discuss in detail, or ignores completely. For example, although the paper discusses a national approach to accreditation of course delivery, the issues of re-accreditation of individual practitioners, and of placing the continuing regulation of individual health professionals on a national platform, receive minimal attention. Yet these are potentially crucial stages in healthcare development in Australia that must be addressed if a cost-effective, safe and efficient health service is to be provided.

Below we make some observations on the recommendations from the position paper.

Proposals 3.1; 3.2.  The endorsement and propagation of the National Health Workforce Strategic Framework (NHWSF). 

The Faculty supports the framework, but wishes to point out that the visibility of this framework amongst educational providers is low. The framework has not been widely disseminated or discussed in the higher education sector. We believe this is primarily due to the very minor representation of the higher education sector in the discussion group that formulated, espoused and launched the framework. The Faculty believes that engaging a wider group of stakeholders in the NHWSF and increasing effort on spotlighting the issues should be a major goal of the current position paper. 

In addition, the Faculty urges caution in the PC’s intention to disregard the NHWSF’s goal of achieving health workforce self sufficiency for Australia. The Faculty is well aware of the apparent economic and social benefits of recruiting international medical graduates to meet the shortfall in the workforce on a short term basis. However the Faculty believes that in the long term such a policy is ethically and globally unsustainable. It is probably also inadvisable in a current global climate in which the international labour market is fragile and susceptible to severe unexpected perturbations. Moreover until the recruitment and assessment of international graduates can be appropriately quality assured on a national scale (see Proposal 6.2), it may also result in significant problems for the health workforce, with areas of highest need most affected.

Proposal 4.1. An advisory health workforce improvement agency to assess new health workforce education and training models. 

There are varied opinions about this issue from within the Faculty’s professional groups. The School of Nursing supports this recommendation with reservations. For example there continues to be value in increasing the number of funded places for Division 1 nurses to supply a sustainable skilled nursing workforce. Education of generic health workers should supplement the workforce, and not risk the replacement of an expert nursing workforce with minimally skilled employees who will require closer supervision. 

However the Faculty acknowledges the argument for devoting considerable effort to making professionals’ roles more transferable. It is vital to extend the competencies of qualified health workers and facilitate wider scopes of practice through clinical protocols that establish minimum levels of quality and standardised processes for care.

Most in the Faculty believe that by concentrating on flexible definition of roles within professions, and allowing shifts in roles between professional groups, (rather than fortifying professional identities) the effectiveness of health care delivery can be increased. For example this is important for the future of nurse practitioners, dual qualified health professionals and other nurse specialists. A number of roles (e.g. counsellor, patient educator, delivery of minor procedures)  could be managed equally effectively by many health professions and may conceivably best be undertaken in some, particularly rural, contexts (c.f. Proposal 10.2) by professionals that do not currently assume these roles.

Proposal 5.1 Changing responsibility for allocation of funding of health professional university places from DEST to DOHA. 

While understanding the advantages to education that such a move would bring, the Faculty would like to see a more comprehensive cost-benefit analysis of this proposal, and a number of other important factors taken into consideration. As stated in the position paper, historically the DOHA focuses on the medical rather than the broad health professional workforce and such a change may not reflect the interests of all the non MBBS health disciplines. In addition, in this model it could be foreseen that responsibility for clinical education would be devolved to healthcare networks resulting in a total lack of control of student experience by education providers, which is counter to the broad intention of the position paper.

Such a reorientation may also increase the complexity in the University sector. For example, it may have the effect of separating health science faculties from the remainder of academia. This would occur at a time when there is considerable concern expressed by many stakeholders that some professions, e.g. medicine, are already educated in too narrow a framework and should have easier access to other disciplines such as humanities, arts and languages.

There may also be unpredictable effects on the research effort of universities. At present DEST funding is used largely for teaching but considerably underpins, especially in biomedical sciences, the research infrastructure needed to keep Australian scientific research at the forefront of international progress. 

Nevertheless, there needs to be national acknowledgement of the realistic costs of training health care professionals and acceptance by the health delivery sector that such training is not only essential, but needs to be nurtured and supported.  DoHA may bring a national perspective on health workforce training needs and better linkage with postgraduate and continuing health care regulation.

Proposals 6.1 6.2, 7.1; 7.2 A nationally consistent approach to accreditation centred on individual competencies would encourage portability, workforce flexibility and help address workforce distribution issues.

We support the recommendation for a nationally consistent approach to health professional accreditation, in the view that this will lead to increased portability of health professionals, an increase in workforce flexibility and improving mutual recognition.

We also support the development of a national approach to the inculcation of international medical graduates into the Australian workforce, and to their monitoring, support and further training.

However, we perceive a number of issues that this suite of proposals raises. There needs to be a common framework for accreditation, continuing regulation and, if necessary, re-accreditation of health professionals. We do not see these proposals as meeting that need. There seems to be an acceptance that the current state-based regulation of practising health workers could continue. There is clear and increasing evidence from around the States, and from overseas, that the operational complexity now needed efficiently to monitor and quality-assure health professionals is substantial, particularly in medicine. This is not sustainable at State level. Duplication or diversification of regulatory procedures and infrastructure between and across States and Territories is costly and inefficient.   Consequently, although Proposal 7.1 describes the enforcement of national standards created by Proposals 6.1 and 6.2, State infrastructure may not be capable of achieving this without substantial investment. This would be more easily achieved with a national system.

Furthermore we strongly support a ‘considered and staged’ approach to this issue. It may not be possible at present to create a common approach to accreditation across all professions, in which one accrediting body is responsible for all health workforce education. Even allowing for workforce flexibility there may be unique attributes to each profession that are best dealt with on a uni-professional basis. Attempts overseas to introduce more commonality (e.g. UK) have concentrated on generic oversight rather than interference with specific professional characteristics. 

Proposals 8.1; 8.2.  Review and rational development of the MBS.

There is a need for a better process for assessing requests to extend coverage of MBS rebates to a wider range of health professionals. We support the recommendation for MBS rebates to be applied to a wider range of suitably skilled and accredited health professionals providing cost effective, accessible service in their area of expertise.  However this review needs to adopt an evidence-based health care approach and make decisions on the basis of efficacy of treatment by and delivery across different professional groups. These decisions also need to be made in the context of international reviews of best practice and evidence on efficacy and cost-effectiveness of procedures, since there are marked differences between how Australia and other western countries deliver health care, for example in midwifery.. 

Proposal 9.1 Rationalisation of institutional structures for workforce planning.

We support this proposal. However its implementation depends upon the quality of the data delivered by the system and the quality of the analyses of those data. There needs to be investment in producing these data and in widening the scope (the size and traceability) of workforce covered by these data. The University sector has well developed Departments of Epidemiology, Public Health, Health Services Research and Health Economics that should contribute substantial expertise to this process. 

Furthermore, there needs to be a recognition by national funding bodies that applied research studies of the nexus between education, training and workforce planning are vital to the well being of Australia’s health delivery system and, by implication, to the health of all Australians.