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Securing a healthy system

By Stephen Leeder - posted Monday, 30 January 2006


The recent report from the Productivity Commission offers strong guidance about how to allocate university places to reflect a better balance among those with different views about the development of the health workforce.

The commission proposes that an agreement be struck between the Federal Government and each state and territory "covering the allocation of available funding for university-based education and training of health workers".

"Workforce" is a term that smells of military might and cordite. So the phrase "health workforce" is odd, even contradictory. Health workers regard themselves as professionals who seek to preserve and restore health. If they are aligned at all with the military, then it is with peacekeepers.

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Another view of the health workforce is that of those who are responsible for health services. Those who manage health services ensure that health care is delivered on time, at high quality, where it is needed. They need foot soldiers - doctors, nurses and other health professionals - and they need them now. Yet health service managers feel that they have little or no say in how many, and what type of, health workers emerge from Australian education and training. Why does it take so long, they ask, to train effective practitioners?

Yet another view of the health workforce is held by those who manage Medicare. To them, a healthcare worker, especially a doctor, is a cost generator, like a teenage son on a spending spree with Dad's credit card. Each doctor spends $300,000 (or more) each year in treating sick people when you count Medicare rebates, pharmaceutical benefits and so on. The fewer the better.

As for university managers, they know that medicine, in particular, brings research money to the university, but this can be a drain on infrastructure, taking resources from the training of the next generation in other professions. The intense interest of the Federal Government (the departments of health and ageing, and education, science and training) in numbers of medical student places, the expectation that universities will offer rural training (often handsomely funded) and incentive scholarship schemes: all of this adds to the administrative and political load in universities.

Thus, many parties are interested in health workforce development and their agendas often clash.

Little wonder, then, that there is such intense interest in questions of how many healthcare workers there should be, of what professional brand (GPs, nurses, physiotherapists), what skills they should possess and how they should be educated, trained, financed and managed.

Thus the report of the Productivity Commission, Australia's Health Workforce, has done remarkably well in a short time to address these questions and point to ways in which we might answer them.

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The fifth chapter, devoted to education and training, is of great interest to the tertiary education and training sector. At issue are both the number of funded university positions for healthcare worker students and the curricular style and content on offer.

The report identifies as the first priority a deficiency in co-ordination mechanisms "both within the education and training area and between this area and the other key components of the health workforce regime". Clinical training for medical students is offered as an example, but the concerns of pharmacy, physiotherapy, podiatry and others are similar.

There are too few opportunities for supervised practical education. Universities do not receive adequate funding for these courses.

The commission's approach would mean that the Federal Government would negotiate an agreed number of university positions, state by state, for all health professional training. The distribution of these places, university by university within each state or territory, would remain a responsibility of DEST. Each agreement would be for three years (which seems bizarrely short, in the circumstances).

This would not preclude closer relations between DEST and the Department of Health and Ageing (although the commission is pessimistic about this happening).

The other, lesser, impediment is the resistance of professions to change. This gums up debate about the relation of specialist to generalist education, the mix of roles and tasks among healthcare professionals and the duration of courses.

To address this, the commission proposes the formation, by the Australian Health Ministers' Conference, of an Advisory Health Workforce Education and Training Council. This would advise on opportunities to improve workforce education and training opportunities, including changes to curriculum and accreditation requirements.

AHWETC would represent a significant shift in the control of university health sciences courses in two respects. First, it would offer a more negotiated, responsive solution to the numbers problem (a plus for health service providers, such as the states). Second, it implies greater control over course content and outcomes (for some universities this would not be a plus, but it could open up a new dialogue between educators and service providers and funders).

Both the proposed federal-state/territory university place negotiations and the AHWETC engage the many interests vested in the education and training of our health workforce. They each seek a more discursive and inclusive approach to health service workforce development. This is urgently needed.

If we accept these two proposals, do we see an agenda for action? Yes and no.

We are left with an urgent need for more doctors, nurses and several other categories of health professionals. This should be the first topic for debate at the AHWETC. Strategies are needed so that services can be delivered in unconventional ways, for example by working across the divisions of the health service professions.

AHWTEC should consider the responses of the British Government to the recommendations of the Wanless Report (2002). That report called for radical change in the health workforce, including a rethinking of the roles and responsibilities of different health professionals. This notion that the patient and their needs should be at the centre of workforce discussion contrasts sharply with recent responses to the Productivity Commission Report. Professional bodies such as the Australian Medical Association show no acceptance of expanded healthcare roles for other professions, such as pharmacists, nurses and physiotherapists.

Australia should embark on an examination of what the future healthcare needs of the nation will be and what skills, structural arrangements and health service financing would best serve our needs. The health workforce and their educators cannot be expected to solve all these challenges. Health and health care are everyone's concern and health is an intensely political matter. Sudden decision-making is usually inappropriate. Wide discussion, frustrating to those obsessed with efficiency, is essential. Real political leadership would be timely and welcome.

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First published in The Australian on January 25, 2006.



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About the Author

Stephen Leeder is professor of public health and community medicine at the University of Sydney, and co-director of the Menzies Centre for Health Policy.

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