Introduction by Croakey: In recent conversations with friends and colleagues and in following the news headlines, members of the Croakey team have been struck by some similarities in the challenges confronting teachers and general practitioners.
Croakey editor Jennifer Doggett explores these issues further in the #LongRead below, and concludes taxation reform is necessary if public education and primary healthcare are to fulfill their potential in contributing to a healthier and more equitable Australia.
Jennifer Doggett writes:
Universal public education and primary healthcare are vital to the well-being of our nation and are essential building blocks of an equitable, democratic society. Given their long-term and far-reaching impacts, we all have an interest in ensuring these systems work optimally and deliver the best possible outcomes.
Yet despite their important roles, both these sectors are currently under stress and struggling to respond to the changing needs of the Australian community.
The reasons for this are complex and there are some clear differences between the two sectors. However, there are also some underlying commonalities between the pressures faced by both health and education and the shared challenges for the key professionals in these areas, namely teachers and general practitioners.
School teachers and GPs are not the only professionals in the education and health sectors, and improving the performance of both these areas requires the involvement of a broad range of other professional groups and experts. However, understanding the central role of these two professions can help suggest potential solutions for education and health systems.
For example, both teachers and GPs are generalists with a wider remit than others within their profession, such as university lecturers and other medical specialists who are more narrowly focused.
Both work in sectors where government has extensive involvement as a funder, policy maker and regulator and which attract a high level of interest from the media and the community.
Both professions have also experienced similar impacts of societal changes over the past few decades which have added to the complexity and intensity of their work.
Well-funded and supported public education and primary healthcare have critical roles in promoting greater equity – however, this potential has been undermined by policy decisions over many years that have led to inequitable funding for these sectors.
The trend towards neoliberalism in public policy over several decades has led to an increased reliance on market-based approaches to health and education, and a shift away from a focus on these sectors as public goods. This has led to a reduction in equity of access and outcomes for health and education services with resultant long term implications for Australian society.
For example, the OECD has found that disparities in student performance related to socio-economic status take root at an early age and widen throughout students’ lives. Its analysis of data on mathematics achievement found that the magnitude of the socio-economic gap at age 10 is about 65 percent as large as the gap observed among 15 year-olds and about 58 percent as large as the gap in numeracy proficiency among 25-29 year-olds, demonstrating how these educational inequalities persist into adult life.
A similar trend can be observed in the health sector, with studies demonstrating the widening health gap between the most and least advantaged in our community.
A study by CSIRO found that since 1987 there has been a growing disparity between the rates of premature and avoidable mortality between the highest and lowest income groups. The researchers looking at this and other indicators of well-being concluded that Australia has become a less equal society in the past three decades, not just due to differences between the most disadvantaged and least disadvantaged, but due to a steepening of the social gradient that leaves all but the least disadvantaged worse off.
Increased intensity and complexity
The role of teachers was once primarily seen as providing academic instruction. However, teachers today are responsible for dealing with a much broader range of social and psychological issues experienced by students, including the impacts of family violence, sexism and racism and rising rates of mental illness.
The trend towards greater inclusion in educational settings, which is broadly supported by teachers and parents, requires teachers to have additional skills in managing classrooms with a much more diverse range of abilities and behaviours than a generation ago.
Similarly, GPs today are typically dealing with much more complex problems than when Medicare was introduced in the early 1980s.
Back then the bulk of GPs’ work focussed on dealing with acute and self-limiting conditions, such as infectious diseases and minor injuries. Today the typical GP patient has one or more chronic conditions which are more complex to manage and require care over a longer period of time, often from multiple providers.
The deinstitutionalisation of people with mental illnesses means GPs are seeing more patients with complex mental health conditions requiring intensive management.
Our ageing population and preference for remaining in our homes in old age also means that GPs are seeing more patients with multiple conditions at a more progressed state than in previous decades.
Peter Breadon, Health and Aged Care Program Director at Grattan Institute, sees some parallels between the increasing societal expectations of GPs and teachers.
“GP jobs are getting harder. GPs are seeing ever more complex patients as people live longer and have more chronic diseases. The same is true of teachers, where some students in classrooms today would not have been in school 40 years ago. Both changes are very positive, but they do require new ways of working,” he says.
Another major societal change affecting both the health and education sectors is the increased importance being placed on engagement with consumers and the community.
A generation ago, consumers in both these sectors played a much more passive role. Patients typically did not question doctors and parents did not expect to have a say in how a school educated their child.
However, the rise of the consumer movement and the widespread availability of information previously restricted to professional groups, has radically changed the expectations of consumers in these sectors and highlighted the importance of greater engagement between professionals and consumers.
These changes bring many benefits but overall they have occurred without sufficient support being provided to professionals to enable them take on these additional responsibilities effectively.
As a result both teachers and GPs report feeling under pressure from increased and unrealistic workloads.
A Grattan Institute report found that on average, teachers work about 44 hours a week during term-time. This is more than many other professionals and is high by international standards.
Despite these long working hours, Grattan’s survey of 5,442 Australian teachers and school leaders found that more than 90 percent of teachers say they don’t have enough time to prepare effectively for classroom teaching and many report feeling overwhelmed by everything they are expected to achieve.
Workload intensity is also an issue for GPs. While in major cities they work fewer hours compared to many other professionals, GPs in small towns work about 20 percent longer and attend callouts after-hours about five times more often.
This has led to burnout, poor health, and concerns for quality of care among the profession. A recent RACGP survey found that nearly two-thirds of GPs (63%) reported workload as a challenge, and half of those (30%) ranked it as their biggest concern.
Lower levels of remuneration
Adding to the pressures facing GPs and teachers is that their pay has not increased in response to their increased workloads. Both professions appear to be under-paid relative to their professional status, responsibility and expertise.
This may reflect the under-valuing of generalist roles within the health and education systems.
Relatively low pay particularly impacts teachers who are one of the lowest-paid professions, according to a study conducted by Professor John Buchanan from the University of Sydney Business School. He found that teachers’ real earnings fell by about 5.7 percent between 2020 and 2022 due to salary increases that were far below inflation increases.
This research also identified a widening gap between the salaries of teachers and those of other occupations that did not require a degree, such as financial brokers and real estate agents.
While GPs in Australia earn significantly more than teachers, they are also underpaid relative to their colleagues in other speciality areas and earn less than the OECD average for their work.
An RACGP report found that Australia ranks 12th of 15 selected OECD countries with GPs in Australia earning on average AU$139,000, which is below the OECD average of AU$195,000.
This report also found evidence that GPs, incomes are not increasing in line with those of other professions with an increased proportion of doctors reporting that their income has remained the same for the past five years.
Lack of respect
While generalisations across these two diverse professions can be fraught, there is some evidence that many teachers and GPs are feeling under-valued by the community, an issue that can be exacerbated by media reporting which they feel does not respect their expertise.
One study of media reporting of teachers in Australia found that journalists describing problems in the education system tend to put emphasis on the purported deficiencies of individual teachers rather than on the systemic issues which are outside of teachers’ control.
This study found that the media reporting on teachers consistently misrepresents their work as “simple and common sense” and is disproportionately negative in its representations of the profession, including through the linking of “crises” in education to “poor quality” teachers.
The impact of this trend was highlighted in a recent survey that found many teachers felt their profession was not valued or respected by the general public and that this was exacerbated by negative media coverage which presented them as “babysitters” rather than professionals.
While GPs have not expressed the same concerns about the media previously, they have also recently reported feeling unfairly attacked by the media in its reporting of research into Medicare billing systems, which indicated that a high proportion of billing may not be compliant with regulations.
High levels of stress and burnout
Unsurprisingly, the increased pressures of their work, combined with relatively low remuneration, is leading to high levels of stress and burnout among both teachers and GPs.
A recent survey found that the proportion of teachers satisfied with their work declined from 65.6 percent in 2019 to 45.8 percent in 2022.
Reasons given for this increased level of dissatisfaction were feeling unappreciated, an increased workload – in part thanks to increasing administrative demands – and a lack of respect from the community.
Research into general practice has also found evidence of declining morale and rising levels of stress and burnout among GPs, including that GPs are much less likely to recommend general practice to junior doctors than they were 10 years ago.
The RACGP’s research identified burnout, unsustainable workload, mounting administrative and regulatory burdens, chronic underfunding and workforce shortages as increasing pressures on GPs and undermining their work–life balance, as also amplified through many media reports.
One GP who has spoken about the impact of burnout is Dr Hilton Koppe whose book “One curious doctor” describes the personal impact of his career as a country GP, including the PTSD he developed which eventually forced him to leave the profession.
Growing workforce shortages
Given the above pressures, it is not surprising that both teachers and GPs are currently in short supply.
A combination of lower numbers of people entering the profession, COVID and burnout is being blamed for widespread teacher shortages throughout Australia, particularly impacting lower socio-economic demographics and rural areas.
Within general practice there have always been problems with workforce shortages in rural and remote areas. However, there are now worrying signs that these have spread to regional and outer-urban areas making it more difficult for these communities to access GP care.
Health and Aged Care Minister Mark Butler recently expressed concern about these workforce shortages after reports of practices closing and evidence that there had been a significant decline in the number of GPs entering the Australian General Practice Training (AGPT) Program.
Breadon also notes another commonality in the education and health workforces towards involving a greater range of professionals, such as team teaching assistants in education and practice nurses and allied health professionals in primary health care.
Systems under stress
The combined impact of the above issues has placed increased pressure on our health and education systems and there is increasing evidence that this is leading to poorer outcomes.
In the health system, evidence of declining bulk billing rates, inequitable geographic access to care, clinical variation and high rates of preventable hospital admissions all indicate that the system is struggling to meet the needs of our community.
This sentiment was recently echoed by Minister Butler, who stated that it was currently “in the worst shape it has been in the 40-year history of Medicare.”
Signs that the education system is not performing as well as it should include recent NAPLAN data showing that our national reading and numeracy results have gradually declined over the last five years with growing inequality between geographic and socio-economic areas.
These results were discussed in a 2023 report from the Productivity Commission, which found that each year almost 90,000 students do not meet minimum standards for reading and numeracy. The report also found Aboriginal and Torres Strait Islander students, students in rural and remote parts of the country, and poorer students are three times more likely to fall behind other students.
Dr Jordana Hunter, the Education Program Director at Grattan Institute, identifies the high degree of variation between teaching practices in schools and from one classroom to the next as another sign of a system not working optimally.
“The evidence tells us that most children learn in a similar way regardless of socio-economic status, geographic location and other demographic factors,” she says.
“With few exceptions, the same effective strategies that work in Toorak [a wealthy area] will work in Broadmeadows or Bairnsdale. But currently there is significant variation in teaching practices between schools with some adopting evidence-based and organisation-wide approaches and others persisting with practices which we know don’t work as well.”
One reason, she says, is the relatively small investment by governments in developing the evidence base about what works best in schools and building the expertise of teachers to support them in their work.
“Just like we shouldn’t roll out a COVID vaccination program with a poor quality vaccine, we shouldn’t be implementing educational programs which we know are ineffective or less effective than the alternatives.”
Addressing systemic issues
Current media attention on the pressures facing the education and health sectors suggests these are issues of significant concern to the community.
Governments appear to be responding to this concern through broad reform processes, such as the Strengthening Medicare Taskforce, and more targeted initiatives such as state government funding programs to attract teachers to areas of need.
However, none of these strategies address the underlying structural and systemic issues which are major contributors to the challenges facing both the education and health sectors and which continue to undermine the success of other policy changes.
These issues include:
Short termism: Governments typically have a short term focus driven by the political cycle (in Australia at the federal level this is typically less than three years). This makes it hard to capture the long term benefits which in sectors such as health and education may be decades (or even generations) in the future.
Siloed budget processes: Australia’s system of government divides funding along portfolio lines which makes it difficult for Ministers to offset spending with savings which accrue to a different portfolio area. Similarly, Australia’s federated system means that governments can be reluctant to spend money in an area in which the benefits will flow to another jurisdiction. This is why the overwhelming evidence for the broad and long-term benefits of spending in both education and primary healthcare do not always translate into government funding decisions.
A failure to address broader determinants: Most of the determinants of health and education status occur outside of these sectors and include factors such as poverty, inequality, racism and other forms of discrimination, climate change and the family and early childhood environment. A failure to invest in these areas makes it far more difficult to achieve optimum outcomes from our health and education systems. As well as supporting teachers and GPs to address the impact of these determinants in their work, we should also put increased efforts into addressing the upstream drivers of poor educational and health outcomes.
Strategies which governments could adopt to mitigate the impact of the above issues include embedding consideration of the health and education impacts in all government decision making via a “health in all policies” approach (or similar for education).
Increased support for consumer and community engagement in policy development and resource allocation, via mechanisms such as citizen’s juries and co-design, would also mitigate the short termism of government horizons and the potential for influence by vested interest groups.
Breadon suggests that a more sophisticated use of data would also improve policy and funding decisions by governments.
“We also need to get smarter around how evidence is used to improve outcomes in both the health and education sectors. There are gaps in the data we collect, and also data that is collected but not used effectively. Improving our use of data requires a collaborative approach between professional groups, governments and other relevant experts, such as research institutions.”
Governments could also do better in developing positive relationships with the GP and teaching professions in order to work together towards shared goals. This includes ensuring bureaucrats have a better understanding of the day-to-day working life of these professionals in order to development meaningful policies, programs and outcome measures.
“We need to invest more in the teaching profession,” Hunter says. “This needs to involve collaboration between government and the profession on the development of evidence-based teaching practices. These don’t need to be prescriptive but they should provide an agreed starting point.”
“We spend $70 billion a year on education and expect it to do some heavy lifting in not just teaching academics but also addressing broader societal challenges. Yet we significantly under-invest in professional development for teachers. Governments around Australia have radically underestimated what we are asking teachers to do. We need to stop pretending teaching is easy as an excuse for under-investment in education.”
GPs and teachers (along with their representative groups) also have a role to play in working with governments to ensure their sectors can meet the changing needs of the Australian community.
This includes recognising the constraints of government and their need for accountability for these large areas of public expenditure and being open to evidence-based changes, even if this means abandoning longstanding practices and allowing other professionals to take on an increased role in their sectors.
Breadon also stresses the importance of engaging with broader government processes around budget setting.
“Both education and health are big and growing drivers of government spending. This means that to attract additional funding they need to get support not just from the relevant minister, but also from treasurers and the other Cabinet members. Often this requires not only demonstrating the benefits of additional spending in their portfolio area, but also making some commitments around productivity.”
Finally, if we want the significant and long term benefits of high quality public education and health systems in the future, the community also has to be prepared to pay more, even if this means raising taxes. However, it is just as important that this funding is directed where it is most needed with a focus on addressing the current inequities in access and outcomes in the health and education sectors.
In education, this means following the findings of international and Australian research (including the Gonski Review Report) which has found that highest performing education systems are those that combine equity with quality and reversing recent trends in the educational outcomes of Australian students and the unacceptable link between low levels of achievement and educational disadvantage, particularly among students from low socioeconomic and Indigenous backgrounds.
In health, this means moving away from a fee-for-service funding mechanism which directs funding on the basis of GPs’ location rather than community need, resulting in those with the lowest levels of need receiving disproportionately more funding than those with the highest requirements for care (known as the inverse care law).
Making it clear to political leaders that voters support increased public investment to improve our health and education systems will help shift entrenched political views about the risks of tax increases and instead highlight the risks of under-investing in these two critical sectors.
See Croakey’s archive of #LongReads