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Addressing some important questions on scope of practice reforms

Introduction by Croakey: Following our recent #CroakeyLIVE webinar on the national scope of practice reform agenda, patient advocate Jen Morris reviewed the discussions, and identified three key questions of concern for people who use health services.

Below she explains why these questions need answering – and we also bring responses from the panel:

  • Professor Mark Cormack, who is chairing the Unleashing the Potential of our Health Workforce – Scope of Practice Review
  • Professor Stephen Duckett, an Honorary Enterprise Professor in the School of Population and Global Health and in the Department of General Practice at the University of Melbourne
  • Carolyn Heyes, president of the Australian Society of Medical Imaging and Radiation Therapy (ASMIRT), which sponsored the webinar.
  • Antony Nicholas, the Chair of Allied Health Professions Australia (AHPA).

Jen Morris writes:

With many competing interests and agendas in play, it is critical that the safety and needs of people who use heathcare are prioritised above all else in the design and implementation of scope of practice reform.

Below I identify three issues about these reforms that are of concern to consumers, and pose some related questions for the panel. I thank the panellists for their time and consideration in providing responses.

1. Address drivers of healthcare need and demand

The scope of practice review is occurring on the background of an omnipresent narrative about a healthcare system unable to keep up with need/demand. Proponents hope relieving this pressure will be one benefit of these reforms. It remains unclear whether scope of practice reform will decrease per capita healthcare need or use over time, or merely distribute it differently across professions and service

If the latter occurs without adequately addressing drivers of healthcare need, there is a real risk bottlenecks in the system will simply be shifted, not dissolved – overwhelming allied health and nursing services. Many consumers already face great difficulty accessing allied health services due to a lack of service/practitioner availability (for example, psychologists and speech pathologists).

People who need healthcare have the right to accessible, safe, high-quality care that meets their needs. However, we are all better off if we don’t need (non-preventative) healthcare in the first place.

We have much to lose if, on the highway to addressing need with ever greater healthcare expansion, we bypass prevention through social determinants of health. Without the latter, scope of practice reform, and other initiatives like it, will be no long-term remedy.

We need to get real about addressing preventable drivers of healthcare need and demand through non-healthcare measures. A society conducive to good health – whether through cleaner air, early childhood education, food security, community sport or social connection – is the best way to reduce healthcare need.

We must also ensure scope of practice reform plays a role in reducing uses of healthcare resources that increase demand, but do not primarily serve true consumer need. These include existing problems with system inefficiency (for example, low-value ‘gate-keeping’ touch points), problematic clinical practice (for example, over-servicing or counter-to-evidence practice), and integrity issues (for example, Medicare non-compliance and fraud).

Q: How might scope of practice reforms promote public health and illness prevention? What is the risk they will entrench healthcare-centric health policy, over addressing social determinants of health? How might these reforms impact on healthcare resource uses that do not primarily serve consumer need?

Professor Mark Cormack: “The policy reform options outlined in the Scope of Practice Review collectively aim to:

  • Strengthen the primary healthcare system through addressing structural workforce design, development and planning barriers (Options 1-3) to health professionals working to their full scope in teams to better prevent and treat illness, keep people well and avoid preventable hospital admissions or more serious illness.
  • Funding and payment policy reforms (Options 7 &8) focus on aligning payment models around the needs of the patient / consumer and the available health professional skill sets to meet those needs. The Scope of Practice Review is proposing a rebalance of payment models away from a predominantly fee for service (FFS) system which supports and encourages single discipline approaches to primary healthcare. It proposes a new blended payment model which encourages team based, multidisciplinary care for those patients who need it. This change can support a focus on value of care, not just volume. FFS will remain a key component of payment arrangements, recognising its value in supporting high volume, episodic care for many conditions.”

Professor Stephen Duckett: “Scope of practice reform, by itself, will probably have little impact on public health and illness prevention. But importantly it is not the only change occurring at present, and the development of multidisciplinary teams in primary care will, in my view, have a greater impact. Hopefully the new Centre for Disease Control will also have an impact.”

Carolyn Heyes: “Scope of practice reform will promote public health and illness reform by assisting patients to access the services they need in a timely manner. If they do not need to return to their GP for referrals, they are more likely to access the services required. Saving time by not having to wait for GP appointments can save a week or significantly more of wait time.

There is a significant risk they will entrench healthcare-centric health policy, over addressing social determinants of health; if the current primary providers feel they may be left out the patient care loop or worry about losing income, they may lobby to block the reform. Good information must be provided to ensure that a system such as my health record is utilised to keep the primary providers ‘in the loop’.

As to how these reforms might impact on healthcare resource uses that do not primarily serve consumer need: Ideally no profession should be disadvantaged. Any care that the consumer/patient needs should be available to them.”

Antony Nicholas: “The scope of practice reforms do not yet articulate options for better aligning the allied health activities funded by our health system with the preventative focus of many allied health professions.

While consideration of social determinants and use of approaches such as social prescribing are at the core of much allied health training, barriers imposed by funding limit practitioners in providing care that focuses on those aspects of consumer need. Medicare allied health funding is extremely limited with the Chronic Disease Management (CDM) program – the primary funding option for consumers needing non-mental health services.

The program does not allow allied health professionals to provide services focused on prevention. The CDM program also imposes an annual limit of five short duration services, regardless of how many of the 13 eligible allied health professions might be relevant, or how complex the person’s needs are. This aligns poorly with allied health practice, which typically involves multi-session programs of care, often in the community, and with a focus on understanding the broader environment and needs of the consumer.

The scope review has identified the barriers that funding policy imposes on allied health practice. Full scope allied health practice is broader than health and recognises the need to fully consider the person and their individual needs. It is our hope that the final recommendations focus on the need for funding to more fully enable allied health services, and that the Commonwealth moves to implement much-needed changes.”

2. Safeguard consumer choice

Any model of care arising from scope of practice reform must ensure consumers have reasonable, equitable opportunities to choose their healthcare providers, if they wish.

Consumers’ ability to choose their providers is already inequitable – based on factors such as financial means and geography.

These reforms have the potential to increase consumers’ ability to choose their healthcare providers (for example, by making in-community allied health and nursing care more affordable).

However, depending on the model chosen, they also have the potential to reduce consumer choice. For example, locking consumers into engaging with a ‘preassembled’ multi-disciplinary team unsuitable to their needs (such as primary care practice ‘enrolled patient’ models), or enforcing a ‘hurdle requirement’ to see an allied health provider unsuitable to a consumer’s needs before they can access necessary higher-level care.

Regarding healthcare providers, ‘what good looks like’ is different for different people.

Many consumers need or prefer to assemble their own care team. Some consumers prioritise providers who speak their language, share their values, are of the same sex, are knowledgeable about their uncommon condition, or whose approach they experience as culturally safe. Others need providers close to public transport, or who use accessible equipment.

Notably, healthcare participation for consumers from poorly-served and priority communities can be particularly sensitive to such factors.

Q: How will scope of practice reforms increase equitable consumer access to choice of healthcare provider? What are the risks for consumers if this does not happen?

Professor Mark Cormack: “Proposed reforms do not reduce choice. The proposed payment changes, i.e. increase blended and block funding models, are designed to broaden the range of healthcare services that can be offered to consumers based on their assessed needs, rather than confining it only to those services on the MBS. Current FFS payment models limit access to multidisciplinary care and reduce that choice through financial barriers.

The scope of practice reform proposals are built on the Strengthening Medicare reforms and this includes voluntary enrolment with a home practice i.e. My Medicare, for people with chronic complex conditions. The evidence underpinning this model is very strong and offers more patient centric, better planned, and comprehensive multidisciplinary care for this large and growing population of consumers. Consumers can continue to choose their practice /provider under this model, and also whether they opt into the My Medicare model.”

Professor Stephen Duckett: “Again, an important adjunct to changes in scope of practice is funding reform to allow changed potential scope to be operationalised as changed affordable or realised scope. If funding reform facilitating equitable access does not occur, then we have missed an opportunity.”

Carolyn Heyes:

Q: How will scope of practice reforms increase equitable consumer access to choice of healthcare provider? 

“The reforms should allow the consumer access to the providers they require. They should not be limited to those that have alliances/ agreements with other healthcare practitioners. Consumers should always have a choice as to who is looking after their health.”

Q: What are the risks for consumers if this does not happen? 

“We may end up with a non-satisfactory system for consumers. If a consumer is referred to a healthcare professional they are not happy with – there can be a variety of reasons such as not building a rapport, ease of access due to limited appointments, and various other reasons, then consumers will be worse off than with the current system.”

Antony Nicholas: “If the proposed reforms are successful in allowing an expanded range of health professionals with the necessary scope and training to provide services, and if funding reforms are also put in place, consumers will gain significantly increased flexibility to choose a provider that is accessible, affordable, has the training and expertise most associated with their health needs.

However, without those reforms, consumers will continue to face significant financial barriers to accessing the most appropriate care, multidisciplinary care. The evidence of that impact is clear – those consumers with the least capacity to pay for their own care, and that are the most vulnerable, experience the poorest health outcomes.

For example, a consumer with musculoskeletal pain can currently access an uncapped number of Medicare-rebated GP services, as well as PBS-subsidised medication and Medicare-funded diagnostic imaging services. However, despite best practice care for most musculoskeletal injuries starting with conservative treatment by an allied health practitioner, and despite evidence of the impact of overuse of pain medication in Australia, those services are only available if the person can afford to pay for them, or worse, is hospitalised.

Even if the person can afford to pay for those allied health services, those practitioners are limited by barriers to the Medicare-rebated diagnostic imaging they can request and options for referring for rebated medical specialist services where conservative treatment is not sufficient to meet the consumer’s health needs. This leads to longer wait times, access issues, more costs for both the consumer and Medicare, and often a reduced health outcome for the consumer.

The impact of not undertaking these reforms is that consumers will continue to be funnelled into using those services that are funded, rather than those that best meet their needs, and access to allied health services will remain inequitable.”

3. Implement robust patient safety monitoring and reform

Patient safety must be the first priority in any healthcare reform. In this instance, we must not assume ‘more access’ necessarily means ‘more safety’. It’s possible the opposite is true.

People are undeniably harmed, often severely, by lack of access to necessary, high-quality, timely healthcare. However, as we rightly strive to minimise the harm of not receiving healthcare, we must also confront the uncomfortable reality that many people are harmed in and by healthcare.

At present, approximately one in 10 patients across all forms of healthcare, and four in 10 patients in primary and ambulatory settings, are harmed by their healthcare encounters. This includes many thousands of preventable deaths.

The design and monitoring of the proposed reforms must be rooted in robust evidence and data about patient harm. Care provided under reformed allied health and nursing scopes of practice could be safer, equally safe, or less safe, than current models.

To know which is true, we need comprehensive, robust, large-scale evidence on patient harm in primary care, particularly high scope of practice allied health and nursing care. Not just data about more comfortable measures like cost reductions, waiting times, bed days, or practitioners’ self-reported perceptions of their competence as a proxy for patient safety. We need data specifically about actual patient harm.

Right now, we don’t have enough such data, because research and monitoring of patient harm heavily prioritises acute settings, neglecting primary care, and allied health in particular.

An absence of data about patient harm does not equate to an absence of harm. Governments and research institutions must urgently redress this imbalance if some professions are to take on new, and likely higher risk, patient care responsibilities.

Gathering data is only the first step. Authorities must then be uncompromising in acting upon it concretely in the best interests of patients, even if that action is unpopular among powerful stakeholders.

Widespread patient harm is the harrowing problem ‘the system’ doesn’t like to talk about publicly.

But we have the right to an unflinching, public, whole-of-society response to this pervasive tragedy. Medicare and scope of practice reforms provide an opportune moment for this reckoning. Not least because up to 16.5 percent of the hospital expenditure these initiatives aim (in part) to reduce is the direct result of patient harm events.

Q: What must be done to ensure patient safety is prioritised in scope of practice reforms? What are the risks to patient safety if we go ahead with scope of practice reform, and if we don’t?

Professor Mark Cormack: “The Scope of Practice Review has identified the critical importance of patient safety and clinical governance in both of the published Issues Papers. Any significant changes to how health professionals practice should be accompanied by robust clinical governance and risk based regulatory mechanisms. The Final Report, due in October 2024 will identify any changed risk profile for patient safety and recommend policy changes accordingly.”

Professor Stephen Duckett: “I think that is the critical issue being addressed in the review: we know that various professions can now safely do more than they are allowed (or have access to funding) to do, and the review is about identifying what changes can be done safely.”

Carolyn Heyes:

Q: What must be done to ensure patient safety is prioritised in scope of practice reforms?  

“The patient must be the only focus in these reforms. If their safety and health are not the priority then the reforms will fail.”

Q: What are the risks to patient safety if we go ahead with scope of practice reform, and if we don’t? 

“If the reforms do not go ahead, then patients will continue to suffer from delayed care and frustrating visits to and from GPs and other professionals for appropriate referrals. In rural and remote areas, this will further magnify the health gap between country and city dwellers. It will also magnify the difference between the socio-economic classes as those that can afford to attend different providers and return to primary clinicians for referrals will receive better care than those who cannot.”

Antony Nicholas: “The scope of practice review reform proposals have the potential to significantly improve the timeliness and appropriateness of care for Australian health consumers by improving access to allied health services, and by allowing allied health professionals to refer directly to appropriate medical specialty services or to request appropriate diagnostic imaging. Access issues, including cost and delays associated with needing to access additional medical services not directly associated with care are key contributors to patient safety. The impact of cost and other access barriers on a range of consumer cohorts are well established as are the poorer health outcomes associated with those. Evidence also shows that increasing the steps and cost required to access appropriate care also increases the likelihood that the person delays or avoids seeking the care they need.

“Importantly, the reforms proposed by the scope of practice review for allied health practitioners do not increase risks for consumers. Allied health practitioners are already university trained, accredited or regulated health professionals. The proposals do not change existing scopes of practice, but rather focus on allowing practitioners to work within their existing scope or knowledge more fully under government-funded programs.

The proposed reforms seek to provide more consumers with more equitable access to the efficient and effective patient pathways and services available to, and used by, those that can pay privately. Given that evidence from AHPRA and other regulators shows that allied health practitioners have very low notification rates (in fact, much lower than medicine or nursing), and that registered or certified allied health practitioners are subject to robust regulatory requirements under AHPRA or their self-regulating health profession, consumers should feel confident in supporting the proposed reforms.”

Author details

Jen Morris is a consumer and community representative working in the health sector, with a particular interest in patient safety, and preventing patient harm. Over the past 14 years, she has worked with over 100 organisations to bring the views and voices of the community and service users to decision-making in healthcare research, education, policy, governance, regulation and safeguarding. She brings her consumer expertise to roles as a healthcare safety researcher, patient safety investigator, board member, ethics advisor, patient experience advisor, accreditor, and advisory committee member. Jen also champions patient safety through academic writing, public speaking, teaching clinical students, and her founding membership of the Society to Improve Diagnosis in Medicine’s Australia and New Zealand Affiliate.


Previously at Croakey


 

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