Ensuring a skilled and appropriately distributed workforce is one of the key challenges for governments in delivering health services to the Australian community. Health workforce issues have therefore been the subject of significant government and parliamentary consideration. This appendix outlines the key national reviews of the health workforce that have been undertaken over recent years, commencing with the 2005 Productivity Commission study into Australia’s health workforce, the recommendations of which have set the trajectory for health workforce reform since that time.
Australia’s Health Workforce – 2005 Productivity Commission Research Report247
In June 2004, the Council of Australian Governments (COAG) requested that the Productivity Commission undertake a research study into health workforce issues, including supply and demand pressures over the following ten years, in recognition that the successful delivery of health services is dependent on the availability of an appropriately skilled health workforce. The report was released on 19 January 2006.
The Productivity Commission was given a broad terms of reference, including consideration of institutional, regulatory and other factors affecting the supply of health workforce professionals, the structure and distribution of the health workforce and its consequential efficiency and effectiveness, the factors affecting demand for services provided by health workforce professionals, and provision of advice on the identification of, and planning for, Australian health care priorities and services in the short, medium and long term. The terms of reference also included a specific reference to ‘the issue of general practitioners in or near hospitals on weekends and after hours, including the relationship of services provided by general practitioners and acute care’.248
The Productivity Commission found that Australia’s health workforce system is inherently complex and interdependent, encompassing a large number of players, both government and non-government, that are involved in the planning, education and training, regulation and funding of the health workforce. The commission identified a range of systemic impediments that it saw as ‘reflecting and compounding this complexity’, including a fragmentation of responsibilities, ineffective coordination, rigid regulatory arrangements, perverse funding and payments incentives, and entrenched workplace behaviours.
The Productivity Commission recommended a package of significant system-wide reforms intended to address these impediments. The key recommendations were:249
- The establishment of an advisory health workforce improvement agency to evaluate and facilitate major health workforce innovation possibilities on a national, systematic and timetabled basis, which would report publicly and make recommendations to the Australian Health Ministers’ Conference (AHMC).
- The establishment of a single national accreditation board for health professional education and training, which would assume statutory responsibility for the accreditation functions carried out by the existing entities, including for overseas trained health professionals. Initially, the board could delegate responsibility for these functions to appropriate existing entities, selected on the basis of their capacity to contribute to the objectives to the new accreditation regime.
- The introduction of uniform national registration standards, and the establishment of a single national registration board for health professionals, with authority to determine which professions to register and specialties to recognise. Pending the new national registration standards, the board would subsume the operations of all existing registration boards and entities.
Other recommendations included the establishment of a number of independent national advisory bodies, including a health workforce education and training council focused on exploring better approaches for health education and training; a COAG-established taskforce to recommend changes to improve the transparency, coordination and contestability of the arrangements for clinical training; and a standing review committee subsuming the functions of the Medical Services Advisory Committee and the Medicare Benefits Consultative Committee and taking a broader, cross-professional approach towards services and referral arrangements under the Medicare Benefits Scheme, and prescribing rights under the Pharmaceutical Benefits Scheme. The recommendations also covered the need for explicit provision for the requirements of rural and remote areas and for special needs groups within broad health workforce frameworks, and Australian government consideration of an agreement with state and territory governments for the allocation of university places in health profession courses.
In response to the Productivity Commission’s recommendations, COAG introduced a significant program of health workforce reforms, including the arrangements under the National Partnership Agreement on Hospital and Health Workforce Reform. These include the establishment of Health Workforce Australia and the National Registration and Accreditation Scheme (NRAS).
Audit of Health Workforce in Rural and Regional Australia – April 2008250
The Department of Health and Ageing (DoHA) was asked to undertake an audit of the health workforce in rural and remote Australia, in order to determine the number and distribution of the health workforce in rural and regional Australia.
DoHA examined national data collections along with its own administrative data at the state/territory level, remoteness, and where possible, by Statistical Local Area (SLA) level. The audit included the professions of medicine, nursing, dentistry, chiropractics, optometry, osteopathy, pharmacy, physiotherapy and psychology (e.g. those to be initially included in NRAS).
The audit found health workforce shortages in rural and remote areas across most of the health professions examined. In particular, the audit found:
- the supply of medical professionals is significantly lower in rural and remote areas , with the number of general practitioners in proportion to the population decreasing with greater remoteness, considerable variation across jurisdictions, and higher rates of overseas trained doctors in rural and remote areas;
- while there was a relatively even distribution of nurses across Australia, and growth in the number of nurses over time, there existed some variation in supply across jurisdictions, and stakeholder evidence of a shortage of midwives in regional and remote Australia;
- the supply of allied health professionals, particularly dentists, was low to poor, with three quarters of dentists working in metropolitan areas;
- the supply and distribution of health professionals largely corresponded with the distribution of state and territory funded health services;
- in addition to the supply and distribution issues, the logistical challenges of servicing a dispersed population over wide and diverse areas is a compounding factor to access problems in rural and remote areas; and
- difficulties in access persist in spite of the numbers of medical and nursing workforces (in proportion to the population) being similar to comparable Organisation for Economic Cooperation and Development OECD countries.
In response to the audit findings, the Australian Government established the Office of Rural Health within the Primary and Ambulatory Care Division in July 2008, which took on responsibility for rural workforce and rural service delivery programs and for progressing reform in rural health.
DoHA internal review of rural health programs and geographical classification systems – 2008
In 2008 the newly formed Office of Rural Health was tasked with undertaking a review of the existing rural health programs and the classification systems for determining eligibility for rural program funding, to ensure that workforce programs and incentives were appropriately targeted and that service delivery programs and rural health professionals could respond to the needs of rural communities. The review focused on five themes:
- improving access to appropriate health and medical services, including health promotion and prevention.
- Investing more effectively in rural health infrastructure (including physical resources, electronic health, data collection/performance monitoring, research, and stakeholder organisations).
- Addressing workforce shortages through better workforce distribution and support.
- Strengthening workforce education and training.
- Fostering partnerships between the Commonwealth and state and territory governments to improve health outcomes in rural and remote areas.
The review resulted in:
- the re-focussing and consolidation of a large number of targeted rural health programs;
- the replacement of the outdated Rural, Remote and Metropolitan Areas (RRMA) classification system that was based on 1991 Census data, with the Australian Standard Geographical Classification – Remoteness Area (ASGC-RA) system for determining eligibility to rural program funding;
- the introduction of ‘scaling’ to a number of Commonwealth initiatives, including rural incentive payments and return-of-service obligations for bonded medical programs, based on the principle of providing greater incentives for more remote areas; and
- a $134.4 million budget package supporting rural health.
Australian National Audit Office, 2008-09 – ‘Rural and remote health workforce capacity – the contribution made by programs administered by the Department of Health and Ageing’251
In 2008, the Australian National Audit Office (ANAO) undertook a performance audit of the effectiveness of DoHA’s administration of health workforce initiatives in rural and remote Australia. The audit included an in-depth analysis of eight rural and remote health workforce capacity programs (representing a cross-section of DoHA’s activities in this area), and focused on whether DoHA:
- had strategies in place to maximise its contribution to Outcome 12 – Health Workforce Capacity;
- had effectively implemented Australian Government programs addressing health workforce shortages in rural and remote Australia; and
- monitored and evaluated its health workforce programs for rural and remote Australia.
The audit found that while DoHA had put in place appropriate structural arrangements for the administration and delivery of rural and remote workforce programs, it had not yet developed a cohesive approach to inform its strategies or to report on its contribution in achieving the specified outcome. In particular, the ANAO found that DoHA:
- only undertook limited monitoring of the key risks identified for Outcome 12;
- lacked a performance information strategy to monitor and assess the impact of workforce programs in contributing to the broader outcome objectives; and
- used out-dated data and geographic classification systems as the basis for providing incentives for rural and remote health professionals.
The report included three recommendations addressing these findings, which DoHA agreed to.
Department of Education, Science and Training, 2008 – Review of Undergraduate Medical Education in Australia252
In 2005 the Review of Undergraduate Medical Education was commissioned for the then Minister Nelson through the then Department of Education, Science and Training. It undertook a systematic examination of critical educational factors contributing to the outcomes of undergraduate medical education in Australia, in terms of how well it prepared graduates for their work as interns and meets the requirements of postgraduate training for future medical careers. There was also consideration of how undergraduate clinical education contributes to these outcomes, in terms of the effectiveness of different models of clinical education.
Key points noted in the synthesis report253of the review included:
- clinical education is regarded as a cornerstone of successful preparation for a medical career and was considered the most effective method of learning;
- there have been no predetermined standards or definitions of what constitutes the fundamental knowledge, skills and attributes required for medical graduates that would improve the articulation between medical schools and clinical practice, although there is agreement that medical sciences and procedural skills are critical;
- early integration of university and postgraduate education, and improved governance between education and health providers would assist in the development of the skills critical to the clinical experience; and
- there were concerns regarding ensuring adequate depth and breadth of clinical training for undergraduate students, in the context of increased students, reduced access to patients in the public health system, and difficulties in maintaining the apprenticeship relationship between the doctor and student.
Report on the 2010 Review of the Medicare Provider Number Legislation254
This review, required under legislation, examined the operation of the Medicare Provider Number Legislation (sections 3GA, 3GC and 19AA of the Health Insurance Act 1973) over the five years from 2005 to 2010.
Overall, the review found that s. 19AA of the Act, which (with a number of exceptions) limits access to Medicare benefits to medical practitioners who are vocationally recognised (VR), is well accepted by the profession. Section 3GA allows non-vocationally recognised (non-VR) doctors to access Medicare benefits if they are participating in an approved workforce or training program, and the review found that the s. 3GA workforce and training programs have assisted in placing doctors in areas where they are difficult to attract. However, the review also noted that the interaction of various parts of the legislation created complexity in implementation for government, specialist colleges and practitioners, and that the Health Insurance Regulations 1975 required updating to reflect recent changes to training programs.
The review made 25 recommendations, covering areas including:
- providing a final opportunity for non-VR GPs to be grandfathered onto the vocational register;
- changes to the Medicare Benefits Scheme (MBS) to allow supervisors to bill for T8 items for specialist trainee doctors performing procedures in private settings;
- additional DoHA support for doctors on s. 3GA workforce programs;
- streamlining a number of administrative processes, including the arrangements for allocating provider numbers;
- amending the regulations to bring them up to date, including adding a number of certified training programs to Schedule 5, which lists the s. 3GA approved programs; and
- legislating to allow the Medical Training Review Panel to undertake additional monitoring activities and to develop formal links with Health Workforce Australia.
Lost in the Labyrinth: Report on the inquiry into registration processes and support for overseas trained doctors – House of Representatives Standing Committee on Health and Ageing, March 2012255
The Inquiry into Registration Processes and Support for Overseas Trained Doctors was established in response to concerns about the transparency and complexity of the arrangements an overseas trained doctor (OTD) must go through to be eligible to practise in Australia.256 The inquiry was referred to the House of Representatives Standing Committee on Health and Ageing (the Committee) on 23 November 2010 by the then Minister for Health and Ageing, The Hon Nicola Roxon MP, following a private member’s motion proposed by the Hon Bruce Scott MP.
The inquiry was established to examine the administrative processes and accountability measures around OTD assessment processes, the support programs available to assist OTDs in meeting registration requirements, and suggest improvements without lowering the necessary standards required by colleges and regulatory bodies. The inquiry’s report was tabled in Parliament on 19 March 2012.
There were 45 recommendations made in the report, covering all major aspects of the assessment and registration of OTDs and proposing a range of improvements to reduce the administrative burden on, and improve support for, OTDs and their families. The key recommendations included:
- establishment of a ‘one stop shop’ to assist OTDs to in navigating accreditation and registration processes;
- a review of the ten year moratorium requiring OTDs to work in a District of Workforce Shortage for up to ten years to be eligible for a Medicare provider number;
- an increase in the validity period for English language test results from two years to four years when applying for certain forms of medical registration; and
- establishment of a central document repository for OTD paperwork to reduce duplication and administrative inefficiency.
Most of the report’s recommendations were directed to the agencies that are responsible for the registration of OTDs and the maintenance of professional standards, such as the Medical Board of Australia, the Australian Medical Council and the specialist medical colleges.
Standing Council on Health, 2012 – National Strategic Framework for Rural and Remote Health257
In April 2012 the Standing Council on Health released the National Strategic Framework for Rural and Remote Health, designed to promote a national approach to policy, planning, design and delivery of health services in rural and remote communities.
The Framework is directed at decision and policy makers at the national, state and territory levels. It emphasises the need for health and prevention services, programs, workforce and supporting infrastructure designed to meet the unique characteristics, needs, strengths and challenges experienced in rural and remote parts of the country.
The Framework outlines five goals, and sets out objectives and strategies to achieve these. The five goals are:
- Improved access to appropriate and comprehensive health care
- Effective, appropriate and sustainable health care service delivery
- An appropriate, skilled and well-supported health workforce
- Collaborative health service planning and policy development
- Strong leadership, governance, transparency and accountability.
Senate Community Affairs Committee Inquiry into the factors affecting health services and medical professionals in rural areas – August 2012258
On 13 October 2011 the Senate called for the Community Affairs Committee to undertake an inquiry into the factors affecting the supply and distribution of health services and medical professionals in rural areas. The committee was given broad terms of reference, including examination of the impact of current incentive programs, the effect of Medicare Locals and the use of the ASGC-RA geographical classification system on the supply of health professionals and services. The inquiry report was released on 22 August 2012.
The inquiry made 18 recommendations. Key points included:
- The deficit of quality data on the numbers and types of health practitioners, which has limited the ability to analyse the factors impacting on the delivery of health services in rural areas. The committee recommended that collection of robust data be a priority for the upcoming review of rural health programs.
- The growing trend towards specialisation has had a disproportionate effect in rural areas, due to the reduction in generalist training pathways. The inquiry noted the importance of rural generalists and recommended the Standing Council on Health (SCoH) consider the expansion of rural generalist programs.
- The limited availability of rural placements for medical interns, both pre-vocationally and vocationally.
- The large disparity between support provided for allied health professionals and that for doctors to work in non-metropolitan areas, with recommendations that the HECS Reimbursement Scheme be extended to nurses and allied health professionals relocating to rural and regional Australia, and that a Rural and Regional Allied Health Adviser be established.
- A recommendation to replace the ASGC-RA with an alternative classification system that takes account of regularly updated geographical, population, workforce, professional and social data to classify areas where recruitment and retention incentives are required.
- A number of (minor) recommendations to support the role of universities and medical schools in encouraging graduates to practise in rural areas, including investigating options for incentives for medical students to study at regional universities, and better support for rural GPs who provide training to pre-vocational and vocational students in rural areas.
- the issue of accommodation for rural health training and placement programs, with a recommendation that a coordinated accommodation strategy, including for Aboriginal health workers, be developed as part of the forthcoming review of rural health programs.
- an acknowledgement of the potential for the Medicare Locals program to fill the gaps between hospital networks and GP community care provision, with the committee noting the primary importance of the needs assessment element of the work of Medicare Locals, and recommending these be made public.
- A recommendation that DoHA provide a bi-annual brief to SCoH on the existing or emerging gaps in service delivery, caused by misalignment between Commonwealth and state policy, and options to address these.
247 Accessed at Productivity Commission (http://www.pc.gov.au/__data/assets/pdf_file/0003/9480/healthworkforce.pdf), viewed 11 September 2012
250 Accessed at Department of Health and Ageing (http://www.health.gov.au/internet/main/publishing.nsf/content/work-res-ruraud), viewed 11 September 2012
251 Accessed at Australian National Audit Office (www.anao.gov.au/uploads/documents/2008-09_Audit_Report_26.pdf), viewed 11 September 2012
252 Accessed at Department of Education, Employment and Workplace Relations (www.deewr.gov.au/HigherEducation/Publications/HEReports/Pages/ReviewUGradMedEduAus.aspx), viewed 11 September 2012
253 Accessed at Department of Education, Employment and Workplace Relations (www.deewr.gov.au/HigherEducation/Publications/HEReports/Documents/SynthesisReport.pdf), 11 September 2012
254 Accessed at Department of Health and Ageing http://www.health.gov.au/internet/main/publishing.nsf/Content/work-pubs-provleg-10, viewed 11 September 2012
255 Accessed at Parliament of Australia (www.aph.gov.au/Parliamentary_Business/Committees/House_of_Representatives_Committees?url=haa/overseasdoctors/report.htm), viewed 11 September 2012
256 House of Representatives Hansard, 18 October 2010, p. 615
257 Accessed at Rural and Regional Health Australia (www.ruralhealthaustralia.gov.au/internet/rha/publishing.nsf/Content/EBD8D28B517296A3CA2579FF000350C6/$File/NationalStrategicFramework.pdf), viewed 11 September 2012.
258 Accessed at Parliament of Australia (www.aph.gov.au/Parliamentary_Business/Committees/Senate_Committees?url=clac_ctte/rur_hlth/report/index.htm), viewed 11 September 2012