National Health Reform

Primary Health Care Reform in Australia - Report to Support Australia’s First National Primary Health Care Strategy

Element 8-9: Working environments and conditions which attract, support and retain the workforce, and high quality education and training arrangements for both the new and existing workforce

Objectives: Primary health care professionals work in environments which support a team-based approach and a work/life balance, with conditions that attract, support and retain a strong local workforce.

The current and future primary health care workforce is provided with high quality education (undergraduate, postgraduate, vocational and continuing) and clinical training opportunities that support inter-disciplinary learning.

Improvement of the current primary health care system, to meet the health needs of all Australians, including those living in rural and remote areas, in disadvantaged communities and in metropolitan and outer urban areas, can only be enabled through developing and sustaining the current and future health workforce. To do this means addressing key issues facing the workforce, assisting those who are part of it, and optimising their use.

Priority issues identified through the Discussion Paper in relation to the primary health care workforce, and confirmed through stakeholder feedback, are:

• the need to address workforce distribution issues including attracting and retaining the existing workforce;
• enabling health professionals to use their skills, training and knowledge to their full potential, through possibly expanding current roles and responsibilities/scope of practice or introducing new professions;
• supporting teamwork and alternative models of care (such as co-located,
  walk-in/walk-out, hub and spoke and/or virtually-integrated service structures) where appropriate; and
• putting in place clinical education and training opportunities that will adequately and appropriately equip new graduates, including a focus on community-based clinical training and inter-disciplinary learning.

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Where are we now?

Workforce distribution, attraction and retention of the workforce

A well distributed, appropriately trained workforce needs to underpin the future primary health care system and arrangements. As noted under Element 1, this has a direct impact on the availability of services, and patient access to these services.

In order to improve distribution of the primary health care workforce, it is essential to ensure that there is an adequate workforce supply. This supply is met through sufficient numbers of medical and health students moving into and through primary health care streams within the tertiary education system, vocational training sector and clinical training systems. But as noted under Element 1, the current health workforce is poorly distributed resulting in a shortage of health professionals in some rural and remote areas, a challenge that has faced Australia for more than forty years.³¹³

The decisions made by GPs on where to establish their private business and how they interact with their client groups are likely to be at least partly influenced by the need to ensure the financial viability of their businesses, in turn reflecting population distribution and ability to pay for care. This has contributed to a mal-distribution in the GP workforce, where the majority of services are not necessarily located where the need is greatest.

Of the approximate 21,250 nurses currently working in Australia, this workforce appears to be relatively evenly distributed across the country, yet there are still variations across jurisdictions.³¹⁴

The supply of other health professionals such as dental practitioners, as a ratio of professional to population, is low to poor in rural and regional areas.³¹⁵ This disparity relates to dentists and equally to other dental health professionals, including dental therapists, hygienists, prosthetists and dental assistants, among others. Most dental care and the workforce who provide it work privately and in metropolitan settings. Access to public dental health care is constrained by the relatively small public sector dental workforce and their reliance on generally metropolitan-based infrastructure. Given the implications dental health has for people’s broader health outcomes, improving access to affordable and timely dental health care would address a substantial gap in primary heath care coverage.

Top of pageThe Report on the Audit of Health Workforce in Regional and Rural Australia identifies that allied health professionals (which includes pharmacists in this Report) are also mostly based in major cities.³¹⁶ An analysis of census data regarding allied health professionals demonstrated that people living in outer regional centres have access to only about half as many allied health professionals as people living in metropolitan centres.³¹⁷

It is widely acknowledged that distribution problems can stem from difficulties in attracting health professionals to work in rural and remote areas and getting them to remain there. Research indicates that it is the total employment experience including non-remunerative benefits and not salary alone that impact on recruitment and retention.^{318 319 320} For primary health care professionals working in rural and remote Australia, key challenges can include:

• the inability to take leave;
• limited availability and cost of locums;
• social isolation and lack of inter-professional support;
• lack of employment opportunities for partners, particularly where the non-health professional partner is male;
• limited training and education, mentoring and career development opportunities – this includes lack of access to face-to-face Continuing Professional Development (CPD) which is often costly and inconveniently located; and
• lack of appropriate/stable remuneration.

Other issues that are generally more relevant to GPs include:

• high patient volume;
• lack of access to specialists and other support services; and
• lower remuneration levels compared to other medical specialties.

As the proportion of Australian graduates entering general practice has declined, there is an increasing reliance on International Medical Graduates (IMGs), previously referred to as Overseas Trained Doctors. IMGs currently constitute 41 per cent of doctors working in rural and remote Australia.³²¹ In terms of those working in Aboriginal Medical Services, IMGs make up 38 per cent of the workforce, which means that they are a significantly represented group of health workers among hard to service populations.³²² There has been criticism about whether there has been sufficient support and recognition of the training needs of IMGs in Australia. Particular issues identified as affecting their long term retention in rural and remote areas, once their service obligations are completed, include the lack of:

• acknowledgement of their status as a doctor, long-term career planning, training opportunities;
• orientation to the Australian health care system, cultural mentoring and briefing about working in Australia and with different communities;³²³ and
• recognition by the Australian medical accreditation organisations of prior education and training and work experience.³²⁴

In addition to the issues noted above, other factors which influence the attraction and retention of nurses in general practice, particularly in rural and remote general practice areas, include:

• lack of career opportunities and a career structure;
• inability to use nursing skills to full potential;
• lack of recognition of ability, skills and training by doctors;
• nurses may not work in a purely nursing role;
• the billing structure through Medicare and the ‘for, and on behalf of, a GP’ item - registered nurses and nurse practitioners are not recognised through the current billing structure for their ability to perform higher duties; and
• lack of recognition for prevention work under the current funding models or workforce arrangements.

Given that 77% of the allied health workforce is female across both major capital cities and rural and remote areas, lack of child care and child care allowances is another factor cited as affecting the decision on whether or not to work in rural and remote areas. For pharmacists, a community’s involvement in welcoming them, and the ability of the pharmacist to extend their scope of practice, was cited in a NSW study³²⁵ as being incentives to moving to work in rural and remote areas and remaining there.

Many of the factors which impact on the attraction and retention of other health professionals in rural and remote areas also apply for dental health professionals. However, the extent of mal-distribution in the dental workforce appears to be exacerbated by structural issues that inhibit training opportunities and subsequent practice across sectors and locations.

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Workforce roles, responsibilities and scope of practice

An important issue to note and which cuts across most of the non-medical professions working in rural and remote Australia, is that without a GP in the vicinity, these health professionals may be unable to work, or be restricted in what work they can do. For example, one study on pharmacists stated that if doctors ‘decide to leave [the country], the [pharmacy] businesses are worth nothing’.³²⁶

Given current pressures, there is considerable support for making best use of the existing workforce, and utilising the full capacity of existing health professionals. However, there are a number of barriers, legislative and financial, which prevent some health professionals from working at the full extent of their training and experience in all sectors and settings. Often there are variances between what a professional may be authorised to do in a public hospital setting compared to what they are able to do in a private setting, such as prescribing under standing orders.

As noted above, community pharmacists are increasingly providing professional services and advice as well as traditional dispensing services, but their full scope of practice is being under utilised and activities are variable across the sector. Similarly, concerns have been expressed by the nursing fraternity that registered nurses with additional skills (such as asthma education or wound management) or nurse practitioners with advanced primary health care skills may not be fully utilised or be supported to provide services that are fully within their skills and capacity to provide. These issues may contribute to hindering nurses entering practice and workforce attrition, in addition to confusion around clinical governance, delegation and supervision in relation to these nurses.³²⁷

In addition to support for some expansion of workforce roles and responsibilities there is an emergence of new professions, such as the rural generalist role in Queensland and physician assistants, being trialled in Australia. To date, this has been done largely on a limited and localised basis. Expansion of these sorts of models would need to address current financial and legislative constraints, including registration requirements.

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Teamwork and alternative service delivery models

Primary health care services are delivered in a range of settings in the community from solo or group practices, to health centres and emergency departments. The type of primary health care service model in place in a particular area can act as an incentive or disincentive for health professionals to get involved in the service.

Across primary health care professions there has been a shift towards greater use of service models involving teams and the delivery of multi-disciplinary care. As noted under Element 4, this model can have proven benefits for both providers and patients, particularly in the management of chronic diseases.³²⁸ However, there are a range of barriers which currently limit the extent to which multi-disciplinary teams can operate effectively. These can include lack of necessary physical and Information Technology (IT) infrastructure; medical indemnity and insurance cover; integrated clinical governance; shared care protocols and defined scopes of practice; and practice management/administrative resources.

Data³²⁹ on GPs currently in the workforce indicates that there remains a significant proportion of GPs in solo practices. However, the next generation of GPs are moving more towards group practices and team-based approaches.^{330 331} Generational and other lifestyle changes have prompted this shift, with fewer professionals prepared to work in isolation, and maintain long and inflexible work hours, or be on onerous on-call arrangements. An increasing number of graduates are also seeking part-time work³³². For example, in relation to the 2006 GP workforce, 15.3% of men and 38.5% of women worked less than 35 hours per week.³³³

An increasing number of GPs are also not as prepared to establish or buy into a practice. The emergence of ‘walk-in/walk out’ or ‘easy entry/gracious exit’ models of attracting health professionals are gaining popularity, where community or university investment in practice capital and infrastructure elements is utilised to attract doctors who wish to be free from practice management and ownership responsibilities.³³⁴ ‘Fly in/fly out’ models also allow primary health care professionals to provide services in hard-to-service or remote locations without needing to be permanently based in the region.

Other innovative models are also gaining increasing recognition as potential solutions to overcome current workforce supply issues, including remote access to health practitioners and mobile health service delivery. Another example of such a model includes ‘hub-and spoke’ arrangements for delivering services to smaller localities, where health professionals may visit smaller communities for short periods within a defined catchment area, but utilising the support structure provided by a larger practice.³³⁵

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Clinical education and training

In Australia, there has been an increase in tertiary training places for medical and health students for some time, yet clinical training capacity has not kept pace with this. Major increases in health training positions are also being implemented through the Vocational Education and Training (VET) sector. Current arrangements also limit the availability of appropriate and adequate clinical training and the settings in which training can be provided.

As health professional education and training has been traditionally structured around an illness model, clinical training of health workers has continued to be largely dependent on acute inpatient services. The changes in case-mix and an increased focus on treating more complex acute conditions in tertiary facilities has reduced the breadth of clinical training possibilities available in the public system.

The growing complexity of care provided in the community setting, and the need to provide more preventive and disease management care, requires that education and training of students and health professionals is better incorporated at all levels, in appropriately resourced multi-disciplinary community-based settings. However, for medical, nursing and allied health students and current health professionals, arrangements to date have offered limited opportunities and support for team-based learning including inter-disciplinary training. For example, there is no integration of specialist trainees into community training. While general practitioners are required to undertake a range of compulsory hospital rotations during their training, the reverse situation, where specialist trainees undertake general practice rotations, does not occur.

Another issue raised by various stakeholders is the growing need to support the role of ‘generalism’ in educational curriculum, to ensure that those health professionals who go on to work in rural and remote areas particularly are able to provide holistic care and have procedural skills if they desire, rather than be limited by skills in one sub-specialty.

In relation to nurses, while their role in primary health care and general practice has expanded, this has not been accompanied by an equivalent expansion of education and training opportunities in primary health care. Undergraduate training opportunities for nurses in community and in general practice settings remain limited. Postgraduate opportunities for practice nurses are only just emerging and need further development, which can lead to frustration for nurses wanting to develop their role but having no defined scope of practice.

Also important to note is that general practices often do not have the training infrastructure required, and practice nurses who are involved in teaching others are usually not trained for this role, nor are they remunerated for their teaching role.

For allied health professionals, clinical training opportunities in primary health care have also been limited – with most clinical training occurring in the acute setting. There is also no rural pathway available to support students who wish to pursue this particular career path (unlike in medicine where a structured rural pathway exists).

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The impact of the recent COAG Health Workforce package

Australian governments recognised the importance of addressing the education and training issues through the COAG announcement of 28 November 2008. The resulting COAG Health Reform Initiative involves a comprehensive package of measures to support Australia’s health workforce now and in the future. The measures contained in the health workforce package include:

• increasing the clinical training subsidy for all pre-professional (eg undergraduate) entry students;
• expanded supervisory capacity to deliver training;
• greater use of simulated learning environments in clinical training; and
• the establishment of a national Health Workforce Agency (HWA) which will be established by early 2010 and will have responsibility for implementing the majority of these measures.

Funding for the package is $1.6 billion – $1.1 billion in Australian Government funding and $540 million in state and territory funding.

This builds on COAG’s Intergovernmental Agreement on health workforce which was signed on 26 March 2008 to create, for the first time, a single national registration and accreditation system for thirteen health professions.³³⁶ The new arrangement will help health professionals move around the country more easily, reduce red tape, provide greater safeguards for the public and promote a more flexible, responsive and sustainable health workforce.

The Australian Government, which funds GP training and determines the numbers entering the Australian General Practice Training program, has recently made several announcements, one through COAG³³⁷, which will result in an increase in commencing registrars from 675 in 2009, increasing to just over 800 from 2011 onwards. It will be important to ensure that a national distribution of these GPs is maintained through this growth phase of the program.

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What the submissions said

Workforce distribution, attraction and retention

A key area of consensus across submissions was that distribution of the primary health care workforce, particularly for rural and remote Australia, needs to be addressed urgently.

Health workforce shortages are now the single largest risk to the rollout of programs to improve the health of people living in rural and remote Australia. It is therefore imperative that planning for services and programs incorporates workforce plans.³³⁸Some submissions also suggested that for the many IMGs, who comprise a significant proportion of the rural health workforce, there are few non-financial incentives offered to them, to assist with their integration and retention:

[IMGs] …do not receive any induction to the Australian health care system and are given little community support. They often work in challenging environments where access to professional support and up-skilling is very limited. Providing these doctors with more support will enhance their contribution to patient care and will also encourage many of them to seek a permanent place in the Australian general practice workforce.³³⁹One submission mentioned that generalist practitioners may be very useful in rural and remote areas but that education must assist in shaping generalist careers:

Queensland has developed specific training and career pathways for ‘rural generalists’ which reflects the importance of broad procedural and cognitive skills and is supported with attractive remuneration.³⁴⁰For allied health professionals and for nurses, it emerged that the lack of non-financial incentives such as skills recognition, role definition and career pathways particularly, are barriers to working in primary health care.

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It is also crucial to educate medical practitioners and health administrators as to the capabilities of registered nurses to ensure that their knowledge and expertise is respected and that their working conditions are satisfying, including appropriate remuneration, flexible education structures and continuing education.³⁴¹A large number of submissions suggested that non-financial incentives such as CPD and training opportunities are vital, particularly to attract and retain health professionals to certain areas:

…whilst accredited courses for practice nurses exist in Australia, the current practice environment provides nurses with little incentive to undertake additional training unless their role is allowed to develop to apply these new skills.³⁴²Continuing professional development (CPD) and opportunities to maintain a strong knowledge base, develop further skills and meet with other professionals in a learning environment contributes to a GP’s commitment to rural towns.³⁴³

Other non-financial incentives to attract students to primary health care were flagged:

…the [general practice] profession [needs] to improve its image with medical students and those thinking of studying medicine and be more flexible in training and working hours to attract young professionals.³⁴⁴ There could be use of incentive programs rather than punitive measures such as bonded medical places. Incentives where teams of professionals are moved to areas of need and collocated together to reduce isolation.³⁴⁵

Workforce roles, responsibilities and scope of practice

Enhancement and development of the practice nurse role was flagged as a key priority in several submissions:

Nurses in primary health care will not replace other health professionals but will (and do) provide a unique service that they are already well prepared and qualified to offer. Extending this service will enable the community to access a level of primary health care that is currently not available to the Australian population.³⁴⁶More generally, the impact of broadening workforce roles on primary health care teams, and where advanced roles could be most beneficial was also raised in some of the submissions:

A common thread in many of the APHCRI [Australian Primary Health Care Research Institute] reviews is the need for adequate quality assured training, sensitive development of roles, mutual trust and respect between team members leading to effective communication and collaboration amongst the primary care team.³⁴⁷ Making greater use of (and, where necessary, incentivising) other health professionals, such as pharmacists and nurse practitioners in delivering prevention interventions.³⁴⁸Many submissions noted the current role of a pharmacist in the primary health care team, and outlined the core skills that can be contributed by the pharmacist workforce and network of community pharmacies.

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The potential for an enhanced role of community pharmacy has been recognised in the United Kingdom, where the Government has issued a White Paper setting out a vision for ‘building on the strengths of pharmacy, using the sector’s capacity and capability to deliver further improvements in pharmaceutical services over the coming years…’ (‘Pharmacy in England: Building on Strengths, Delivering the Future’, Department of Health, United Kingdom, 2008). The paper describes ways in which pharmacists will work to complement GPs in promoting health, preventing sickness and providing care that is more personal and responsive to individual needs.³⁴⁹ Views around introducing new roles into the primary health care workforce, to assist current health professionals, were mixed.

The World Health Organization (2008) suggests that primary care requires teams of health professionals including physicians, nurse practitioners, and assistants with specific and biomedical and social skills.³⁵⁰ The evidence base for the introduction of new models of care or roles is insufficient to support their introduction at this time … just expanding services or introducing new categories of workers will at best be a short term bandaid solution.³⁵¹ Teamwork and alternative service delivery models

Submissions suggested that the right infrastructure is important in order to assist health professionals to work in teams and for clinical education purposes.

The existing funding systems are not designed to adequately provide for the proper working and training space of GPNs [General Practice Networks] and offer little support in the training of new GPNs.³⁵² Also noted in submissions were the enablers needed to make multi-disciplinary teams work, for example:

A number of enablers are required to enable team members to work together [including] …e-Health tools …[the development of] multidisciplinary models …funding mechanisms …[and] education and training at all levels…³⁵³ Several submissions identified alternative service delivery models that are operating in rural and remote areas, recommending that, where appropriate, these be promulgated more broadly:

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The Geraldton Regional Aboriginal Medical Service Diabetes model is another success story in Western Australia. This model involves one General Practitioner and up to four allied health professionals (e.g. dietician, podiatrist, diabetes educator) travelling together by bus to rural and remote areas in the Mid West to provide diabetes screening and mentoring.³⁵⁴ The RFDS [Royal Flying Doctor Service] ‘hub and spoke’ model of service delivery is able to provide regular and frequent services to otherwise inaccessible communities. Flexibility in visiting schedules enables visits to be set depending on community size and health needs. The model assists in retention of health professionals enabling a workable lifestyle in the RFDS base ‘hub’ usually in a larger regional centre.³⁵⁵

Clinical education and training

Many submissions supported more horizontal integration in education, including inter-disciplinary clinical placements to encourage multi-disciplinary care teamwork. Some commented that this would require funding to support universities to develop this and funding to create inter-professional bodies.

The future education of the primary health care workforce should actively facilitate the development of functional primary health care teams. A starting point would be to increase inter-professional health care education and clinical placements. This is currently extremely difficult to achieve due to poor vertical integration of undergraduate-postgraduate training as well as almost no horizontal integration of medical, nursing and allied health training. Improving integration will be an additional cost to universities which provide medical and nursing training. First steps forward should include supporting the development of inter-professional primary health care organisations and providing targeted funding to universities to improve integration.³⁵⁶ Many submissions suggested that an important component of inter-disciplinary learning is teaching health students what the roles and skills are of all types of health professionals.

One of the greatest barriers to multidisciplinary approaches and patient centred care in the primary health care setting is the lack of awareness of various professional groups about the skills and potential contributions of other health professionals.³⁵⁷Another submission suggested that clinical training for non-medical students needed to be more focussed on the primary health care sector and be funded for this.

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Clinical placement in the private primary care setting is currently a difficult proposition due to financial and indemnity insurance barriers. There is support for medical students and this should be extended to other primary health care professions. Currently all professional placements for dietetics are in the public sector and this does not equip graduates for primary care roles in the private sector with many being reluctant to enter this area and those who do so often struggle. The development of regional primary health care organisations may assist in supporting this and in developing a multidisciplinary approach to professional placement.³⁵⁸Various stakeholders supported the idea of vertical integration to make all levels of medical education more cohesive and coherent.

In Australia… [basic medical curriculum through to the vocational general practice curriculum] have traditionally been delivered separately by Universities and vocational training organisations respectively. This has largely prevented the natural integration and progression of curricula and training resulting in confusion at the recipient end and a waste of resources.³⁵⁹ However, some submissions were supportive of vertical integration but only under certain conditions.

The concept of vertically integrated teaching assumes that a single teacher can simultaneously support learners at different stages. Although this is possible for a few skilled educators it is a demanding expectation for professionals whose primary role is patient care.³⁶⁰ To assist with vertical integration, suggestions were made to provide single accreditation for training providers for undergraduate to postgraduate and CPD.

The regional training network supports the concept of a single accreditation process for training sites which can be applied across the training spectrum. The accreditation should be targeted at the highest level (specialist college accreditation) therefore enabling any practice to deliver training from undergraduate to vocational without the need for multiple certification.³⁶¹ Many submissions suggested that in order to engage primary health care providers in clinical training for health students, particularly in rural and remote areas, strong financial incentives are required.

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… to truly support and recognise the role of teaching would be through a Medicare item for teaching consultations. At the very least, we believe that the teaching PIP requires a significant increase, at least by 50%, if it is to truly be an ‘incentive payment’ and reflect the critical importance of undergraduate education in general practice.³⁶² Several submissions noted the difficulties associated with providing clinical placements in the primary and community health care setting including problems associated with lack of infrastructure, human resourcing, and remuneration issues.

Community student placements require extensive teaching and infrastructure resources due to the need for high teacher to student ratios and close supervision. These are currently very poorly remunerated, which has created an enormous barrier to recruitment and retention of quality GP teachers, with the conflicting demands of their busy practices. This has been recognised through recent funding from the Federal Government for the Crescent Project, which is establishing two community clinical schools in northern and western suburbs of Melbourne. This recent development provides an exciting opportunity to develop a high quality and relevant community-based medical training and is a useful model for future funding initiatives.³⁶³

What is the way forward?

As noted above, there have been significant changes in the delivery of health services, with an increasing emphasis on the primary health care sector to manage a range of complex care needs and chronic disease in the community.

Health outcomes depend on the availability of a skilled health workforce. For many Australians, having timely and affordable access to the services provided by skilled primary health care professionals remains difficult. As the preceding comments demonstrate reforming the system to improve supply, access and health outcomes will require a multi-faceted approach. We need to:

• create appropriate practice environments that function effectively as both service delivery and training precincts for multi-disciplinary teams;
• provide training for all health disciplines in the environments in which services are delivered. This will need to also consider the implications of our current mixed funding of primary health care services, including patient contributions;
• provide suitable infrastructure and professional capacity for all health professionals to ensure appropriate teaching opportunities, research and evaluation of primary health care programs can be achieved; and thereby
• create workplaces which are attractive and relevant to students, which creates sustainability within the primary health care sector.

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Workforce distribution, attraction and retention of the workforce

Significant consideration needs to be given to improving the current discrepancy between supply and demand for primary health care services, and the factors contributing towards attracting and retaining workforce in hard to service areas.

There is an ongoing need to consider the effectiveness of the current range of initiatives available to encourage the workforce to less attractive areas/populations, and how these could be built upon in the future to better distribute the primary health care workforce. The 2009-10 Rural Health Budget measures include the establishment of a National Rural Locum Service in addition to other initiatives that will seek to improve retention and provide greater support for the rural primary health care workforce.

In relation to better recognising the role played by IMGs, the Rural Health Workforce Measures announced in the 2009-10 Budget are a significant first step to addressing these challenges. The newly recruited IMG will face many of the same education and support needs of the newly graduated Australian-trained doctor, with additional needs due to cultural and language differences and lack of knowledge of the Australian health care system.

Through these new Budget measures, development of standardised induction programs and cultural mentoring will assist in supporting newly arrived IMGs through ongoing support, for them and their families. Access to locum relief will also be crucial factors in retaining these IMGs in rural and remote locations. These support services will also become available for other overseas trained primary health care professionals, such as nurses, allied health and dentistry, through the expansion of funding agreed by COAG for international recruitment (under the National Partnership Agreement on Hospital and Health Workforce Reform).³⁶⁴

Workforce roles, responsibilities and scope of practice

There is considerable support for using the existing workforce more effectively, through, for example, broadening the current roles and responsibilities of primary health care professionals. Primary health care service delivery models that rely heavily on nurse-led services are increasing in number. For example, the Walwa Bush Nursing Centre is run by a nurse practitioner and staffed by advanced practice nurses who work to their full capacity and thereby ease the workload for medical staff who can address more complex cases.³⁶⁵ The recent Budget decision to provide access to the MBS and PBS to nurse practitioners working in primary health care, and advanced midwives providing care from November 2010, provides opportunities for new models of care to develop in collaborative partnerships, and for a new career pathway to open up.

Making optimum use of the workforce can also involve consideration of changing current scopes of practice, for example, in relation to prescribing arrangements through implementing delegated prescribing models. Under such a model, the GP would be able to authorise other health professionals working in a collaborative team to prescribe certain medications or authorise repeat prescriptions as appropriate to the skill level, experience and knowledge of that individual. Changes to some of these structural barriers may free up resources to enable more effective service delivery within the primary health care sector.

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Teamwork and alternative service delivery models

Research indicates that a healthcare system that supports effective teamwork can improve the quality of patient care, enhance patient safety, and reduce workload issues that cause burnout among healthcare professionals.³⁶⁶ Evidence shows that for teams to work most effectively, they need to have a clear purpose; good communication; co-ordination; protocols and procedures; and effective mechanisms to resolve conflict when it arises.³⁶⁷

Greater acknowledgement of the value of teamwork, particularly in managing chronic and complex conditions, is a clear priority for the Draft Strategy. This will need to include looking at how current financial arrangements can be made more flexible to ensure that multi-disciplinary teams are properly supported in service delivery. At the same time, there are considerable issues to overcome in terms of how practices can be supported to establish the necessary infrastructure required for delivering multi-disciplinary care (eg additional consulting rooms and office space) – as discussed under Element 4.

Alternative primary health care service delivery models (such as remote access to health practitioners and ‘hub and spoke’ arrangements) will be key in considering how quality health care can be delivered sustainably into the future, in light of shifting service demands resulting from demographic changes, changing clinical practice, and other factors. In this context, a model that has growing support in Australia is the use of inbound/outbound call centre networks to assist the general population or provide services to targeted groups. The COAG initiative, healthdirect Australia, takes inbound calls while selected jurisdictions and some private health insurers provide inbound/outbound telephone support for patients with chronic disease. ³⁶⁸

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Clinical education and training

Importantly, there is a need to develop more training to complement where health care is being delivered and underpin the most appropriate areas where it should be developed. Careful consideration will need to be given to how to best facilitate moving more training of primary health care professionals into the sector in which they will be working, while acknowledging the mixed nature of funding of primary health care services at present, including patient contributions.

The health workforce reform package announced by COAG will support a significant expansion of clinical training opportunities within the primary health care setting, in both the private and public sector, by providing specific funding for all major health professions to assist them to meet the costs associated with providing clinical training to pre-professional entry students, which many submissions noted was a significant barrier.

As the clinical training subsidy is linked to individual students regardless of health discipline, there will no longer be funding barriers between health professionals in terms of providing clinical training experiences. For example, students from nursing or allied health will be funded if they have clinical training in a general practice setting. This provides an opportunity to further some of the work engaged in by some universities to reflect the growing
multi-disciplinary approach to primary health care.

This initiative should have a significant effect in increasing the number of clinical training places available to students in primary health care settings, thereby exposing students to the range of issues and challenges that face primary health care practitioners. Early exposure and positive learning experiences are linked to specialty choices of students.^{369 370}

The use of Simulated Learning Environments (SLEs) has increased particularly for training of procedural skills in rural and regional environments. The COAG workforce package contains additional funding to assist in the establishment of new SLE centres, focussing on rural and remote provision of training. With an increasing demand for clinical training, further use of SLEs could take some of the demand for clinical training off the clinical service delivery environment. Rural clinical schools have already demonstrated that the use of SLE facilities can provide great value in augmenting patient-centred clinical training experiences. Further investment in video-conferencing facilities and live web-based educational delivery also has the potential to alleviate a lack of dedicated physical training capacity.

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Inter-disciplinary learning and competency-based assessment

It is likely that the clinical training arrangements put in place through the HWA will be administered through a regional partnership for all relevant professions. This provides an opportunity for further consolidation of inter-disciplinary learning (or horizontal integration) of pre-entry health professionals. It would be feasible, using the opportunity presented by the new clinical training arrangements, to streamline organisational infrastructure at the regional level with one university-based regional structure and one prevocational/vocational structure. Such an arrangement would require close cooperation and sharing of resources between professional organisations, Divisions, Regional Training Providers, universities and other stakeholders, but may result in a significant release of resources to facilitate multi-disciplinary training for both students and established professionals within a region. This would particularly be the case if individual accreditation requirements for specific professions could be streamlined by accreditation authorities and universities, thereby simplifying the requirements for primary health care providers who train students from a variety of disciplines.

Expanding multi-disciplinary training infrastructure would also need to be coordinated with a revision of curriculum to ensure that all health professions are able to provide the increasingly complex primary health care, including multi-disciplinary team-based care and preventative health care. Most health disciplines have closed and single pathways of training with little cross-discipline recognition of learning or competency-based assessment. Through cross-discipline learning, health professionals would be equipped with a thorough understanding of each profession’s skills and expertise, which would ensure maximum use of each person’s competencies in the multi-disciplinary team.

In addition, emerging models of new primary health care will need to be underpinned by appropriate and implementable education and training. Development of core competencies in primary health care will assist this process. It is important to note, however, that establishing competency-based training presents a number of challenges, particularly in determining a means of assessing some of the skills and personal attributes needed for successful primary health care service, with its emphasis on diagnostic skills, chronic disease management and patient communication.

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Vertical integration of education and training

There may also be value in further investment and coordination at the regional level to test different operational models of vertically integrated training. The opportunity most readily presents itself in general practice settings, where vocational training is already organised on a regional basis, as is proposed for clinical training of medical students under the new funding arrangements proposed for HWA. While there is clear agreement between stakeholder groups of the value of providing integrated career pathways, barriers to the successful implementation of practical models still need to be removed and greater collaboration between professional organisations needs to be encouraged.

Infrastructure support for community-based learning/teaching

Underpinning these initiatives, there needs to be consideration of infrastructure issues, both in terms of capital development of training facilities, and in terms of the ‘human capital’, that is support for supervisors and teachers. Current initiatives, such as GP Super Clinics which allow inter-disciplinary learning opportunities will be a key component, as will the infrastructure development opportunities presented through the Australian Government’s capital funding provided in the COAG package, and more broadly through the Health and Hospitals Fund.

It will be important to ensure that the available infrastructure funding is focussed on projects which maximise the opportunities for training a variety of health professionals, both pre-entry and continuing professional development. This is particularly the case for the additional funding available for SLEs, which have a strong focus on providing training for rural and remote health professionals.

To address the issue of a clinical training capacity shortage, COAG also agreed funds to train approximately 18,000 nurse supervisors, 5,000 allied health and other supervisors and 7,000 medical supervisors. Supporting adequately the supervisors of primary health care health students, however, requires reconsideration of the funding arrangements for primary health care, as previously noted. The clinical training subsidy arrangements under the COAG workforce agreement are an important step in this direction, and will defray some of the costs of teaching, but full integration of teaching in all aspects of the primary health care sector will require some significant rethinking of the current arrangements.

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Capacity to address needs of Indigenous Australians

For particular groups, notably Aboriginal and Torres Strait Islander peoples, whose needs have not been addressed adequately by the existing health system, improvements in the capacity of the health workforce, in primary health care and other spheres, will be critical to close the gap in life expectancy and other key measures, identified as a priority by the Australian Government. If Indigenous health is to be addressed effectively, it will depend on a fundamental shift in the capacity of the health workforce to meet their needs. This will mean:

• increasing the awareness and understanding of Indigenous health across the health workforce generally;
• incorporating effective content and standards into health course curricula;
• increasing the number of health practitioners providing appropriate and ongoing care to Indigenous people; and
• substantially increasing the representation of Indigenous people in the health workforce, including in the tertiary trained sector, where they are most under-represented.

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313 Australian Government Department of Health and Ageing, 2008. Report on the Audit of Health Workforce Regional and Rural Australia, April 2008, Commonwealth of Australia, Canberra.

314 ibid.

315 ibid.

316 ibid.

317 Keane S, Smith TN, Lincoln M, Wagner SR, Lowe SE, 2008. The rural allied health workforce study (RAHWS): background, rationale and questionnaire development. Rural and Remote Health, vol. 8, no.1132.

318 OECD, 2008. The looming crisis of the health workforce: How can OECD countries respond? Introduction of Report available from: http://www.oecd.org/dataoecd/25/15/41509236.pdf (accessed June 2009).,

319 Gillham S & Ristevski E, 2007. Where do I go from here: We've got enough seniors? Australian Journal of Rural Health, vol. 15, pp. 313-320.,

320 Armstrong B, Gillespie J, Leeder S, Rubin G, and Russell L, 2007. Challenges in health and health care for Australia, Medical Journal of Australia, vol. 187, no.9, pp. 485-489.

321 Australian Government Department of Health and Ageing, 2008. Report on the Audit of Health Workforce Regional and Rural Australia, April 2008, Commonwealth of Australia, Canberra, p. 3.

322 Gilles M, Wakerman J, Durey A, 2008. If it wasn’t for OTDs, there would be no AMS: overseas-trained doctors working in rural and remote Aboriginal health settings, Australian Health Review, vol. 32, no. 4, pp. 655-663.

323 ibid.

324 ibid.

325 Harding A, Whitehead P, Parisa A, Chen T, 2006. Factors affecting the recruitment and retention of pharmacists to practice sites in rural and remote areas of NSW: a qualitative study, Australian Journal of Rural Health; vol 14, no.5, pp. 214-18.

326 ibid.

327 Australian Practice Nurses Association, 2008. Building Blocks: Nursing in Primary Care (unpublished).

328 Dennis S, Zwar N, Griffiths R, Roland M, Hasan I, Powell Davies G et al, 2008. Chronic disease management in primary care: from evidence to policy, Medical Journal of Australia, vol. 188, s. 8, pp. S53-S56.

329 Primary Health Care Research and Information Services, 2009. Fast facts: General Practice Size in Australia, 2005-06 to 2007-08, available from: http://www.phcris.org.au/fastfacts/fact.php?id=4970 (accessed May 2009).

330 Rural Health Workforce Australia, 2009. Why is rural Australia not an attractive workplace?, available from: http://www.rhwa.org.au/client_images/528159.pdf (accessed June 2009).,

331 The growth in less segmented, multi-disciplinary practice is progressing alongside enhancements in the roles and number of health professions, such as practice nurses and nurse practitioners.

332 Rural Health Workforce Australia, 2009. Why is rural Australia not an attractive workplace? available from: http://www.rhwa.org.au/client_images/528159.pdf (accessed June 2009).

333 Australian Institute of Health and Welfare 2008, Medical Labour Force 2006. Cat. no. HWL 42, available from: http://www.aihw.gov.au/publications/hwl/mlf06/mlf06.pdf (accessed June 2009).

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334 Wakerman J, Humphreys J, Wells R, Kuipers P, Entwistle P & Jones J, 2006. A systematic review of primary health care delivery models in rural and remote Australia 1993-2006, Australian Primary Health Care Research Institute, Canberra.

335 ibid.

336 From 1 July 2010, the following health professions will be regulated under the new National Registration and Accreditation Scheme: chiropractic, dental (including dentists, dental hygienists, dental prosthetists, dental therapists and oral health therapists), medicine, nursing and midwifery, optometry, osteopathy, pharmacy, physiotherapy, podiatry, and psychology. From 1 July 2012 the following health professions will be regulated under the scheme: Aboriginal and Torres Strait Islander health practice; Chinese medicine; and medical radiation practice.

337 Council of Australian Governments, 2008. Council of Australian Governments Meeting 29 November 2008, available from: http://www.coag.gov.au/coag_meeting_outcomes/2008-11-29/index.cfm (accessed June 2009).

338 Submission from Rural Health Workforce Australia (Sub #247)

339 Submission from Australian Medical Association (Sub #51)

340 Submission from Australian Primary Health Care Research Institute (Sub #226)

341 Submission from Royal College of Nursing, Australia (Sub #127)

342 Submission from Australian Association for Academic General Practice (Sub #38)

343 Submission from Australian Primary Health Care Research Institute (Sub #226)

344 ibid.

345 Submission from Victorian Association of Maternal and Child Health Nurses (Sub #66)

346 Submission from Australian Nursing Federation (Sub #200)

347 Submission from Australian Primary Health Care Research Institute (Sub #226)

348 Submission from National Prescribing Service (Sub #103)

349 Submission from The Pharmacy Guild of Australia (Sub #178)

350 Submission from Australian College of Nurse Practitioners (Sub #104)

351 Submission from Rural Doctors Association of Australia (Sub #262)

352 Submission from Australian Practice Nurses Association (Sub #203)

353 Submission from Australian General Practice Network (Sub #141)

354 Submission from Rural Health West (Sub #235)

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355 Submission from Royal Flying Doctors Service (Sub#97)

356 Submission from Australian Primary Health Care Research Institute (Sub #226)

357 Submission from Dietitians Association of Australia (Sub #26)

358 ibid.

359 Submission from University of Melbourne, Department of General Practice (Sub #105)

360 Submission from Greater Green Triangle GP Education and Training (Sub # 120)

361 Submission from Association of Chief Executives for Australian General Practice Training (Sub #80)

362 Submission from Australian Association for Academic General Practice (Sub #38)

363 Submission from University of Melbourne, Department of General Practice (Sub #105)

364 Schedule B of the National Partnership on Hospital and Health Workforce Reform includes information on improving international recruitment efforts, available from: http://www.nhwt.gov.au/documents/COAG/National%20Partnership%20Agreement%20on%20Hospital%20and%20Health%20Workforce%20Reform.pdf (accessed June 2009).

365 Australian Nursing Federation, 2009. Primary health care in Australia – a nursing and midwifery consensus view, available from: http://www.anf.org.au/anf_pdf/publications/PHC_Australia.pdf (accessed June 2009).

366 Canadian Health Services Research Foundation, 2006. Promoting Teamwork in Health Care, available from: http://www.chsrf.ca/research_themes/pdf/teamwork-synthesis-report_e.pdf (accessed June 2009).

367 ibid.

368 Examples of jurisdictional inbound/outbound call centre activities include:

• a trial of outbound call coaching service for the Western Australian Department of Health for low risk participants with diabetes and other chronic diseases who have never been hospitalised.
• Medibank Private’s ‘Better Health’ service for members with heart disease, heart failure, COPD and diabetes which includes telephone coaching to assist patients better manage their condition.
• the Department of Veterans’ Affairs congestive heart failure program for veterans in NSW (under the study Care coordination in the delivery of health services to veterans).
• HCF’s Healthy Heart program for members with congestive heart failure or coronary artery disease which includes telephone coaching to help people better understand their care plan and their condition; and to better monitor and manage their health.

369 Harris M, Gavel P & Young J, 2005. Factors influencing the choice of specialty of Australian medical graduates, Medical Journal of Australia, vol. 183, no. 6, pp. 295-300.,

370 Gang X, Veloski JJ, Barzansky B, Mohammedreza H, Diamond J & Silenzio MB, 1997. Comparisons among three types of generalist physicians: Personal characteristics, medical school experiences, financial aid, and other factors influencing career choice, Advances in Health Sciences Education, vol. 1, no. 3, pp. 197-207.

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