Submission by OT AUSTRALIA to Australia’s Health Workforce: Productivity Commission Position Paper

November 2005

General comments on draft proposals:
OT AUSTRALIA (Australian Association of Occupational Therapists) welcomes the release of the Productivity Commission’s Position Paper on Australia’s Health Workforce. 
The Position Paper outlined numerous areas of deficiency as well as opportunities for improvement to the health system, as identified by the various submissions. The Commission is to be applauded for its significant efforts in collation and analysis of the submissions and synthesis of the Position Paper. 
While the majority of the Commission’s draft proposals are visionary and provide a direction for policy makers to shape the Australian health system positively, some proposals will require further clarification and significant input from relevant stakeholders. 
Allied health professional associations such as OT AUSTRALIA differ from those representing the medical and nursing professions. Unlike bodies such as the Royal Australasian College of Surgeons, OT AUSTRALIA does not provide post graduate education, training and assessment of occupational therapists. The primary objectives for OT AUSTRALIA are to support its members via continuing professional development (CPD) and effective representation with key stakeholders. Similarly, unlike the Australian Nursing Federation, OT AUSTRALIA is not an union and does not impose working conditions such as practitioner to patient ratios in health facilities.
Whilst acknowledging that “the accreditation arrangements for the medical profession are complex and diverse” (Position Paper, p. 90), the Commission appears to have painted all the health professions in one broad brush when it called for the establishment of a single national accreditation agency under draft proposals 6.1 and 6.2. OT AUSTRALIA is concerned that such “one size fits all” approach has the potential to disadvantage allied health professions due to the relative small sizes of their workforces. 
The health professions are different because they have different areas of training and specialisations and contribute toward their clients’ health and wellbeing holistically. Allied health professionals work closely with medical and nursing staff in multidisciplinary teams. The creation of a single national accreditation agency can potentially distort the roles and contributions of allied health professionals, thereby creating opportunities for less than adequately trained health workers to assume such roles and impacting negatively on the safety and quality of care delivered to consumers. 
The Commission proposed the establishment of three separate agencies under the Australian Health Ministers’ Conference (AHMC) for workforce improvement, education and accreditation. Although the Commission outlined their respective functions, the creation of three agencies for a workforce of less than half a million, servicing some twenty million consumers, does not appear to be the most efficient use of resources. 
OT AUSTRALIA believes that an alternative is the creation of two national agencies, with one responsible for workforce improvement incorporating health education and training and a separate agency for accreditation. This arrangement would provide greater levels of responsiveness to health workforce issues by minimising the shifting of responsibilities between agencies, allowing for greater levels of transparency and accountability as well as enhanced communication and cooperation with external stakeholders. OT AUSTRALIA will outline the proposed functions of the two agencies in this submission. 
The concept of “generic health workers” (pp 62-64, 93) as suggested by some submissions to the Commission requires further clarification. As the Commission pointed out, health is not a commodity due to asymmetry of information between the provider and the consumer (p5). This probably explained why there is not a single submission from a consumer representative group among the some 180 received by the Commission to date. 
However, as a number of the submissions to the Commission pointed out, increased consumer demand and expectations will require some major, if not radical, redesigns of the Australian health care system. This has lead to some submissions to outline the concept of “generic health workers”. While such “skills escalator” or shopping basket approach towards health professional education made economic sense, none of the proponents of this concept made any mention of any studies or discussions with consumers in relation to this concept. 
OT AUSTRALIA is concerned that there seems to be disproportionate attention paid in the Position Paper to an untested concept at the expense of the allied health professions, which has long been neglected in educational funding. OT AUSTRALIA believes that the challenges of the Australian health care system are best addressed by “up skilling” or increasing the competencies of health professionals, allowing for the expansion of clinical roles and scopes of practice, rather than introducing a new class of health care workers that can potentially jeopardise the safety and quality of care provided to consumers. 
The issues for the Commission’s consideration are complex and interlinked. OT AUSTRALIA congratulates the Commission on the Position Paper and believes that its specific feedback to the draft proposals would assist in shaping the futures of the Australian health care system for all stakeholders. 

DRAFT PROPOSALS 3.1 and 3.2
OT AUSTRALIA strongly supports draft proposals 3.1 and 3.2. The submission by OT AUSTRALIA called for commitment, leadership and vision by all levels of government to address current issues of the health workforce. Endorsement of the National Health Workforce Strategic Framework (NHWSF) by Council of Australian Governments (CoAG) is a critical step in demonstrating such initiatives. More importantly, endorsement by CoAG must be backed up by demonstrable action by all levels of government. To this end, OT AUSTRALIA urges the Commission to recommend that the NHWSF be endorsed and implemented as a matter of priority by CoAG. 
As a key stakeholder, OT AUSTRALIA would like to participate in ongoing consultations as part of the NHWSF implementation and review processes.

DRAFT PROPOSAL 4.1
OT AUSTRALIA strongly supports draft proposal 4.1. The submission by OT AUSTRALIA recommended the establishment of such a central workforce agency to liaise, consult and facilitate communication between key stakeholders. 
As with any government agencies, its success would depend largely on adequate and continued funding. Broad representation from all relevant stakeholders on the agency board is also vital to ensure transparency and accountability of process. 
Specifically, OT AUSTRALIA proposes that the Health Workforce Education and Improvement Agency (the Agency) operates as a conduit of information and a link between key government departments, professional associations and other relevant health agencies. The Agency would collect and analyse data from sources such as the Australian Institute of Health and Welfare (AIHW), professional associations and government departments. Such information would enable the Agency to provide advice to key decision and policy makers on workforce training, utilization and participation.  The Agency would be funded by the government and be established as an independent body and reports to the government via the Australian Health Ministers’ Conference. Please refer to Diagram 1 on page 4 for the proposed function and relationship of the Agency with other relevant key stakeholder groups. 
The Agency would be ideally suited to implement the following original recommendations forwarded by OT AUSTRALIA to the study:
1.	A study to identify systemic barriers towards effectiveness of health service delivery across the continuum of client care, consulting widely with industry stakeholders and identify opportunities to reduce or eliminate duplication that will improve current workforce productivity, increase job satisfaction and ultimately improve health outcomes for clients and carers.  
2.	Coordination of workforce data collection and analysis, including advising the Department of Health and Ageing (DoHA) to immediately release the necessary funds to the AIHW for the analysis and reporting of allied health data collected in 2003/2004. 
3.	Recommending that allied health professions identified as skills in shortage by both DIMIA and DEWR be immediately classified as national priorities for education funding by DEST similar to that of nursing and teaching. In addition, DEST to reclassify education funding for these allied health professions from Cluster 6 to Cluster 9 to ensure clinical education for allied health professionals is not compromised at the expense of quality of health care to the Australian public. 

AUSTRALIAN HEALTH MINISTERS’ CONFERENCE (AHMC)

Australian Health Workforce Officials’ Committee (AHWOC)

Australian Health Ministers Advisory Council (AHMAC)

Health Workforce and Education Improvement Agency 
(HWEIA)

Professions

1.	Development and maintenance of professional standards of practice
2.	Profession specific accreditation 
3.	Profession specific CPD
4.	Inter-professional CPD (e.g. case management for chronic conditions)

National Health Workforce Accreditation Agency

1.	Development of strategies for national framework for health professional accreditation
2.	Development of strategies for national framework for health professional regulation (inc. framework for cross-jurisdictional recognition and assessment of overseas qualified health professionals)
3.	Setting direction for the advancement of agreed strategies for improving professional accreditation

Core operations:
 
•	Funded through Govt similar to Productivity Commission
•	Reports to Govt via AHMC
•	Consists of advisory councils on key issues (eg. education, health policy advice)
•	Numerical workforce planning
•	Investigation of health workforce innovation projects

Provides advice to:

•	ABS/AIHW: labour workforce statistics, workforce projections
•	DEST/Uni: number and mix of training places, enhancement of entry level education
•	DoHA and state counterparts: dissemination and integration of workforce innovation projects

Diagram 1: Health Workforce and Education Improvement Agency
DRAFT PROPOSAL 5.1, 5.2 AND 5.3
While the transference of allocation of funding for health workers from DEST to DoHA has the potential to increase the flexibility and intake mix of university trained health professionals, there are some concerns that this arrangement can also lead to shifting of responsibilities between the two government departments. This arrangement has the potential to create confusion and frustration among external stakeholders between DEST and DoHA. 
Of particular concern to OT AUSTRALIA in relation to draft proposal 5.1 is the potential for DoHA direct universities into vocational education rather than having an equal focus on research activities. Research drives innovation and improves efficiency. The proposed allocation function of DoHA for university training places can be interpreted as overtly prescriptive and directive on the number and distribution of training places at the expense of quality research activities. As such, OT AUSTRALIA is unable to support draft proposal 5.1 in its present form.
OT AUSTRALIA agrees with the Commission’s view that the education and training of health professionals requires independent and transparent assessment. However, OT AUSTRALIA disagrees that a separate advisory council needs to be established to conduct such assessment. In its view, such functions can be carried out by the proposed Health Workforce Education and Improvement Agency as outlined in our response to draft proposal 4.1. 
Moreover, the Agency is also ideally placed to advise the Australian Health Ministers’ Conference strategies on enhancing the transparency and contestability of health education funding as outlined in draft proposal 5.3. 
OT AUSTRALIA is disappointed that the Commission’s Position Paper did not outline any specific proposals for workforce retention and re-entry. However, OT AUSTRALIA believes that the three recommendations outlined under our response to draft proposal 4.1 will address many of the current barriers in workforce retention and re-entry and urges the Commission to reconsider these recommendations as immediate measures to address such barriers. 

DRAFT PROPOSAL 6.1 AND 6.2
OT AUSTRALIA, in its submission to the Commission, recommended a nationally consistent framework for registration of the profession, as statutory regulation provides the optimal level of protection to the consumers and ensures quality and safety of services delivered by its practitioners. However, OT AUSTRALIA is unable to support these two draft proposals without further clarification from the Commission and significant engagement and debate by all key stakeholders. 
While the proposal for a national framework for accreditation is sensible from consistency of approach point of view, OT AUSTRALIA is firmly of the view that from a quality and safety point of view, the professions still need to be responsible for their own accreditation processes, given their specialist expertise and knowledge. 
The Commission made little reference to or acknowledgement of the key roles played by professional associations on continuing professional development (CPD) and its link to regulation. OT AUSTRALIA contends that CPD activities, as provided by their professional associations, are vital links between health professionals’ entry level training and their ongoing competencies to practice to ensure that the quality and safety of client care are not compromised. 
The proposed National Health Workforce Accreditation Agency would essentially be responsible for establishing nationally consistent frameworks for professional accreditation and regulation for all health professions, including the specialities within the medical professions. This arrangement would then allow the professions to engage their practitioners in their profession specific accreditation, CPD and the development and maintenance of profession specific standards of practice. 
The Accreditation Agency would operate at arms length to, but assist in formulating policy advice by, the Health Workforce Education and Improvement Agency on key issues. Please refer to Diagram 1 on page 4 for further information on the operations of the two agencies. 

DRAFT PROPOSAL 7.1, 7.2 AND 7.3
OT AUSTRALIA supports these draft proposals but believes that these they should be addressed as precursors to consideration of draft proposals 6.1 and 6.2.  In other words, there must be a nationally consistent framework for professional regulation prior to any initiatives to introduce nationally consistent approaches towards accreditation or credentialing. 
As stated above, the process of accreditation of university courses should remain within the professions to ensure quality and safety, but the actual approach or framework for accreditation could be agreed to at a national level. The establishment of the National Health Accreditation Agency provides an ideal vehicle to develop such framework for accreditation, in consultation with and support from the professions.

DRAFT PROPOSAL 8.1 AND 8.2
OT AUSTRALIA strongly supports draft proposal 8.1 but seeks further clarification from the Commission in relation to draft proposal 8.2. 
A GP does not delegate to an orthopaedic surgeon. Instead, clients are referred to the surgeon, who is asked to assess clients’ condition and intervenes in the most appropriate manner consistent with the surgeon’s training and competencies. Similar referral arrangements occur daily in healthcare services throughout Australia between medical practitioners and other health professionals, including occupational therapists. Referral to another professional is an acknowledgement that the referred professional has different skills and expertise to that of the referring professional, even though both professionals contribute towards the health and wellbeing clients. 
Delegation, on the other hand, occurs between professionals and para-professionals such as therapy aids or assistants. In this instance, both have the same skills and training in some tasks, and the professional makes a clinical decision to defer or delegate such tasks to the para-professional. 
For example, a client suffering from hemiplegia as a result of a stroke requires a piece of equipment to shower independently. The rehabilitation physician refers the client to an occupational therapist, who has expertise and competencies in assessing the client’s condition, functional deficits and home environment. A piece of equipment is then chosen based on the therapist’s assessment. The therapist can then choose to delegate the task of fitting the equipment to the client’s home environment by a therapy assistant provided that assistant had the required training and skills in such tasks. 
Therefore, OT AUSTRALIA does not support delegation between health professionals whereby the services are billed under the delegating professional with the delegated professional receiving a reduced rate of rebate. Such arrangement perpetuates the outdated medical model of care and fails to recognise the skills and competencies of health professionals and their contribution in the health and wellbeing of consumers. 
However, OT AUSTRALIA does support delegation of tasks from health professionals to para-professionals such as therapy assistants, provided that the para-professionals have the required skills and training in such delegated tasks. Delegation under such circumstances has the potential to increase the flexibility and productivity of the health workforce, which would lead to enhanced job satisfaction and workforce retention.

DRAFT PROPOSAL 9.1 AND 9.2
OT AUSTRALIA strongly supports draft proposals 9.1 and 9.2. In particular, the establishment of the Health Workforce Education and Improvement Agency allows for the logical transfer of duties such as numerical workforce planning to the new agency.
OT AUSTRALIA suggests that the Commission make two minor changes to draft proposal 9.2:
1.	Re-word the term undergraduate entry to entry level education in recognition of graduate entry courses to the professions.
2.	Remove the subjective word “larger” as a prefix to describe the allied health professions.

DRAFT PROPOSAL 10.1, 10.2 AND 10.3
OT AUSTRALIA broadly supports the direction these draft proposals point to. However, there are concerns that “major job redesign opportunities specific to rural and remote areas” may result in consumers in these areas receiving less-than-optimal level of health services.  
OT AUSTRALIA believes that the standards of care need to increase in both quality and quantity in rural areas given their populations’ poorer health status compared with their counterparts in metropolitan areas. The proposed changes to the operations of the MBS and the creation of national agencies for accreditation and workforce education and improvement have the potential to expand and enhance the scope of practice of health professionals. The involvement of key stakeholders in designing and implementing these proposed changes would assist in maintaining safety and quality aspects of client care. 
OT AUSTRALIA agrees with the Commission’s views expressed in draft proposal 10.3 and believes that the Health Workforce Education and Improvement Agency is ideally placed to conduct such evaluation exercises.  

DRAFT PROPOSAL 11.1
OT AUSTRALIA agrees with this draft proposal in principle, but notes that it is not substantiated by any concrete suggestions and therefore unable provide any specific feedback.