Deeper malaise threatens system

17 July 2013

As professional associations joined with students, universities and education providers in Canberra last week to protest against the federal government's proposed $2000 cap on self-education tax deductions, health and medical workforce representatives spoke loudest.

They were out in force to oppose this rushed policy announced in April without consulting those affected. But there was much more behind their protest.

This proposed reform hit a nerve as a crisis is looming for Australia's health and medical workforce education, affecting the entire life cycle of learning across all professions. The sector's heightened advocacy mirrors growing concerns about sustainability of the health education system, and long-term implications for quality of our health system.

In its report, Health Workforce 2025: Doctors, Nurses and Midwives, Health Workforce Australia (HWA), the agency tasked with coordinating the national effort to renew and enhance our health workforce,found that without nationally coordinated reform, Australia was likely to experience "workforce shortages and mal-distribution, inefficiencies and insufficient capacity in the training system, and continued reliance on poorly coordinated skilled migration to meet essential workforce requirements".

HWA predicts a shortfall of more than 109,000 nurses by 2025, along with a continuing mismatch between graduate supply and community needs. It advocates supporting growth in clinical training places, improving clinical supervision across the higher educational continuum, improving rural training opportunities and better national training organisation. This is no easy task when you consider the policy and funding environment in which health education must occur.

There are multiple layers of funding arrangements between state and federal governments over the health system, including the provision of pre and post-registration education. Then there are costs with the need to accommodate on-the-job training for the estimated 28,000 extra students by next year compared with 2009, while dealing with budget cuts, increasing technology costs, increased chronic diseases and increasing community expectations about standards of care.

Universities have been doing their bit by responding to government funding drivers to increase student numbers to meet anticipated workforce shortages.

This is despite budget cuts and the federal government rejecting successive independent reviews recommending funding increases per student place in high-cost disciplines such as medicine and dentistry.

But the problems begin well before graduates even enter their professions, with limited clinical placements for growing student numbers in public hospital systems that are buckling with cost pressures of their own.

The vexed question of who should pay for clinical education in an environment of chronic underfunding, and where demand outstrips available supply of places in state-run public health systems, should be of growing community concern.

Victoria has moved to plug funding gaps in its health budget by charging education providers daily fees to place students in its facilities. Local health districts in other jurisdictions including NSW have sought to do the same.

At the University of Sydney, with 6000 students enrolled in health courses doing more than 200,000 clinical placement days annually in the state's public health system, we conservatively estimate a similar shift would cost us $15 million extra yearly. This is money we don't have, after already cross-subsidising 47 percent of the cost of educating each medical student from fees from other students and philanthropy.

Addressing the issues affecting the health education continuum will require all stakeholders to collaborate on a national solution.

Universities Australia recently formed a dedicated health professions education standing group charged with a mandate to engage governments, the professions and other stakeholders to find solutions collaboratively. It is a heartening move, which shows that despite competition between universities and some professions we ultimately aspire to work more effectively as a sector and with community representatives to solve our most important societal challenges.

This group is already talking with government about policy cohesion needed to address workforce challenges. We need a national framework for the provision of clinical training and national principles for how it is constituted that are fair, transparent and clear to all parties.

In the meantime, we need to stop chaotic cost shifting, by federal and state health ministers agreeing on a national moratorium on any new clinical training charges for education providers.

With 75 percent of the clinical education burden falling on the public health system, we need dialogue with the private health sector about how it could make a greater contribution to the workforce challenges. And we must talk about developing innovative, more cost-effective models of clinical education.

We respectfully ask governments that all policy announcements affecting health workforce education be considered holistically. Our ability to deliver the health and medical workforce of the quality and numbers to service Australia's future ageing population depends on it.

Dr Michael Spence is Vice-Chancellor of the University of Sydney and inaugural chairman of Universities Australia's health professions education standing group.

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