Building the health workforce we need

Invest in sustainably attracting and retaining healthcare workers

Enable different ways of working and innovative models of care

Empower professionals and communities to embrace better paradigms of healthcare

It is vital to collect the right data to understand, track and improve the outcomes that matter to consumers, carers and families. We use our evaluation and data analysis expertise to improve governance and data collection to enable continuous quality improvement. We remove barriers to accessing, using and linking data to better enable the development of integrated care pathways and evidence-based models of care.

Monitoring and evaluation enables continuous improvement

Invest more in home-based care and educate the community about the benefits. People are increasingly choosing to be treated at home. Hospitals are designed to deliver high-risk, urgent and complex care but are usually not the right place for chronic disease management or less urgent conditions. Surveys by Palliative Care Australia and Taking the Pulse of the Nation show a large majority of people want to be treated in their homes, but less than 20 per cent of people actually are treated there. Hospitals have inherent risks, so if a patient does not need to be there, care should be in the community. Home-based care can be safer, more comfortable for the patient and less burdensome on their families, carers and emergency services. According to the Australian Institute of Health and Welfare, in 2020-21 on average across Australia, less than 70 per cent of emergency department cases were seen on time while ambulance services struggle to keep up with rising demand. Unsurprisingly, there are similar workforce pressures on paramedics, who are working harder to keep up with rising community demands with fewer of them to carry the load. More investment in keeping people safe at home will reduce pressure on essential hospital services. In well-documented reforms, Denmark went from 98 hospitals in 1999 to 32 by 2019. The country re-invested billions of dollars in extra funds to deliver services through primary healthcare, community health centres and outpatient clinics – where care was needed. Denmark consolidated smaller hospitals into larger specialised services, then mapped out where newer hospitals were needed for the population. Years later, Denmark still has one of the highest standards of living and some of the best health outcomes in the world. I was there in 2019 and saw it with my own eyes – it was brave reform and sustainable change. The community must be educated about the benefits of home-based care and the dangers of relying on ambulances and emergency departments when these are definitely not required.

Empower professionals and communities to embrace better paradigms of healthcare

Use GPs across the health system and make them gatekeepers of health resources. Emergency departments (EDs) are under growing strain, impacting patient outcomes, waiting times and staff satisfaction. A significant proportion of demand for ED comes from walk-in patients, many with concerns more appropriately dealt with in primary care settings. Rotating GPs through EDs more broadly, means they can assess and treat non-emergency patients. In cases where this model has been introduced, it has led to positive health outcomes, including a large shift of demand from hospital care to primary care, a decrease in waiting and consultation times, and decrease in patient self-referrals. The use of GPs in EDs has been trialled in the United Kingdom, The Netherlands and parts of Australia. Importantly, GPs in the community need authority to act as gatekeepers of health resources, as they do in countries like Denmark. GPs are the ‘glue’ across the sector. They make most health service referrals, and their expertise can effectively distribute healthcare needs, thereby easing the pressure on hospital resources and demands on the sector as a whole. GPs are increasingly playing co-ordinator roles for managing the growing demands for aged care, mental health and disability services. More GPs are needed overall. Indeed, general practice is a critical specialty for community health and this fact should be re-iterated to medical students when promoting this specialty as a career path. Develop health service planning embed at the coalface. National, state and territory governments each have workforce strategies and policies, but many do not align nor have practical recommendations for implementation. In fact, very few workforce strategies or policies have impact at the local level, as each health service has its own challenges and structures, and in many jurisdictions health services are left fighting their own fires. Due to our federated system, and with states subject to devolved hospital governance, there is very little policy binding our approximately 700 public hospitals, and even less so when you include over 600 private hospitals, which deliver a substantial chunk of healthcare services. Sensible and practical workforce policy is needed. This needs to be separate from the political cycle, needs to foster innovation without the undue influence of advocacy groups, and should be led by an interjurisdictional and neutral body, such as the now-defunct Health Workforce Australia. Any future policy needs to heed lessons from the pandemic and take a hard look at the future of healthcare – that is, the shift from the institutional paradigm of large hospitals toward community and home-based care. Acknowledging that more staff will be needed in the community as this paradigm evolves, this changes how we must analyse the healthcare worker pipeline and accordingly, what policy we must develop. Employ health professional students to improve their training and make the workforce more agile. Many medical, nursing and allied health students feel intimidated when they move from the classroom to clinical settings. This was evident during COVID-19 given students were largely barred from high-risk clinical settings, which jeopardising their learning. This can be overcome through employing students into low-risk clinical roles. Creating the Registered Undergraduate Students of Nursing (RUSON) and Clinical Assistant (CA) roles during the pandemic, have been a resounding success. RUSONs and CAs involve students undertaking a defined scope of practice, primarily tasked with low-risk clinical procedures (such as taking blood samples) and providing administrative and other support to nursing and medical teams. Pilot programs found that RUSONs and CAs are more likely to continue their studies despite the pandemic’s disruptions, acquire a richer learning experience and understanding of the healthcare system, and have a smoother transition to the workforce. Staff members working alongside RUSONs and CAs reported improved job satisfaction due to decreased workload, the ability to take scheduled breaks and increased time to focus on more complex tasks. Importantly, patients being treated by these students reported greater satisfaction with health services due to students spending more time with patients and providing basic care. More of these roles need to be funded and, as is the case in New Zealand, these roles must become standard features of all health professional courses in the penultimate year of study. Furthermore, RUSONs and CAs need to follow the trends of healthcare delivery and be placed in the community. RUSONS, CAs, and paid allied health students can play pivotal roles as community health ‘navigators’ or ‘partners’ for patients who choose to be treated at home, for vulnerable older people and for consumers who find the health system complicated. Acting as navigators or partners, these paid students can improve the patient experience, facilitate an effective community patient journey and help allocate health resources more appropriately, easing the strain on the hospital and its staff. Develop alternative workforce models and roles. A silver lining of the pandemic was the speed at which innovation spread. But must we wait for necessity to show us the need for invention? In addition to the RUSON and CA models, allied health assistants gained greater traction and pharmacists grew their scope to administer vaccines and conduct basic assessments. Disciplines need to lay down their arms during times of crisis, so that scope of practice is properly reviewed and discussed collectively rather than in siloes, as is common in Australia. We must ask what skills are missing and systematically fill that gap, rather than starting with what skills we already have, and potentially forgetting the root cause of a potential skills shortage. In the spirit of person-centred care, we must also not forget the roles of carers and families. During COVID-19 there was a purported rise in hospital-associated complications; the sudden absence of visitors meant that patients may not have been assisted to walk or to eat as much as with carers around. Patients also reported more loneliness at home, and many older people reported a greater fear of falling during the pandemic. Staff likely could not keep up with the demand. Therefore, developing safe ways to allow patient carers and families to come back into hospitals more formally may reduce preventable incidents and greatly assist the stretched workforce. These patient helpers may become formalised and compensated through short courses and free parking. They should be helped to feel like they are part of the healthcare delivery team, not a barrier to it. We could also consider more radical models given the workforce crisis is big and big ideas are needed. In the US, doctors are often supported by a physician assistant (PA) whose qualifications involve an undergraduate degree and a two-year master’s degree. There is substantial evidence that PAs can improve healthcare productivity, reduce stress on doctors, expand clinical education opportunities, and improve the continuity of care. Trials for PAs in South Australia and Queensland had positive results, but pressure from advocacy groups limited the idea’s evolution. A role based on the PA – but re-named and adapted for Australia – must be reconsidered. Ensuring this role does not detract from the practical experience of nurses, doctors and allied health professionals is crucial, and basing it on a skills gap analysis is important. Giving this new role a community function as much-needed health system navigators or ‘concierges’ for people’s health queries and needs may be glue for a better and more connected patient journey.

Enable different ways of working and innovative models of care

Incentivise training for rural and regional health professionals. The workforce shortage is particularly acute in rural and regional areas, where overworked staff are often isolated from support. While there are lifestyle benefits to working in regional and rural areas, worse roster and workload issues can discourage healthcare professionals from staying. The Australian Government had a rural bonded scheme until 2014, but the long-term benefits are yet to be seen and incentives for metropolitan doctors to relocate to regional areas lack the sustainability and scalability the problem demands. Universities need to train more health students from rural and regional areas, and these programs, when done properly, need significant investment. We also need more specialty training courses in rural and regional areas so medical staff there can advance their skills. Health professional colleges should consider satellite sites in rural and regional areas to show genuine commitment. Mentoring programs for health professionals in rural and remote areas can help them overcome problems involving patient expectations, work-life boundaries, and time management. We in the city cannot continue fixing the problem from afar – serious commitment, investment and local presence is needed.

Invest in sustainably attracting and retaining healthcare workers

How do we reshape the system?

Create better conditions for self-care. Nurses are the backbone of the health industry, comprising 59 per cent of all health professionals, and create the scaffolding for other health professionals and services. But nurses are overworked and underappreciated, with a heightened risk of burnout and suicide. Medical professionals are the least likely people to seek help for poor health and mental health conditions, with the doctor suicide rate being 2.2 times higher than the general population for female doctors, and 1.4 times higher for male doctors. Wellness programs for healthcare workers and promoting self-care can significantly reduce burnout, fatigue and mental ill-health. But this means tailoring staff members’ self-care needs rather than imposing organisation-led wellbeing activities that may not benefit the individual and their circumstances. Sometimes, staff just need to be able to take leave they are entitled to, or to secure a non-hospital secondment – potentially the difference between getting a second wind or burning out. We need to enable system innovation led by health professionals in the trenches because they are best placed to inform administrators what is wrong with the system. This empowers staff to make a positive difference. Improve rostering and workload management. The rostering of doctors – especially junior ones – is commonly out of touch with what happens at the coalface. Overtime is part of any busy profession, however administrators commonly miss the potential savings (or funds for reinvestment) from efficiently managing overtime. Nursing and allied health disciplines are more advanced in their rostering practices, but overall, healthcare workload management has not kept up with contemporary practice.

If we assume a working day in healthcare is 8am-6pm and also assume that most services run 24/7, then 70 per cent of services run after-hours – yet a large majority of staff are rostered during business hours. This is like an aeroplane flying overnight with fewer pilots and attendants. Research shows cultural and work-life preferences push medical and allied health staff into business hours, which condenses important tasks (and risks) into fewer hours, leading to excessive hours, more intense shifts, and less incentive to work in acute health services. Introducing 24-hour medical specialists – akin to ‘hospitalists’ in the United States – can ensure ‘pilots’ are there around the clock, which may dramatically improve after-hours workload management and ultimately improve patient outcomes. Furthermore, our health system does not easily enable senior doctors to work full-time in a single institution, plus there is cultural resistance. However, this barrier may soon need to come down as full-time medical specialists in hospitals – like in the UK or US – can pave the way for a 24/7 ‘hospitalist model’, and provide more continuous supervision of junior medical staff, greater efficiencies in patient care and better, safer staffing. Use permanent staff and promote flexible work, rather than high-cost contractors. Backfill for permanent staff and gaps from staff shortages have long been provided by locums, which are usually provided at a great expense to taxpayers. Commission rates for locum agencies are usually around 20 per cent and when shifts are requested within 24 hours of the need, crisis rates are added. There are reports of some locums being paid up to $4,000 a day in regional Australia. Enormous savings could be realised if these funds are diverted towards strategies for permanent staff recruitment. The expense of short-term contractors during the pandemic threatened the financial sustainability of many smaller health services.

Use community-led models for Indigenous health services. Due to generations of trauma and a scarcity of culturally safe health services, there is a substantial gap in health outcomes for Indigenous people and a gap in the workforce to provide appropriate care to this community. Lasting change requires the health system to embrace community-led models of care that practice cultural responsibility and safety. Aboriginal Community Controlled Health Organisations and Services are exemplars of this practice, but more is needed with regards to volume, and across the spectrum of healthcare services. While government resources – for infrastructure, workforce, policy and funding – are essential, real change for the workforce requires community participation, formal partnerships and local leadership. For Aboriginal and Torres Strait Islander people who want to become doctors, nurses and allied health professionals, initiatives and programs exist to fund training and work placements. There needs to be greater promotion of health professional courses to Aboriginal and Torres Strait Islander people and incentives to return to their communities to improve health outcomes for their own people. There also needs to be more Aboriginal and Torres Strait Islander healthcare professionals overall, in order to establish healthcare worker communities of practice and support as rising demands will take a toll. A good starting point is the National Aboriginal and Torres Strait Islander Health Workforce Strategic Framework and Implementation Plan 2021-2031, which sets out six strategic directions to support ongoing development of the size, capability and capacity of the Aboriginal and Torres Strait Islander health workforce.