CHAPTER 6 The health workforce
This chapter describes the health workforce, how it is organised, the role of professions and the way regulation and accreditation operate. It concludes by discussing some of the health workforce trends and issues that have emerged and the responses that have been developed to deal with them.
The Australian health professional labour force is made up of 450 000 health workers who have a professional qualification in health. Not all health professionals in the labour force work in health services. Some people leave the health workforce to retire. Others have a health profession qualification but take up positions in management, administration or education. Others leave the workforce for family reasons or illness. The health workforce is therefore those people who actually work in health settings. Only about 75% of the professional labour force is employed in health services (Australian Productivity Commission 2005).
Registered and enrolled nurses are by far the largest labour force group (43%). Nursing assistants and personal carers make up 11.2% of the labour force. Medical practitioners are 11.5% of the total and allied health professionals, including physiotherapy, psychology, occupational therapy, speech pathology, podiatry, audiology, dietetics, prosthetics, orthotics and orthoptics, are 8.6%. Smaller groups include dentists and dental technicians and assistants (5.8%), medical imaging (1.8%), medical scientists (2.6%), ambulance officers and paramedics (1.5%). Complementary health workers, including naturopathy, herbal medicine, massage, acupuncture and traditional Chinese medicine, comprise 1.9% of the professional health workforce (Australian Productivity Commission 2005).
A straightforward approach to understanding the way the health workforce is organised is to consider pathways consumers follow when they become ill and the settings in which services are provided. This section sets out the main pathways for consumers, and explains the role that various professionals play and some key features of their working conditions.
A number of health services are available to people directly in the community. These are often called primary care services. Primary care services can be accessed directly by consumers in the community without the need for referral.
Most commonly, when people experience illness, they first consult a general practitioner (GP). If the condition is uncomplicated, GPs will take the role of the primary or main practitioner for assessment, treatment and management. GPs often refer patients to pathologists and imaging services for diagnostic information to assist them with assessment. They frequently prescribe pharmaceuticals as part of their treatment and increasingly they refer to allied health professionals such as physiotherapists and psychologists to assist them with their treatment.
General practitioners are private practitioners who generate their income through fee-for-service payments, much of which is reimbursed by the Commonwealth Government through the Medicare program. By and large, GPs work during the day with some extended hours during the evening. They are usually not available late at night and only provide limited services on the weekend. Out-of-hours services are provided by locum services.
Most dentists practice privately in the primary care sector. Only a limited range of services attract a Medicare rebate. Private health insurance is available for dental services, but consumers can expect to have to meet significant out-of-pocket costs. A limited public dental scheme is available for people on low incomes in most states and territories. Apart from state- or territory-operated dental hospitals, dental services are usually only available during office hours.
Pharmacists in the primary care system operate as private practitioners who either own or work in pharmacies where they are paid for dispensing pharmaceuticals through the Pharmaceutical Benefits Scheme (PBS). They also earn income through a range of over-the-counter medications provided through the pharmacy. Generally, pharmacists in the primary care system are available during office hours, but a number of pharmacies provide extended after-hours services at night and on the weekend.
More recently, increasing numbers of people have been making use of the complementary health care system when they become ill or in order to optimise their health. Complementary health professionals are private practitioners who earn their income through fee-for-service payments. For some practitioners reimbursement is available from private health insurance, but these arrangements are very limited.
Uncomplicated primary care involves assessment and treatment over one or a series of episodes provided by a single practitioner, sometimes supported by an assistant (e.g. dental care). Usually the health condition resolves within a relatively short period of time and there is little need for additional care or the involvement of other health professionals.
For less frequent or more complex conditions or those that require highly specialised skills, GPs will make referrals to specialist medical practitioners (e.g. cardiologists, dermatologists, psychiatrists, ophthalmologists). These specialists may in turn make referrals to other specialists (e.g. surgeons), manage the condition themselves or provide advice to the referring GP on treatment. Often, specialists will function like primary care practitioners, working on their own with limited support to address patient issues.
Specialist medical practitioners practice either privately and provide services directly to consumers and to hospitals, or they are employed in staff positions by hospitals. Medicare rebates are available for services provided by specialist medical practitioners.
For more complex conditions which require intensive support and treatment, services are provided through hospitals. Hospitals integrate a range of general and specialist assessment, treatment and support services around the patient. Rather than operating individually with limited support, hospital staff are organised in multidisciplinary teams. Most staff in hospitals, apart from specialist medical practitioners, are employed by the hospital on a salary. Nurses are by far the largest group and they are the mainstay for running the hospital, along with resident medical officers. They work day, afternoon and night shifts to provide services to patients.
Whereas GPs generally act as the ‘gatekeeper’ for access to specialist services, specialist medical practitioners are generally the ‘gatekeepers’ for access to planned hospital admissions, although GPs continue to be able to admit patients to smaller rural hospitals. Most commonly, specialists admit people to hospital for surgery or more intensive investigations of their conditions. Patients admitted for surgery by their specialists will undergo preparation, surgery and post-operative care while they are in the hospital. Some will also need more intensive care. However, as a result of improvements in technology, increasingly many more straightforward surgical procedures do not require patients to be admitted to hospital overnight. These are referred to as same-day procedures because patients undergo pre-operative preparation, surgical procedures and post-operative recovery in the one day and return home for care. The other major route for hospital admission is through the emergency department. Emergency admissions usually involve intensive and specialist care for people experiencing life threatening or extremely painful, disabling or distressing trauma (e.g. motor vehicle accident) and acute illness (e.g. pneumonia).
Often the first professionals to respond to emergencies are paramedics who staff ambulance services. They provide emergency care to stabilise patients at the scene of the emergency and then transport them to the Emergency Department. Paramedics are generally employed by specialist ambulance services. Emergency Departments in hospitals are staffed by multidisciplinary teams of medical practitioners, allied health staff and nurses employed by the hospital who specialise in emergency treatment. When they determine someone is seriously injured or ill, the patient will be admitted to stay in the hospital and becomes an inpatient.
Patients who are admitted to hospital will be cared for in hospital units or wards with other inpatients. A range of assessment and treatment services are then provided by medical practitioners, nurses and allied health professionals. Inpatient acute services are organised around multidisciplinary teams of staff who provide care in general and specialist wards or units based on patient groups (e.g. maternity, psychiatric, surgical). The units are staffed by nurses and resident medical officers and specialist departments (e.g. cardiology, oncology, obstetrics, radiology) — staffed by specialist medical practitioners, nurses and allied health professionals — that provide services to the units.
When hospital inpatients have recovered sufficiently from their surgical procedures or acute episode of illness they are discharged from the hospital. Hospital staff will usually prepare a discharge summary and plan which is provided to the patient’s GP if the patient is returning directly home. Where post-discharge care is needed, this is often provided by the GP or through hospital outpatient services where specialists continue to see patients who have been admitted.
Sometimes, following treatment for acute illness in hospital, patients remain too disabled or ill to return home. In these circumstances they may be admitted to a specialist sub-acute facility. This commonly occurs with conditions such as severe spinal injury, cerebrovascular accidents (strokes), and psychiatric conditions. These facilities are staffed by specialist medical practitioners, allied health staff and nurses who provide assessment and rehabilitation services to assist people to recover from their injuries and illness to function as independently as possible. Once rehabilitation has been completed, people either return home or, if they are unable to manage independent living in the community, they are admitted to a residential care facility. These facilities are generally staffed by nurses, assistants and allied health staff who provide ongoing care in a supported environment that seeks to maximise the quality of life for residents.
People who are dying as a result of their illness or injuries (terminally ill) may be admitted to a palliative care service, either at home or in a hospice. Palliative care services are staffed by specialist medical practitioners, nurses and allied health staff who try to ensure death is humane, dignified and painless, and that relatives and friends are supported through the process.
Increasingly, treatment, care and support for more complex conditions has been provided at home and in the community. This is particularly the case for chronic conditions such as mental illness, diabetes, heart disease, cancer and chronic obstructive pulmonary disease (COPD). These conditions usually last for more than six months and treatment is focused on managing symptoms, pain, distress and discomfort to optimise quality of life and independence rather than trying to cure the condition. Primary and community care is provided by GPs and specialist medical practitioners, community nurses, allied health practitioners and support staff. Sometimes these services are organised through primary and community service providers (e.g. community health services). At other times they are organised through hospitals (e.g. hospital-in-the-home, rehabilitation-in-the-home) or residential care service providers (e.g. community aged care packages).
When more complex, intensive or ongoing assessment, treatment and support is needed, professionals are organised into multidisciplinary teams. This often involves admission to a hospital, sub-acute service or residential care. But more recently, a range of more intensive services have been provided in primary and community care settings.
Pause for reflection
Multidisciplinary teams are common when treatment and care is complex and/or intensive. Consider multidisciplinary teamwork during a surgical procedure and to support someone dying of cancer at home. What do you think the differences in the way these two teams will operate will be? Why are multidisciplinary teams necessary? What are the key attributes of these teams?