Primary Care Workforce

Adjunct Associate Professor John Rasa CEO Networking Health Victoria and

CEO General Practice Victoria

Regional Integration

• Integration of public and private services

•Health Pathways

• Integrating assessment & advice lines into health pathways

• Developing advanced care planning systems

• Patient-centred medical home trial

• Better health care management in Aged Care Homes

• Prevention, screening & early intervention

Information & Technology

• eHealth adoption

• Establishing a coordinated telehealth system

• Information provision in EDs about available after hours services

• Community education regarding service options

Infrastructure

• Improved PHC infrastructure

Skilled Workforce • Development of the primary health care workforce especially Allied Health Services

•Support for placements of health care students in PHC

PRIMARY HEALTH CARE REFORM FRAMEWORK

The Context of Primary Care

Workforce Challenges

Australians are living longer due to scientific advances in

medical care and public health policy

Growing proportion surviving with multiple chronic

diseases

Study by Australian Primary Health Care Research

Institute (2013) found that amongst 4574 respondents

82% had at least one chronic condition

52% had at least two chronic conditions

Average of 2.4 co-morbid conditions

Has implications for training & development of a disease

management skill set of clinicians

Challenge of Chronic Illness

in the Community

Britt H., Miller G., & Henderson J., ‘Multimorbidity’ Australian Family Physician, Vol 42, 12, Dec 2013

The Context of Primary Care

Workforce Challenges

Australia has a policy reform agenda to shift care

from acute care towards the delivery of a connected

primary health care system

There is a focus on prevention & better

management of chronic disease.

Encourage health practitioners to work at the fullest

extent of their scope of practice, encourage greater

flexibility and multidisciplinary learning

Promoting the concept of medical home, patient

centred models with strong consumer engagement

What we are doing to address the identified challenges?

• Addressing the shortage of skilled health professionals

• Current issues for regional and remote areas

• Investing in nursing and allied health

• Workplace training programs

Examining the key work of Health Workforce Australia and the

outcomes of the Mason Review of Australian Govt Health

Workforce Programs

Primary Care Workforce

Primary Care Workforce

Work of HWA 2010-11

HWA Key Principles

• Initiatives must build capability and explore roles based

on a better balanced skill mix to meet community need

rather than traditional professional demarcations.

• A whole of workforce approach to reform should be used

to ensure change is scalable, sustainable and replicable.

• Reforms must span boundaries, geographical,

jurisdictional, organisational and/or professional.

Primary Care Workforce

Mason Review of Australian Govt Health

Workforce Programs (April 2013) identified

Substantial growth in Commonwealth funding for health

workforce programs from $286m in 2004-5 to $1.79b

expected in 2016-17

HWA committed to $425m to support 1.7m additional

clinical training placements for medicine, nursing & AHPs

over 3 year period 2011-14

Support for rural medical training & expansion of

vocational training programs (GP & specialist training)

Support for nursing/midwifery & dentistry, & to a lesser

extent allied health.

Primary Care Workforce

Mason Review of Australian Govt Health

Workforce Programs (April 2013) identified

Identified the average working hours of many health

professionals was in fact reducing

With the exception of nurses & midwives, the relative

number of health professionals diminishes for

communities located further away from major centres

The increasing prevalence of chronic disease has

implications not only for number of health professionals

but also the skill mix & models of care (ie. multi-

disciplinary/team based care)

Primary Care Workforce

Primary Care Workforce

Medical Workforce in Australia (AIHW, 2012)

91,504 registered medical practitioners

79,653 (87%) were employed in medicine

Almost 2 out of 5 were women

1 in 4 were aged 55 or older

Work on average 42.7 hours per week

94.5% of all employed medical practitioners were working in a clinical role

3,035 domestic students commenced undergraduate training in Australia

Primary Care Workforce

Medical Workforce in Australia (AIHW, 2012)

Average age of employed medical practitioners was

46.0 years with 37.9% being women

Age distribution is uneven with 51.8% women in 20-34

year age group but only 13.8% in the 75 and older age

group

There were 221 (0.3%) Aboriginal or Torres Strait Islander

employed medical practitioners reflecting a significant

under-representation of Aboriginal people in the health

workforce and there were14,022 Aboriginal health

professionals overall (1.81% of all health professionals).

Primary Care Workforce

Medical Workforce in Australia (AIHW, 2012)

Overall supply of clinicians (involved in diagnosis, care

and treatment rose from 323.2 FTE per 100,000 population

in 2008 to 355.6 FTE in 2012 (10% change)

But the supply of general practitioners only increased

from 109.1 FTE per 100,000 population in 2008 to 111.8

FTE per 100,000 pop. in 2012 (2.5% change)

Employment settings of clinicians

Primary Care Workforce

0 10 20 30 40 50

Hospitals

Group Private Practice

Solo Private Practice

Community Health Care

Education

Other

% Employed

% Employed

Health Workforce 2025 (HWA, 2012) key findings were:

A sufficient number of medical specialists is projected

but not in the communities that need them

There is a growing trend towards specialisation and

sub-specialisation, which means Australia does not have

enough generalists.

It is projected there will be a geographic

maldistribution for general practitioners (GPs) and a

number of other medical specialties, with a shortage in

rural and remote communities and too many in

metropolitan areas.

Primary Care Workforce

Geographic maldistribution of general practitioners (GPs)

raises a number of issues

Mason review recommends a modification of the ASGC-

RA (remote areas) to a ‘modified Monash Model’ giving

recognition to smaller communities (population <15,000)

that are more vulnerable to workforce pressures

discriminating between large and small towns in bands

RA 2 & 3 while retaining the current RA 4 & 5 areas.

Mason review also recommends broadening the settings

for the return of service obligation to include rural and

remote areas in the Bonded Medical Places scheme,

including Aboriginal Medical Services & defence force

facilities.

Primary Care Workforce

Health Workforce 2025 (HWA, 2012) key findings were:

The medical training pathway were poorly coordinated,

which contributed to:

An uneven distribution of numbers between specialties.

Lost opportunities to address issues around geographic

distribution and promote a better balance between generalist,

specialist and sub-specialist training.

The Mason Review identified a lack of a clear pathway

from undergraduate rural training into employment as a

rural doctor. It identified the missing link as the lack of

availability of rurally-based internership positions through

which rurally trained medical students can transition

directly to vocational GP training.

Primary Care Workforce

Primary Care Workforce

General Practice Workforce Statistics NATIONAL FIGURES

2012-13 2003-04 % Increase

Head Count (a) 30,681 22,949 34%

FTE 18,398 14,246 29%

FWE 22,087 16,872 31%

Total Services (b)

['000] 132,399 100,340 32%

Primary Care Workforce

Major Cities

Inner

Regional

Outer

Regional

Remote/

very remote TOTAL

Population 2002 13,471,492 3,654,851 1,881,014 487,853 19,495,210

FWE – GP

(2001-2002) 12,443 2,777 1,275 241 16,736

Ratio pop/FWE 1,083 1,316 1,475 2,024 1,165

Population 2012 15,976,750 4,161,150 2,047,432 525,020 22,710,352

FWE – GP

(2011-2012) 15,109 4,014 1,677 319 21,119

Ratio pop/FWE 1,057 1,037 1,221 1,646 1,075

% Change

pop/FWE 2% 21% 17% 19% 8%

Medical Workforce definitional issues with Primary Care

Supply Data

RWA data looks at FWE-equivalents, which is based on

Medicare billing data and doesn’t count non-Medicare

billable work undertaken by GPs

AIHW FTE data is based on medical practitioners/GPs

working 40 hours per week (in line with National

Healthcare Agreement)

ABS distinction of full-time and part-time based on a

standard 35 hour week

Primary Care Workforce

Key trends and small wins

(Rural Health Workforce Australia (Nov 2012)

7378 GPs working in rural and remote Australia (6.1% increase)

The proportion of female practitioners working in ASGC-RA 2 to ASGC-RA 5 locations has also increased by 1 percent to 37.8%, from the previous year.

There are increasing numbers of female practitioners in younger age groups.

Average age for male GPs was 51.7 years and 46.7 years for females, with the average age for all practitioners was 49.9 years.

Proportion of female GPs working full-time increased from 40.5% in 2011 to 45.8% in 2012.

Primary Care Workforce

Key trends (Rural Health Workforce Australia

(Nov 2012)

• A small increase in the average number of GP clinical hours worked per week from 34.3 hours in 2011 to 35 hours in 2012 which is consistent with the average observed in 2010 (35.1 hours).

• The average length of stay in practitioners’ current practice has reduced slightly from 8 years in 2010 to 7.6 years in 2012.

• Whilst there has been an increase in the number of GP proceduralists, the proportion of practitioners providing procedural services in 2012 (12.6%) is relatively steady compared to the year before (12.2%).

Primary Care Workforce

Primary Care Workforce -Nurses

Nurses can play a significant role in primary health care to manage people with chronic and complex conditions

Nurses can provide care equivalent to doctors within their scope of practice but have longer consultations.

Lifestyle interventions provided by nurses have been shown to be effective for cardiac care, diabetes care, smoking cessation and obesity.

Parkinson, A.M. and Parker , R. Addressing chronic and complex conditions: what evidence is there regarding

the role primary healthcare nurses can play? Australian Health Review, 2013, 37, 588–593

Primary Care Workforce -Nurses

Mason review found that with the introduction of degree level study for nurses/midwives, for nurses who have been out of the workforce for more than 10 years, it acts as a disincentive to return to the workforce – particularly impacting rural settings and Aboriginal communities.

The Mason Review suggested support for re-entry programs for this group

Commonwealth has increased investment in practice nursing and scholarships totalling 34% of the funding under the Health Workforce Fund in 2011-12

Actions suggested increasing opportunities for enrolled nurses, nurse practitioners & personal care workforce

HWA Initiatives

Initiatives including National Medical Training Advisory

Network

Developing a nationally consistent approaches to

funding clinical training placements in the public, non-

government & private sectors.

$425m investment in Clinical Training Fund to increase

the number of clinical placements across all parts of

Australia. The number of clinical placement days

increased by 50% in 2012 compared to 2010.

Primary Care Workforce

HWA Initiatives

$85m investment in the Simulated Learning

Environments to support simulation equipment/capital

($44.4m)& recurrent investment ($30.2m)in simulated

training delivery. Delivered a 115% increase in simulation

education hours in 2012 compared to 2010.

Primary Care Workforce

HWA Initiatives

Integrated Regional Clinical Training Network was

provided $32m over three years to support IRCTNs

Case Study of Inner East Melbourne Medicare Local

which accessed Innovative Clinical Teaching and

Training Grants for GPs & other health professionals in

expanded learning environment to support 250

placements over three years utilising <$100k grants.

Melbourne University provided field support.

Primary Care Workforce

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IEMML Strategic Actions :

Clinical Education Alliance with Deakin,

Melbourne & Monash Unis, VMA,

RACGP, GP practices & others.

Expand local practices capacities to host

learners.

Support education providers re local

practice based clinical placements.

Advocate for clinical training resources.

IEMML’s role to assist but not replace

effective engagement between educators

& practices.

29

Clinical Education Alliance outcomes to

date include:

ICTTG (DoH) infrastructure funds for

practices.

HWA / Vic Gov clinical placements

Expanded Settings funds.

Major baseline increases in nursing and

medical student placement capacities.

Clinical supervisor training for in-

practice teachers (TOTR).

Clinical training support web portal for

practices.

30

Initial Clinical Training

Support Partners: 1

discipline medicine;

with 1 service type

GPs (total 186

practices); with 4

education providers

& 1 professional

college.

Future Clinical Training

Support Partners: 15 +

health disciplines; with

many different PHC

service types (total

1950 service entities);

with multiple education

providers/ professional

associations.

Final Observations

Additional GPs still required for rural and remote areas

so funding formulas need further refinement to

incentivise

Maximise the workforce participation of existing GPs

New models of care with greater use of up-skilled nurses

and AHPs & greater collaboration in clinical placements

Capitalise on innovations in telehealth, online learning,

and facilitate the development of health professional

networks

Primary Care Workforce

Primary Care Workforce

Thank You

Adjunct Associate Professor John Rasa CEO Networking Health Victoria