This review of the health workforce programs funded by the Australian Government was commenced in October last year, with terms of reference to:
- analyse existing programs to ensure these are aligned with workforce priorities;
- analyse existing rural health programs to ensure optimal service delivery;
- analyse existing information and key stakeholder experiences to evaluate whether the objectives of current measures are being met and whether these programs could be improved;
- provide opportunities for stakeholder consultation;
- identify opportunities to better align measures with workforce priorities, including through modifications and amendments to existing measures, or development of new measures; and
- provide advice to government about how to support the delivery of a high quality, well distributed optimally utilised and responsive health workforce.
The remit of this review has been tightly focused and time limited, concentrating on appropriate evaluation of those programs currently funded and administered through the Health Workforce Division of the Department of Health and Ageing (DoHA). The aim has been, so far as possible, to make concrete recommendations for practical reforms which are administratively achievable in the short to medium term.
The programs which are the subject of this review are important and significant. However, “root and branch” reform of the major drivers of the Australian health workforce cannot be achieved by the levers available to Health Workforce Division, or indeed DoHA, alone. Two other review processes are therefore important. The first is the scheduled analysis of the ongoing role and function of Health Workforce Australia, as part of the National Partnership Agreement on Hospital and Health Workforce Reform, which is due to expire at the end of 2012-13. The second is a fresh analysis of the health workforce in its entirety by the Productivity Commission, which has been foreshadowed to take place in the medium term and which would undoubtedly be valuable.1
Without the active cooperation of the states in addressing many of the issues facing Australia’s health workforce, and comprehensive data from the private sector and nongovernment organisations, as well as industry policy, immigration and the wider tertiary sector, initiatives in this area will continue to be piecemeal at best.
With respect to the review’s methodology, a triangulated approach was taken which was designed to provide extensive analysis of the health workforce programs funded through the Health Workforce Division. The three major activities undertaken were:
- Analysis of each individual program/activity managed by Health Workforce Division and other workforce programs implemented by other divisions within the department;
- Research and development by the secretariat of a series of papers including ‘context papers’ written to provide background on health workforce issues. A literature review was also undertaken of all relevant program evaluations, reports and parliamentary inquiry reports; and
- Consultations with stakeholders, undertaken between October and December 2012, which included interviews, written submissions and roundtable discussions aimed at identifying health workforce issues and program delivery concerns.
Some overarching themes have emerged from this review:
- The health system exists in order to improve the health of the population and of health consumers. Health workforce programs, in turn, exist to assist in meeting patient need. While this should be self-evident, it is too easy in considering health workforce programs to become focused on whether they meet the needs of practitioners or institutions, rather than those of patients and consumers.
- The current system, despite reforms, continues to be focused heavily around increasingly expensive and specialised acute care in major metropolitan centres, rather than on measures to redirect resources to the provision of high quality primary care, population health initiatives and preventative care. This is both unaffordable in terms of escalating future cost, and inimical to optimum patient care, particularly of chronic conditions.
- It is imperative both economically and for population health to move beyond a focus on specialist medicine and acute care beds, to appropriate generalist skills, team based community care and the training and development of the nursing and allied health workforce.
- The most significant health workforce issue, particularly in the area of general practice medicine, is not one of total supply but one of distribution, which is to say inadequate or non-existent service provision in some rural and remote areas, and to populations of extreme disadvantage, most particularly the Aboriginal and Torres Strait Islander communities and some outer metropolitan communities.
In recognition of the importance of these issues, the strongest recommendations arising from this review concern the imperative to create a coherent pathway for rural and regional education and training – in the short term and as a matter of urgency for medical training, especially generalist training – but which over time should also produce more appropriate resource allocation to nursing, allied health and dentistry. If implemented, these recommendations have the potential not only to achieve better health workforce outcomes in rural and regional areas, but to foster more generally an emphasis on generalist medicine and integrated primary care.
Substantial recommendations are made for the reform of a number of programs, particularly the rural classification system currently used to determine eligibility for incentives. The most ambitious recommendation concerns the development over time of a regionally determined incentive model, moving away as far as possible from a centrally mandated incentive structure toward a model under which packages of incentive funding may be flexibly deployed to meet identified local need and service gaps.
Consistent with the identified priorities of the Health Workforce Fund (through which the bulk of the programs are funded), the report and recommendations are organised thematically to focus upon strategies to:
Ensure a capable and qualified workforce – through registration, accreditation, training and development;
Increase the supply of workers in all health professions – and facilitate a more even distribution of workforce in terms of geography and of the types of services provided;
Support the Indigenous health workforce – throughactivities that promote an increase in the Aboriginal and Torres Strait Islander health workforce and increase the capacity of the broader health workforce to address the needs of Indigenous people.
Address health workforce shortages in regional, rural and remote Australia – through, for example, rural workforce programs and better targeting of workforce incentives.
The report also contains specific sections on the nursing and midwifery workforce, the dental and allied health workforces and on program management reform within DoHA.
Chapter 1: Review background
Chapter 1 of this review outlines the review methodology and consultation process. This chapter provides a short summary of the various Australian Government health workforce programs. Part of the agenda of this review is to make available to stakeholders and the wider public a substantial amount of material which has not previously been in the public domain.
It is clear that there has been a substantial growth in Commonwealth funding for health workforce programs – from $286 million in 2004-05 to a projected $1.79 billion in 2016-17. Growth in funding for medical training programs has demonstrably increased, particularly to support rural medical training and the expansion of vocational training programs (GP and specialist training).
There has also been an increasing emphasis on support for nursing/midwifery and dentistry and, to a lesser extent, allied health.
The investment in Health Workforce Australia (HWA) has been a major factor in the growth in Australian Government funding for health workforce development. The data collated and analysed by HWA – summarised in chapter 2 – is subject to continuing refinement and improvement, but provides a strong foundation to inform evidence-based policy for the future.
Chapter 2: Health workforce context
This chapter provides an overview of the current Australian health workforce, largely drawn from HWA’s Health Workforce 2025 – Doctors, Nurses and Midwives (HW2025), including data by professional group, and distribution as well as projected education and training requirements.
It is clear that the distribution of the workforce, work practices and an ageing population profile all heavily affect the supply of health services.
Labour force survey data shows that the average working hours of many health professionals are reducing and research shows that the working hours of future graduates will continue to fall. Given the ageing of the workforce, and reduction in work hours from both genders, the evidence is that the increased training, graduation and recruitment of health workers will in many locations lead only to a small net increase in the number of full-time equivalent (FTE) practitioners.
The current geographic spread of the health workforce does not reflect the distribution of the population. With the exception of nurses and midwives, the relative number of health professionals diminishes for communities located further away from major centres. Allied health, dental practitioners and medical specialists are in severe shortage in outer regional, remote and very remote areas. This has been a key focus of the review.
The demand for health services is projected to increase for a variety of reasons including increased chronic disease, greater consumer expectations and a treatment and funding model which has been built around short-term acute interventions. The increasing prevalence of chronic disease has implications not only for the number of health workers required in the future but also the skill mix and models of care required. Multi-disciplinary and team-based care is becoming increasingly important in the management of many chronic diseases.
Health Workforce 2025 report
In the context of increasing demand for health services and current shortages, a workforce projection study was undertaken by HWA to assist in future workforce planning. The study modelled future health workforce supply and demand across a number of possible policy scenarios taking into account the ageing population and current service utilisation rates. Without reform, the report predicts a shortage of 109,490 nurses and a shortage of 2,701 doctors by 2025. The recruitment and training of this number of health professionals is neither possible nor affordable and is predicated upon an unsustainable model of health care delivery. Many of the issues and challenges identified in this report have been considered during the review.
It is important to recognise the implications of wider changes to health policy for the development of the health workforce. In particular, the national health reform process is predicated upon a shift in focus away from acute care and toward more coherent delivery of connected primary health care, with a focus on the prevention and better management of chronic disease.
Even with substantial reform, it is likely that the increasing demand for health services will result in a shortage of doctors, nurses and a likely shortage of dentists and some allied health professionals. This has consequences for government policy in terms of training, immigration, role redesign and incentives used to encourage a more even distribution of health professionals across Australia.
The HWA modelling indicated that the most effective policy intervention for meeting the increased demand would be to adopt a process of reform and innovation to increase the productivity of the future workforce. Along with the use of technology, increased productivity can be gained through role redesign which will allow health practitioners to work at the fullest extent of their scope of practice, encourage greater flexibility and multidisciplinary learning, and allow practitioners to use more varied and transferable skills. There is a need to reshape health services, particularly for chronic conditions, to a patient centred model built around consumer engagement. The primary care concept of the “medical home” is an important model here.2
Chapter 3: Ensuring a capable and qualified health workforce
This chapter outlines the quality framework applying to health professionals, and describes, in broad terms, the Australian health education and training system. It discusses the Commonwealth programs that support this system and investments in clinical training for health professionals, and vocational training for medical practitioners. There is also discussion of the impact of the introduction of the National Registration and Accreditation Scheme (NRAS) in 2010.
This chapter also examines the use of scholarships as a mechanism to promote the growth and sustainability of specific sectors of the health workforce.
The introduction of NRAS was intended to assist health professionals to move around the country more easily, reduce red tape, provide greater safeguards for the public and promote a more flexible, responsive and sustainable health workforce. However, while the introduction of the scheme has delivered many benefits, there are a number of residual issues that may be impeding the ability of some health practitioners to provide the full range of care allowed within the relevant professional scope of practice.
In particular, strong evidence to this review was that the introduction of a requirement to undertake new degree level study for nurses and midwives who have been out of the workforce for more than ten years is one of a number of disincentives discouraging return to the workforce. This has particular impact in rural settings and for Aboriginal and Torres Strait Islander communities. The review suggests that supports for re-entry for this group should be a priority.
Another issue relates to arrangements for prescribing. A range of health professionals currently prescribe medications in Australia, but authority to prescribe is determined by state and territory drugs and poisons legislation, and there are differences between the jurisdictions in terms of the authorised professions and associated conditions. This creates some barriers to the benefits of workforce flexibility and mobility that were delivered with the introduction of national registration.
HWA has been undertaking work in this area with a view to advancing a nationally consistent approach to prescribing by health professionals other than doctors. The Health Professionals Prescribing Pathway (HPPP) project is aiming to establish a common framework for all non-medical prescribers to advance workforce reform.
Several professions made representations during the review seeking to be included in NRAS, and raising concerns about the decision of Health Ministers to limit consideration of national registration for any extra professions. They perceive that this has had an unintended consequence of stratifying the allied health professions with loss of professional status for those not registered, and in some cases, the professions being overlooked to assist in service delivery under Commonwealth and state programs.
Health education and training
Concerns about the capacity of the health sector to support the clinical training needs of an increasing number of undergraduate health students have been expressed over a number of years, and were consistently raised during the course of the review.
HWA’s Clinical Training Funding program is discussed in the review and some stakeholder concerns are expressed about unintended consequences of the provision of this funding, including an escalation of the cost of clinical training services, mainly in the hospital sector.
The private health care providers consulted as part of the review consider that there is a significant level of untapped capacity in their sector for the clinical training of all health professions.
While the move to a demand-driven system of university places (outside medicine) will assist in responding to Australia’s future health workforce needs, its impact on the clinical training system needs close monitoring, given the extensive clinical placements required as part of a health professional’s training. Expanded use of simulated learning environments is likely to be necessary.
With the increase in medical students, there has also been a substantial increase in the overall number of intern training positions, from around 1,500 in 2004 to 2,753 in 2011.
Despite this growth, current accreditation requirements have been raised as a barrier to more innovative solutions to expanding intern capacity, particularly in the rural and private sectors. The Australian Medical Council is implementing new national standards for the accreditation of intern positions. This is likely to improve the consistency between jurisdictions in the medium term. Discussions are ongoing about the adoption of a new national process for intern selection, and indeed about a fresh approach to the definition of internship going forward.
The Australian Government’s major contribution to prevocational medical training to date has been its support for the Prevocational General Practice Placements Program (PGPPP).
PGPPP has been used as a solution to building prevocational training capacity. Moving interns out of hospital settings, even for a short period, frees up additional placements in settings which provide training for interns.
The current challenge is to develop a system that maintains the benefits of prevocational training in private general practice and community settings while establishing a more cost-effective and sustainable funding base for this activity. One element of such a proposal in the form of a new rural training pathway is outlined in Chapter 4.
Stakeholders have advocated for an increase in the overall number of placements on the Australian General Practice Training (AGPT) program on top of current growth, with a suggested expansion of up to 600 additional places to a total of 1,800 per annum.
Stakeholders have presented strong arguments during this review that increasing the number of GPs and “generalists” needs to be a key priority in workforce planning and future funding for medical training. This is supported by the findings of the third volume of HW2025 – Medical Specialties – released in November 2012.
Concern is frequently expressed about the lack of clear linkages between the different initiatives investing in medical education. There is no requirement for universities, GP regional training providers or specialist colleges managing the Specialist Training Program (STP) to collaborate to ensure that career pathways are transparent for either students or graduates participating in these initiatives.
The STP has been successful in extending vocational training into new settings, particularly the rural and private sectors. It has demonstrated that specialist colleges can take a flexible approach to accrediting new positions and to supporting networked training arrangements involving multiple health care settings, sometimes in different regions. However, the program’s national application rounds have been consistently oversubscribed and there is no further growth built into the program beyond 2014.
Although the STP is widely regarded as a successful initiative, there is no clear pathway for graduates interested in working in the type of settings supported by STP (i.e. rural and private) to enable them to plan to undertake placements in this program. This problem persists beyond STP, and the lack of structured pathways into vocational training outside general practice is an issue.
The Standing Council on Health (SCoH) has recently acted to address this lack of coordination in the medical training system through the introduction of a National Medical Training Advisory Network (NMTAN), which was agreed in November 2012. The NMTAN has strong potential to improve the connection of the various stages of the medical training pipeline and the capacity to make evidence-based decisions.
Inter-professional learning (IPL) presents opportunities for efficiencies in how training is delivered which could be applied in a broader range of settings.
Some institutions which coordinate rural clinical placements – particularly universities delivering the Rural Clinical Training and Support (RCTS) program and the University Departments of Rural Health (UDRH) initiatives – have demonstrated success in pursuing a more inter-disciplinary approach.
There has reportedly been a degree of professional resistance to the concept of IPL.
Health education scholarships
The majority of the scholarship programs in the Health portfolio are managed within Health Workforce Division, although scholarship programs have also been established elsewhere in the Department, in areas including Ageing and Aged Care Division and Pharmaceutical Benefits Division.
There is limited evidence to show whether desired workforce outcomes are actually achieved through scholarship programs. There is some evidence (mostly career intention data) to support continued investment in scholarships targeted at distribution, e.g. the Rural Australia Medical Undergraduate Scholarship Scheme (RAMUS).
As part of the review’s consultations there was detailed discussion of the Medical Rural Bonded Scholarship (MRBS) scheme. Evidence is lacking that coercive schemes of this type result in longer term positive connection to rural life. The scheme is administratively expensive, relying on complicated contractual arrangements and enforcement action. This review recommends that it should be phased out and funds redirected to non-bonded scholarship schemes such as RAMUS which is targeted at those from rural backgrounds and with demonstrated financial need. Administrative and other savings should enable broadening of support beyond medical students with additional funds to nursing and allied health professions, which is both equitable and desirable in health workforce terms.
The rationalisation of some scholarship schemes in 2010, while not universally popular, did produce administrative savings and program efficiencies. There was discussion during the review process as to whether further consolidations should occur, as there are still many Commonwealth health scholarship programs.
This could encompass programs managed within HWD and might extend to include all scholarship programs managed within DoHA, including aged care scholarships and pharmacy scholarships. There is potential for external scholarship administration to be streamlined.
There are inconsistencies between the criteria under which different scholarships are awarded. It would be beneficial to have some consistency amongst the different schemes, allowing for the necessary differences in the target recipients. A commitment to a consistent evaluation framework based on workforce outcome data should be built into all contracts with scholarship administrators going forward.
In some areas, particularly nursing and midwifery, Commonwealth scholarships are in competition with those offered by the states and territories. This could represent a duplication of resources, and is likely to be causing some confusion among students.
Key stakeholders, including the Australian Nursing Federation, have asked the Commonwealth to consider increasing the number of scholarships available to nursing and allied health students. Allied health stakeholders also raised this issue during review consultations.
Chapter 4: Addressing health workforce shortages in regional, rural and remote Australia
This chapter examines workforce distribution programs, including educational initiatives, rural incentive schemes and professional support programs, such as the various locum initiatives. The chapter also outlines options for reform of the much contested Australian Standard Geographical Classification – Remoteness Areas (ASGC-RA) system, including a discussion of issues surrounding its usage across different programs.
Health education strategies for rural distribution
The use of education and training programs to influence health workforce distribution has been a major focus over more than a decade. Policy and programs targeted at this issue are based on evidence that students who come from rural backgrounds and/or those who spend (well supported) time training in a rural setting will be more likely to pursue a rural career upon qualification.
Rural training programs received strong stakeholder support during the review and in general, issues related primarily to new proposals to expand activities to enhance distribution outcomes. The evidence supporting rural training initiatives is encouraging but not yet conclusive. The review suggests a number of program reforms to enhance outcomes, with the major issues discussed below.
Most Australian medical schools receive Government funds under the RCTS program. There are currently 17 universities participating in the program. The RCTS program targets include:
- 25% of Australian medical students are to undertake a minimum of one year of their clinical training in a rural area (defined as ASGC-RA 2–5) by the time they graduate;
- 25% of Commonwealth supported medical students are to be recruited from a rural background; and
- all Commonwealth-supported medical students must undertake at least four weeks of structured residential rural placement in an ASGC-RA 2–5 region.
A consistent theme in recent studies of the RCTS program has been the suggestion that longer placements generate better outcomes. It is recommended that the current mandatory short-term placements be abolished and replaced by longer term elective placements. This would mean that the considerable cost of supporting rural placements for all medical students should be diverted towards other priorities within the program. In particular, nursing, allied health and dentistry students may thereby gain access to supports such as accommodation which are currently entirely absorbed by short-term medical student placements.
The UDRH program establishes a university presence in rural areas and offers clinical training opportunities for medical, nursing and allied health students. It also offers research and educational opportunities for students and health professionals in rural areas. There are 11 UDRHs nationally.
UDRHs are managed under funding agreements with a single host university, but often support student placements from multiple universities. A benefit of both the RCTS program and the UDRH program is the infrastructure support they provide to rural centres and their ability to reduce the professional isolation of local practitioners. Important initiatives for support and training of locally recruited students and staff offer the best prospects for long-term retention of a viable health workforce.
Rural education strategies for allied health
At present, the UDRHs are very active in coordinating rural clinical placements for allied health students, with pharmacy, physiotherapy, dentistry, occupational therapy, dietetics and oral hygiene students among those regularly placed. A number of UDRHs, such as the Broken Hill UDRH, have recently pioneered a new service learning model aimed at strengthening clinical training.
The model is based on the principles of improving community access to health care while providing enhanced student learning, and involves students providing services to patients under supervision in carefully controlled clinical environments. Expansion of this model is constrained by current UDRH funding limitations. The role of UDRHs could be enhanced with further funding.
It has been suggested that current university rural origin entry targets for medicine should be extended to the allied health disciplines. Due to the high numbers of allied health courses and the large number of allied health and nursing students in the tertiary education sector, the costs of implementing such a target could be significant, as well as difficult to set and monitor.
Rural training pathway – post university
Training doctors in rural areas is a key part of the strategy to ensure that there is a measurable increase in the supply of health services to those communities. All medical graduates need to complete an internship to gain general registration. Under current models, the intern year tends to be spent in metropolitan centres where teaching hospitals are located – rotations in medicine, surgery and emergency medicine are compulsory but not available everywhere.
During the review stakeholders cited the lack of a clear pathway from undergraduate rural training into employment as a rural doctor (post-fellowship) as a key reason why students who are interested in rural health are regularly lost to the metropolitan health system. There is strong merit in exploring more structured investments in networked intern places based in rural areas, involving a combination of acute care and primary care training in a range of settings (e.g. private, community or Aboriginal Medical Service), with transfers back to metropolitan areas for rotations where necessary.
A rural training pathway already exists for general practice under the AGPT. However, the missing link is the availability of rurally-based internship positions through which rurally trained medical students can transition directly to vocational GP training.
In the other specialties, this lack of rurally-based intern positions is further hampered by limited rural training opportunities for trainees seeking fellowship of a specialist medical college, noting that the STP (see Chapter 3) has made some difference in this area.
One of the key recommendations of the rural chapter and indeed the report is that a more integrated rural training pathway focused on encouraging generalist training should be developed, the genesis of which could be funded through some redirection of existing program funding. The chapter outlines a potential model for delivering this integrated pathway, with a significant emphasis on the need to foster regional partnerships and ensure greater collaboration between the various programs to ensure sustainability and better clarity on options for students. There is also potential for extending this model to other health disciplines, particularly in areas such as advanced nurse training.
While some existing program resources could be used to establish the national rural pathway, it is likely that new funding would be needed to support large numbers of graduates.
Rural recruitment and retention strategies
Financial incentives for rural doctors should continue to be supported by the Government. However, there are concerns around whether current programs are effective and financially sustainable. The causal impact of financial incentives upon recruitment and retention is often asserted, but seldom demonstrated. The evidence suggests that these payments are only one factor in a complex series of influences on whether health professionals choose to stay in, or move to, rural areas. Local recruitment, training and professional development opportunities as well as community engagement have been demonstrated to be the key factors in attracting a stable long-term health workforce.
The discussion in this report mainly focuses on the General Practice Rural Incentives Program (GPRIP) and recommends this program should undergo substantial reform to address stakeholder concerns and problems identified in its design.
The unsustainable growth in GPRIP retention payments to doctors in inner regional areas (RA2), relative to those in more remote locations, is a concern, as is the demonstrable lack of impact of currently available relocation payments. It is suggested that the current focus on financial incentives for doctors, at the exclusion of other health professional groups, is neither equitable nor evidence-based.
Chapter 4 outlines a new program concept to replace GPRIP based on a regionalised system for distributing incentives to doctors and other health professionals. This option is based on transferring GPRIP funds to a capped incentive pool which could be allocated through a combination of the Rural Workforce Agencies and the Medicare Locals.
This proposed system would shift incentives away from the current entitlement approach and allow funded agencies to determine need at the local and regional level, guided by overarching program parameters set by the Government. This would allow flexibility in how different regions use incentives (either for relocation or retention) to support workforce development in their area. While this proposal appears to offer a number of advantages, it will require substantial operational development.
An alternative solution relates to how the current rural classification system is used to determine eligibility. It is suggested under this second option that GPRIP could be retained but underpinned by an enhanced classification system allowing incentives to be more sharply targeted towards smaller and more remote communities with greater workforce needs (see below).
Allied health and nursing groups strongly support the extension of the HECS Reimbursement Scheme to their professions. However, the current program is administratively complex, effectively operating as a cash grant to rural doctors rather than a revenue foregone scheme involving discounting HECS debts through tax returns.
It is suggested that rather than expand the current DoHA program, it should instead be integrated with the similar scheme for nurses managed by the Department of Industry, Innovation, Climate Change, Science, Research and Tertiary Education through the Australian Taxation Office. Subject to funding availability, this might provide a platform for the extension of HECS forgiveness to other professions targeted as areas of future workforce need such as the allied health professions.
The Rural Health Continuing Education program provides professional development support for rural health professionals in two streams – one for specialist doctors (stream 1) and the other for allied health professionals, GPs, nurses/midwives and Aboriginal health workers (stream 2). Both streams are oversubscribed, with particularly strong demand for more support under stream 2, and it is recommended that the Commonwealth should consider expanding this program. The value of the various rural locum programs as an important support mechanism assisting with rural workforce retention is also acknowledged. However, it is suggested that there could be efficiencies in streamlining the administration of the various schemes while still enabling funds to be directed towards specific workforce groups.
Reform of the ACGC-RA rural classification system
The impact of the adoption of the ASGC-RA classification system was one of the key issues raised by stakeholders during the review process. The issues with the current system revolve around the large area of the country classified as RA2 and, to a lesser extent, RA3, which contain a diverse mix of large and small towns, and which the evidence suggests may have very different workforce challenges.
A broad stakeholder working group was formed as part of the review to examine options for improving the current classification system. While there were some divergent views, general consensus was reached around a number of key principles, which revolve around better use of evidence to determine the relative needs of communities while maintaining a stable, regularly updated geographic system that measures both town size and remoteness without being subject to arbitrary changes.
It was recognised by the group that any system will have imperfections. There was general agreement that the core of the ASGC-RA system should be retained but that it should be customised to provide a more advanced system of classifying rural locations for health policy decisions.
The enhancement to ASGC-RA proposed by the Monash University School of Rural Health is a valuable one. At the heart of the “Monash model” is the recognition that smaller communities (population less than 15,000) are more vulnerable to workforce pressures and have a greater need for financial incentives.
While using population size as a determinant of need has its limitations, it appears to be based on reasonable evidence derived from data generated through the Medicine in Australia: Balancing Employment and Life (MABEL) Study.
While the “Monash model” is supported, it should be further refined to allow continued consideration of remoteness to be a factor in funding and program eligibility decisions.
A “modified Monash model” is therefore recommended which would provide an extra layer of discrimination between large and small towns in ASGC-RA bands 2 and 3, while retaining the current RA4 and 5 areas. The analysis of this hybrid model outlines that while some weaknesses in the model remain and there would be some complexities in implementation, the new system would be an improvement and should be developed further in consultation with an implementation working group.
Chapter 5: Aboriginal and Torres Strait Islander health workforce
This chapter provides an overview of the Aboriginal and Torres Strait Islander health workforce and Commonwealth programs (and national initiatives) that are intended to strengthen Aboriginal and Torres Strait Islander health workforce capacity and improve the ability of the broader health workforce to address the needs of Aboriginal and Torres Strait Islander people.
Aboriginal and Torres Strait Islander health workforce participation
There has been a relative increase in Aboriginal and Torres Strait Islander participation in health-related training and education as well as in the health workforce, although the fundamental issue of underrepresentation across the board remains. Under-representation of Aboriginal and Torres Strait Islander people in the health workforce is clearly one factor contributing to the lower rates of Aboriginal and Torres Strait Islander people accessing health services.
Increasing the rates of participation and completion of training by Aboriginal and Torres Strait Islander people in the Australian health workforce, along with improving their employment and education generally, is fundamental to achieving better health outcomes.
Leadership, mentoring, prevocational training, vocational training and work experience are highlighted as being crucial in providing an appropriate Aboriginal and Torres Strait Islander health workforce and developing a broader health workforce able to deliver culturally appropriate care.
The Council of Australian Governments (COAG) National Partnership Agreements have been a key contributor to improved Aboriginal and Torres Strait Islander health outcomes and increased health workforce participation in recent years. Other key national initiatives assisting with Aboriginal and Torres Strait Islander health outcomes and the increased rates of participation include:
- National Aboriginal and Torres Strait Islander Health Plan;
- Aboriginal and Torres Strait Islander Health Performance Framework;
- National Aboriginal and Torres Strait Islander Health Workforce Strategic Framework;
- the National Registration and Accreditation Scheme; and
- Health Workforce Australia activities.
While these significant ongoing consultation, planning and policy development processes are all important steps in addressing Aboriginal and Torres Strait Islander health outcomes they will not, by themselves, translate into measurable change at the community level. The report stresses the importance of cohesive implementation of recommendations arising from this review with the soon to be finalised National Aboriginal and Torres Strait Islander Health Plan. This will necessitate close and cooperative work with the National Congress of Australia’s First Peoples’ National Health Leadership Forum, the collective and consultative forum of peak Aboriginal and Torres Strait Islander health workforce bodies.
There are many crossover points in Aboriginal and Torres Strait Islander health workforce funding, not only within DoHA but also between other Commonwealth agencies. It is important to take a more collaborative approach to the training of the Aboriginal and Torres Strait Islander health workforce.
Aboriginal and Torres Strait Islander leadership is recognised internationally as a key factor in the development and sustainability of programs aimed at increasing workforce capacity, and influencing the non–Aboriginal and Torres Strait Islander workforce to provide culturally safe and appropriate services. Aboriginal and Torres Strait Islander leadership is also relevant in guiding tertiary education for Aboriginal and Torres Strait Islander students and developing health courses that integrate Aboriginal and Torres Strait Islander health competencies.
There is no standardised approach to incorporating Aboriginal and Torres Strait Islander health competencies as part of curricula in Australian universities. In many cases, it is left up to individual universities to incorporate these competencies into their programs, with variable outcomes. Developing Aboriginal and Torres Strait Islander health competencies and cultural competencies has the potential to improve the integration of Aboriginal and Torres Strait Islander health into health training.
There are no standardised Aboriginal and Torres Strait Islander health student targets in Australian universities. Currently, it is up to the individual universities to set their Aboriginal and Torres Strait Islander student admissions. Setting or incentivising targets would lead to growth in the Aboriginal and Torres Strait Islander health workforce, allow progress to be more easily measured, and increase accountability for outcomes. This area may require new funding support across disciplines.
Incorporating later-year elective placements in Aboriginal and Torres Strait Islander communities appears to be an effective way to increase non–Aboriginal and Torres Strait Islander students’ ability to provide culturally safe care, provided students are well prepared in terms of cultural knowledge and have well-supported access to clinical training.
There is currently funding for a number of Aboriginal and Torres Strait Islander organisations, including Aboriginal community-controlled registered training organisations (RTOs) to promote pathways for Aboriginal and Torres Strait Islander people into the health workforce. Funding allocations however are inconsistent between groups.
Funding to RTOs has not been reviewed until recently (as part of the Battye Review). In line with the Battye Review’s recommendation, this review finds that funding to RTOs would be better aligned with the expertise of the education portfolio(s).
More generally, there is a need to progress the implementation of the recommendations of the Battye review to bring some certainty to this area of policy.
Chapter 6: Managing the supply of health workers to meet community needs
This chapter links in with many of the workforce supply issues discussed in Chapters 3 and 4, but focusses more on regulatory issues, primarily for overseas trained health professionals. This includes suggesting substantial reforms to the current districts of workforce shortage (DWS) system.
The chapter also recommends major reform of the Bonded Medical Places (BMP) program and discusses broader issues about the effectiveness of return of service schemes for health professionals, and concludes with an analysis of the various workforce distribution measures for non–vocationally recognised (VR) doctors; the “other medical practitioners” and “section 3GA” programs.
International recruitment, support and regulation
This section discusses current activities to recruit and support overseas trained doctors (OTDs) to work in Australia. The recruitment activities of Rural Workforce Agencies under the International Recruitment Strategy (IRS) are outlined, with some suggestion that current targets should be reviewed.
The activities of both HWA’s International Health Professionals Program and DoHA’s IRS are valuable in attracting overseas trained health professionals to Australia. However, it is suggested that arrangements for these initiatives may be better managed through a single fund holder.
Information systems, training arrangements and support mechanisms for OTDs are discussed in the following section, with reference to the findings of the House of Representatives Standing Committee’s inquiry into OTDs, Lost in the Labyrinth. Many of the recommendations of this report, relating to enhancing training and support, are endorsed.
The need to increase awareness of the diversity of the OTD workforce, with its corresponding need for targeted support reflecting different backgrounds and skill levels, is a major theme. The interplay between the immigration, registration and assessment systems in Australia often presents barriers to OTDs wishing to work in the country.
District of workforce shortage (DWS) classification system
While the core principles of the current system, which regulates the locations where OTDs are able to work in Australia and access Medicare rebates, are supported, significant reforms are suggested in the use of the DWS system. A DWS stakeholder working group was convened as part of the consultation process and, while continued use of a system such as DWS was generally supported, there was a strong view that there are areas for improvement.
This is a complex and technical area (and is linked to the rural classification system issues discussed in chapter 4), but the proposed reforms can essentially be broken down into:
- The use of more up to date population data, as well as adopting the more refined ASGS system developed by the ABS.
- Providing greater certainty in the way general practice is treated, with the suggestion to move away from quarterly updates against the national service level average to annual updates.
- Ceasing use of out-dated metropolitan area classifications.
- Providing automatic DWS status for smaller population areas in RAs 3–5, if possible aligning this with the “modified Monash model” for the enhanced rural classification system. Once implemented, this approach would be used for both GPs and specialists.
- Allowing flexibility in the DWS assessment process by applying a 10% buffer for locations marginally higher than the national service average.
The most potentially contentious change is the proposed alignment of automatic DWS areas with location population size through the enhanced ASGC-RA system. This presents some complexity in implementation, and will need to be carefully worked through with an implementation working group.
Return of service obligations
Stakeholders have expressed strong concerns about the potentially stigmatising effect of the Bonded Medical Places scheme upon students and upon the nature of rural practice itself. There are also concerns about lack of international evidence for the success of mandatory or bonded schemes in terms of achieving long-term sustainable increases in the rural health workforce.
However, given the very long lead time in medical training, very few students have yet become eligible for return of service under this scheme and it may well be argued that without meaningful data it is premature to consider abandoning the scheme in the absence of an effective alternative. The review has with some reluctance, supported the continued retention of the Bonded Medical Places scheme, but suggests major reforms to address stakeholder concerns and improve administrative sustainability. The following changes are suggested:
- broadening the settings for the return of service obligation (RSO), to include rural and remote areas (regardless of DWS status) and settings such as Aboriginal Medical Services and defence force facilities;
- retaining “scaling”;3
- changing the point of commencement of the RSO so that it applies after attainment of fellowship (offset by a shorter RSO period);and
- changes to the buy-out arrangements.
The review also gives some consideration to the more dramatic option of extending RSO arrangements to all new medical graduates, with reference to international models in countries such as South Africa and Canada. Section 51(xxiiiA) of the Constitution (civil conscription) presents a major obstacle to this approach. Nevertheless, the review flags broader use of RSO arrangements as a future option if current workforce distribution mechanisms don’t prove to be successful.
Distribution arrangements for non-VR medical practitioners
The various other medical practitioners (OMPs) programs are discussed in the final section of the chapter. The review supports maintaining arrangements which encourage non-VR doctors to pursue college fellowship training, while also serving as a workforce distribution mechanism. However, administrative complexity and the proliferation of different OMPs programs is presented as a problem that could be addressed by consolidating four of the OMPSs programs into one measure.
It is also suggested that there could be efficiencies in consolidating the various programs relating to Section 3GA of the Health Insurance Act 1973, such as the Approved Medical Deputising Service Program and the Special Approved Placements Program.
Chapter 7: Nursing and midwifery workforce
This chapter considers issues relating to the nursing and midwifery workforce which is the largest part of the health workforce. As the major employer of nurses and midwives, the states and territories are largely responsible for recruitment and retention.
The Australian Government has a less direct but important role, contributing funding for the delivery of health services and for university education of nursing and midwifery students. However, given the predicted future shortfall of nurses, the Commonwealth has recently increased its investment in nursing and midwifery supply and support measures, including investments in practice nursing and scholarships. These nursing initiatives totalled about 34% of the funding under the Health Workforce Fund in 2011-12.
Nursing and midwifery education
This section covers issues raised during the consultation process around student numbers, access to quality clinical placement experiences, perceptions of graduates’ “work readiness” and current Commonwealth programs that relate to education (both academic and clinical experience requirements).
Increasing the number of students undertaking registered nursing courses at university is clearly not achievable at a level which would enable projected supply to meet HWA’s forecast “as is” demand by 2025 for this workforce.
Current limitations on the education of enrolled nurses will need to be addressed to ensure this is not an inhibiting factor in greater use of this workforce.
Effort is required to enhance workforce retention, particularly by offering nurses and midwives the opportunity to upskill and take on more senior and diverse roles.
Commonwealth effort in this area should focus on ensuring access to appropriate ongoing educational opportunities to keep more nurses in the workforce. In addition, there should be better targeting of financial support via scholarship schemes aimed at nurses considering postgraduate studies.
Access to education to enable easier re-entry to the nursing profession is also presented as an issue of high importance that needs to be resolved in some jurisdictions.
A major recommendation arising from this section is that the Commonwealth should work with the profession and across jurisdictions to establish a National Nursing and Midwifery Education Advisory Network (NNMEAN) that would develop nursing education plans across the whole training pipeline from enrolled and undergraduate nurse training to advanced scopes of practice and nurse practitioner candidates.
Other suggested actions include workforce innovation and reform including a greater role for nurse practitioners, and roles commensurate with the skills of registered nurses, enrolled nurses and the personal care workforce – at the top of their scope of practice.
Nursing and midwifery workforce development and retention
The review outlines stakeholder concerns about the immediate employment prospects of newly graduated registered nurses, as recently discussed by health ministers.
HWA has undertaken a short-term project to address recruitment issues for graduate nurses and midwives, including a web-based information portal providing links to existing graduate programs.
The main focus of recommendations arising from this section is based on the premise that there should be two separate but complementary actions to help in retaining nursing and midwifery staff:
- assistance with further career development and the opportunity to adopt more advanced roles for nurses (such as an eligible midwife or nurse practitioner);
- enhancing non-salary conditions of employment including organisational culture and the behaviour of an employee’s manager.
A major recommendation is that the Commonwealth should consider providing seed funding for a feasibility study of a national rollout of leadership courses to mid-level nurse and midwife managers, based on the NSW Government sponsored Essentials of Care program.
It is also suggested that the Commonwealth should consider investing in a new training model based on the Remote Vocational Training Scheme (RVTS) to assist rural Nurse Practitioner candidates and other nurses seeking to undertake advanced roles.
Nursing and midwifery workforce sustainability
This section discusses a range of issues including nurse and midwifery career development, registration, credentialing and re-entry requirements and their impacts on opportunities for nurses and midwives to remain in or return to the workforce.
It also highlights the need for innovation and reform in the way nursing and midwifery care is delivered, and in job/role redesign and improvements in the productivity of the current workforce, including the development of trained assistant roles and extended scopes of practice.
The discussion extends the arguments presented in the education and retention section of this chapter, in that sustainability of the nursing and midwifery workforce is closely linked with educational and career progression opportunities across the spectrum from assistants in nursing, to nurse practitioners and independent practising midwives.
The subsequent recommendations suggest that funding should be considered for pilot studies of new and innovative methods of service delivery, developed through analysis of the best available evidence both nationally and internationally to inform policy development in this area.
The NNMEAN, once established, could lead this work (including commissioning research) with HWA.
Chapter 8: Developing the dental and allied health workforce
This chapter provides an outline of the current dental and allied health workforce, and Commonwealth initiatives and jurisdictional approaches aimed at increasing the supply and distribution of both the dental and allied health workforce.
This chapter is informed by discussions at the Dental Workforce and Allied Health round tables as part of this review. The dental section of the chapter is also informed by the Final Report of the National Advisory Council on Dental Health (NACDH), released in 2012.
There is currently a significant maldistribution of the dental workforce between the public and private sectors and geographically. All of the HWD dental workforce initiatives currently in place, as well as those under development, have a central objective of addressing distribution issues.
Collaboration across the key dental stakeholders is vital if workforce reforms are to be successful. This includes clarity about funding responsibilities (between the Commonwealth and jurisdictions). Two initiatives which have improved collaboration are the National Oral Health Plan and the NACDH.
Supporting dental students and the academic workforce
Dental schools in Australia are currently experiencing a shortage of academic dental personnel. A key reason is disparity between the salaries for academics and those of dentists in the private sector.
The academic dental workforce is ageing. Incentives for experienced dentists to join academia and strategies to retain current academics (for example, ensuring flexible employment conditions) are vital.
The Australian Rural Health Education Network (ARHEN) submitted a submission proposing a new program for supervised clinical training for final year dental students on placement with a UDRH for 12 or more weeks. Clinical training would occur in public dental services and students would deliver services supervised by a qualified dentist/academic. The program model is based on principles of community-engaged learning and teaching and service learning.
University dental schools support the activities undertaken by the UDRHs to increase dental education and training in rural locations. There is potential for greater collaboration with UDRHs, with an increased number of dental students taking up rural training placements.
The Australasian Council of Dental Schools provided advice that economies of scale would allow them to increase their student training target under the Dental Training Expanding Rural Placements (DTERP) program from five to ten FTE with modest additional funding, creating greater opportunities for increased student numbers and longer rotations.
The review supports both the expansion of DTERP and further examination and potential funding of the ARHEN dental education proposal.
Allied health workforce
With allied health being a key part of the primary health care team with a focus on prevention and maintenance of function in the community, it is important that health outcomes from allied health management are better understood.
Collaboration and communication in patient care between allied health disciplines is crucial, particularly given the increased focus in recent years on a more multidisciplinary approach to patient health care.
Further investigation into the overlap of roles/skills between allied health disciplines, and indeed with nursing, should be explored when developing new models of care. The use of allied health in specific areas of extended scope of practice in interdisciplinary teams also merits further work.
Innovation in telehealth and online training as well as development of professional networks for support is required. Inspirational leadership in allied health is required to move services from traditional service delivery to innovative interdisciplinary approaches.
Allied health leadership and management positions are important as they provide allied health disciplines with a “voice” in policy decision making as well as impetus to continue to work towards integrating allied health services into core health service delivery.
Consideration should be given to a Coalition of National Nursing Organisations–type model where allied health stakeholder representatives would meet on, for example a quarterly basis. It is possible that the new Australian Allied Health Alliance could play a role here.
Allied health organisations have been advocating for a Chief Allied Health Officer in DoHA for some years. Additionally, the recent Senate Inquiry into ‘the factors affecting the supply of health services and medical professionals in rural areas’ recommended a rural allied health officer role in DoHA.
The recent establishment of a Commonwealth Chief Allied Health Officer position within DoHA is supported by the review. It will be important for DoHA to consider and liaise with relevant areas to determine the scope of this role and the type of representation that is necessary across disciplines.
Allied health assistant roles
The allied health assistant role is a possible solution to increase access to services in rural and remote communities. Research into the clinical effectiveness and safety of allied health assistants needs to be conducted, to see efficiencies and productivity gains as well as increased access to services.
Rural allied health professionals and local managers appear to be supportive of allied health assistant roles. However, advocacy and peak groups for the sector are less supportive. At the consultative Allied Health round table for this review there were strongly expressed views in favour of increased specialisation in some allied health disciplines and opposition to any erosion of professional boundaries.
Currently, reliable data sources are limited for the allied health workforce across the different sectors and settings. Better data collection across settings should provide useful information for policy development. This is particularly important in regard to the disability sector, with the establishment of the National Disability Insurance Scheme, as well as in aged care.
Chapter 9: Opportunities for reform in program delivery and policy development
This chapter examines recent reforms by DoHA to streamline grants management processes; roles, responsibilities and relationship between DoHA’s Health Workforce Division and HWA and the potential for better alignment; and current arrangements for providing funding support for the operation of organisations representing health professionals.
Grants management reform
As a result of a strategic review in 2010 the Health Workforce Fund (HWF) was established (along with a number of other flexible funds across DoHA) and an updated IT system to streamline funds management was introduced.
The new grant-related funds have been envisaged to provide a reduction in red tape through a simplified application and funding agreement establishment process.
This is consistent with the more general whole-of-government work, led by the Department of Families, Housing, Community Services and Indigenous Affairs under the National Compact to free up non-government agencies from reporting requirements, improve information sharing and reduce over-regulation.
However, the benefits of grant reform have yet to flow through to stakeholders, some of whom continue to report high levels of compliance-based reporting, red tape and the continued involvement of DoHA staff (from multiple divisions of the Department) on questions of detail and process, rather than outcomes. The report recommends that the Department needs to “keep itself honest” by appropriate mechanisms to measure the degree to which reform is actually occurring, including regular feedback from peak groups and stakeholders.
More effectively integrated policy development
Consultations with DoHA staff outside Health Workforce Division in the course of this review indicated that policy proposals developed within DoHA have not always demonstrated appropriate internal consideration of current and future workforce impacts. There would be merit in developing a formal process within DoHA to ensure that, for all new policy proposals or activity streamlining and amalgamating programs an internal health workforce impact statement/check sheet is completed through collaboration between divisions of DoHA.
Program evaluation and risk assessment
During the course of this review, a large number of programs were identified which had been established over recent decades without any evaluation framework or meaningful performance measures. There are a number of programs which have grown out of historically based grants funding, and others which require administration costs out of all proportion to demonstrated health workforce benefits. It is a matter of some urgency that a comprehensive outcomes-based evaluation framework for each health workforce program should be developed. This should be complemented by an assessment of risk management across health workforce programs following this review.
Health Workforce Division and Health Workforce Australia
The National Partnership Agreement (NPA) on Hospital and Health Workforce Reform, which governs the allocation of funding to HWA, is scheduled to expire at the end of June 2013. A broad review of the overarching NPA is expected.
States and territories have not provided funding directly to HWA. HWA has a complex governance structure requiring it to report to all Health Ministers. The CEO of HWA reports to the Board consisting of a Chair, three independent members and nominees from all jurisdictions. Following approval of the Board, HWA then seeks approval from all health ministers through SCoH for major pieces of work.
While there is general acknowledgement that HWA has done valuable and important work, in terms of ongoing program management there is uncertainty from the perspective of stakeholders about HWA roles and responsibilities, as against those of DoHA. This needs to be resolved.
There are three broad options for HWA’s ongoing operation that could be considered in the context of the NPA review:
- HWA becomes a data and policy agency, with a brief to fund innovative or pilot programs, and ceases to manage mature programs;
- HWA takes over the management of selected DoHA programs; or
- HWA operations remain the same.
While the first option has strong advocates, it will be a matter for the forthcoming NPA review to determine which of these options is to be preferred.
Health workforce data
Allied health professional groups expressed a sense of grievance in the course of this review that the need for coherent data for their sector had not yet been addressed, particularly for professions not covered by NRAS.
This review has also revealed some challenges in the sharing of data between organisations, which could be impeding some program outcomes. It has been suggested that overly prescriptive interpretations of the Privacy Act 1988 have been used by some organisations to avoid sharing even de-identified participation data that could be of great benefit to inform policy development and program delivery.
The future unaffordable escalation in health expenditure has been well documented, as has the contribution to future costs of a health system configured increasingly around highly specialised acute care services concentrated in the most affluent parts of the major metropolitan centres.
In seeking to create a health system which is more affordable, more equitable and more responsive to primary health care needs, health workforce programs are a key policy lever. For that reason, this review has focused on measures which might strengthen those programs which are built around the identification of local need and more investment in regionally-based education, training and incentive programs.
Wherever possible, the report recommends consolidation of programs and reduction of regulatory and administrative processes, to maximise expenditure on direct programs. In parallel, local and regionally-based funded agencies need to be given strong incentives, including through contracting and tendering processes toward more formal collaborative structures
Recommendations are outlined in each chapter and a comprehensive schedule of all recommendations is found at page 345.
There are numerous recommendations aimed at more specific administrative or legislative problems raised during the consultation phase of the review. It is hoped that the cumulative effect of these recommendations, some of which are relatively simple, will provide an opportunity to improve the efficiency and fairness of the system. The chair would very much like to thank the secretariat for their hard work, most particularly in organising the consultative roundtables, which were uniformly positive and productive, but also for preparing enormous quantities of background and research material, only a fraction of which is reflected in the material provided here.
The chair would also like to thank the participants in the formal roundtables, and the many individuals and organisations who provided formal submissions and informal suggestions and feedback. A number of Federal Members of Parliament from all sides of politics gave valuable insights about the impact of health workforce issues on the lives of their constituents.
Any mistakes, omissions or errors of fact are mine.
1 There is some discussion of these forthcoming reviews in Chapter 9 of this report.
2 The ‘Medical home’ concept is described in Box 2.4 of the report.
3 The scaling initiative was announced in the 2009-10 Federal Budget as part of the Rural Health Workforce Strategy. It applies to a range of government programs including rural incentive payments and programs with a return of service obligations such as the BMP Scheme, based on the principle of providing greater incentives for more remote areas.