Politics Sector News — 16 June 2014

Health Workforce Australia, based in Adelaide, was one of the many agencies axed in the federal budget. This statement says its existing grants and programmes are to be transferred to the Department of Health in Canberra, suggesting it is likely to lose much of its in-house expertise and corporate knowledge.

Workforce is one of the most contested areas of health policy; the layers upon layers of complexity make it very difficult to determine and balance public interest amid the many competing professional, institutional, commercial and bureaucratic interests.

In the article below, Professor Simon Willcock, who has longstanding experience in health workforce policy and training, and who was an HWA board member from 2010-2013, explores the agency’s achievements.

Given the fraught history of health workforce policy and the challenges ahead, it is worrying that so many questions have been left hanging about future directions.

“Letting the market decide” will not be a useful approach, cautions Willcock, Professor and Head of the Discipline of General Practice in the Sydney Medical Program at the University of Sydney.
Reflections on the dismantling of HWA

Simon Willcock writes:

The life cycle of Commonwealth funded health programs follows a predictable trajectory. Established in response to a “need” determined by a mixture of evidence, media profile and electoral expediency, they are funded to achieve a defined set out outcomes.bigstock_Resignation_527483

Funding is maintained for a period, but subsequent changes in health system priorities and political focus lead to a decline in funding and relevance, ultimately resulting in the incorporation of the program and its activities into a new or rebadged entity.

Typically such cycles last from ten to fifteen years, and there may be a certain logic in limiting the life cycle of publicly funded entities, thereby minimising the risk that organisations established out of need do not evolve into bureaucracies mired in process rather than focussed on outcomes.

However, the rise and fall of Health Workforce Australia (HWA) seems to have deviated from the model, with its demise coming well before any sense that it has achieved its purpose or outgrown its utility.

HWA was established as a result of the 2008 National Partnership Agreement on Hospital and Health Workforce Reform, and commenced operation in January 2010, with significant funding from the Commonwealth over three years matched by “in kind” funding from the states and territories.

This was in response to a number of factors, the most pressing being the decision by some jurisdictional health authorities to implement market-based charging for undergraduate clinical placements. This decision occurred in an environment of growing cost pressures on health authorities, exacerbated by a significant increase in the numbers of health students requiring clinical training and supervision.

Some clinical placements were already subject to a fee payable by the tertiary training organisation, but such fees were generally not applied to the larger health disciplines such as medicine and nursing, nor did they reflect any robust assessment of the actual costs of providing the placement.

Concurrently with the clinical training initiatives, HWA’s brief also included the development of a national approach to health workforce development and distribution, with workforce training matched to predicted community need.

Finally, there was to be a specific focus on innovation, encouraging the evolution of all components of the health care system to models that provided optimal health outcomes for the community at a sustainable cost.

The urgent initial focus for HWA was the identification and funding of new resources for clinical training. Initiatives ranged from significant infrastructure investments to the funding of individual new clinical placements. The process was complicated by the opposing tensions of a rushed political agenda confronting the real need to develop sound governance and accountability mechanisms for the funded entities.

Once the immediate funding “crisis” for increased student placements was addressed, this stream of funding was progressively withdrawn.

In retrospect, these initiatives have contributed significant new capacity to the national health workforce training landscape, but the failure to develop a strategy or budget to define lines of responsibility for the ongoing management and support of the new positions is likely to see tensions over funding resurface in the near future.

In parallel with the clinical training initiatives, HWA initiated a national approach to health workforce development and distribution in the context of identified workforce requirements. The organisation consulted widely and developed sophisticated data collection and analysis tools.

The result was predictive templates for future workforce development, primarily in the areas of the medical, nursing and midwifery workforces. HWA readily acknowledged the potential limitations of these reports, but they nevertheless provide a comprehensive modelling tool, with capacity to incorporate future developments and update the predicted outcomes

Finally, what of innovation? This was always going to be the hardest part of the HWA brief, necessitating a review of highly sensitive areas such as professional industrial awards, models of care and professional scope of practice.

However, this is arguably the critical component of a sustainable Australian health system into the 21st century. If the role is to be taken from HWA, which organisations will assume this task, and how will their independence be ensured?

The governance model for HWA was predictable but challenging. While HWA had its own Board of Directors, the decisions of the Board were no more than recommendations that had to pass through the dual filters of the Heath Workforce Principals Committee (HWPC) and the Australian Health Ministers Advisory Committee (AHMAC) before being accepted and turned into policy.

The establishment of other structures that dabbled in the same space (eg The Teaching, Training and Research Working Group established under the Independent Hospitals Pricing Authority) diluted the role and impact of HWA.

It is a credit to the Chair and CEO of HWA that they were able to tread the fine line required by the Commonwealth, State and Territory “owners” of the organisation, and nevertheless produce some very useful outcomes that will inform the successor structures. We can only hope that the investment in developing those skills and tools will be effectively utilised by those successors.

In summary, the establishment phase of the HWA has ended, but rather than moving to a maintenance phase, the program has been ceased, with no clarity around what will replace this model.

With respect to health workforce planning, my understanding is that some components of HWA that have developed expertise in this domain will be incorporated into the Department of Health.

This is to be strongly encouraged given the need for a strategic focus on health workforce development (as opposed to “letting the market decide” which is likely to see a proliferation of cosmetic physicians and a decline in clinicians working in, for example, mental health and aged care).

However, as with many of the announcements in the budget, the details of the implementation are either unclear or, more likely, yet to be determined.

HWA was on track to establish a reputation as an independent authority that applied evidence and reason to the questions surrounding Australian health workforce development in the future.

It remains to be seen if a new, different approach (ie revisiting the “establishment phase”) will achieve better outcomes.

This article first appeared on ‘Croakey’ on 16 June 2014.

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