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Some solutions to health workforce shortages

Health Workforce Australia recently released the first two volumes of its three-volume report, Health Workforce 2025, which provides medium to long-term national workforce planning projections for doctors, nurses and midwives up to 2025.

The main contribution of the report, according to Professor Richard Murray, President of the Australian College of Rural and Remote Medicine, is to show that ‘more-of-the-same’ approaches to health workforce will not work, and that new models of care and financing are needed.

The critical issues that need addressing, he argues in the article below, are: the concentration of doctors in the wealthy suburbs of major cities; that sub-specialty medicine is out of balance with ‘generalist’ medicine; and that doctors are performing tasks that could be done by other members of the team.

***

Health Workforce 2025:  why ‘more-of-the-same’ in producing doctors does not add up

Richard Murray writes:

The much-anticipated analysis of health workforce demand and supply for doctors, nurses and midwives in Australia has just been released. Health Workforce 2025, is an important contribution for one main reason.

It shows that ‘more-of-the-same’ for health workforce in Australia will simply not work. Full stop.

Countries the world over are grappling with how to provide effective health care for all in the face of ageing, rising costs and increasing levels of chronic disease. There will be around 27 million Australians in 2025.

Whereas there are 5 people of working age for every person aged 65 or more now, by 2025 that figure will be 3.5. The health workforce has to come from a pool that is shrinking relative to demand.

In plain terms, the Health Workforce 2025 analysis is as follows: Imagine that we froze the arrangement of health care in 2009 (warts and all) and applied it to 2025, adjusted for ageing and population growth. Then consider how many doctors, nurses and midwives that would mean, factoring in training, immigration, working hours and retirement. Then press the ‘calculate’ button.

For doctors, the answer is frightening. The computer model says that Australia will ‘need’ an additional 37,000 doctors by 2025, 20% higher than population growth. To achieve this staggering figure will take every one of the record number of doctors being trained at present (and Australia is near the top of the league table among wealthy nations in terms of doctor production).

It will also take all of the record levels of importation of overseas-trained doctors, a great many from low-income countries that cannot afford to lose them. And there would still be a gap of 2,700.

Bizarrely (and in spite of the present deficit of doctors in the bush) the model says that only 1 in 5 of the new doctors would be ‘needed’ outside the major cities. In other words, the answer to the rural health workforce problem is to make it worse!

Of course, this is no answer at al. What must change are the models of providing care.

On a population basis, Australia is actually average among wealthy countries in doctor numbers, and is well ahead of the USA, Canada, the UK and New Zealand. We have more doctors for population than at any point in our history. And having more than doubled medical school intakes, we will shortly be producing two to three times more than comparable countries.

That being so, what is the problem? The real issues behind doctor shortages on the ground are three:

  1. doctors are concentrated in wealthy suburbs of major cities;
  2. sub-specialty medicine is out of balance with ‘generalist’ medicine; and
  3. doctors are performing tasks that could be done by other members of the team.

Some of this relates to how health care is paid for. For instance, with insurance and an uncapped fee system, there is an almost unlimited range of problems that a doctor might attend to. This perpetuates Dr Julian Tudor-Hart’s ‘Inverse Care Law’: the availability of medical care tends to vary inversely with the need for it.

If no income is generated unless the doctor personally performs the service, then there are pressures for doctors to keep doing all the tasks – a key barrier to flexibility and team-work.

How medical training is arranged is also critical. A lot has been achieved already to increase admission of medical students of rural origin into medical schools and to provide training exposures in rural and regional communities. The missing piece of the puzzle is training after graduation. This is the phase of ‘vocational training’ towards Fellowship with one of the specialist medical Colleges.

We need many more general practitioners, and particularly those trained in extended ‘generalist medicine’ – the domain of the Australian College of Rural and Remote Medicine. These are the doctors trained and credentialed for ‘Jack-or-Jill-of-all-trades’ medicine in the clinic, the hospital, the emergency setting and the community. These doctors are the backbone of health care in rural communities and are increasingly needed in the cities.

In other specialities we need many more ‘generalists’ too: general surgeons, general physicians, general paediatricians and so on. These are the consultant doctors who, on referral, can advise on the totality of a patient’s complex problems, not just their particular organ of expertise.  Sub-specialists are required as well, just not as many.

Importantly, we need to train specialists in regional areas. There is no point forcing junior doctors to the cities to compete for sub-specialised training posts, hoping that they might return one day. The paradigm must be turned around: regionally-based ‘generalist’ specialist training with a city attachment as required.

Finally, governments, the community and the professions must embrace innovation and team-based care. There is no choice. Doctors must do only those things that doctors can do best, working with nurses, allied health professionals and various ‘health care extenders’ to meet priority community needs.

There is a fork in the road: a bankrupt health system and decent care for a few; or effective health care for all on the basis of need, not ability to pay. The time for honest conversations and action is now.

***

PS from Croakey

Volume 1 of the report contains the overall findings from a workforce planning analysis of the trends in the supply and demand of doctors, nurses and midwives in Australia. Volume 2 contains detailed supply and demand projection results for midwives and registered and enrolled nurses by area of practice, as well as state and territory projections for all professions.

Volume 3, due to be delivered to Health Ministers later this year, will contain detailed supply and demand projection results for the medical workforce, by specialty.

 

Comments 7

  1. Jenny Haines says:

    Given the success so far of the Nurse Practitioner program in rural areas, maybe we don’t need doctors in those areas. An experienced, well qualified, accredited Nurse Practitioner can be more useful than a doctor and all of the expense involved in getting them and their families out to rural areas. The Nurse Practitoner Program is gradually growing in this country in line with the expansion of these programs in the UK and USA. Medical staff in the cities with radio and television and video services enhanced by the NBN may be consultants to these Nurse Practitioners. ( I think I can hear members of the AMA having a heart attack !!)

  2. Duggy the DC3 says:

    A problem I see continually replayed is the Egos in the Nurses Union and the AMA. Perhaps Jenny you are just showing your colours. The solution are Health Care teams, not an independent “this or that”. Funding methods need to change. The Power balance, b#tching on both sides, and the education/training of clinicians needs review.

    People need to work together not try and out do one another to prove a point.

    There is a third party that is challenging the two Peak Political Voices and that is the Physician Assistants. This group has the potential to bridge the expertise of Rural Doctors, Rural Nurses in specific and identifiable ways that support each others Unique Skill Sets with specific contributions in Rural Health Service Delivery.

  3. Jenny Haines says:

    Hey Duggy I agree with you. It would be wonderful if we could have such health care teams, but you can’t have successful teams where practitioners won’t commit to team work. I was lightheartedly having a go at the AMA and defending NPs because there are still some doctors who are fighting to the death against NPs when NPs are proving a successful model of nursing care. Physicians Assistants as I understand them are proving their role in the US but their place in the sun in this country is yet to be decided.

  4. Duggy the DC3 says:

    Thanks Jenny, and please accept my appologies. I am a Rural Doctor, a member of the AMA and other Rural Bodies. My suspicion is that there are many Rural Doctors that would agree with you, since I suspect most, like me, are there because of a love of the work, and a love of the Bush and its people. We could not sustain the committment without the partnerships with other Health Professionals, nor should we expect too.

  5. Jenny Haines says:

    Duggy, no need to apologise. Nice to meet a rural doctor on this blog.

  6. Reed Sandy says:

    I agree with what you said.Keep posting helpful blogs!Thanks..

  7. Norman Hanscombe says:

    No one wants to face up to the fact that is what we already provide is unsustainable but research is constantly coming up with even more unsustainable possibilities. We shall [as is happening in a whole range of un-related areas]continue down this path until disaster of one kind or another engulfs us. But as a Qld Premier used to say, don’t you worry about that, which kept those who didn’t like harsh realities happy.

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co-payments
Cochrane Collaboration
complementary medicines
conflicts of interest
death and dying
diabetes
digital technology
disabilities
e-health
emergency departments and care
Equally Well
euthanasia
evidence-based issues
general practice
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health and medical education
health and medical research
Health Care Homes
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health reform
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HIV/AIDS
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HRT
infectious diseases
influenza
international medical graduates
journal articles
LGBTIQ
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Medicare Locals
men's health
mental health
MyHospitals website
National Commission of Audit 2014
National Health Performance Authority
naturopathy
NDIS
NHMRC
non communicable diseases
nurses and nursing
oral health
organ transplants
out of pocket costs
pain
palliative care
paramedics
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Pharmaceutical Benefits Scheme
pharmaceutical industry
pharmacy
Pregnancy and childbirth
primary health care
Primary Health Networks
private health insurance
quality and safety of health care
rural and remote health
screening
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social media and healthcare
suicide
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swine flu
telehealth
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TGA
trauma
women's health
youth health
Indigenous health
#CTG10
#NTRC
Acknowledgement
cultural safety
Indigenous education
Lowitja Institute
NT Intervention
social and emotional wellbeing
Uluru Statement
WA community closures
News about Croakey
PIJ Commissions 2021
Public health and population health
#PreventiveHealthStrategy
#UnmetNeedsinPublicHealth
air pollution
alcohol
consumer health matters
COVIDwrap
environmental health
Fetal Alcohol Spectrum Disorders (FASD)
food and nutrition
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Government 2.0
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Health in All Policies
health inequalities
health literacy
human rights
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Media Doctor Australia
media-related issues
nanny state
National Preventive Health Agency
obesity
occupational health
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plain packaging
prevention
public health
public interest journalism
road safety
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Web 2.0
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Royal Commission
Social determinants of health
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education
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Justice Reinvestment
NBN
Newstart
poverty
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Summer reading 2020-2021
Tasmanian election 2021
Testing Croakey News category 1
The Croakey Archives
#cripcroakey
#HealthEquity16
#HealthMatters
#IHMayDay (all years)
#IHMayDay 2014
#IHMayDay15
#IHMayday16
#IHMayDay17
#IHMayDay18
#LoveRural 2014
Croakey Conference News Service 2013 – 2019
2013 conferences
Australian Centre for Health Services Innovation Forum 2013
Australian Health Promotion Association Conference 2013
Closing the Credibility Gap 2013
CRANAplus Conference 2013
FASD Conference 2013
Health Workforce Australia 2013
International Health Literacy Network Conference 2013
NACCHO Summit 2013
National Rural Health Conference 2013
Oceania EcoHealth Symposium 2013
PHAA conference 2013
2014 conferences
#IPCHIV14
AIDA Conference 2014
Congress Lowitja 2014
CRANAplus conference 2014
Cultural Solutions - Healing Foundation forum 2014
Lowitja Institute Continuous Quality Improvement conference 2014