Introduction by Croakey: The novel coronavirus pandemic has cast a sometimes uncomfortable spotlight on our health care systems, highlighting both strengths and systemic shortcomings.
As evidenced by mounting second waves the world over, particularly in places where earlier outbreaks were severe and took a steep toll, it is important to learn from earlier experiences and reform our systems so they are fit for purpose.
In this piece for John Menadue’s blog, Pearls and Irritations, and republished here with permission, Croakey contributor Lesley Russell and colleagues Mary Chiarella and Peter Brooks ask whether Australia is ready to confront its COVID-19 calls for reform.
Mary Chiarella, Lesley Russell and Peter Brooks write:
We urgently need healthcare reforms: better workforce planning, more equitable workforce distribution, more efficient workforce utilisation, improved workforce productivity, and financing reforms to sustain these changes.
We call for the restoration of an independent health workforce agency to drive this essential work.
In 1896 the architect Louis Sullivan coined the phrase that “form must follow function”. Today in 2020 this maxim can be equally applied to our health workforce, although the argument here needs to be that health workforce re-form must follow health work re-function.
Australian healthcare is rated highly but it is beset with inherent problems that make reforms difficult. There are multiple funding streams, responsibilities divided between federal and state and territory governments, a public – private divide that defies purpose, and a lack of integration across systems.
With increasing burdens from chronic illnesses (both physical and mental), an ageing population and poorly distributed resources, healthcare services have long been stressed. The coronavirus pandemic and its consequences are highlighting the weaknesses and exacerbating the pressures on the healthcare system and healthcare workers.
However, the pandemic has also served to drive changes in healthcare service delivery and to mainstream some successful pilot programs. But, to underpin and sustain these changes we need better workforce planning, more equitable workforce distribution, more efficient workforce utilisation, improved workforce productivity, and financing reforms to sustain these changes.
Much has been made of the advantages of telehealth services, by both phone and video links, and these have been supported by a range of new Medicare items (although it is currently unclear if these will last beyond the pressures of the pandemic). Telehealth has become standard practice in many hospitals and in the offices of some doctors and mental health professionals, but its real value will not be seen unless access is expanded to include all members of the healthcare team in all geographic regions.
It has been ably demonstrated, through the use of virtual wards and telehealth, that it is possible to keep people (some of whom are quite unwell) at home, in “virtual hospital”, monitored carefully by highly-skilled nursing and allied health staff working in coordination with GPs and specialists. Home-based care and monitoring in the community is seen as essential when hospitals and nursing homes are under pressure because of COVID-19 but it is also the choice of many patients, especially those with chronic and complex conditions who regularly require acute and sub-acute care.
There is a push to boost primary care services to provide better access to early interventions and – long-term – to lessen the pressure on acute care from avoidable presentations and hospitalisations. The primary care team extends well beyond the GP and a practice nurse to mental health, management of substance abuse and allied health professionals, midwives, dental professionals, pharmacists, geriatricians and paediatricians, nurse practitioners and Aboriginal Health Workers.
Public health services in some states have multidisciplinary teams which provide a range of preventive, maintenance and rehabilitative services for patients in the community. In New South Wales, these services link in the Primary Health Networks, GPs, and the proximate Local Health District.
Beyond the biomedical
There is growing recognition that delivering holistic, patient-centred care requires much more than medical services and thus there is a pressing role for social prescribing, to address the social determinants of health (issues like nutrition, transport, housing, domestic violence, and poverty). These factors act together to strengthen or undermine the health of individuals; failure to address them is the main reason for health inequalities across population groups.
In the United Kingdom there is a special workforce especially charged with helping patients manage the intersection between medical care and social care – the social prescribing links worker. This is a role that is not unlike that of case manager or care navigator, but they operate in primary care with a focus beyond the healthcare system. The Royal Australian College of General Practitioners and Consumers Health Forum have called for investments in social prescribing in Australia and there are least a few local pilot programs that could serve as exemplars.
The workforce that will deliver these innovative approaches to care needs to be funded adequately to work as part of that caring team and this will require a major re-think of the Medicare and public hospital funding systems. These are substantial “asks”, but the blunt fact is that there can be no reforms to healthcare without the ability to deliver a well-trained and diverse healthcare workforce that can work effectively and efficiently across the spectrum of patient needs.
Even in the absence of needed reforms in healthcare delivery and financing and new models of care, there is an urgent need to do something about workforce. The data show it is inadequate for Australia’s needs, poorly distributed geographically, stressed as a consequence of over-work, and, in some areas, failing to gain new recruits. Like the rest of society, the health workforce is ageing; one in four medical practitioners and two in five nurses are aged 55 or over. There are critical challenges ahead, especially for the nursing workforce, with an unexpected undersupply of 123,000 nurses by 2030.
The expansion and reworking of the healthcare workforce should be seen not as a budget burden but an investment. The health and social care workforce is the largest in Australia, accounting for 14.0 percent of the total workforce. Workforce demand in these areas is expected to increase by 14.9 percent over the next four years.
There is a paucity of action on all the health workforce fronts. The federal Department of Health apparently does not see workforce as a priority issue. The medical colleges have acted to limit their memberships. Protection of professional turf is too often seen as the major issue when new healthcare roles are raised.
The independent agency Health Workforce Australia, which formerly had responsibility for health workforce planning, was abolished by the Abbott Government in 2014 and its activities were subsumed into the Department of Health where they have languished ever since. Much of the information on the health workforce section of the Department’s website is dated (the data section has not been updated since January 2017).
We call for the restoration of this independent agency – properly resourced – as a matter of urgency. The future of safe, high quality and modernised healthcare in Australia depends on it and we surely owe that to all Australians.
Mary Chiarella is Professor Emerita, Susan Wakil School of Nursing and Midwifery at the University of Sydney
Lesley Russell is Adjunct Associate Professor, Menzies Centre for Health Policy, University of Sydney
Peter Brooks is Honorary Professor, University of Melbourne School of Population and Global Health and Research Lead, Northern Health Epping