With predicted shortages and poor distribution across the health workforce, there is a pressing need for new ways of working to deliver care within the framework of new models of practice. This is especially the case with CVD and chronic disease, where evidence for the benefits of multidisciplinary, co-ordinated care is strong.
Making the best use of a scarce workforce is particularly important in the rural setting, where recruitment and retention of health professionals is challenging. For Indigenous communities, particularly those in remote areas, alternative ways of delivering services such as cardiac rehabilitation are dependent on new approaches to recruitment, employment, training and supporting Indigenous and non-Indigenous health workers. These issues are recognised by the Australian Government and are being considered as part of the wider health reform agenda.
A key theme in the Australian reform literature relates to the need to break down existing professional silos and develop a health workforce that is structured around the needs of consumers rather than institutions or professions. This is particularly relevant for models of care which rely on care co-ordination and integrated care teams. To do this requires a rethink of what health professionals currently do and how we can better use their particular skill sets.
Australia has opportunities to extend the practice capacity and payment models for existing professions or introduce new professions, which are being developed or trialled nationally and internationally. There are a number of international examples that are being adapted to the Australian context.
In the UK, research has shown that substituting nurses for doctors in delivering care for chronic conditions, other low acuity presentations and preventative health care results in equal care outcomes and a general increase in patient satisfaction, although not necessarily a reduction in cost. 86 The key word here is substitution rather than duplication; if this process is structured properly it can free up doctors for higher complexity care, hence making better use of their specific skills. With GPs and other doctors becoming extremely scarce in rural and remote areas, this approach can deliver real benefits.
Australian jurisdictions have been developing the role of allied health assistants, who work across a number of allied health professions. This could support the delivery of more accessible and flexible cardiac rehabilitation by using allied health assistants supported by allied health therapists.
Queensland is currently trialing an adapted version of physician assistant positions, which were initially developed in the USA and are also being trialed in Scotland and Canada and provide medical care under the supervision of a licensed physician. Frossard, et. al., note that a number of other countries are also considering the introduction of physician assistants. 87
Pharmacists’ scope of practice has been extended in Alberta, Canada to include prescription of specified drugs, administration of some injections, assessment of patients and prescription of drugs without, in some cases, physician authorisation. 88
In a program aimed at improving the coordination of patient care and utilising hospital beds more effectively, NSW Health recently created the position of Hospitalist, a cross specialty doctor who provides care under the delegation of specialty units. The use of Hospitalists originated in the US, and the driving factor behind the rationalisation of the medical workforce within the acute hospital setting. 89
Nurse Practitioners are nurses trained and accredited for advanced and extended practice, including defined diagnostic and prescribing functions, capacity to refer and management and clinical care of patients. Nurse Practitioners work in emergency care, primary health care and in specialist clinical areas such as diabetes or renal care.
Nurse Practitioners are already working in most Australian states and territories. Nurse Practitioners for Cardiac Care already exist in SA with positive feedback about their role and function in teaching hospitals.
86 Sibbald B, Should Primary care be Nurse Led? Yes, BMJ 2008;337:a1157
87 Frossard L, Liebich G, Hooker R, Brooks P and Robinson L, Conference Report - Introducing physician assistants into new roles: international experiences, MJA, Vol188, No 4, February 2008.
88 Health Council of Canada Annual Report to Canadians 2006
89 Hillman, K, 2003, The hospitalist: a US model ripe for importing?, MJA 2003 178 (2): 54-55