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Incredibly stressed: how the pandemic is affecting the health workforce and service delivery

Introduction by Croakey: Right across Australia the health and medical workforce is stretched thin and fatigued by COVID-19 outbreaks, lockdowns, border restrictions and the vaccine rollout program.

Workforce shortages are particularly severe in remote, rural and regional communities, and have highlighted Australia’s longstanding reliance on overseas-trained health professionals.

With around 13.7 million people in lockdown in NSW, Victoria and South Australia – trying to suppress the spread of the Delta variant – health leaders are calling for a national strategy to deal with the workforce demands of the pandemic now and into the future.


Linda Doherty writes:

In Western Australia, the remote communities in the Kimberley rely heavily on a fly-in fly-out workforce of remote area nurses who spend six weeks living and working in Aboriginal communities, then rotate for two weeks’ isolation leave and a week of annual leave.

But since COVID-19 arrived in Australia 18 months ago, the nurses – and other health professionals like doctors and Aboriginal Health Workers – have been harder to recruit and retain.

The annual turnover rate of healthcare staff in the five remote communities serviced by Kimberley Aboriginal Medical Services (KAMS) is now 87 percent, more than double the rate of 35 percent a year ago.

Julia McIntyre, KAMS Executive Manager Workforce, said staff have simply got “isolation fatigue” from having to quarantine for 14 days almost every time they entered WA.

Staff had been “incredibly accommodating”, taking leave in Perth or Broome because they could not return home, but KAMS had insisted on paying for their holidays home and for their subsequent isolation time.

“Isolation the first time, even the second time, was probably a bit of a novelty but over 18 months now a number of staff have said ‘I’ll just go and work in my home state for a while’,” said McIntyre.

Nurses account for 65 percent of KAMS workforce in the remote communities of Balgo, Beagle Bay, Bidyadanga, Billiluna and Mulan. Overall, the service employs 290 people and has a footprint across 421,000 square kilometres. Up to 70 staff work in the remote communities.

Compounding domestic recruitment problems is the inability to use overseas staff, who make up a significant percentage of KAMS’ workforce, with registered nurses from New Zealand, renal nurses from the Philippines and China, and a South African GP who is currently unable to enter Australia.

The impact of the staff shortage has resulted in reduced clinic hours, the use of more telehealth, redirection of clinical staff away from working on programs such as smoking cessation, and calls to recruitment agencies in Perth and the Northern Territory.

“But we can’t let it affect the vaccine rollout, that’s absolutely our priority,” McIntyre said. “We have a separate strategy for that, a dedicated FiFo team and the Royal Flying Doctor Service is now working with us to do Pfizer [vaccine] drops.”

Poor national planning

The Kimberley is one of the most remote parts of Australia but across the country health leaders and unions are reporting a clinical health workforce under incredible stress.

Recruitment agencies are reporting high demand, particularly with additional staff needed for the COVID vaccine rollout. A spokeswoman for Healthcare Australia said it was supplying staff for both existing needs and the vaccine rollout program in “an environment where supply of healthcare workers is limited by single site restrictions on workers and an inability to source an international workforce”.

Annie Butler, Federal Secretary of the Australian Nursing and Midwifery Federation, said: “We are seeing five to 10 years of very poor national workforce planning coming home to roost.”

Gabrielle O’Kane, Chief Executive Officer of the National Rural Health Alliance (NRHA), said: “What COVID-19 has highlighted is there is a workforce shortage in rural areas and one of our biggest concerns is workforce fatigue and burnout.

“In rural and regional areas there are already 50 percent fewer health professionals than in the major cities and the pandemic stretches that even further.”

Since 2014, when then Prime Minister Tony Abbott axed Health Workforce Australia there had been no independent body advising on health workforce supply and demand. The Federal Department of Health is working on a National Medical Workforce Strategy but it is well behind schedule and as it was meant to be endorsed by health ministers early this year.

“This timeline may change slightly in light of the current COVID-19 pandemic,” the department’s website said.

Annie Butler said the Federal Government had to better coordinate with the states and territories and the private health system, “because we need to have some forecasting of supply and an understanding that demand is increasing, not just due to COVID but because of population growth and the ageing population”.

“In times of outbreaks like in NSW now, there has to be a sharing of services between the public and private systems, even aged care, as we did in Victoria during its second wave. You have to shut or limit elective surgery and free up the workforce to deal with the crisis you’ve got.”

Nurses on the frontline

Nurses are one of the health professions most affected by the pandemic, in terms of workforce demands and the risk of infection.

“What we’re seeing across the country is incredible stress on both public acute and primary health,” Butler said.

“Every time there is an outbreak, minor or major, nurses are pulled out of acute care and put into increased testing and vaccination. That leaves gaps and we’re hearing from our members across the country they are constantly asked to do extra shifts or double shifts.”

Nurses are also being snapped up by the large state and territory-run vaccination hubs.

Dr Jason Agostino, medical adviser with the National Aboriginal Community Controlled Health Organisation (NACCHO) said funding was available from the Federal Government for additional staff for the vaccination rollout but smaller health organisations were at a market disadvantage.

“There is a real challenge with the inflated rates state health clinics are paying nursing staff to be involved in their vaccination clinics, which has taken them away from the pool available for our health services,” he said.

Hitting the regions

When COVID-19 hits rural and regional areas, the effect on the health workforce can be devastating.

This week Mildura Base Public Hospital put out a plea for more staff after 45 staff had to go into isolation when a man presented to the emergency department and later tested positive to COVID.

Hospital CEO Terry Welch told the ABC that some services had been cut back to keep the hospital’s emergency department operating and health services in Mildura were bracing for more cases to emerge.

Sunraysia Daily journalist Else Kennedy tweeted live updates about the impact on Mildura’s healthcare services and surrounding towns: “Mildura’s experience shows how little it takes to overwhelm a regional healthcare system.”

Remaining Mildura hospital staff had to work double shifts to keep the hospital running, the peak Aboriginal health service, Mallee District Aboriginal Services, had to close and put vaccinations on hold so staff could be tested for COVID-19; and Mallee Family Care, which offers mental health and family violence support, reported increases in calls for help and had to isolate several staff and run services remotely.

“Bendigo rapid response testing team sent a team of 10 to Mildura on Sunday night and managed 750 tests on Monday despite ICT systems going down and staff resorting to pen and paper,” Kennedy tweeted.

Kennedy also documented the community support for healthcare staff: “A local cafe has donated coffees, a restaurant is supplying free meals and the local hardware has delivered heaters to keep workers warm.”

Having to isolate large numbers of hospital staff, as in Mildura now, “is a nightmare”, according to Dr Tony Sara, President of the Australian Salaried Medical Officers Federation of Australia (ASMOF).

In April last year Tasmania closed a public and a private hospital in Burnie due to a coronavirus outbreak, putting hospital staff and their households – more than 1,000 people – into quarantine for two weeks.

Sara said his colleagues at the North West Regional Hospital in Burnie had described how difficult it was to get extra staff and prepare the hospital to reopen.

“The amount of work you have to do, planning, operationalising, infection control processes, to get back to work is unbelievable. It puts pressure on everyone, people are asked to do extra shifts and then you add fear of contagion to that pressure,” he said.

Scared staff

Hospital staff – and their managers – are very scared about the highly infectious Delta variant, Sara said.

“When Liverpool hospital [in Sydney] had its infection scare last week half a dozen staff were ‘locked’ in one of the theatres for eight hours without food or water,” he said.

“People are scared they are going to get infected and they’re aware, of course that the Delta variant is far more transmissible.”

In another recent case, a fully vaccinated nurse at Sydney’s Westmead Hospital tested positive to COVID-19 despite wearing full protective equipment.

The Australian Society of Anaesthetists (ASA) last week called for an urgent investigation into how an anaesthetist contracted COVID-19 after seeing patients at Sydney’s Liverpool and Campbelltown hospitals.

ASA president Suzi Nou said hospital healthcare workers needed a guarantee on safe work conditions and improved personal protective equipment.

“In Australia we have been too slow to recognise the threats facing healthcare professionals. For over a year the ASA has been calling for recognition that COVID-19 is an airborne contagion and that frontline healthcare workers need far improved PPE,” she said.

With predictions that Sydney may be in lockdown until September, the pressures on frontline workers are unlikely to ease anytime soon.

Rural and regional concerns

Rural, regional and remote Australia was already experiencing health workforce shortages well before the pandemic arrived.

Gabrielle O’Kane from NRHA said shortages in rural areas were compounded by the pandemic, including border closures, lockdowns and quarantine requirements, which restricted movement of the health workforce into regional and remote areas.

“Pre-existing workforce shortages are most persistent in small rural towns, which have the largest deficit in terms of health workforce expenditure. Our analysis has demonstrated that these small towns comprise roughly three-quarters of the total $4 billion rural deficit,” she said.

“Medical practitioners, nurses and midwives and allied health professionals all face significant undersupply issues in rural areas.”

In a worrying sign, COVID-19 vaccination rates are currently lower in rural areas than in the cities.

“The latest information we have from the [Federal] Department of Health is that vaccination doses per 100 people in the population is approximately 25% less in inner and outer regional areas and approximately 50% less in remote and very remote communities,” she said.

One positive development welcomed by NRHA has been the opening up of the vaccination program to community pharmacists.

A spokesman for the Pharmaceutical Society of Australia confirmed to Croakey that community pharmacists had started delivering vaccinations in Queensland, Victoria, NSW and South Australia – largely in rural and regional areas. By the end of July it was expected that 300 pharmacies nationally would be offering vaccinations.

Shortages in Indigenous communities

Staff shortages are affecting healthcare services in Aboriginal communities in the Northern Territory, with five government-run clinics across Central Australia operating at reduced capacity.

John Paterson, Chief Executive of the Aboriginal Medical Services Alliance (AMSANT) in the Northern Territory, told The Sydney Morning Herald he was concerned about the effect of staff shortages on the vaccine rollout program.

“Some of our remote communities are experiencing that workforce [shortage], and it’s impacting on a very successful, good process for rolling out the vaccination,” he said.

Dr Dawn Casey, deputy chief executive of the National Aboriginal Community Controlled Health Organisation (NACCHO), told the SMH that overall the national vaccine rollout for First Nations people was progressing well and staff shortages had not halted the rollout in remote communities.

The Royal Flying Doctor Service has been brought in to help Aboriginal Community Controlled Health Organisations (ACCHOs), and federal, state and territory governments with the vaccine rollout, and expects to deliver 50,000 vaccines by the end of the year.

An emerging issue for Aboriginal medical services is the Federal Government’s decision in the recent Budget to restrict telephone telehealth from July 1 to short and standard consultations and make long consultations available by video only. The measure was later wound back for patients in declared COVID-19 hotspots, who can still talk to their GPs for longer on the phone.

NACCHO’s Dr Jason Agostino said medical services that were already short-staffed relied on telehealth but some of the Medicare Benefits Schedule items were removed. “It was super bad timing and done without any consultation”.

“We’ve heard from our services that these changes are really hurting them. With issues of cost and connectivity, Aboriginal and Torres Strait Islander people are much less likely to have access to video and they have a greater need for these long consults,” he said.

The Australian Medical Association also opposed the change to longer consultations by video. AMA president Dr Omar Khorshid said telephone consultations were critical for patients with complex health needs.

“The latest COVID-19 outbreak in Sydney has demonstrated consultations with GPs via the telephone remains critical for patient safety and access during lockdowns,” he said in an AMA media release.

“For many patients, using the telephone is their preferred method and it helps ensure that people, who lack technological expertise of videoconferencing software or don’t have access to adequate internet speeds, are not denied access to essential GP services.”

Sense of helplessness

CRANAplus, the peak professional body for the remote and isolated health workforce, said the pandemic had made it so difficult for some staff who work remotely that they were considering leaving the sector.

The agency offers a 24/7 phone support line to remote health professionals and their families and while calls are confidential some common themes have emerged.

“The workforce is certainly fatigued, more so than we’ve seen before. This is particularly concerning when remote health professionals typically work with grit and great resilience,” Chief Executive Officer Katherine Isbister said.

Access to locum and agency staff was still impacted by border closures, resulting on existing staff being asked for contract extensions or to cancel leave.

“Leave cancellations and the inability to take regular breaks away from their isolated posts is undermining resilience. These breaks are important for recharging and reconnecting with family and friends, who often live vast distances away,” Isbister said.

“Many in the workforce are concerned about their older relatives and parents and how they are faring during the pandemic. This concern is cumulative so as the pandemic continues, the concern increases. There is a sense of helplessness around this.”

Border constraints

The pandemic has also thrown into sharp relief Australia’s heavy reliance on overseas-trained health and medical professionals – around 40 percent of the workforce in rural and regional areas and 30 percent in the cities.

The NRHA’s Gabrielle O’Kane said rural areas were already challenged by the current lack of access to workforce supply and had an increased reliance on locums and overseas-trained doctors.

Katherine Isbister from CRANAplus said there was a significant cohort of New Zealand-based registered nurses who moved back and forth between longer contracts in remote Australian locations.

“Most New Zealand RNs went home when the pandemic commenced and have not returned since,” she said.

Tony Sara from AMSOF said the traditional influx of British doctors into WA, in particular, usually from July each year, had also dried up.

But when the Federal Government recently approved visa entry for the British far-right racist commentator Katie Hopkins, many Australians were quick to complain about the double standard when thousands of Australians still remain stranded overseas.

Others, like Spinner Medical Recruitment – which recruits in Australia and internationally for psychiatrists and other medical specialists – raised objections that Hopkins had been granted entry when healthcare professionals were being refused.

“#Australia, How can you give Katie Hopkins a visa but refuse a visa exemption for a consultant psychiatrist, with a job offer from regional mental health service and assessed by RANZCP [the Royal Australian and New Zealand College of Psychiatrists]?” Spinner Medical Recruitment tweeted.

Medical recruiter Alasdair Spinner later told Croakey that the British-trained psychiatrist, who is a United Kingdom citizen currently living in India, had been refused visa exemptions “at least twice”.

“Last year I helped six senior specialists travel to Australia despite the pandemic,” he said. These specialists received visa exemptions between May and December 2020.

“I haven’t moved any in the last six months. You may be aware that it takes 12 months to move senior specialists. During a pandemic stick another three to six months on that due to flight availability.”


Croakey acknowledges and thanks donors to our public interest journalism funding pool for supporting this article.

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