9 The health workforce: innovation, substitution and reform

community. Policy responses to be discussed include the Productivity Commission report and the subsequent Council of Australian Government (COAG) responses. Powerful health professional groups perceived several of the key recommendations in the policy responses as professional substitution strategies which would lead to a diminution of the relative position of their occupational group. In the latter part of the chapter the focus is on the role of professional substitution and delegation models to illustrate the volatile and contested nature of some reform strategies. The health workforce is a perennial problem in Australia, which is usually dealt with piecemeal by increasing either nursing or medical numbers after levels have reached so-called ‘crisis’ proportions, but for these professions it is now becoming an emerging problem as major structural reforms are suggested.

IDENTIFYING THE HEALTH WORKFORCE PROBLEM

Working together to create solutions, as urged by WHO, at local, national and global levels, is inherently complex. The need to draw together a diverse cohort of actors and agencies made up of individual practitioners, health service organisations, professional associations, government agencies of various jurisdictions, and education, health, aged care and community service agencies in both public and private sectors at each jurisdictional level is complicated. Other actors with a stakeholder interest in healthcare range from consumer advocacy groups through to political decision makers.

The definition of the ‘problem’ in relation to health workforce, and the consequent ‘solutions’, are highly contested in each national context because of the multi-professional nature of the stakeholders that constitute the clinical workforce (medical, nursing and allied health professions). This is made worse by the shift in inter-professional authority relations that frequently accompanies workforce reform agendas (Fournier 2000, Hunter 1996). The public perception of the quality and safety of health services, and its nexus to political outcomes, is a strong indicator of the political sensitivity of health policy generally, and health workforce policy specifically.

The recent backlash against overseas trained medical practitioners and the emergence of ‘medical racism’ following the Dr Patel (‘Dr Death’) case at Queensland’s Bundaberg Hospital is reflective of that sensitivity (Haikerwal 2005, and see Ch 15). The contemporaneous concerns about the national supply and regional maldistribution of health service practitioners, and vociferous criticism of the quality of medical education in the public media, for example, anatomy training (Cresswell 2007), has served to portray the health workforce as in ‘crisis’, rather than as a problem to be solved. Workforce indicators, focusing events, and the community’s susceptibility to politicised reports all work in concert to keep health workforce on the policy agenda (Kingdon 1995).

Health workforce as an arena of contest

Hall (2005 p 66), commenting on the inherently political nature of workforce planning, noted: ‘If healthcare policy is a strife of interests masquerading as a contest of principle (Sax 1984), workforce planning is one of the arenas for the contest’. And within that ‘contest’, the concept of professional boundary change or substitution as desirable workforce strategies is one of the most vigorously debated. At the front-line of contestability are the competing positions on how substitution strategies will be put into effect. The discussion on ‘professional substitution’ later in the chapter allows us to make visible one of Kingdon’s important conclusions about how particular constructions of ‘problems’ and ‘solutions’ interact together in a ‘policy primeval soup’ to advance on the political agenda. ‘Getting people to see new problems, or to see old problems in one way rather than another, is a major conceptual and political accomplishment’ (Kingdon 1995 p 115).

Health workforce complexity and multi-professionalism

A feature of the healthcare system in developed countries is the inherent complexity of the multi-professional workforce that provides services. Multi-professionalism has been identified as a key difficulty in health sector organisational reform because of the different values, practices, identity and autonomy of the various groups (Braithwaite & Westbrook 2005; Callan et al. 2007). This complexity is increasingly apparent, both vertically and horizontally, within the workforce. The number of distinct professions and occupations providing and supporting care has grown, as has the internal differentiation within these groups through the emergence of specialities and super-specialties (Weiner 2002). Traditionally a feature of medicine, this progressive specialisation toward speciality-based practice, and some would argue fragmentation, is increasingly evident in the nursing and allied health professions.

The proliferation of professional and occupational categories is well illustrated by attempts to define membership of the Australian allied heath professions. In the original survey a list of 68 ‘possible inclusions’ was ultimately reduced to 13 professions ‘generally included’ as part of the allied health collective. A further 35 were considered as ‘variously included’ depending on the context (O’Kane & Lowe 2003). The general shift over recent decades from conceptualising healthcare as services provided by medical professionals to one in which inter-professional care and teamwork is the dominant discourse reflects the progressive complexity of coordinating care.

Indicators of health workforce problems

Kingdon (1995) has highlighted the importance of indicators for capturing the scope and volatility of ‘problems’. The way in which indicators are presented can suggest certain policy solutions. Quantifiable indicators are valued highly and the health workforce arena is replete with indicators that are eminently ‘countable’. For example:

the ratio of professionals per 100,000 population
professionals in rural geographical areas vis-à-vis urban areas
vacancy rates in health service organisations
graduates per professional education program
changes in practitioner numbers over time
gender ratios and consequences of feminisation on workforce capacity
professionals in part-time practice and their hours
ageing of the health workforce as a percent of the workforce over 45 years of age etc.

The indicators that are the most powerful in shaping the perception of a ‘crisis’ in the Australian health workforce are twofold.

1. Continuing shortages despite a protracted period of growth

The investment in expansion of the health professions is evident from the growth rates reported in the inter-census analysis period of 1996–2001. Table 9.1 (overleaf) shows the growth rates for the key health professional groups, all health occupations and population increase, based on the Australian Bureau of Statistics (ABS) figures (Australian Institute of Health and Welfare [AIHW] 2003). The growth rates for allied health occupations, at 26%, far exceeded that of medical occupations at 12%, and nursing occupations at 5%. All health occupations grew at 11% and population growth for the period 1996–2001 was 6%. More recent data from the ABS for the years 2000 and 2005 showed that the health workforce grew by 26% while all occupations grew by 10% over the same period (AIHW 2006).

Occupation group/Segment	Percent
Table 9.1 Relative growth in Australian health occupations 1996–2001
Allied health occupations^a	26.6
Medical occupations	12.6
Nursing occupations	5.4
All health occupations	11.4
Population growth	6.0
Source: compiled from data from AIHW 2003 pp 20–4
^aData excludes medical imaging workforce (+25.0%), pharmacy workforce (+13.0%) and social work workforce (+26.7%) as these are not included in the ABS allied health category.

Although these growth figures suggest a robust health workforce, the trends related to occupational exits, lower working hours, impending retirements, regional maldistribution and increasing demand for service from the population suggest a different picture. The Department of Employment and Workplace Relations (DEWR) Migration Occupations in Demand List (MODL) specifies those occupations and specialisations in short supply. Twenty-six of the 43 entries in the professionals section of the 2006 MODL are health-related occupations. Table 9.2 shows the occupations listed as in demand. Of the 26, 13 are medical, 8 are from the allied health professions and 3 are nursing. The preponderance of health professions listed to be in shortage in Table 9.2 sits in sharp contrast to the picture of robust growth in Table 9.1.

Health professionals – Migration Occupations in Demand List (MODL) 2006
Table 9.2 Health professions in demand
Anaesthetist	Physiotherapist
Dental Specialist	Podiatrist
Dentist	Psychiatrist
Dermatologist	Radiologist
Emergency Medicine Specialist	Registered Mental Health Nurse
General Medical Practitioner	Registered Midwife
Hospital Pharmacist	Registered Nurse
Medical Diagnostic Radiographer	Retail Pharmacist
Obstetrician and Gynaecologist	Specialist Medical Practitioners (nec)
Occupational Therapist	Specialist Physician
Ophthalmologist	Speech Pathologist
Paediatrician	Sonographer
Pathologist	Surgeon
Source: Compiled from Department of Immigration and Citizenship data. Online. Available: http://www.immi.gov.au/skilled/general-skilled-migration/skilled-occupations/occupations-vin-demand.htm [accessed18 Mar 2007]

2. A projected significant reduction in total workforce entrants: all industries

The figures in Table 9.1 and Table 9.2 relate to immediate past growth and current shortages of health occupations in demand. Adopting a longer term view for the decade 2020–2030, and broadening the labour market analysis outside health to an all-industries perspective, the prospect for a sustainable health workforce are gloomy, despite the relative attractiveness of health careers. Current total workforce entrants (all occupations, all industries) are approximately 170,000 persons. This is projected to decline to 125,000 for the decade of 2020–2030, or a mere 12,500 persons per annum (Access Economics 2001).

Sustainability of new entrant policies

Taken together, the negative direction of most of these indicators has raised issues about the sustainability of the workforce to meet future demand (AIHW 2006). Many of these indicators readily suggest solutions on the supply side of the workforce capacity dynamic; that is, to ‘pump prime’ places for more students to enter the professions. The policy task is ‘easier’ at the front end of the workforce pipeline. Creating more student places is an easier implementation task when considered against the relative difficulty of ascertaining why professionals are leaving the industry, reducing their hours, or retiring early, and then developing the multiple policy responses needed to reverse these trends (Black et al. 2004). Policy instruments which must be carried out at the organisational or workplace level of diverse health service organisations are inherently more difficult because their implementation is open to shifting levels of commitment and resourcing by organisational-level leaders in the various state and territory jurisdictions.

Policy approaches, which rely extensively on funding new student places, particularly for medical students, have been criticised for unduly draining resources from other effective public health strategies. Reflecting on the American case, Weiner (2002 p 161) argues, ‘US taxpayers now contribute more than $500,000 to train each MD [doctor of medicine]. Moreover, an active US doctor typically generates at least that much in annual healthcare spending. If the real goal is to improve the population’s health, there are many other ways to use such massive resource infusions’.

Gathering rigorous qualitative and quantitative empirical evidence rather than relying on assumptions about the motivations for workforce participation is essential. The motivations cannot be assumed to be identical across professions; for example, it is an assumption that motivators and stressors for nursing are identical to those in the allied health professions. Nor should the individual professions be reduced to a homogenous set of interests. Robust sampling strategies are needed to discriminate between generational, gender and lifecycle segments within the professional group so that policy initiatives are not blunt instruments.

Profession-centred workforce planning

A major problem with the traditional profession-specific approach to workforce planning is the failure to grasp, and respond to, the inherent interdependence between the professions when in practice settings. ‘Pump priming’ in one area can produce a dramatic downstream problem for the interdependent professions that received no such equivalent stimulation. Stimulation of medical student numbers will place significant demands on the nursing and allied health professions (and health service infrastructure) once those graduates enter practice, particularly if those other professions are not simultaneously stimulated at the entry-point level. To prevent this type of maldistribution of health practitioner resources every policy and funding response for one professional group should be analysed against the implications from a whole-of-health workforce perspective. The creation of federally funded additional student places continues to be a common policy response. For example, Australian medical schools will see domestic graduates rise by 81% in the 7-year interval between 2005 and 2012 from 1348 to 2442. The rate of growth has been accompanied by predictions of serious downstream resource implications for postgraduate medical training (Joyce et al. 2007). The Australian Medical Association’s (AMA’s) submission to the Productivity Commission Review of the Health Workforce in 2005 recommended that all government spending decisions related to health policy should require a ‘health workforce impact statement’ (AMA 2005).

Within the Australian context, the thrust of health workforce planning and analysis has been consistently preoccupied with the medical profession, and cyclically concerned with the nursing profession (Australian Health Workforce Officials Committee 2003, Brooks et al. 2003, Hall 2005, Joyce et al. 2004). Despite their importance to the much vaunted ‘healthcare team’, workforce knowledge and research in relation to the allied health professions is rudimentary in terms of methodological approach, and lacking in comprehensiveness both in Australia and internationally (Australian Health Workforce Advisory Committee 2004).

The implementation of formal workforce advisory committees at the national level under the auspices of the Australian Health Ministers’ Advisory Council (AHMAC) reflects this difference in focus between the different professional segments of the clinical health workforce. The Australian Medical Workforce Advisory Committee (AMWAC) was established in 1995 and has produced over 40 reports. The Australian Health Workforce Advisory Committee (AHWAC) was established in 2000 and has produced a dozen reports focused on the nursing profession. Responsibility for the allied health professions was added to AHWAC 4 years later with one major report produced. These committees were restructured in June 2006. The AHMAC established a series of principal committees to advise it on priority issues. The Australian Health Workforce Officials’ Committee (AHWOC) has been replaced by a new Health Workforce Principal Committee which will coordinate all of AHMAC’s workforce subcommittees. The various state and territory jurisdictions have produced a further range of reports that reflect a similar differential focus on these professions (AHWOC 2003). Given that the health professions work in an interdependent fashion in patient care settings, the primacy given to profession-centred rather than service-centred workforce planning models is increasingly recognised as ineffective for developing sustainable whole-of-workforce planning models.

New models of workforce planning

Despite improvement in modelling and underpinning data over the past decade, the outcomes with health workforce planning using profession-specific approaches have not been immune to the swinging pendulum effect of shortage-surplus-shortage (Hall 2005). On the supply side, it takes long periods of time to effect changes, given the length of time a new student entrant reaches full practice. Yet, labour markets for health professions can change very quickly, as has been observed from the recent sharp downturn in employment opportunities in the UK’s National Health Service (NHS). Aligning supply and demand, and monitoring the dynamic nature of labour markets is a difficult balancing act (Joyce et al. 2004).

The narrow focus on profession-specific workforce planning models has been responsible for a lack of integrated planning around major healthcare categories or disease profiles. Little work has been done on advancing alternative planning models but significant attention has been paid to refining existing approaches over the past decade. This overarching whole-of-profession work needs to continue, but complementary work at the level of services and patient populations needs to progress rapidly. A ‘planning how to plan’ process has been conducted recently at a national level on the prospective of a ‘models-of-care’ workforce planning model (AHWAC et al. 2005). Some pilot studies have been conducted by the states using variously defined ‘models-of-care’ or ‘models-of-service’ approaches. Potential advantages of a ‘models-of-care’ approach to workforce planning outlined by the ‘planning to plan’ process referred to above (AHWAC et al. 2005 p 8) included a greater emphasis on:

a consumer focus
alignment with service delivery plans
multi-professional/multi-occupational approach capability
a holistic approach to workforce issues.

One of the major planning difficulties underpinning a models-of-care approach is the lack of rigorous data for the array of professions that constitute the teams that deliver services in specific clinical settings. Such attempts at inter-professional planning will be impeded by the weak link in the chain, that is, by the low knowledge base about professions other than medicine and nursing (Boyce 2004). Buchan and Poz (2002), in their review of the evidence on skill mix and its role in health service planning, stressed that there was no skill mix algorithm that could be applied across contexts. Prescriptions about universal or ideal skill mixes are a misnomer. Skill-mix planning needs to start from the specific analysis of the patient population in question and their health needs in order to determine the type and mix of staffing required. This level of context-specificity points to the importance of localised workforce methodologies guided by national overarching policy instruments.

The preceding discussion focused on trying to capture the scope and nature of some of the policy problems that beset the capacity to undertake rigorous health workforce planning. The next section turns to examining the key recent policy responses that have been undertaken to respond to the growing policy panic surrounding the sustainability of the health workforce. The discussion centres on the development of the National Workforce Strategic Framework, the Productivity Commission review and the Council of Australian Governments’ (COAG) responses. From there we engage with some of the policy issues inherent in future strategies, such as professional substitution.

THE POLICY RESPONSE TO THE HEALTH WORKFORCE ‘CRISIS’

The challenge of health workforce problems has led to a series of high-level responses that have attempted to draw together a coordinated response across the many constituencies that have a stake in how the health workforce is reformed. Creating a policy infrastructure that has an overarching coordination focus to guide the developments at national, state, territory and regional levels is seen as a high priority. AHWOC, together with its subcommittees, was a forum for coordinating efforts across jurisdictions and developing a number of national strategic frameworks. Although the series of advisory committees managed under the auspices of AHMAC were reorganised in mid 2006, the work done by the AHWOC, AMWAC and AHWAC has been instrumental in building a body of work to provide the basis for a series of national plans with more rigorous policy analysis and development. AHMAC has also auspiced a number of working groups and taskforces to examine specific workforce issues. These include the: