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:
- doctors are concentrated in wealthy suburbs of major cities;
- sub-specialty medicine is out of balance with ‘generalist’ medicine; and
- 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.