Australian Health Care Reform - Essay Example

?Australian Health Care Reform Introduction Among underdeveloped countries, the insufficiency of health care resources is always a matter of primary concern. Such should not be the case for Australia, however, since the country has the best health care educational system in the world (Cross, 2009), and substantial resources are devoted to the upkeep of its citizens’ general health. About 8.5% of Australia’s gross domestic product, amounting to approximately $A79 billion is in health care. Through the years, the Commonwealth accounted for 46% of health care spending, the State and Territory governments shouldered 23%, and remainder of spending in health care was attributed to private sources (Weller & Veale, 1999). Despite this fact, however, problems in workforce shortages threaten to compromise the delivery of adequate health care in the country. The mounting problems in this sector have recently sought to be addressed by the National Health Reform Agreement arrived at by the Council of Australian Governments (COAG) in April 2010, the latest in a series of health care reforms pursued in the country over the decades. The agreement guarantees provision by the Commonwealth of no less than $16.3 billion in additional growth funding to the States and Territories, within the period 2014 to 2020 (AHMC, 2011). The principal directions are provided by the eight streams identified in the COAG agreement, and this paper shall treat on the sixth stream concerning the health care workforce. While this discussion on the health care providers is relevant across disciplines, the focal point shall be on the nursing profession, inasmuch as nurses and midwives comprise 55% of the entire health workforce in Australia (Bryce, 2009). The Sixth Stream – Workforce The best-laid plans, though well-funded and sufficiently provided with the necessary logistics, could not hope to attain success if the available manpower pool is inadequate or lacking in the necessary skills. Workforce shortages have plagued the Australian health care system in the last decade, for which reason the development of a skilled and adequate workforce has been specified as the Stream 6 in the Health Care Reform plan presented by the COAG agreement. The stated stream purpose is “to improve Australians’ access to health and aged care services by expanding the health care workforce and providing health professionals with the skills and training opportunities necessary to delivery Australia’s future care benefits” (NHHN, 2010, p. 40). According to the Agreement, substantial resources are to be provided by the Commonwealth in the realisation of the objective of this Stream. In the plan, the Commonwealth has committed to invest over the next four years a total sum of $1.2 billion, for the purpose of providing training to general practitioners and specialists; for supporting nurses working in the areas of general practice, care for the aged, and those working in rural areas; and for providing assistance and support to other professionals in allied fields rendering service in rural communities (NHHN, 2010). In the plan, the Commonwealth commits to fund 60% of costs of staff training in public hospitals, for which the following targets have been articulated (NHHN, 2010, p. 42): 1. Delivery of 5,500 new general practitioners (GPs) throughout the coming decade, amounting to a total of $345 million for the first four years; the target calls for 1,375 additional GPs who are either practicing or in training as of 2013; 2. Designation of 975 places annually as training ground for future physicians in their postgraduate training period, to experience how it feels to have a possible career in general practice; this requires $150 million as of 2012; 3. Provision of 680 additional specialist doctors spread throughout the coming ten years, for which an estimated $145 million shall be provided for the first four years; 4. Creation of a comprehensive and integrated package of programs in order to provide greater support to health professionals working in the aged care, necessitating $390 million, $103 million of which $103 million will be funded from new sources; 5. Over the next decade, provision of support for 7,500 rural nurses and 1,50 rural health professionals in allied fields; the aim is for these health care professionals to take leave in order to undertake courses in professional development, in order for their skills to be updated; funding required is $34 million for the first four years; 6. Granting of 1,000 extra clinical placement scholarship for students pursuing an allied health course for the entire decade; estimated funding is $6 million over the first four years; and 7. Allocation of $390 million via the Practice Nurse Incentive Program to support nurses in general practice. The intended outcome of these programmes and commitments is to “enable the health and aged care workforce to meet the needs of today and growing demands of the future” (NHHN, 2010, p. 40). Three of the more important issues shall be first presented, namely the increase in the workforce, the development of general practitioners, and the provision of aged care. Afterwards, observations on possible shortcomings and suggestions shall be provided. Initiatives to address the workforce shortage Workforce shortages in the public healthcare system have been exacerbated by many factors. According to the Australian Nursing Federation (ANF), some 30,000 nurses are presently registered but not working as nurses. Since nurses are mostly women, they leave work when they begin to raise families. More than that, however, several leave when the workloads have become too heavy that they feel they could not provide sufficient care for their patients (“Brave New Policies,” 2008). The push to improve preventative health care, early intervention, and chronic disease management in the new health care reform provisions will tend to further constrain the already tight workforce requirements, including doctors, nurses, midwives and other allied services. Presently there are already unfilled requests for more workers in the fields of rural obstetric, indigenous health, and mental health. This has prompted initiatives from other sectors towards workforce enhancement. Labor announced its intention to spend $81 million to attract some 9.250 nurses back to the public health care system over the next five years, and its commitment to provide a $6.000 bonus to 7,750 nurses who have been out of the profession for 12 months in order to entice them to return. Additionally, $6.6 million shall be allocated over five years for the purpose of attracting 1,000 nurses to work in aged care (Dragon, 2008). Also, included in the $81 million workforce package, federal Labor announced the opening of 1,000 extra university places for nursing for each year, from which 1,500 new nurses are expected to graduate in five years (Dragon, 2008). While the provisions are explicit in the promised resources and targets, scepticism on the manner by which targets shall be attained has been expressed by officials of professional nursing associations and nursing academic institutions. These observations are presented in the latter part of this paper. General practitioners The sixth stream pursues the initiative towards the establishment of an expanded role for the nurse practitioners, in the context of a multidisciplinary framework that brings together practitioners of the allied health care disciplines in a complementary manner. The demand for additional health workers has put a strain on the health care system and brought it to crisis situations, leading to fresh ideas for the expansion of health care to include all those who need it most. The intention is to create a “seamless” approach, anchored on the special expertise and clinical skills of nurse practitioners. Up to a certain point, the nurse practitioner is able to diagnose the patient’s malady, prescribe certain medications, and perform an expanded scope of practice to ensure that administration of a holistic, patient-centred type of quality care. In this manner, this step in the evolution of health care calls for a dynamic attitude of the professional to his job, a greater openness towards the expansion of duties, and flexibility in the manner one works (“Nurse practitioners”, 2008, p. 7). The General Practise Strategy was actually begun in 1992 as part of the policy of the Commonwealth government to address the isolation of GPs and help reduce the rising costs of general practice. The strategy is comprised of five components (Weller & Veale, 1999): 1. Division and Project Grants Programme, the stated purpose of which is to provide corporate infrastructure for GPs in defined geographical areas; 2. Rural Incentives Programme, which aims to address issues confronting the workforce, most especially concerning GP retention in the rural areas; 3. Better Practice Programme, which provides fixed payments for GPs who commit to provide a wide range of comprehensive services; 4. Support for standards and accreditation for general practice, in order to promote improvements in the quality of general practice; and 5. General Practice Evaluation Programme, aimed at monitoring and assessing the GP Strategy as a whole and to evaluate if the adopted changes truly lead to the improvement of quality of care, not only in general practice but also across the broader health care system. The setting up of an integrated and “seamless” network in support of general practitioners is not as simple or straightforward as may initially be conceived. There exists “a complex web of interdependent work-related relationships” between GPs and other providers of health care (Naccarella, 2009, p. 312). Work-related relationships in general practice were determined by research to generally fall within four main types: clinical problem solving, obtaining metaknowledge, obtaining legitimisation, and validation; key qualities to address these relationships include competence, accessibility, goodwill, honesty, consistency, and communication styles. These research findings point to failings in the current presumption that the mere provision of structural reforms (e.g. prescribed service delivery processes and financial incentives) is sufficient to encourage multidisciplinary teamwork between the GP and other health care providers (Naccarella, 2009). Aged Care In aged care particularly, poor working conditions and low pay compound patient acuity, adding to the demoralization of nurses working in this area (“Brave New Policies,” 2008). Special challenges face nurses who work in aged care; a major barrier to the aged care sector is the large gap in wages compared to other areas of nursing. On the average, nurses in aged care are approximately $150 to $250 per week (approximately $20,000 per year) worse off than their counterparts in the public sector. Aside from pay issues, the skills mix problem in aged care must likewise be resolved. This pertains to the greater complexity of health issues encountered by the elderly, a problem which becomes more pronounced as the expected life span is lengthened by discoveries in medicine and innovations in general health care. Furthermore, there is a general attitude that government agencies and institutional aged care providers that the health needs of the elderly are not as important as those of younger people with serious illnesses (Kearney, 2009). Apparently, this translates to the value attributed by the government and institutions to nurses who specialize in this field, redounding to poorer working conditions and institutional support for them. There is also a severe shortage of health care workers who are forced to attend to both high and low care individuals; in some places, the workforce to patient ratio is one registered nurse (RN) responsible for 230 resident patients, both high and low care. This presents risks that may give way to accidents just waiting to happen (Hale, 2011). Ideally, those resident patients who have been assessed as in need of high care should be specifically attended to by RNs in specially provided high care facilities that provide 24-hour care. As it presently is, a good number of high care patients are found in low-care facilities which are inadequately staffed numbers-wise as well as skills-wise. Shortcomings of the measures proposed One area where the proposed health care reform policies fail is the lack of recognition of the more than 250,000 nurses who have remained and continued to work in the system despite the unfavourable working conditions. Adequate remuneration must be extended to those nurses who have continued working under extreme pressure and duress (“Brave New Policies,” 2008). While it is a helpful sign that nurse practitioners and eligible midwives had been given the long-sought-for access to the Medicare Benefits Schedule (MBS) and the Pharmaceutical Benefits Scheme (PBS), it is but a start for those who have been clamouring for such reforms for the past 20 years (Bryce, 2009). However, much mention is made of resources to attract back former registered nurses, but those who have remained in the service al this time appear generally ignored in the provisions. The provisions also appear lacking in the details the professional associations are eager to know. The plan of action should not merely concentrate on the availability and appropriation of the necessary funds and resources, but moreso the support of “brave new policies” to give effect to the plan (“Brave New Policies,” 2008, p. 7). Systemic failings must be addressed which drove the nurses out in the first place, otherwise when the funding stops or slackens, the system promises to once more suffer the haemorrhaging of skilled health care professionals. Retention strategies must be put into place to keep those already in the system within it. The primary issue is still poor pay and working conditions, and the difficulties of heavy workloads (Dragon, 2008). Furthermore, a national workforce strategy that couples education to workforce enhancement, as that described by ANF assistant federal secretary Ged Kearney (2008). This is also the observation of the Australian Nursing Federation (ANF), which has publicly commented on the health reform provisions and the subsequent reports on the status of health care in the country. The report of the Productivity Commission released on 21 January 2011 is one such example. While as a matter of policy the general terms of the health reform agreement are well taken, the ground level reports lack the specificity needed for concrete and decisive action. The main concern of the ANF is that the language in the reports are vague, particularly in the recommendations on the need to provide nurses in aged care with competitive wages, the specific measures towards the resolution of the wage gap, skills development for aged care workers, and the tie-up between the education of medical, nursing and allied health students, and aged care training (Hale, 2011). Lost in all the talk of funding and logistics is the matter of tying in concepts of quality and risk in future initiatives in the development of the health care workforce. Such directions should be integrated into the education and periodic skills development and training programmes which should support the workforce; as it is, not enough emphasis is given this area. Quality and risk considerations should be centered on new developments in consumer empowerment, primary care and health promotion, sub-acute care, end-of-life care, as well as the provision of health care to marginalized groups such as the Aboriginal and Torres Strait Islanders and those in rural and remote areas, and the mentally ill (Cross, 2009). In this regard, policy directions, institutional infrastructures and operational guidelines will enhance the effectiveness of whatever logistical and funding support shall be extended to the workforce enhancement stream. The aim is ultimately the provision of the “right care in the right place at the right time by the right professional” (NHHRC, 2009). Other than workforce supply and retention of health care professionals but particularly of nurses, a host of other concerns have been expressed by proponents in nursing employment reform. Considerations of workforce redesign, role substitution, role expansions, interdisciplinary learning, and other work enrichment directions present opportunities for the improvement not only of nurses’ skills and their ability to address the challenges of a difficult workload, but also their morale as new insights and techniques are gained on patient health care (Cross, 2009). Conclusion The COAG health reforms agreement represents a remarkable effort by the health policy makers of Australia, and may well comprise the boldest and most tangible commitment ever made by Territory, State and Commonwealth officials particularly in addressing the workforce shortage dilemma in this industry. There are still some well-founded reservations, however, expressed by nursing and health care professional associations as to the manner these directions have been articulated. Concerns include the vagueness of the terminologies and statements as to concrete directions to alleviate problems on workload and adverse working conditions, the inadequacy of focus on quality and specialized skills training, and matters such as job enhancement and enrichment. Most importantly, however, is the apparent lack of attention and importance given to the loyal and existing workforce which never left the service, with greater importance (and rewards or benefits) being devoted to the attraction of professionals who have left the service. Commensurate recognition of these individuals who have worked under conditions of comparative disadvantage to their peers who left, and development of workforce retention programs, should be devoted attention by policy makers in order to ensure a more effective health service delivery system to the members of the citizenry who need it most. 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