ACT Government’s Response to the

Productivity Commission Position Paper 

– Australia’s Health Workforce

Introduction

The Productivity Commission’s Position Paper contains a number of proposals that are aimed at systemic reform within the health sector.  These proposals address a number of the concerns highlighted by the ACT Government in it’s second submission to the Productivity Commission, namely the disconnect between the health and education sectors and the requirements to increase workforce utilisation via improved productivity and flexibility.

This submission will indicate ACT Government’s position on the proposals and provide further information for the Productivity Commission’s consideration on a number of the proposals.

This submission should be considered in conjunction with the State and Territory Health Chief Executive Officers/Departments’ response.  The ACT Government response is consistent with this response and provides further detail in relation to a number of proposals.

			ACT Responses to Draft Proposals
Proposal 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.
ACT Government Position:	Supported.  
In supporting the proposal for CoAG to adopt the NHWSF, the ACT Government notes that the National Health Workforce Strategic Framework does not explicitly refer to rural and remote areas (Proposal 10.1) or people with special needs (Proposal 11.1)
These needs should be considered for incorporation in the NHWSF, any changes to the wording of the Framework should be approved through the Australian Health Ministers Conference process.
A small jurisdiction such as the ACT will never have the capacity to “grow it’s own” to meet it’s health workforce needs.  The ACT is therefore reliant on attracting graduates from interstate or overseas.  The ACT Government acknowledges the tightening global health workforce and therefore contends that Australian jurisdictions should reduce their dependency on an overseas trained workforce.  Implicit in this strategy is a need to address the current shortfall in the provision of available undergraduate health places.
Proposal 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.
ACT Government Position:	Supported. 
Proposal 4.1
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.
ACT Government Position:	In principle support. 
The ACT Government supports the creation of a health workforce improvement agency.  The agency should take direction and report to AHMC.  Given the need for this agency to have close links with the health workforce education and training council – the ACT proposes the functions of the two bodies could be merged into a single entity.  This would allow for a more efficient use of resources and has the benefits of facilitating an integrated approach to workforce innovation (the competencies for new/redesigned roles would be more closely aligned to education and training requirements) and establishing articulated pathways from the VET sector to tertiary education.
The governance arrangements of this entity will need to be considered carefully, as will the funding mechanisms. 

Proposal 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.
ACT Government Position:	Supported. 

Proposal 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.
ACT Government Position:	In principle support
The ACT Government supports the functions proposed for the council but would recommend that they be undertaken by the health workforce improvement agency.  See comments on draft proposal 4.1
Proposal 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.
ACT Government Position:	In principle support
Education and training needs to align with the health service provision.  In particular, consideration needs to be given to the trends and demographics of our population, the growing needs and complexities of certain populations, the increases in chronic disease and the aged population and new models of care.
Attraction and retention are major issues for smaller jurisdictions as they cannot offer the full range of courses for health workforce requirements.  This needs to be taken into consideration when aligning funding and clinical training to meet population needs.  
Policy efforts should encompass all aspects of education and training of the health workforce and should therefore consider:
•	universities, VET sector and specialty colleges
•	involvement of Commonwealth, State and Territory Education Ministers as they currently provide some of the funding for clinical education
•	adequacy of and responsibility for funding of undergraduate clinical training
•	better alignment between growth in trainees numbers and clinical training capacity
•	contestability of post graduate medical training
•	effectiveness of clinical training, particularly in terms of “job ready” graduates.
As the proposed expansion of scope of practice for both the nursing and allied health workforces will be dependent on innovative clinical training and educational resources, consideration must be considered to developing appropriate postgraduate training and education infrastructure for both nurses and allied health professionals, that is akin to the current scheme for medical graduates.
This infrastructure includes the creation of conjoint (university-health department) clinical Professorial positions with access to clinical research.  This scheme would also provide a career pathway, mentoring and appropriate supervision.  Advanced clinical competency networks would need to be established as would recognition of specialist qualifications.
Another role, which would enhance the development of extended scope of practice roles for both nursing and allied health professionals, would be that of a “registrar”.  This position would allow the development of advanced practice roles such as that of nurse practitioner and the consultant physiotherapist.  Currently it is custom and practice that both nursing and allied health professionals will expand their professional skills and qualifications in their own time and at their own cost where as comparable medical trainees (registrars) are supported for clinical training in “work-time”.
This infrastructure would require additional funding, however  the potential  benefits of developing expert clinical leaders who have the ability to apply evidence into practice in the clinical environment would be substantial.

Proposal 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.
ACT Government Position:	In principle support
The ACT Government supports the establishment of a national accreditation agency for university-based postgraduate and VET health workforce education.  However The ACT Government recognises that accreditation is closely linked with registration and therefore it is suggested that a single entity with responsibility for both accreditation and registration is created.  This agency should report to AHMC.   Development of national accreditation standards should be in consultation with professionals and professional associations to ensure quality and safety.  The accreditation agency would also need to work closely with the health workforce improvement agency.

Proposal 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.
ACT Government Position:	Supported
Proposal 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.

ACT Government Position:	See response to draft proposals 6.1 and 7.2

Proposal 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.
ACT Government Position:	Not Supported
The ACT supports the Productivity Commission’s intent to address the issues restricting mobility of health professionals, however the experience from the development of Nationally Consistent Medical Registration through the Australian Health Ministers Conference has led The ACT Government to believe that to extend this approach to other registered professionals would be a difficult and time consuming process.  
The ACT Government believes that the most effective way to achieve the outcomes would be through the development of national scheme for health professional regulation.  
In establishing this body it will be important to ensure appropriate involvement of relevant professional expertise in accreditation and registration activities such as the development of professional standards.  

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.
ACT Government Position:	Not supported
The ACT Government supports the concept of delegation, however this proposal could impede the creation of a more flexible health workforce.  The suggested accreditation/regulation entity and credentialing arrangements within health organisations may be more appropriate mechanisms for ensuring quality and safety standards are maintained.

Proposal 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. 
ACT Government Position:	In principle support
In principle, The ACT Government supports changes to the MBS and PBS where these are likely to create positive incentives to more effective workforce utilisation and equity of access to quality services. The scope of the review body should be broadened as the review body described above does not necessarily address the effects of MBS on workforce issues such as the current financial disincentives for medical generalist, non procedural specialties or other areas of specialty shortages eg. Paediatric sub-specialities. The Governance arrangements should clearly outline this role and consideration given to a mechanism for AHMAC and jurisdictions to refer matters to the review body.

Proposal 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.
ACT Government Position:	In principle support
The ACT Government supports delegated access to the MBS, however notes that the delegation aspect can maintain the current restrictive work practices particularly in areas of shortage of delegating professionals.  Direct access to MBS rebate for a range of health professional services should be considered in areas of a GP shortage.  Such approaches should be trialled and evaluated and based on integrated models of care.
Nurse Practitioners work in areas of need and demonstrate advanced clinical knowledge, skills and extended practice with the ability to undertake timely comprehensive health assessments of clients/patients utilising evidence based practice.  Nurse Practitioners are able to instigate timely interventions, monitoring and follow up of clients/patients in diverse health care environments.  They work within their scope of practice, referring on when this is appropriate.  The impact of the nurse practitioner role significantly increases client/patient outcomes and satisfaction rates.  Currently, although a nurse practitioner is competent and legally able to refer there is no MBS rebate.    
Pilot programs have also been conducted in Victoria, where senior physiotherapists with extensive orthopaedic experience conducted the primary assessment of newly referred patients. The results were that waiting times and average costs were reduced.

Proposal 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.
ACT Government Position:	Supported.
This agency should report to a national decision making forum such as AHMC or AHMAC. 

Proposal 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.
ACT Government Position:	In principle support
The ACT Government recommends that workforce planning is not to be limited to roles set out by the Productivity Commission but also be able to consider related issues eg. retention strategies, capacity to use refresher/ re-entry programs to meet shortages.
Workforce planning should shift its current focus on professional silos to a model of care approach.  Such an approach would describe patient journeys and identify the competencies required to perform the various health care roles (existing or new), supports and interventions.  These roles need to reflect the research and evidence base to ensure patient safety. 

Proposal 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.
ACT Government Position:	Supported
Proposal 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.
ACT Government Position:	Supported

Proposal 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

ACT Government Position:	Supported

Proposal 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.

ACT Government Position:	Supported

Under this proposal “Groups with Special Needs” should be included in the National Health Workforce Strategic Framework.
Inclusion of these groups in frameworks does not in itself mean that these groups special needs will be addressed. The Health Workforce Improvement Agency should consider these as priority areas for educational support and improved remuneration arrangements.