Health care falling victim to turf wars

The Productivity Commission Health Workforce Study (pdf file 1.52MB) released in January recommends a standing committee advise the relevant minister on the feasibility and appropriateness of changing services covered under the Medicare Benefits Schedule (MBS).

Recommendation 8.1 addresses the question of whether any areas currently the exclusive domain of medical practitioners can be undertaken reasonably and safely by non-medical practitioners - and funded under the MBS scheme.

Not surprisingly, groups like the Australian Medical Association (AMA) and the Australian Doctors Fund (ADF) have come out against the notion.

Even more recently, Stephen Leeder published an article in The Australian (8 February), and subsequently reprinted in On Line Opinion, calling for general practice psychologists to be funded through Medicare. It would be safe to assume Dr Leeder will come under attack for floating the idea as well.

After the Commission handed down its report, the AMA protested the idea of role substitution. In a media release in January, the AMA’s vice-president, Dr Choong-Siew Yong, said “proposals to replace doctors with lower trained and lesser trained health workers is totally unacceptable”.

Also, late last year - and aware of draft proposals coming from the report - the ADF published a response to the draft proposals, commenting on the notion of task substitution.

In particular reference to nurses, the ADF said the imposition of university education for them was responsible for a fall in nursing numbers, together with unrealistic expectations that they may engage, or yearn to engage, in quasi-medical activities.

The ADF called for a return to the hospital-based apprenticeship form of training - clearly the nurses were thinking well above their station!

Sharp debate over role delineation is commonplace in the health industry, occurring for instance between the various nursing divisions where one historically, lesser trained group aspires to a role or task traditionally the turf of the higher trained group.

When health professionals in many disciplines are thin on the ground, the public become unwitting victims of these internecine struggles, irrespective of the profession involved. And, in this instance, the Productivity Commission report’s recommendations appear to have given rise to just such an unproductive tussle.

Arguments against role and task, and role substitution, are littered with the notions of quality, expertise and accountability.

In the AMA’s August 2005 media release leading up to the report’s release, its current president, Dr Haikerwal, is quoted as saying, in clear objection to the concept of role or task substitution, “We must put an end to any moves towards sudden or forced role substitution”.

He goes on to add, “Australia has a world-class health system. To keep it world class, we need world’s best solutions, not second best.”

The introduction of role substitution has not been sudden, or forced. It has been steadily evolving, particularly within the public sector where it has been seen as safe and expedient for a nurse and allied health workers to undertake an expanding number of tasks.

And the AMA is correct when it represents Australia as having a world-class system. That is an incontestable fact - but equally incontestable is that role and task substitution have been a widespread trend within our health sector for years.

Section 8 of the Productivity Commission’s report lists areas of practice that professionals other than doctors are already undertaking.

From that list you can draw countless individual tasks formerly done by medical practitioners, now done by others: it’s a strong feature of our world-class system already.

The report goes on to list other areas that also may lend themselves to task or role substitution. Given the extent of role and task substitution that we are more than happy to live with today, the quality and safety argument starts to look a little less potent.

The argument is further diluted when one considers the AMA supports the notion of “task delegation”, but opposes “task substitution”. The definition doesn’t alter the fact that non-medical people are doing the task.

In terms of getting the job done, however you describe it, the outcome is the same. One of the differences here though is that “substitution” is potentially linked to MBS funding while “delegation” is not.

It would be churlish to suggest this debate is all about money. But it would also be naïve to accept the argument that it is solely about quality and safety, given the realities of our system today.

There is clearly an unmet need for healthcare services in Australia, and ageing will exacerbate the demand. It is therefore time to seek out a new paradigm for delivering health services under the weight of that unmet need.

The Australian Government has the report before it right now. The recommendations offer some possible paths towards safe change in the face of significant workforce challenges, and deserve serious consideration and prompt action.

The Australian public deserves better than to be asked to stand by and watch while the professions engage in what is essentially little more than a turf war.