Whenever the professional classes find themselves bogged down in routine, a new class of worker generally comes into existence: the adjuncts and the paraprofessionals. It’s happened in law, education, accounting and libraries, with the emergence of staff like teachers’ aides, conveyancing clerks and assistant librarians.
These new workers generally bring higher productivity, creativity and innovation in their wake, as they enable the professionals to get on with developing new and better ways to do things. But the new workers can also generate resentment. The professional becomes worried that the market will prefer these cheaper, lesser-trained workers, and that standards will slip. The paraprofessional becomes resentful about doing much the same work as the professional, without the recognition, the prestige or the pay.
These are real issues. But mostly it’s assumed that the more a knowledge system opens, the more flexible it becomes and the more the whole industry benefits. What, then, happens in a system where the knowledge workers refuse to let go? Or where they can’t let go, because what they’re doing is so important that it’s dangerous to tinker with the system?
The Australian health care system is a case in point, which has rigid professional boundaries in place, with the doctor at the top. Yet now there are too few doctors to man the system and it’s creating a crisis. But would opening up the healthcare system be dangerous to our health—or a source of innovation?
Relieving the pressure
“We haven’t got enough health care workers, basically,” says Professor Peter Brooks, executive dean of Health Sciences at the University of Queensland. “We have to be very careful of looking at it as a medical problem rather than a health system problem.”
Brooks says that the crisis is partly because of poor planning. “The government reduced the number of medical students about 20 years ago,” he says, adding this coincided with the feminisation of the workforce. “We know that women work about 70-75% of the lifetime hours of male doctors.”
All of which means less doctors in the face of an ageing population that needs more medical services, not less. “At the moment, about 11.5% of the total workforce is involved in health,” says Brooks. “You can extrapolate and suggest that by 2025 we need 20% of the total workforce involved in health.”
So acute is the problem that the Council of Australian Governments (COAG) commissioned a 2005 paper on health workforce issues from the Productivity Commission. Its recommendations included giving routine medical work to other healthcare workers. Aboriginal Health Workers, for example, could take routine x-rays and practice midwifery. It also suggested that the Medicare Benefits Schedule (MBS) should be opened to other healthcare providers. This would mean routine work being done more cheaply by non-doctors, with less need for costly GP referrals.
In theory it sounded good, but the Australian Medical Association (AMA) was incensed. In a cautionary tale that should encourage micromanagers everywhere to start delegating, the AMA’s refusal to even consider delegating to other workers is entrenching the rigidity of the whole system.
A new type of health care professional
“The nurse practitioner is an independent practitioner who works by themselves,” explains Brook. “In a way, the midwife is a sort of nurse practitioner.”
Brook says nurse practitioners (NPs) can be used to manage patients with chronic diseases, rather than have that patient continually return to their doctor. “In terms of diagnostic skills, that’s the sort of thing that’s the purview of the doctor. But if the doctor has worked out a management plan, they could hand that continuing care to a nurse practitioner.”
Professor Judy Lumby, executive director of the College of Nursing, says that Australia has used NPs for almost a decade. “They arose out of the continuing professionalisation of nursing,” she says. “Particularly in rural areas, you’ll find nurses working alone and often doing things like having to hold drugs in their community centre.”
Lumby says these situations require a new legal framework for nurses to work within, to acknowledge the sorts of responsibilities they’re actually assuming. Lumby adds that nurse practitioners are not substitute doctors. “They’re a response to new demographics. We need people at an advanced level of practice who can help people live a quality life outside institutions—an adjunct between the hospital and the community.”
Brooks also says the use of NPs would eliminate some of doctors’ most boring jobs. “If someone’s coming in to get their scripts renewed, why couldn’t they be reviewed by a nurse practitioner if they’re getting their lipids checked?”
Another possible way to ease the burden on doctors is to use American-style Physicians Assistants (PAs), who were created after the Vietnam War to absorb army medics into the civilian system. Where NPs are autonomous, PAs work under medical supervision, and can perform minor operations, prescribe drugs and administer anaesthesia. There are around 65,000 PAs in the USA. Four years ago the British moved to set up their own training program.
Other health care professionals, like radiographers and sonographers, could also take a more active role. Brooks says shifting this routine work away from specialists could be a blessing for the doctors themselves. “There must be nothing more boring for a radiologist than to read through 150 chest x-rays.”
So taking routine medical work from doctors could retain NPs and others by giving them more satisfying work to do; create more flexibility in the system; and even bring overall costs down, as it’s cheaper for a radiographer to look at a chest x-ray than a radiologist. Except the whole idea couldn’t please doctors less, who argue that the stake are too high to experiment with health care. “The nursing profession is a profession in its own right,” says Dr Rosanna Capolingua, spokesperson for the AMA Federal Executive and a GP. “They’re an essential part of the workforce.” But, she points out, doctors are the only ones trained to diagnose.
“I might be just doing a ‘routine’ pap smear, but notice the patient has a melanoma on the inner thigh,” she says. “A patient might drop a line into a clinical history which takes me down the investigative process. The nurse is not able to do that, because that’s not what their training is about.” Nor does she want to see radiographers doing even the most routine diagnostic work. “If they’re looking at a chest x-ray to check TB, that’s all they’re going to see or not see.”
Brooks says that’s not so. “In the UK, 30% of the x-rays done under the National Health are read by radiographers,” says Brooks. “There are a number of clinical trials that show it makes no difference [to patient outcome].”
But Capolingua strongly disagrees. “There’s this big whitewash happening across health, where everybody pretends they can do anything,” she says. “We have tertiary standard and accreditations to define particular skills and responsibilities and now everything thinks they can just whitewash over that. I don’t think so.”
She positively explodes at the idea that NPs should have their own provider numbers. “Oh for God’s sake! The health budget is so tight that the blow out in costs will be such that the whole funding will be changed,” she says.
Nor does she have time for the argument that nurses need legal protection when working in isolation. “Just because people do something doesn’t mean it’s the best operative practice. And what legal framework do nurses have? Do they have indemnity? Are they as accountable as the doctor? Does what they do fall back on the supervising doctor? I would argue it would be better for them to sit under the legal framework of the doctor.”
Tempers are running so hot over these issues that it’s damaging professional relationships. “The doctors say nurse practitioners would mean ‘barefoot doctors’ all over again,” says Lumby. “It’s horrible what they’re saying. It’s very frightening and demeaning to our nurse practitioners. Doctors aren’t willing to work in rural areas or aboriginal communities, but they’re willing to throw stones at nurse practitioners who do.”
When this is repeated to Capolingua, she says it’s “Rubbish! Absolute rubbish! The rural workforce is a complicated issue, and doctors are happy to work in rotation in those areas if they’ve got support. Why would nurses want to go there more than doctors?”
One reason is that nurses seem to like going where they have autonomy. “The nurse practitioner role is a really good thing, because it gives nurses a career path,” says Associate Professor Lynn Robinson, director of University of Queensland’s Centre for Health Innovation. She agrees with Brooks that giving nurses more responsibility is one way to attract and retain them. “We have to be clear that the health sector is competing for a limited number of young people against other sectors. We have to provide people with flexible career paths, and allow people to move between roles over time. We are in danger of becoming the sector that nobody wants to work for.”
She also believes that the existence of NPs could keep doctors working in remote communities. “The thing that’s been evidence in other countries is that if you have a community that really needs two or three doctors, and there’s only one doctor left standing, that one doctor may be able to stay there is they have a nurse practitioner and a physicians assistant working in conjunction with them. That way they’re not on call 24 hours a day.”
As for the criticism that giving other professionals provider numbers will blow the whole system apart, Robinson merely says, “These are the same people who say the model has structural rigidity. The system has to follow what the community wants.”
Rigidity and innovation
Intellectually heterogeneous groups can be much more innovative than homogeneous groups. So in theory, a team approach to patient care that allows different professionals to have input, could produce a better patient outcome than the doctor-in-control model. Lumby says there is some anecdotal evidence to support this. She cites a gastroenterologist she worked with who insisted that everybody dealing with his patients attend the clinical rounds together. “The patient drove the care, because they would talk to the whole team about their needs rather than just the doctor,” says Lumby. She says “patients were healing better and being discharged earlier. People came to look at why he had such fantastic outcomes.”
Capolingua says there’s no need to change the current hierarchy in search of innovation. “Doctors and nurses have been working together in parallel for a very long time,” she says. “Doctors being doctors and nurses being nurses doesn’t stifle anything. The ultimate issue is about patient care.”
Robinson says that that while these issues remain politically charged, nobody really has the evidence to say which models are best for patients. “There is a political bunfight between doctors and nurses,” says Robinson. “We need to stop talking and engage in a rational and evidence-based fashion, with controlled experimentation to see if the nurses are right. If people really were serious about their patients, they would stop talking politics.”
She says the University of Queensland wants to launch controlled research into the whole question. “We would place a combination of fully-trained physicians assistants, locally trained nurse practitioners and other local people into health care services. We would then continuously evaluate the impact on these people over 12 months, and modify the approach as we go.”
The problem with getting a pilot up and running, says Robinson, is that they need to find funding and health services to work with. “The politics make it difficult, because the health services are nervous to take on the AMA,” she says. But Robinson’s optimistic. “Politics cannot stand up against appropriate research.”
And once the answers are in, Robinson expects to see a system-wide transformation. “Breaking down the rigidity will bring innovation,” she says, though she acknowledges health is necessarily a risk-averse environment. “But we are capable of innovating much more than we are.”
Professor Brooks would like to see a complete transformation of the way health care is delivered in Australia. “I want a health system, not a medical system, with a significant breaking down of the professional silos and a recognition by all health professionals that they each have a significant role to play,” says Brooks. “But most importantly, I hope we have a health profession that encourages patients and the community to take more responsibility for their own health.”
It’s what business would all a customer-centred model. And in most industries, it works.
I wrote this back in 2006 for Fast Thinking magazine. At the time, expanding the health workforce by the use of para-professionals seemed a great idea. This has recently become an issue in the NHS, where it turns out that using less-qualified medical staff is dangerous.
