Introduction by Croakey: A comprehensive national review on scope of practice issues for primary care practitioners is at the “business end” of its process, with a final report due by the end of October.
The head of the review, Professor Mark Cormack, joined other stakeholders at a #CroakeyLIVE webinar this week, the latest in a series of Croakey events marking the 40th anniversary year of Medicare, to discuss the opportunities for meaningful reform.
The webinar was sponsored by the Australian Society of Medical Imaging and Radiation Therapy (ASMIRT).
Marie McInerney writes:
Does the Federal Government have the gumption for real reforms on the fraught and pressing issue of scope of practice for health professionals, which are crucial for delivering more equitable and efficient access to multidisciplinary primary care?
That was the “burning question” for many who attended a #CroakeyLIVE webinar this week on the independent national Scope of Practice Review, which aims to address the barriers to health practitioners working to their full scope of practice in primary care.
“I certainly wouldn’t put the time and effort into this work if I didn’t think it was going to go anywhere,” said Professor Mark Cormack, who is leading the review and brings decades of experience working with governments to the task, including as former CEO of Health Workforce Australia.
Federal Health Minister Mark Butler has been “incredibly supportive of the work”, he said. State and territory governments and departments are also very engaged, given they are “very much feeling the brunt of a primary healthcare sector that’s struggling…and of having a workforce that’s not being optimally utilised to deliver the care,” he added.
Health policy expert Professor Stephen Duckett also was optimistic that the review would result in significant reform, saying Butler “is a reforming Minister”, absolutely committed to improving Medicare, and “totally invested” in the importance of multidisciplinary care.
Cautioning the sector not to expect huge change overnight, given the scale and complexity of the issues involved, Duckett said it would be important for the Government to set the overall direction, and then take the incremental steps each year to actually build the reform.
But, the webinar heard, it’s the scale of the crisis in primary healthcare that could finally deliver the momentum for reform, amid workforce shortages and pressures that contribute to reduced access to care, increased workloads, overuse of higher cost services (such as emergency care) and poorer patient outcomes. The crisis is especially acute for people living in rural and regional areas.
The review quotes a consumer saying the idea of access to multidisciplinary care “is a luxury” for people living outside major cities who don’t even have access to GPs within an hour’s drive.
“We now have an opportunity and, in a sense, an urgency, because waiting times are so bad,” Duckett said. “The opportunity costs are so high that we ought to be moving and moving quickly.”
Unleashed
The Scope of Practice review, titled Unleashing the Potential of our Health Workforce, emerged from the Federal Government’s Strengthening Medicare Taskforce Report.
It outlines the benefits to individual practitioners, patients and consumers and the health sector more widely of health professionals being able to work to their full scope of practice – that is, for all professional activities that a practitioner is educated, competent and authorised to perform.
That’s a complex task, as the review’s two issues papers illustrate. The webinar also heard about many of the challenges, including the need for change to be systematic and structural, for new funding and payment models, to transform “ossified” professional cultures, improve education on primary care, and address regulatory blockages and institutional failure to scale up innovation.
There’s also alarm and opposition from some doctors’ groups, with the Australian Medical Association (AMA) saying it is “very concerned” that scope of practice reform may be used as an opportunity to substitute GP care with “less expensive alternatives”.
The AMA and Royal Australian College of General Practitioners (RACGPs) have been pointing to controversial changes underway in the UK with the introduction of medical associate professions (MAPs) and physician associates (PAs), which have led to a call this week from the Royal College of General Practitioners (RCGP) for a freeze until regulation and scope of practice guidance is finalised.
The AMA’s submission to the review cited a media article reporting that non-medical health professionals were “performing surgery on brains and spines” in the UK.
On the other hand, Croakey contributor Charles Mansell-Knight wrote recently of concerns that, in Australian primary care, GPs currently “act as monopoly providers, gatekeepers or supervisors for many services that could be provided within the scope of their training by other health professionals”.
The Scope of Practice review maps out individual, local and system wide costs to limiting scope of practice, including reduced workforce mobility and skills portability, poor workforce retention, restricted consumer access to optimal care, particularly in regional and remote areas, and reduced multidisciplinary care.
It highlights examples, such as where pharmacists working in regional Victorian Urgent Care Centres can’t supply medicines unless there is a medical practitioner on the premises, despite most weekend and after-hours urgent care being provided by nurses. It also points to the lack of an MBS-funded pathway for registered nurses that would enable them to assess mental healthcare needs and instigate a mental health plan.
It also provides a number of insights and exemplars of change, including: an umbrella framework applied in Canada which recognises skills and competency areas across professions rather than being tied to titles; a Tasmanian after-hours nurse-led service that maintained a multidisciplinary care team through a ‘blended funding model’; and a New Zealand midwifery model, which provides bundled funding to the parent to use across services.
The review says that Aboriginal Community Controlled Health Organisations (ACCHOs) were frequently raised through consultations as an example of best practice from which the broader primary health system could learn, but that discrimination and lack of cultural safety were significant barriers for Aboriginal and Torres Strait Islander health professionals, including Indigenous Health Practitioners.
Referring to the importance placed on community paramedic roles in regional and remote communities, the first issues paper highlights the Ngangganawili Aboriginal Health Service community paramedicine service on Martu Country in Western Australia, which has seen improved primary care availability over a wide geographic area, and improved continuity of care from onsite primary care to inpatient settings.
In the webinar, Professor Bronwyn Fredericks, Deputy Vice-Chancellor (Indigenous Engagement) at the University of Queensland, and co-chair of Croakey Health Media, welcomed the recognition for the sector’s work but also warned that mainstream health services had to step up in improving primary healthcare for Aboriginal and Torres Strait Islander people, not all of whom accessed ACCHOs or had ACCHOs in their regions.
“Incredible support”
Cormack said the review, which will produce a final report in October, has had “incredible support and input”, including more than 1,100 submissions, 31 consultation sessions attended by more than 700 people (including targeted sessions for consumers, rural and remote stakeholders and Aboriginal and Torres Strait Islander people), 100 virtual sessions with more than 200 organisations, and a literature and evidence review that considered more than 1,300 articles.
Of a range of barriers identified, two stood out, he said. One was the payment system in the primary care system where professional custom and cultures seem to “work against obvious evidence-based improvements that can be made with incredible benefits – cost benefits, experiential benefits for consumers and retention benefits for health workers”.
The other was in the unintended way that the National Registration and Accreditation Scheme (NRAS) restricts scope for non-regulated professions. The review provides an example where self-regulated professions are precluded from being authorised to prescribe, supply/dispense or administer medicines, even where these activities may fall under their training, competency and scope.
However, Cormack said there is “certainly a strong mood for change” and he has been both delighted and surprised by the level of emerging consensus for the eight reform areas identified by the review.
Cormack and Duckett were also optimistic the reform process might survive a change of government if the Coalition wins in 2025 – though Duckett noted that Opposition Leader Peter Dutton had been responsible in 2014, as Health Minister, for the abolition of Health Workforce Australia, headed at the time by Cormack.
“We had an organisation which was trying to lead reform in the workforce – it was abolished and nothing was heard in that space for a decade,” Duckett said.
Nonetheless, he said, a future Coalition Government would be facing the same problems as Butler is now trying to address, particularly rural workforce shortages “and the reality that we just cannot continue to provide services in rural Australia in the way we’ve provided them in the past”.
State and territory governments are also critical to change, Cormack said — only one of the eight substantive reform areas could be addressed solely by the Federal Government.
A recent sponsored content article at Croakey highlighted how some state government services are already driving scope of practice reforms, including embedding paramedics and Aboriginal Health Practitioners in multidisciplinary teams, and enabling audiologists to proactively assess children for earlier conservative intervention or earlier escalation for surgical management.
Duckett told the webinar about an innovative approach he was involved with many years ago in Queensland that led to an advanced practice physiotherapist-led model of care developed initially to address overburdened specialist orthopaedic outpatient public hospital services.
Its long-term its results had been reported recently, described as “a health service masterclass”, yet its work has not been replicated elsewhere, he said.
He blamed an “ossified” culture in some hospitals that sees physiotherapists, for example, “bashing their heads against a brick wall within a hospital to try to get change”. He hoped the review would “legitimise” that frustration and create an authorising environment to scale up such efforts.
Retention and equity
Radiographer Carolyn Heyes, president of the Australian Society of Medical Imaging and Radiation Therapy (ASMIRT), said her profession is limited in many ways by what radiologists will allow them to do.
While there is more flexibility in public hospitals, many radiographers in private practice are not permitted to report their observations directly to a referring clinician, meaning that patients and clinicians have to wait unnecessarily for results, she said
Lack of portability of skills is also a big issue, she said. ASMIRT has an Advanced Practice pathway, but there have been problems where skills have been recognised in one practice but not in another. The professions are also struggling with retention, where “really bright people” are attracted but become frustrated, after a few years, with the lack of advancement available.
Full scope of practice would also have system-wide benefits, Heyes said. Expanded multidisciplinary teams in general practice that meant patients no longer had to traipse back and forth to appointments would stop many using emergency departments as their “one stop shop”.
“In the long run, everybody’s health will be improved because access will be improved,” she said.
Both Heyes and Duckett highlighted their own personal experiences as patients, where restrictions on scope of practice meant discounting the skills of health professionals who had the expertise to order medical imaging and assess an ultrasound but not the authority to do so.
For Antony Nicholas, who is also Chair of Allied Health Professions Australia, and, like Duckett, an appointee on the Strengthening Medicare Taskforce, scope of practice reform is an equity issue.
Many people experience and value the benefits of allied health in tertiary care, but then find in primary care that “the only way you’re really going to access allied health is if you can afford to pay for it”.
“If we want a primary care system that is focused on consumer and consumer access, we have to think about how every Australian get access to allied health, not just those who can afford it,” he said.
Nicholas, who outlined some early recommendations for action in his preview of the webinar, is also concerned that improved scope of practice arrangements are too often “GP centric”. An allied health practitioner who is employed in a general practice may be subsidised, “but not the one who’s working in a rural or local community down the road in their own practice”, he said.
He said there are thousands of cases where patients seeing an allied health practitioner could not get a direct referral to a specialist or for diagnostic imaging and get caught in a “loop” of going back and forwards to a GP.
This means their access to healthcare “is getting worse, their out of pocket [cost] is getting higher, [and] chronic and complex disease is just going through the roof”, he said.
Funding models
Proposals on funding models to enable full scope of practice are also likely to be a flashpoint in reform efforts, with the RACGP having warned that “funding must be flexible and fee-for-service retained so GPs can best respond to our patients’ needs”.
Cormack and Duckett acknowledged concerns raised at the webinar by Professor Kathy Eagar about further embedding fee-for-service to extend scope of practice for nurses and allied health, rather than ensuring payment models support integrated, multidisciplinary practice.
Cormack said the review did not want to compound problems with the fee-for-service model by “adding more individual, isolated practitioners” to it.
Rather, it wanted to look at “blended, holistic, population based, risk adjusted funding arrangements that enable healthcare organisations, whether it be a practice, a group of practices, a healthcare entity, to have the flexibility to employ whoever they need to employ to meet the needs of the of their enrolled population”, he said.
“I think there’s certainly a case for expanding funding in primary healthcare, but I think to expand it in a way that just overlays the existing 90/10 split of fee-for-service versus blended payments would be unwise,” he said.
Eagar later told Croakey that extended scope of practice for nurses and allied health without expansion of fee-for-service is the key to long term sustainable reform and requires a change of mindset among the nursing and allied health professionals.
“Getting their own items in the CMBS (Commonwealth Medicare Benefit Scheme) has been the focus of much lobbying in recent years, with fee-for-service seen as the only option for extended scope roles,” she said, adding that this has been reinforced by the NDIS fee-for-service payment model.
“Getting new items in the CMBS is not evidence of the legitimacy of the extended scope of practice of the different professions and should not be seen as the end game.”
Eagar urged governments to “wean GPs off a sole reliance on fee-for-service”.
Finally, asked what he’d like to see changed in five years’ time, Cormac listed four priorities:
- A strengthened primary healthcare sector where people choose and maintain a career and where allied health enjoys the same level of retention as medical practitioners.
- Funding and payment models that incentivise outcomes and disincentivise low value care, and are “linked to the need of populations as opposed to the location of health practitioners who dispense that care”.
- A health system that finally embraces a digital infrastructure that revolutionises and supports health professionals to work to their full scope.
- A reliable institutional mechanism, such as operates for bringing new pharmaceuticals or treatments to the health system, to “bring advancements in innovation, in health workforce practice and models into the mainstream and…up to an industrial scale”.
The webinar discussions were also reported by Health Services Daily.
Watch the webinar
More from Croakey
In coming days, Croakey will also publish reflections on the webinar discussions from health consumer advocate Jen Morris.
Register here to attend another #CroakeyLIVE webinar on scope of practice, from 5-6pm AEST on Tuesday, 13 August. It is sponsored by the Australian Physiotherapy Association, which this week released a report by Nous.
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