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To address the rural health workforce crisis, we need to ensure allied health professionals can contribute

Introduction by Croakey: A Regional Health Workforce Summit was held on Latji Latji Country in Mildura from March 1-2, hosted by Shadow Assistant Minister for Regional Health Dr Anne Webster, and facilitated by a former Deputy Chief Medical Officer, Dr Nick Coatsworth.

Presumably, the event was aimed at helping the Federal Opposition build their rural health policy in preparation for the next election.

The gathering produced some promising discussions but also highlighted under-investment in the allied health workforce, which affects its capacity to contribute to critical policy development and implementation, reports Cath Maloney, CEO of Services for Australian Rural and Remote Allied Health (SARRAH).


Cath Maloney writes:

Around 140 delegates attended the Regional Health Workforce summit in Mildura at the invitation of Federal Member for Mallee, Dr Anne Webster. Delegates included medical, nursing, a smattering of allied health representatives and others, gathered to address the rural and remote health workforce shortage crisis and, more broadly, to tackle primary healthcare reforms as the Liberal National Party Coalition members in the room formulated their rural health policy in preparation for the next election.

Cath Maloney

While the summit was not a bipartisan event, it seemed like  a rare opportunity to come together to hear a broad range of views from local (rural) health practitioners, university educators, Primary Health Network and Rural Workforce Agency representatives, as well as national health peak bodies, in a bid to generate solution-focused strategies to some longstanding and thorny issues.

With such a mix of experience in the room, it was always going to be a challenge to ensure everyone was heard equitably, especially with an agenda that revolved largely around medical training, international medical graduates, and specifically the recent changes to the medical workforce Distribution Priority Area (DPA) classification to include some MMM2 areas. These changes had an immediate impact on many rural communities that saw dozens of overseas-trained doctors, no longer bound to stay in small and medium sized rural townships as a result of the classification changes, depart for regional cities.

A notable absence was the direct voice of the Aboriginal Community Controlled sector, although non-Indigenous GPs employed within ACCHOs were present. Considering that there were numerous references to alternative funding models, including block-funding in areas of market failure, the discussion would have been enriched by an opportunity to hear from those using similar funding models and delivering culturally safe services to Aboriginal and Torres Strait Islander communities.

While the discussion was dominated by the medical peak bodies – the Royal Australian College of General Practitioners (RACGP), Australian Medical Association (AMA), Australian College of Rural and Remote Medicine (ACRRM), Rural Doctors Association of Australia (RDAA) etc ­– over the course of the two-day summit, there was a noticeable shift in the tone of the conversation towards conciliation, collaboration, collegiality and cooperation.

After two days of working through a structured series of questions (albeit through the lens of the medical professions), there emerged an apparent collective will to find ways of working together, to navigate ways through some of the historical conflict lines and barriers that have previously stymied progress towards enabling all health professionals being able to work to their full scope of practice without the constraints resulting from unnecessarily onerous regulatory frameworks. What we need to see, of course, is the translation of these good intentions into action.

Transformation

If Medicare is to be truly transformed, all members of the primary healthcare multidisciplinary team will need to have a clear understanding of each other’s skills sets and scopes of practice to enable and support the regulatory changes needed to improve access to care.

The role of community pharmacy in the COVID-19 vaccination roll-out was offered as an example of how the regulatory system was flexed to support pharmacists to deliver vaccinations at a time when health workforce was being stretched in all directions. In rural and remote settings where workforce capacity is perpetually stretched and, in some places broken, such flexibility will be a necessary part of an effective model of care.

For example, enabling people to head straight to the physiotherapist for musculoskeletal injuries without first seeing a GP would free up the doctor’s time to focus on more complex and/or life-threatening conditions, while providing a pre-screening service to the GP for those presentations that do require further investigations.

Such models have been successfully trialled and evaluated in hospital emergency department settings and the evaluations demonstrating their effectiveness and safety are readily available; they just need to be trialled in primary healthcare settings.

Despite what appeared to be a general agreement that a more flexible regulatory environment would support reform, it also seemed evident the medical professions will continue to dig in behind some long-defended positions, such as opposing limited prescribing rights for non-medical health professionals like pharmacists, physiotherapists and nurse practitioners. It also seemed evident they will continue to be challenged on these important matters.

There was shared interest in supporting the early, mid-career and future health workforce through undergraduate, postgraduate and high-school programs that identify students interested in careers in health from an early stage. It is also important these programs provide long-term support to prepare aspiring health professionals for rural and remote practice – all very pertinent in the context of multidisciplinary teams-based care as the foundation of rural and remote primary healthcare.

In a similar vein, rural generalism featured as an example of a postgraduate program considered to be working well across medical and allied health professions (acknowledging that rural generalist nursing is at an early stage of development).

Rural generalism is an important workforce development initiative with clear application in primary healthcare that needs equitable investment across all professional streams and sustained support to continue to grow a fit-for-purpose rural health workforce that understands teams-based care.

Ultimately, it seemed we all have more in common than perhaps we initially thought – acknowledging the significant inequities that exist in the level of investment and availability of health workforce development initiatives and programs between the professions.

Indeed, the politicians present, including Dr Anne Webster, Senator Anne Ruston, state member for Mildura Jade Benham, and former ACT Deputy Leader of the Liberal Party, now CEO of Pain Australia Ms Gulia Jones, made it abundantly clear they want to see us all come together and develop solutions to address access issues to healthcare for rural and remote Australia.

It can only be hoped that the Labor Government has a similar focus on rural and remote health. Indeed real outcomes can only be achieved where there is cross-partisan support for reform.

Implications for allied health sector

So how do we as allied health professionals engage with these issues?

It’s a critical question to consider in response to the Strengthening Medicare Taskforce report with the ensuing discussions about multidisciplinary care.  It’s been heartening to hear Ministers and politicians from across the political spectrum acknowledge that allied health services are intrinsic to the reforms. But what mechanisms exist to enable allied health professionals to participate in developing solutions?

Numerous proposals have been put forward to suggest how multidisciplinary services might be arranged in primary healthcare settings (for example, the Grattan report ‘A new Medicare: strengthening general practice’).

While we understand the need for broad brushstrokes at the outset in designing new service models, consulting directly and in-depth with allied health professionals is more likely to result in robust models of care that accommodate the nuances of allied health service delivery in primary healthcare settings, and harness the work that has already been done to demonstrate the effectiveness of allied health-led models of care.

The funding of health services by population and complexity has been considered and shown to be effective from the successful Coordinated Care trials dating back decades. These trials were shown to improve health and wellbeing within existing resources and demonstrated that pooling of funds between governments is possible, and providers can cooperate at a local level to design and develop a radically new approach to health care in Australia.

There needs to be incentives for primary healthcare to be planned and provided to the whole population along life’s continuum. Fee for service is unsustainable and will never be suitable for the allied health professions who already function in this continuum paradigm.

Grant funding distributed via Primary Health Networks (PHNs) has been suggested as one potential mechanism by which some primary healthcare reforms could be implemented – particularly for rural and remote areas where workforce shortages and service access issues pose particular challenges.

The National PHN Allied Health in Primary Care Engagement Strategy published in the latter months of 2022 acknowledges that a greater focus on the allied health professions as part of primary healthcare is essential to improving access, outcomes, integration, safety, quality and cost-efficiency across the health system.

However, the PHNs themselves acknowledge they have much work to do to engage with and fully understand the capacity that exists within the allied health workforce in their respective footprints. Indeed, when the Australian Government still cannot count the number of allied health professionals working in this country and in the absence of a national allied health workforce strategy to support the growth of this essential workforce, it seems there is much work to be done – and quickly – to achieve the integrated multidisciplinary primary healthcare needed to deliver Medicare reforms.

As a sector, allied health professionals are going to need to be ready to engage at all levels – nationally through the Australian Allied Health Leadership Alliance (of which SARRAH is a member), and also at a state and/or regional and local level.

We will need a veritable army of experienced and politically-savvy allied health professionals – from where? And who then will do the clinical work? Or carry on the teaching and training of the next generation? – ready to take on project positions with PHNs, Rural Workforce Agencies and state health services to ensure effective engagement and co-design of primary care service occurs with Allied Health at the table. And we need to be coordinated and linked up to ensure models of care and governance frameworks are developed that harness our expertise, professional standards and service delivery contexts.

Investment needed

It will be crucial that as a sector we are effectively resourced to do this work.

Currently the Australian Department of Health invests a paltry amount in the allied health sector through the Health Peak and Advisory Bodies Program, approximately $300,000 per year from the $23.7 million allocated to the program over three years.

Yet allied health represents the second largest arm of the health workforce behind the nursing disciplines, encompassing 26 unique professions.

In Mildura last week the allied health sector was significantly under-represented, while acknowledging that several allied health professionals attended, including local allied health professionals representing their respective associations and eminent allied health leaders representing in other capacities on the day. In a room dominated by the medical peaks, it was unreasonable to expect our large and complex sector to be represented effectively by this handful of people.

For my part I did my best to represent the SARRAH membership, being rural and remote allied health professionals and service providers with specific expertise and lived experience of rural and remote workforce development and service design and delivery. We needed to be in the room – despite not being in receipt of peak body or other funding that would support this aspect of our work.

It was especially important to represent rural allied health professionals as viable and sustainable service providers intrinsic to the primary healthcare landscape – this is SARRAH’s primary role. It is not to represent the professions, or the Indigenous health workforce sector, or the education sector, or the jurisdictional health services, notwithstanding our long-established and constructive relationships with these groups. Multiple voices are needed to ensure that the complexities of the allied health sector are appropriately represented in meetings such as this.

We are consistently advised that the Government expects us to speak with one voice – how is that possible?

We know through our engagement with our colleagues that the allied health peak bodies are very aligned on most things and that there will always be nuances between professions and between service settings (think disability, aged care, early childhood, mental health, rural and remote health…) that mean we need to be talking to multiple government agencies. The longstanding low level of investment in the allied health peak bodies is inadequate to this task.

Starting with a level playing field would make a very good beginning – where allied health peak bodies including SARRAH are adequately resourced to engage at national, state and, through our individual and corporate members, at a local level to address the healthcare reforms in the pipeline.

Tangible benefits and key performance indicators (KPIs) would come from this investment that are well-aligned with the work SARRAH does on behalf of our membership, who currently underwrite our work.

The return on investment will be a connected, well-informed and thriving rural allied health workforce, enabled and mobilised to address the health and wellbeing needs of rural and remote communities.

Rural and remote Australia is in the midst of a health workforce shortage crisis that has emerged from a longstanding workforce maldistribution exacerbated by the pandemic. Poor health outcomes and high rates of avoidable hospitalisations are unfortunately the status quo for rural and remote communities.

So while it is encouraging to see the good intentions of those participating in the Summit, we need those intentions to be put into action with bipartisan support and collaboration between the spheres of government, the professions and others. And that action must include investment in the allied health workforce, including in our capacity to contribute to policy development and implementation at all levels.