11 November 2005

Commissioners Mike Woods 
Health Workforce Study
Productivity Commission
PO Box 80
BELCONNEN  ACT 2616

Email: healthworkforce@pc.gov.au

Dear Commissioners Woods,

Re: 	Response to Australia’s Health Workforce Position Paper

Thank you once again to provide feedback into this important study.  The Queensland Nurses’ Union (QNU) appreciated the opportunity to send a representative to the round table meeting on this study in Brisbane on 31 October 2005.  As per your request at that meeting, we are now providing comment on each proposal in the draft position paper.  We also intend to highlight a number of issues of concern to the QNU that we believe have not been addressed adequately in your position paper.  These relate namely to contextual issues that significantly impact on the health workforce.

QNU response to draft proposals

Productivity Commission Proposal	QNU Response	
3.1 In its upcoming assessment of ways to improve the level of integration within the health care system, the Council of Australian Governments (CoAG) should consider endorsing the National Health Workforce Strategic Framework (NHWSF), subject to broadening of the self sufficiency principle, in order to enhance cohesion between the various areas and levels of government involved in health workforce policy.	The QNU supports this proposal.  However in our view CoAG needs to do more than endorse the framework – health workforce issues need to be seen as a priority issue for CoAG and should be afforded appropriate resources in order to achieve a coherent and nationally consistent approach.	
3.2 CoAG, through its Senior Officials, should commission regular reviews of progress in implementing the NHWSF. Such reviews should be independent, transparent and their results made publicly available.	The QNU supports this proposal. In our view regular independent and transparent reviews of progress are essential as is making results publicly available and therefore subject to scrutiny and debate.	
3.3 The Australian Health Ministers’ Conference should establish an advisory health workforce improvement agency to evaluate and facilitate major health workforce innovation possibilities on a national, systematic and timetabled basis.
• Membership of the board should consist of an appropriate balance of people with the necessary health, education and finance knowledge and experience.	The QNU supports this proposal on the basis that the board of this agency (and indeed focus of activity) is truly representative of the broader health workforce.  That is, the QNU would not support an agency that operates from a medical model – all health professional disciplines must be adequately represented if innovation is to be promoted.	
5.1 The Australian Government should consider transferring primary responsibility for allocating the quantum of funding available for university-based education and training of health workers from the Department of Education, Science and Training to the Department of Health and Ageing. That allocation function would encompass the mix of places across individual health care courses, and the distribution of those places across universities. In undertaking the allocation function, the Department of Health and Ageing would be formally required to:
• consider the needs of all university-based health workforce areas; and
• consult with vice chancellors, the Department of Education, Science and
Training, other relevant Australian Government agencies, the States and
Territories and key non-government stakeholders.	The QNU is not convinced that transferring primary responsibility for allocating quantum funding for university based education and training of health workers to DoHA would result in more rational and consistent outcomes.  We note that you recommend that DoHA be formally required to consult widely and consider the needs of all health workforce areas but we firmly believe that the establishment of open and transparent processes are central to ensuring accountability.  It is also the case that the funding allocated by government for university based education must be adequate to address health workforce shortages in a timely and sustainable manner.  In our view DEST has been constrained by budgetary inadequacies.  Having this function remain with DEST would also ensure a consistent approach to higher eduction funding.  It is also of concern to the QNU that DoHA currently is operating from a predominantly medical model and this has resulted in non-medical disciplines receiving inadequate consideration in a policy and funding sense.  These issues would need to be addressed before any transfer of responsibility takes place.

No matter which Commonwealth agency is ultimately assigned responsibility for university funding, the QNU does strongly support them taking a holistic view (i.e. considering the needs of all health workforce area) and genuinely consulting with vice chancellors, the Department of Education, Science and
Training, other relevant Australian Government agencies, the States and
Territories and key non-government stakeholders (including health unions) 	
5.2 The Australian Health Ministers’ Conference should establish an advisory health workforce education and training council to provide independent and transparent assessments of:
• opportunities to improve health workforce education and training approaches (including for vocational and clinical training); and
• their implications for courses and curricula, accreditation requirements and the like.	The QNU supports this proposal on the proviso that this council is genuinely representative of the health workforce, independent, its policies and processes are subject to public scrutiny, there is the ability for key stakeholders to have timely and meaningful input into assessment processes and that determinations are subject to appeal.  It is essential that an independent body is established to ensure consistency of approach and avoid duplication of effort across jurisdictions.  It is essential that such a body is independent and its processes are rigorous and transparent – its decisions must be based on sound evidence.  We believe that a process that ensures sound and independent evaluation of evolving health workforce roles and the outcomes of the implementation of such roles for the community in terms of the safety and quality of care provided is essential going forward. 	
5.3 To help ensure that clinical training for the future health workforce is sustainable over the longer term, the Australian Health Ministers’ Conference should focus policy effort on enhancing the transparency and contestability of institutional and funding frameworks, including through:
• improving information in relation to the demand for clinical training, where it is being provided, how much it costs to provide, and how it is being funded;
• examining the role of greater use of explicit payments to those providing infrastructure support or training services, within the context of a system that will continue to rely on considerable pro bono provision of those services;
• better linking training subsidies to the wider public benefits of having a well
trained health workforce; and
• addressing any regulatory impediments to competition in the delivery of clinical training services.	The QNU supports this proposal with a number of provisos.  We agree that greater transparency and contestability of institutional and funding frameworks is required.  The aim of any changes made in this regard should be to ensure consistency of approach (especially in relation to the funding of training) and maintenance of appropriate standards relating to safety and quality.  In our previous submissions to this inquiry the QNU raised concerns about inconsistencies that currently exist regarding the disproportionate burden being met by nurses for the cost of education and training, especially post graduate nursing education. This issue needs to be addressed as a matter of urgency through the establishment of consistency of approach between the various health professional groups.  

Although we acknowledge there is a need to address significant barriers and restrictive practices that are aimed primarily at maximising/protecting the earning capacity of some specific health occupational groups great care must be taken to ensure that appropriate standards are maintained and the broader health needs of the community are met.  In this regard there is a need for a rigorous, consistent, independent, transparent and open process for “addressing regulatory impediments” to be established.  This issue requires further close attention and consultation with key stakeholders.  The QNU’s experience with such assessments in the past (e.g. the NCP Review of the Queensland Nursing Act) was far from positive.  (The outcome of this review was that limited changes were made to the Queensland Nursing Act 1999 however the review process was in our view inadequate in many ways.  For example, the regulation relating to each health professional group in Queensland was reviewed in isolation.)   	
6.1 The Australian Health Ministers’ Conference should establish a single national accreditation agency for university-based and postgraduate health workforce education and training.
• It would develop uniform national standards upon which professional registration would be based.
• Its implementation should be in a considered and staged manner.
A possible extension to VET should be assessed at a later time in the light of
experience with the national agency.	The QNU supports the concept of a nationally consistent approach to health workforce education and training.  However such an approach must not have the effect of stifling innovation or resulting on a “lowest common denominator” approach.  It is also essential that any single national accreditation agency is based on appropriate consultative arrangements with all key stakeholders including unions and existing regulatory bodies.  It is essential in our view that if such an agency is established that it adopts a “best practice” model approach.  It would therefore be important to ensure that mechanisms exist to adequately capture examples from around Australia of “best practice” or innovation as well as identifying and addressing issues of concern in a timely and consistent manner.  Given the important role that the VET sector plays in preparation of health workers if a nationally consistent approach is established for the university sector then we believe that it would be essential to establish a nationally consistent approach for this sector.   	
6.2 The new national accreditation agency should develop a national approach to the assessment of overseas trained health professionals. This should cover assessment processes, recognition of overseas training courses, and the criteria for practise in
different work settings.	The QNU supports this proposal on the proviso that the “best practice” policies and processes used by the various health professional group regulatory bodies are incorporated into a nationally consistent approach and that the independence and integrity of the various health professional groups are not compromised by such a change. (That is, we would oppose nursing being subsumed within a medical framework.)  The QNU would be concerned if a new national accreditation agency for overseas trained health professionals adopted a “lowest common denominator” approach to recognition of qualifications.  A nationally consistent approach makes a lot of sense (the current inadequacies associated with some current assessment processes have been starkly highlighted by the current Bundaberg Hospital Commission of Inquiry on Queensland) but such a process must be rigorous. The Australian Nursing and Midwifery Council have in large part achieved consistency of approach across various jurisdictions in Australia for nursing and midwifery and this should be examined as a model for the broader health professional workforce. 	
7.1 Registration boards should focus their activities on registration in accordance with the uniform national standards developed by the national accreditation agency and on enforcing professional standards and related matters.	The QNU believes that the splitting of regulatory processes (registration and course accreditation) is potentially very problematic.  This should not occur until there is a detailed analysis of the impact of splitting such processes given that currently they are inextricably linked.  The critical issue that underpins this proposal however will be the efficacy of the process by which uniform national standards are developed and agreed.  As highlighted in our previous submission, we oppose consolidation of regulation across professional groups if this in any way compromises the hard fought for professional autonomy of individual professional groups such as nurses. We are assuming that the intent of establishing a national accreditation agency as outlined in proposal 7.1 is not to achieve de facto consolidation but rather a uniform approach for each distinct professional group. It is also essential, in our view, that such national standards encompass the adequate regulation of currently unregulated health workers.  

The QNU has argued for some years now that Assistants in Nursing (whosoever titled) should be regulated by the Queensland Nursing Council (QNC).  The QNC has developed a framework for delegating nursing activities to such workers but in our view this does not adequately patient/resident safety.  (For example, unregulated health care workers can be providing unsupervised care at present.)  In our view there are significant deficiencies in the current regulatory arrangements that must be addressed as a matter of urgency.  Ignoring the reality of currently unregulated care providers in the health and aged care sectors cannot be sustained. We elaborated on our concerns in this area in our July submission to this study. 	
7.2 States and Territories should collectively take steps to improve the operation of mutual recognition in relation to the health workforce. In particular, they should implement fee waivers for mobile practitioners and streamline processes for short term provision of services across jurisdictional borders.	The QNU supports this proposal.	
7.3 Under the auspices of the Australian Health Ministers’ Conference, jurisdictions should enact changes to registration acts in order to provide a formal regulatory framework for task delegation, under which the delegating practitioner retains responsibility for clinical outcomes and the health and safety of the patient.	The QNU supports this proposal.  As stated above, the Queensland Nursing Council has already developed a framework for task delegation along the lines suggested by the Commission.  However, the QNU has concerns that such a framework is fundamentally flawed unless the regulatory body has the ability to regulate clinical outcomes when a currently unregulated health worker is carrying out clinical duties outside of a formal; delegation framework. The QNU believes that it is essential that nurse regulatory authorities such as the QNC regulate the practice of all categories of nurses - Registered Nurses and Midwives, Enrolled Nurses and Assistants in Nursing (howsoever titled).	
8.1 The Australian Government should establish an independent standing review body to advise the Minister for Health and Ageing on the coverage of the Medicare Benefits Schedule (MBS) and some related matters. It should subsume the functions of the Medical Services Advisory Committee, the Medicare Benefits Consultative Committee and related committees. Specifically, the review body should evaluate the benefits and costs, including the budgetary implications for government, of proposals for changes to:
• the range of services (type and by provider) covered under the MBS;
• referral arrangements for diagnostic and specialist services already subsidised under the MBS; and
• prescribing rights under the Pharmaceutical Benefits Scheme.
It should report publicly on its recommendations to the Minister and the reasoning behind them.	The QNU supports this proposal.  Such an independent standing review body is long overdue. It is essential that the recommendations of such a body and the reasonings for the recommendations be made public as should the Minister’s response to the recommendations and reasonings.  It is also essential that the focus of the Medicare Benefits Schedule (MBS) is expanded to include the payment for provision of services to health professionals other than doctors.  	
8.2 For a service covered by the MBS, there should also be a rebate payable where provision of the service is delegated by the practitioner to another suitably qualified health professional. In such cases:
• the service would be billed in the name of the delegating practitioner; and
• rebates for delegated services would be set at a lower rate, but still sufficiently high to provide an incentive for delegation in appropriate circumstances.
This change should be introduced progressively and its impacts reviewed after three years.	The QNU believes that it should not be a requirement for a rebate to be payable if the service is delegated by the (medical) practitioner to another suitably qualified health practitioner.  This would perpetuate the predominance of a medical model.  If the independent standing review body referred to in proposal 8.1 is established and recommends that new MBS items be created for services provided by a non-medical health practitioner and this is accepted by the Minister then this payment should be made directly to the health professional performing the task (or to the “practice” where the health practitioner is directly employed by a practice rather than on a fee for service basis) and no delegation from a medical practitioner should be required.  The issue at hand in terms of potential cost blow outs is the “fee for service” arrangements.  Surely alternative funding model models should be investigated for all health practitioners. The cost pressures associated with “fee for service” arrangements will not be adequately addressed by the proposal outlined in 8.2.  (This will only be of marginal benefit as the fees set for “delegated” tasks are to be at a lower rate that if it were to be performed by a doctor. Many nursing activities are not currently delegated by a medical practitioner and this is also the case for other non-medical health practitioners.  The “ cost control” mechanism should be incorporated in the process outlined in 8.1 and examination of alternatives to “fee for service” must be considered.  The QNU supports a collaborative model of health service delivery and we believe the proposal as outlined will serve to reinforce a medical model rather than a multi-disciplinary model of health service delivery. 	
9.1 Current institutional structures for numerical workforce planning should be rationalised, in particular through the abolition of the Australian Medical
Workforce Advisory Committee and the Australian Health Workforce Advisory
Committee. A single secretariat should undertake this function and report to the Australian Health Ministers’ Advisory Council.	This proposal is support by the QNU on the proviso that the new arrangement ensures that each health professional occupational group is adequately represented on such a forum and no group/s received preferential treatment/attention.  A coordinated and consistent national approach to health workforce planning is required but this should not occur at the expense of particular needs of specific occupational groups.  Although nursing is the single largest occupational group in the health sector when compared to our medical colleagues we have received inadequate attention under current health workforce planning arrangements.  A number of reviews in recent years have identified the problems and solutions for nursing – all that has been missing has been the political will by government in particular to take the necessary action.	
9.2 Numerical workforce projections undertaken by the secretariat should be directed at advising governments of the implications for education and training of meeting differing levels of health services demand. To that end, those projections should:
• be based on a range of relevant demand and supply scenarios;
• concentrate on undergraduate entry for the major health workforce groups,
namely medicine, nursing, dentistry and the larger allied professions, while
recognising that projections for smaller groups may be required from time to
time; and
• be updated regularly, consistent with education and training planning cycles.	The QNU supports this proposal.  Sound ongoing planning and supply/demand evaluations are of critical importance and there has been a failure to date to undertake this in a coordinated and consistent manner. 	
10.1 The Australian Health Ministers’ Conference should ensure that all broad institutional health workforce frameworks make explicit provision to consider the particular workforce requirements of rural and remote areas.	This proposal is supported by the QNU.  Health workforce shortages are particularly acute in rural and remote areas.  These shortages have resulted in some significant areas of innovation in these areas however and these need to be closely examined and evaluated as it should be possible to extend “best practice” examples to non-rural and remote areas.	
10.2 The brief for the health workforce improvement agency (see draft proposal 4.1) should include a requirement for that agency to:
• assess the implications for health outcomes in rural and remote areas of
generally applicable changes to job design; and
• as appropriate, consider major job redesign opportunities specific to rural and remote areas.	The QNU supports this proposal but also believes that this brief should not be constrained to rural and remote areas.  As stated above, many innovative practices in rural and remote areas should be able to be “rolled out” in non-rural/remote areas.  	
10.3 The Australian Health Ministers’ Conference should initiate a cross program evaluation exercise designed to ascertain which approaches, or mix of approaches, are likely to be most cost-effective in improving the sustainability, quality and accessibility of health workforce services in rural and remote Australia, including:
• the provision of financial incentives through the MBS rebate structure versus practice grants; and
• ‘incentive-driven’ approaches involving financial support for education and training or service delivery versus ‘coercive’ mechanisms such as requirements for particular health workers to practise in rural and remote areas.
There should also be an assessment of the effectiveness, over the longer term, of regionally-based education and training, relative to other policy initiatives.	This proposal is supported by the QNU on the proviso that the program evaluation tool is rigorous, the assessment process is open and transparent and the overriding objectives are improving quality and safety and access to care.	
11.1 The Australian Health Ministers’ Conference should ensure that all broad institutional health workforce frameworks make explicit provision to consider the particular workforce requirements of groups with special needs, including:
Indigenous Australians; people with mental health illnesses; people with disabilities; and those requiring aged care.	This proposal is supported by the QNU.  Indeed we believe that it is essential that the health needs and expectations of the Australian community underpin all health policy and service delivery. However the processes for achieving meaningful community input are currently woefully inadequate.  Although this issue is outside of the specific brief of this particular study, establishing a sound process of ongoing community engagement is essential to the sustainability of our health system going forward.  This issue will be the subject of further detailed discussion at a meeting of the Australian Health Care Reform Alliance to be held in Adelaide on 16 and 17 November 2005.  We understand that Commissioner Woods has been invited to attend this meeting and we hope that he is also available to hear the debate over the full two days.	

Other comments

The QNU would also like to provide brief comment on a major contextual issue that has not received attention in your position paper – that of the Howard government’s proposed industrial relations reforms.  In our previous submission were outlined in some detail our concerns about the decentralisation and de-regulation of the health labour market that has taken place over the last ten to fifteen years.  We will not revisit our concerns about enterprise bargaining in the health sector in great detail but we do wish to state that we believe that it is essential that your final report to government address this issue.  This is particularly the case given that the Howard government’s recently tabled industrial relations legislation proposes significant further deregulation of the labour market.  In our view the impact of labour market de-centralisation and de-regulation in the health and aged care sector that has occurred to date has not been adequately assessed and yet the Howard government plans further widespread reform.  

The QNU has previously outlined to you why we believe that a system such as enterprise bargaining is problematic in health and aged care – we believe that an alternative approach to the determination of wages and conditions of employment is required in this sector.  Our fear is that the planned industrial relations changes will simply serve to make health workforce planning harder.  The rights of health workers to take industrial action to secure improvements in wages and conditions will be significantly curtailed through the introduction of national essential services legislation.  In this regard the federal government views the health workforce as being somehow “different” to the broader workforce – there is a special “public interest” to protect that is seen as taking precedence over the industrial rights of workers in this sector.  Yet nurses and other health workers are expected to now try to achieve improvements to pay and working conditions (which is certainly required if we are to attract and retain people in nursing) with one hand tied behind our backs.  

We believe that the industrial relations system is a significant contextual issue that must be addressed in any examination of the health workforce in Australia.  The QNU therefore strongly recommends that in your final report to government on Australia’s health workforce that you address both the appropriateness of the current industrial relations system and the likely impact of the proposed significant amendments to this system by the Howard government.  These issues are of such central significance to health workforce planning, funding, recruitment and retention that we cannot see how they cannot be canvassed and debated openly. Please refer to our July submission for further details of the QNU’s concerns regarding the current decentralised and adversarial wages system, a system that is about to become more adversarial, decentralised, complex and in our view grossly unfair when the Howard government changes are implemented.  This significant issue cannot be ignored in your final report to government.  We (and we are sure other branches of the Australian Nursing Federation) would be happy to elaborate on our concerns in greater detail should you require this. 

Thank you again for the opportunity to provide feedback on the position paper for this important review.  Please do not hesitate to contact me (on in my absence QNU Project Officer Beth Mohle) should you wish to discuss any issues raised in our materials or if you require any additional information.  

Yours sincerely,

Gay Hawksworth
SECRETARY