Health Workforce in Australia and Factors for Current Shortages

Health Workforce in Australia and Factors for Current Shortages

Current Shortages Contents Author s Note 1 Executive summary 3 1 Introduction 8 1.1 Scope 8 1.2 Approach 8 1.3 Defining the Australian health workforce 10 2 Demand for the health workforce 11 2.1 Australian demographic trends 11 2.2 Australian burden of disease 14 2.3 Changes in service delivery 21 3 Characteristics of current health workforce in Australia 26 3.1 The total Australian workforce 26 3.2 The Australian health workforce 27 3.3 Description of health workforce characteristics 29 4 Supply drivers for shortages in the health workforce 40 4.1 Competing demand for labour 41 4.2 Shrinking workforce pool 42 4.3 Changing workforce intentions and availability 43 4.4 Nurses 45 4.5 Workforce expectations and availability 49 4.6 Education and training of health workforce professionals 52 4.7 Workforce specialisation 60 5 Emerging strategies 62 Glossary 65 A Clinical training placement calculation 66 B Reference list 70 National Health Workforce Taskforce - 6 May 2009 i

Current Shortages Figure 2.1: Australian population by age and sex from 1996 forecast to 2021... 12 Figure 2.2: Australian population aged over 85years from 2006 forecast to 2036... 13 Figure 2.3 Differentials in Burden (DALYs) by geographic region for ten leading cause groups 2007... 17 Figure 2.4: Differentials in Burden (DALYS) by state/territory for the leading 10 cause groups 2007... 18 Figure 2.5: Prevalence of Long Term Health Conditions 1990-2005... 19 Figure 2.6: Proportion of Australians with obesity by age group 1995-2005... 20 Figure 2.7: Public and private hospital admissions 2001-2006... 22 Figure 3.1: Total employed and unemployed workers in Australia 1996-2016 forecast... 26 Figure 3.2: Number of Australians employed in health workforce occupations as a proportion of the total Australian workforce 1996-2018... 27 Figure 3.3: Number of Australians employed in health workforce occupations 1996-2018... 28 Figure 3.4: Summary of GP characteristics 1998-2008... 31 Figure 3.5: GP workforce in Australia 1986 and 2001... 32 Figure 3.6: Nurse workforce in Australia 1986 and 2001... 32 Figure 3.7: GP, Nurse and Specialist health workforce - average age 2002 and 2005... 33 Figure 3.8: GP, Nurse and Specialist health workforce - average hours worked 2002 and 200533 Figure 3.9: Average hours worked by nurses and medical practitioners by state and territory 2001-2005... 35 Figure 3.10: Average age for nurses and medical practitioners by state and territory 2002-2005... 35 Figure 4.1: Duration of current job 1986-2006... 51 Figure 4.2: Student characteristics entering higher education medical degrees 2005-2007... 56 Table 2.1: Australia s ethnic mix 1996 2006... 14 Table 2.2: Causes of Burden (DALYs) by Sex Australia 2003 and 1996- MALES... 15 Table 2.3: Causes of Burden (DALYs) by Sex Australia 2003 and 1996 - FEMALES... 16 Table 3.1: Nurse and Specialist health workforce - average hours worked and average age 2001 and 2005... 34 Table 4.1: Separation of doctors from the Australian Medical workforce... 43 Table 4.3: Separation of nurses from the Australian medical workforce... 45 Table 4.4: Employed doctors: country of first qualification, states and territories, 2005... 47 Table 4.5: Country of qualification of doctors in medical labour force in Australia, 1998 and 2005... 47 Table 4.6: Number of Australian doctors not in the medical labour force... 48 National Health Workforce Taskforce - 6 May 2009 ii

Current Shortages Inherent Limitations This report has been prepared as outlined in the KPMG engagement letter dated 29 September 2008. The services provided in connection with this engagement comprise an advisory engagement, which is not subject to assurance or other standards issued by the Australian Auditing and Assurance Standards Board and, consequently no opinions or conclusions intended to convey assurance have been expressed. The findings in this report are based on a qualitative study and the reported results reflect a perception of the Australian health workforce market but only to the extent of the literature surveyed No warranty of completeness, accuracy or reliability is given in relation to the statements and representations made by, and the information and documentation provided by, the Tasmanian Department of Health and Human Services or National Health Workforce Taskforce consulted as part of the process. KPMG have indicated within this report the sources of the information provided. We have not sought to independently verify those sources unless otherwise noted within the report. KPMG is under no obligation in any circumstance to update this report, in either oral or written form, for events occurring after the report has been issued in final form. The findings in this report have been formed on the above basis. Third Party Reliance This report is solely for the purpose set out in the KPMG engagement letter dated 29 September 2008 and is not to be used for any other purpose. This report has been prepared at the request of the National Health Workforce Taskforce via a letter of engagement with the Tasmanian Department of Health and Human Services in accordance with the terms of KPMG s engagement letter dated 29 September 2008. Other than our responsibility to the Tasmanian Department of Health and Human Services neither KPMG nor any member or employee of KPMG undertakes responsibility arising in any way from reliance placed by a third party on this report. Any reliance placed is that party s sole responsibility. National Health Workforce Taskforce - 6 May 2009 iii

Author s Note Since the draft of this report was issued there have been a number of recent key events which are likely to have varying degrees of impact in respect to the Australian health workforce shortages. We have had no opportunity to give purposeful consideration to these events in finalising this report, but provide examples of these events to highlight the ongoing complexity of interconnected influences on health workforce shortages: (1) Council of Australian Governments additional funding In December 2008 the Commonwealth and the States committed to an unprecedented reform package of $1.6 billion investment in the health workforce, comprising $1.1 billion of Commonwealth funding and $540 million in State funding. 1 This is aimed at meeting the future challenges of the health system through workforce reform by providing $500 million in additional Commonwealth funding for undergraduate clinical training, including increasing the clinical training subsidy to 30 per cent for all health undergraduate places. The package also provides for an increase of 605 postgraduate training places, including 212 GP places, and the establishment of a national health workforce agency and health workforce statistical register to drive strategic long-term planning for the health workforce. Investment of $175.6 million over four years in capital infrastructure will also be provided to expand teaching and training, especially at major regional hospitals to improve clinical training in rural Australia. The 212 additional ongoing GP training places will boost the total number of GP training places to over 800 from 2011 onwards, and 73 additional specialist training places in the private sector. Funding will also be provided to train approximately 18,000 nurse supervisors, 5,000 allied health and other supervisors, and 7,000 medical supervisors. 1 (2) Global Financial Crisis (GFC) The GFC has been an unpredictable influencer in recent months, bringing uncertainty to a range of drivers impacting the Australian health workforce. At this stage there is limited information as to the extent of the impact (directly or indirectly) the GFC will have on aspects of the health workforce. Potential impacts may include, a declining Australian dollar that could mean that the Australian health workforce proves less attractive to international applicants, but an increasing unemployment rate within Australia may increase the employment pool from which the health workforce is drawn. 1 http://www.coag.gov.au/coag_meeting_outcomes/2008-11-29/attachments.cfm#attachmentab viewed 11 March 2009 National Health Workforce Taskforce - 6 May 2009 1

(3) National Health and Hospitals Reform Commission The Commission s interim report agenda introduced micro-economic reform, increased workforce flexibility and greater use of competition. There was an emphasis on better use of workforce capabilities including proposals to improve the productivity of the Australian health workforce, workforce planning and training and a workforce competency-based framework. 2 (4) Deregulation of university places from 2012 Student places at Australian universities will be deregulated from 2012. Under this change, universities will be able to decide how many students they admit to each course, funding will follow the student rather than being allocated to universities for a capped number of places. 3 (5) National recruitment approach for foreign doctors COAG's National Health Workforce Agency has been given the task of consolidating six separate state and territory recruitment schemes into a single program. The new scheme will be given $63-million over the next four years to advertise the thousands of health vacancies and also to train overseas recruits so they meet registration requirements. 4 2 http://www.nhhrc.org.au/internet/nhhrc/publishing.nsf/content/ba7d3ef4ec7a1f2bca25755b001817ec/$file/s ummary%20of%20the%20interim%20report.pdf viewed 11March 2009 3 http://www.deewr.gov.au/ministers/gillard/media/releases/pages/default.aspx viewed 11 March 2009 4 Ryan, Siobhain. unite to entice overseas health professionals. The Australian. 10 March 2009 National Health Workforce Taskforce - 6 May 2009 2

Executive summary Introduction KPMG was commissioned at the request of the National Health Workforce Taskforce via a letter of engagement with the Tasmanian Department of Health and Human Services to prepare this document that outlines the factors influencing current and projected workforce shortage and that considers the implications that these factors may have on workforce development strategies. It is generally accepted that Australia will continue to experience increasing demand for health care workers and at a rate that will challenge Australia s training and service delivery systems without significant change to it s approach to workforce development. At the broadest level, this is evident from the projected increase in health care expenditure that will grow at a rate greater than the nation s Gross Domestic Product (GDP) which is the consequence of the increasing need for health care services, the introduction of a diverse range of health service interventions and the increasing cost of delivery of some services. The underlying health service demand drivers include; population growth, ageing of the population, changing nature of the burden of disease and greater focus on health prevention, which taken together with consumer and workforce expectations, combine to result in increasing demand for health care services and for healthcare workforce. The current and projected shortage in the Australian health workforce are driven by a complex interaction of demographic, socio-cultural, clinical and professional factors that exert influences on both the demand for health workers services, and the supply of health workers. These shortages are not uniformly distributed, but vary by health profession, specialty, jurisdiction and geographical location (metropolitan, rural, remote). They also occur within a broader international context in which it has been estimated that there is currently an absolute shortage of 2.3 million physicians, nurses and midwives across 57 countries. Over recent years, there have been numerous strategies and initiatives that seek to address workforce shortages and their impact upon the provision of health care services. Since the factors driving the shortage are multifaceted, and the nature of the shortage is itself variable, it is not surprising that these strategies tend to be partial in focus. Ironically, many in turn become yet another factor within the complexity of interconnected influences resulting in particular shortages. It is clear that a multi-dimensional and coordinated approach to address health workforce shortages is needed one that not only focuses on strategies to manage/reduce demand and increase supply, but also considers the actual structure, composition and training of the workforce itself. National Health Workforce Taskforce - 6 May 2009 3

Factors influencing demand and supply The interconnected factors driving workforce shortages in Australia are generally well understood. These factors broadly relate to one of the following three themes: 1) The escalating demand for health care workers. 2) Labour market competition - the health care system is competing for skilled and professional labour internationally and with other sectors that will constrain its ability to recruit into the Australian health care worker market. 3) A constrained training system - that has limited capacity and structure to accommodate the increasing number of students entering the system sufficiently to meet their training requirements and provide workers in a timely manner to meet demand. The escalating demand for health workforce There are a number of factors that are expected to escalate demand for health workforce: The burden of disease in the Australian population the burden of disease is contributing to the demand for health services and is driven by the ageing population, environmental and lifestyle factors. Chronic diseases such as Type II diabetes and coronary heart disease, comorbidities and complex care needs associated with illnesses in older age such as dementia, contribute to the increasing demand for services. Together with other diseases not solely associated with older age such as cancer, anxiety, depression and asthma, all contribute to the requirements for particular skill mixes within the health workforce, and new models of care. Changes in service delivery numerous factors such as new technologies, pharmaceuticals and treatment modalities, coupled with policy drivers contribute to a changing pattern of health service delivery, and the skill mix required within the health workforce. Same day hospital admissions have substantially increased, both increasing the acuity of overnight admissions and influencing the skills required of the acute sector workforce. Concurrently, increasing management of chronic diseases within the primary care setting increases the demand for workforce within this setting. Community expectations the Australian population has been well served by a quality health care system and has expectations about ready access to the services they need at the time they require such services. Workforce shortages pose significant challenges for health decision-makers in addressing these expectations, with lengthy waiting times in an emergency department, ambulance by-pass and difficulties in getting an appointment to see a GP (i.e. examples of the impact of workforce shortages) creating a strong imperative for action. Workforce expectations the expectations within the existing health workforce about their work, and in particular the hours they are prepared or able to work, are changing, influencing overall supply as workers opt for fewer hours and/or working hours more conducive to participating in family/social life. Factors contributing to this change include the increased feminisation of the workforce, Generation Y and an increased general cultural interest in a work/life balance. Workforce specialisation over time the health workforce has become increasingly diversified and specialised in response to numerous factors such as professionalisation, scientific and technological developments, credentialing, changing models of care and National Health Workforce Taskforce - 6 May 2009 4 limited by a scheme approved under Professional Standards Legislation

identified needs. As the workforce has increasingly fragmented into professions, and into sub-specialities within these professions, each group delineates and protects its own role through mechanisms such as controlling the entry criteria, registration, industrial action, and political influence. The greater control each group has, the greater its potential to influence the supply of its own discrete contribution within the health workforce. Unintended effects of workforce strategies strategies implemented to address workforce shortages may, in turn, create new or additional shortages, or shift the shortage from one region or sector to another, due to the complexity and interconnected nature of the health workforce. For example, hospital demand management strategies can result in shifting demand from the acute to the community sector. Increased recruitment of nurses into general practice, to bolster shortages in the capacity to manage demand, may lure nurses away from the acute sector. Attracting international medical graduates to fill vacancies in Australia potentially increases the supervisory burden on the existing workforce. The workforce impacts will not only be for more health care workers but also on the composition of the workforce, the range of skills required and how health care workers interact. For example, the growth in prevalence of long-term health conditions require multi-disciplinary support and long term care plans and support will change the nature and requirements of the health workforce as well as respective burden. Workforce competition Australia has relied upon two main sources to increase the number of healthcare workers, namely, recruiting from international sources and increasing the number of Australian recruits into the education and training system together with various strategies to increase the retention rate. Australia is only one of a number of countries seeking health workers in an international market characterised by general labour shortages. The ability of Australia to attract international workers is expected to be challenged given a range of factors beyond the control of the Australian health system. These include the strength of the Australian dollar (currently declining), strategies adopted by other nations to recruit international health workers, and strategies adopted by other nations to address the historical drain of health workers from less developed nations to developed nations, such as the UK and Malawi. The UK Department for International Development is now funding local wage increases and benefits to enable Malawi to keep and bolster its health workforce. As international economies develop and opportunities change Australia should not rely too heavily on international markets to address workforce shortages at home. There has been a recent substantial increase in medical school places in response to health workforce shortages. The number of domestic medical graduates expected to enter the Australian workforce each year is projected to rise from 1,586 graduates in 2007 to 2,945 graduates in 2012 an 85.7 percent increase. However, the Australian labour market is forecast to grow by 0.8 percent per annum (to 2016) in comparison to 1.7 percent per annum forecast growth for the health workforce labour market (to 2018). This suggests that the pool from which these graduates are recruited is not going to be able to keep up with demand for them within the health workforce. National Health Workforce Taskforce - 6 May 2009 5

The training system s capacity and structure Numerous factors associated with undergraduate and postgraduate professional education influence the supply of graduates able to participate in the workforce. These include the number of places available and the entry score necessary to achieve a place (based on competition): the course requirements and the individual s ability to meet these requirements; the availability of clinical placements through which the individual can acquire the requisite skills necessary for subsequent practice. The existing workforce is required to contribute to the future workforce through supervision of the supernumerary undergraduates, thereby increasing the demand on their time and availability for actual service provision. The training system has limited capacity and structure to accommodate the increasing number of students entering the system to sufficiently meet their training requirements and provide workers in a timely manner to meet demand. There is continuing focus on meeting the needs of the acute sector in nurse training, despite the steady shift towards other settings of care which are increasingly managing complex health care conditions (long term and chronic conditions), such as general practice and community settings. There is a lack of identified supervisors and respective clinical environments available to accommodate the increase in number of students graduating from medical school moving into specialist and clinical training. In part this is due to the heavy reliance on the public sector for specialist and clinical training environments, effectively limiting the opportunity for training to a sector already resource constrained. For example a variety of conditions are now managed predominantly in the private sector and are not accessible to specialist trainees who are primarily working only in the public sector, this includes aspects of ophthalmology, dermatology, radiology and pathology. There is also a reliance on pro bono provision by senior clinicians for aspects of clinical training, which could often mean that the priority for provision of clinical training is not given due precedence. Projections of workforce need based on continuation of existing demand, service and workforce models, suggest that regardless of recent increases in training numbers for occupations such as General Practitioners and nurses, there will not be sufficient numbers of professionals trained and available to deliver services within existing service and workforce models over the short to medium term. Implications for future workforce strategies The factors driving the shortages within the Australian health workforce are multi-dimensional, with the levels of shortage varying across professions, specialties, jurisdictions, sectors and regions. Decision-makers at all levels within the health system (e.g. health authority, organisation, organisational sub-unit) face significant challenges in addressing these shortages. Strategies developed tend to be partial in nature. They tend to focus on either reducing demand or increasing supply through focussing on a specific targeted aspect, such as a single profession, a type of location (rural/remote), a sector (acute or primary care) or form of demand (e.g. chronic disease (self)-management). These strategies tend to have flow-on implications for supply in other areas outside their specific targets, due to the overall workforce shortage. It is clear that a coordinated and integrated approach to the development of future workforce strategies is needed in which the implications for each targeted strategy for other components of National Health Workforce Taskforce - 6 May 2009 6

the overall health care system and the workforce are considered. This approach needs to consider all aspects contributing to the shortage, focussing not only on demand reduction factors, or mechanisms to increase supply, but also on the workforce itself. This includes workforce structure (e.g. the roles and relationships between roles) and the educational preparation for such roles (e.g. time required, entry criteria, clinical placement requirements). It is possible that new ways of structuring and preparing a future health workforce can be developed that contribute to addressing the predicted future workforce shortages in Australia. National Health Workforce Taskforce - 6 May 2009 7

1 Introduction 1.1 Scope This project aims to develop an evidence base for the current factors that are influencing and impacting on the workforce shortages experienced in the Australian health sector, and outline why reform is required. It is widely known that there are health workforce shortages within Australia. These shortages vary in their intensity by health profession, specialist and geographically, by state and territory and by metropolitan, regional, rural and remote area. There are a range of factors driving current shortages in the health workforce, which require consideration in outlining why reform is required. We have categorised these factors into supply and demand factors. Supply Factors: are those factors driving the supply of health workers and would include the structure of education and training programs, competing demands for labour, workforce intentions and availability, migration of health workers into and out of Australia, workforce choices made by health workers, clinical training provision aspects of programs and changing profile of entrants into the health workforce. Demand Factors: are those factors driving demand for health worker service provision and would include changes to the general population demographics (age, sex, ethnicity), prevalence of long-term conditions and contributory factors such as obesity, changes in clinical practice and models of care, growth in new treatment options and therapies, number of visits to allied health, community health and primary care providers. The National Health Workforce Taskforce has a particular interest in further understanding the Supply Factors as a major driver for the current health workforce shortages. The premise is that the current system will not be able to supply enough health professionals to meet demand if they continue to be trained, recruited, deliver care and utilise staff in the traditional ways which have occurred to date. 5 1.2 Approach This report contains findings and evidence obtained using a desk based literature research methodology. The perspective and analysis undertaken in this report is from a general population, jurisdictional and sector/specialist perspective. The literature review was conducted on government, academic and medical workforce papers, surveys and reports with support from the National Health Workforce Taskforce. Key areas focused on and described in the review are: Demand for services provided by the health workforce - Australian population growth and changes in demographics 5 Project Brief, Health Workforce the case for change, National Health Workforce Taskforce, August 2008 National Health Workforce Taskforce - 6 May 2009 8

- Australian changes in burden of disease - Australian growth in prevalence of long term health conditions The changing ways in which services are delivered - Service settings - Service delivery Characteristics of current health workforce - Total Australian workforce growth - Proportion of total workforce that is health workforce (historic and forecast growth) - Growth in (FTEs) health workforce by occupation (historic and forecast growth) - Growth in OHPs, representing more detailed breakdown of health workforce occupation - Description of health workforce characteristics GP Nurses OHPs - Generation Y Supply drivers for health workforce shortages - Competing demand for labour - Education and training systems The findings from the desk-based review provide a broad evidence base for the supply and demand factors influencing health workforce shortages in the context of forming the basis of a case for change with respect to existing service and workforce models. This report has not sought to explore in detail every state, region and health workforce speciality and associated supply and demand factors. Instead, it provides examples of particular health workforce trends by speciality, geographic and functional locations. National Health Workforce Taskforce - 6 May 2009 9

1.3 Defining the Australian health workforce For the purposes of this project, the Australian health workforce has been defined as all those professionals who work in the health sector, State, Commonwealth and privately funded in: acute health care, rehabilitation, aboriginal health care, pharmacy, care for people with disability, young people, maternity care, care for families, mental healthcare, care for people with alcohol and drug issues, aged care, care for people who are dying. A broad definition of the setting of care and health workforce provision of care includes acute hospitals, people s homes, residential facilities, workplaces and schools. Geographic location of residence is defined as cities, outer metropolitan areas, rural areas and remote areas. National Health Workforce Taskforce - 6 May 2009 10

2 Demand for the health workforce It is generally accepted that the increasing demand for health care workers will continue well into the future. At the broadest level, this can be seen from the expected increase in health care costs which are the consequence of the increasing demand for health care services and the increase in the cost of those services. This encompasses a broad range of factors which include; population growth, population demographics, burden of disease and interest in health promoting activities. In addition to illness and injury, the way in which health services are delivered will also be considered a demand driver; as delivery methods and settings change, this will place differing demands for services provided by the health workforce. A recent study 6 estimated that total health expenditure (including residential aged care) will increase by 127 percent over the three decades between 2002 2003 and 2032 2033, from $71 billion to $162 billion (in constant prices), an increase of $91 billion. Over the same period, GDP is predicted to increase by 97 percent 7, thus health expenditure is projected to increase from 9.4 percent of GDP to 10.8 percent. While health authorities have embarked on a wide range of initiatives to dampen the rate of increase in demand for health care services and to improve productivity of health service delivery, the need for workforce growth is inevitable. This section explores the three main service demand drivers that have implications for the level of workforce growth and implications for the composition and nature of the health workforce. Australian demographic trends. Australian burden of disease. Service delivery. 2.1 Australian demographic trends The demand for health care services is driven by not only an increase in the Australian population but also by the changing demographic characteristics of the population: Growth of the population as the population increases, more health services will be required as a result of increasing prevalence of illness, increasing incidence of injury and increasing need for preventative health care services. Ageing of the population Australia is expected to experience an increase in the proportion of the population that are aged, an increase in the number of aged persons and an increase in life expectancy, all of which will create a demand for not only more health services but also impact on the type of health services required to meet these needs. Cultural and linguistic diversity Australia is experiencing a change in the cultural and linguistic diversity of its population which is expected to continue into the future; different 6 Vos T, Goss, J, Begg, S & Mann N (in press). Projections of health care expenditure by disease for Australia to 2003. Canberra: AIHW. 7 Treasury 2002. Intergenerational report. Canberra: The Treasury National Health Workforce Taskforce - 6 May 2009 11

ethnicities have differing health needs which have an impact on health services demand and impacts on the skill requirements of health care workers. This is also the case with linguistic diversity, there are impacts on the skills requirements and way health care is communicated by health care workers which require consideration. The following information outlines how the demographic profile has changed in recent years and how it is expected to change in the near future for Australia nationally as well as by state and territory. 2.1.1 A growing population In 1996, there were some 18.3 million people in Australia. By 2021, this is projected to reach 25.6 million. 8 This represents a growth of 7.3 million or an average annual percentage change of 2.7 percent. 2.1.2 An ageing population In 1996, the most populous age cohort in Australia was 30-39 (Figure 2.1). This cohort accounted for 2.9 million persons, or 15.8 percent of the Australian population. By 2021, the 30-39 age cohort is still projected to be the most numerous, accounting for 3.6 million persons but representing a smaller proportion of the total population (14.2 percent). However, the proportion of the population 70 years and over is expected to increase substantially, both in actual number and proportionally; namely, people of 70 years of age and over are projected to account for 12.1 percent of the total population by the year 2021 (compared to 8.3 percent of the population in 1996). Figure 2.1: Australian population by age and sex from 1996 forecast to 2021 2001 2016 2011 1996 10% 2006 2021 8% 6% 4% 2% 0% 0-9 1019 20-29 30-39 40-49 50-59 60-69 70 and over Males Females 8 www.abs.gov.au viewed 5 December 2008 National Health Workforce Taskforce - 6 May 2009 12

Source: www.abs.gov.au, viewed 15 October 2008 The growth rate of those aged 85years and over is projected to be even more significant. Between 2006 and 2016 alone, the number of people over 85years will have grown by over 60 percent to 521,000; by 2036, this is expected to have more than doubled again to 1.1 million (Figure 2.2). This represents a growth in the proportion of those aged 85years and over from 1.6 percent of the population in 2006 to 3.3 percent of the population in 2036 (based on an estimated total population of 33.1m people in 2036 9 ). Figure 2.2: Australian population aged over 85years from 2006 forecast to 2036 1200 1108 1000 800 690 Total Number ('000s) 600 521 Aged 85+ yrs 400 333 200 0 2006 2016 2026 2036 Source: ABS publication Population Projections, Australia, 2006-2101 (2008). 2.1.3 Increasing cultural and linguistic diversity The Australian population increased in cultural, linguistic and ethnic diversity between 1996 and 2006. Based on data for country of birth (from ABS), it can be seen that the proportion of those living in Australia and born in Australia has fallen from 74.5 percent in 1996 to 70.9 percent in 2006 (Table 2.1). Of those people born outside of Australia, the proportion of people born in the UK and now living in Australia has fallen from 6 percent to 5.2 percent over the 10 years 1996 to 2006. Those born in New Zealand and now living in Australia has risen from 1.6 percent in 1996 to 2 percent in 2006 and the proportion born in China has increased from 0.6 percent in 1996 to 1 percent in 2006. 9 www.abs.gov.au viewed 5 December 2008 National Health Workforce Taskforce - 6 May 2009 13

Table 2.1: Australia s ethnic mix 1996 2006 1996 2006 Country % Country % United Kingdom 6.0 United Kingdom 5.2 New Zealand 1.6 New Zealand 2.0 Italy 1.3 China 1.0 Vietnam 0.9 Italy 1.0 Greece 0.7 Vietnam 0.8 Australia 74.5 Australia 70.9 Source: www.abs.gov.au viewed 15 October 2008 More recent migration trends that have seen an increase in migration from African countries, for example, will further add to the changing cultural diversity of the population. An increasing cultural, linguistic and ethnic diversity will drive changes in demand for health services. Different cultures have different health needs, driven by a wide range of factors such as diet, number of children per family unit, cultural values and ability to speak English. The data shown here does not seek to analyse how these factors change demand on the services provided by health workers, but highlights that demands on health workers will be affected by changing cultural, linguistic and ethnic diversity of the Australian population. 2.2 Australian burden of disease The burden of disease has multiple and interrelated impacts on demand for health services and therefore on the health workforce: The increasing prevalence of chronic conditions drives both the need for more health workers in primary health care and acute care as well as influencing the role of health workers. The changing nature of burden of disease drives the demand for specific types of health workers. The variation in burden of disease, geographically and demographically and, in some cases, the widening of gaps in health status, influences varying demand for health services across regions in Australia. Policy decisions formulated in response to the changing nature of burden of disease in turn has implications for the types of health workers, distribution of health workers and training and education of health care workers. The current burden of disease is well understood and documented in Table 2.2 and Table 2.3. These tables summarise the top 10 diseases affecting the Australian population by male ( Table 2.2) and female ( Table 2.3) and the change in burden of diseases between 1996 and 2003. As is generally known, the conditions that affect women are different to those that affect men, though, in general, ischaemic heart disease, anxiety and depression and Type II diabetes had the National Health Workforce Taskforce - 6 May 2009 14

largest impact on healthy years lost for both sexes in 2003. There has been a shift however, in the conditions contributing to healthy years lost by both sexes. For males, although ischemic heart disease continues to be the dominant cause of burden between 1996 and 2003, conditions like lung cancer, stroke and COPD have declined as primary causes of burden of disease, whereas conditions like prostate cancer, diabetes, anxiety and depression have all seen significant growth as primary causes of burden of disease. Table 2.2: Causes of Burden (DALYs) by Sex Australia 2003 and 1996- MALES 2003 1996 Males DALYs % of Total DALYs % of Total Ischaemic heart 151,107 11.1 180,630 13.6 1 disease 2 Type II diabetes 71,176 5.2 39,438 3 Anxiety & 65,321 4.8 11,342 2.7 3 depression 4 Lung cancer 55,028 4 60,000 4.5 5 Stroke 53,296 3.9 64,330 4.8 6 COPD 49,201 3.6 55,860 4.2 Adult-onset 42,653 3.1 33,012 2.5 7 hearing loss Suicide & selfinflicted 38,717 2.8 44,531 3.3 8 injuries 9 Prostate cancer 36,547 2.7 32,448 10 Colorectal cancer 34,643 2.5 35,511 2.7 Source: Begg S, Vos T, Barker B, Stevenson C, Stanley L, Lopez AD, The Burden of Disease and Injury in Australia 2003, Cat. no. PHE 82, Canberra, 2007. Mather, C, Vos, T, Stevenson, C, The Burden of Disease and Injury in Australia 1999, Cat. No. PHE 17, Canberra Note: The Disability Adjusted Life Years also known as DALYs measures the impact that long term conditions have on the public in terms of the years of healthy life lost due to disability. There has been an observed change in the burden of disease for females between 1996 and 2003 (Table 2.3). Anxiety and depression has seen significant increase from 1996 to 2003, becoming the primary burden of disease for females in Australia in 2003. Breast cancer and diabetes have also seen growth as a burden of disease. But, while still dominant contributors to the burden of disease, conditions such as ischaemic heart disease and stroke have seen a large decline between 1996 and 2003 for females. While it is beyond the scope of this paper to consider the factors underlying this increase in and the changing nature of burden of disease, the trends themselves have implications for health care workforce demand. National Health Workforce Taskforce - 6 May 2009 15

Table 2.3: Causes of Burden (DALYs) by Sex Australia 2003 and 1996 - FEMALES 2003 1996 Females DALYs % of Total DALYs % of Total 1 Anxiety & 126,464 10 57,109 4.8 depression 2 Ischaemic heart 112,390 8.9 130,700 11.1 disease 3 Stroke 65,166 5.1 72,248 6.1 4 Type II diabetes 61,763 4.9 35,493 3 5 Dementia 60,747 4.8 55,510 4.7 6 Breast cancer 60,520 4.8 54,109 4.6 7 COPD 37,550 3 37,521 3.2 8 Lung cancer 33,876 2.7 30,521 2.6 9 Asthma 33,828 2.7 36,242 3.1 10 Colorectal cancer 28,962 2.3 31,440 2.7 Source: Begg S, Vos T, Barker B, Stevenson C, Stanley L, Lopez AD, The Burden of Disease and Injury in Australia 2003, Cat. no. PHE 82, Canberra, 2007. Mather, C, Vos, T, Stevenson, C, The Burden of Disease and Injury in Australia 1999, Cat. No. PHE 17, Canberra Note: The Disability Adjusted Life Years also known as DALYs measures the impact that long term conditions have on the public in terms of the years of healthy life lost due to disability. Figure 2.3 highlights the differences in burden of disease by geographic location. The cause that contributed the greatest difference between geographic categories was injuries. Intentional and unintentional injuries contributed a far higher burden in remote geographies than major cities. Diabetes and chronic respiratory disease also contributed significantly higher burdens in remote geographies than major cities or regional areas. This highlights the fact that, not only do burdens of disease vary over time, but they also vary by geography, and that the consequential number, specialties provided and distribution of health workers in Australia must reflect this. National Health Workforce Taskforce - 6 May 2009 16

Figure 2.3 Differentials in Burden (DALYs) by geographic region for ten leading cause groups 2007 2.5 2 1.5 DALYs per 1000 of Population 1 Major Cities Regional Remote 0.5 0 Cancer Mental Chronic Respiratory Unintentional Genitourinary Injuries Cardiovascular Neurological Diabetes Musculoskeletal Intentional Injuries Source: Begg S, Vos T, Barker B, Stevenson C, Stanley L, Lopez AD, The Burden of Disease and Injury in Australia 2003, Cat. no. PHE 82, Canberra, 2007. The proportion of burden experienced by each state and territory jurisdiction was similar (Figure 2.4), except for the Northern Territory. The Northern Territory had the highest and almost twice the rate of total burden of disease compared to the Australian Capital Territory for both males and females. This was primarily driven by higher rates of burden for chronic respiratory disease, diabetes and injuries and matches the dominance of such conditions in remote areas reflected in Figure 2.3. National Health Workforce Taskforce - 6 May 2009 17

Figure 2.4: Differentials in Burden (DALYS) by state/territory for the leading 10 cause groups 2007 18 16 14 Ratio of DALYs 12 per 1000 area : DALYs per 10 1000 for Australia 8 6 4 2 Intentional Injuries Genitourinary Musculoskeletal Unintentional Injuries Diabetes Chronic Respiratory Neurological Mental Cardiovascular Cancer 0 NSW VIC QLD SA WA TAS NT ACT State/Territory Source: Begg S, Vos T, Barker B, Stevenson C, Stanley L, Lopez AD, The Burden of Disease and Injury in Australia 2003, Cat. no. PHE 82, Canberra, 2007. Note the over representation of smaller states due to population differences The changing burdens of disease over time and by geographic region will have an impact on the demand for health services and for the health care workforce, including: An increase in chronic illness will require more health care workers across the span of primary care, acute care to post acute care. Increase in mental illness will have implications for all health care workers given that people with mental health often have associated physical health issues. A shift in policy focus that often follows change in composition of burden of disease will for example, see a greater demand for health care workers in primary care and preventative health care roles. As the burden of disease changes across geographical areas, the spatial demand for health care workers will change. It is difficult to predict accurately specific changes to the burden of demand and the conditions/ailments which will be contributing to these changes. The implications for this are the need for flexibility within the workforce, both in its structure, service delivery model and education, to ensure the workforce is as adaptable as possible to respond to planned and un-planned changes in demand in a timely manner, but allows sufficient time in training to National Health Workforce Taskforce - 6 May 2009 18

ensure speciality and sub-specialities develop clinical skills to provide the expected level of care and service demanded. The health workforce must also have a degree of mobility or appropriate geographic distribution factored in to meet differing and changing demands by region. 2.2.1 Long-term health conditions Long-term health conditions are another factor driving demand for services provided by the health workforce. Long-term health conditions as described by the World Health Organisation are any ongoing or recurring health issue that has a significant impact on the lives of a person and/or their family, or other carers. These will include conditions such as chronic pain, asthma, arthritis, coronary vascular disease, cancer, anxiety, depression, diabetes, alcohol and drug dependency. The proportion of Australians with a long-term health condition has been increasing. For example, between 1990 and 2005, it increased from 66.6 percent to 75 percent for males and from 69.6 percent to 78.4 percent for females (Figure 2.5). Figure 2.5: Prevalence of Long Term Health Conditions 1990-2005 100.0% 90.0% % Population 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 66.6% 69.6% 74.3% 76.7% 76.9% 78.8% 75.0% 78.4% 20.0% 10. 0% 0.0% Female Male 1990 1995 2001 2005 Female Male Source: ABS publication National Health Survey (2001/02 & 2004/05); ABS publication Deaths Australia, 2006 (2007) The growth in long-term health conditions has been largely attributed to the ageing population as well as other contributing factors such as lifestyle related trends that has seen an increase in for example obesity rates. Long-term health conditions are highly prevalent and increasing in prevalence in Australia as Figure 2.5 highlights. In 2005, 78.4 percent of female respondents and 75 percent of male respondents in the National Health Survey (ABS) said they had one or more long-term health conditions (i.e. one that has lasted or is expected to last for six months or more). The proportion of women with a long-term condition is growing at a faster rate than men (8.8 percent versus 8.4 percent increase from 1990-2005 respectively). This may be attributed to National Health Workforce Taskforce - 6 May 2009 19

the typically longer lifespan of women than men (83.5 and 78.7 years respectively for persons born in 2006 10 ). The trend in long-term health conditions is expected to continue based on historical trends for significant contributing factors, such as an ageing population and growth in obesity rates. The proportion of Australians who are classified as obese has increased in all age categories, between 1995 and 2005, see Figure 2.6. The greatest increase observed was in those aged 35-44 years of 6.8 percent between 1995-2005, closely followed by those aged 55-64 years of 6.4 percent. The links between obesity and long-term conditions has been well documented. 11 Figure 2.6: Proportion of Australians with obesity by age group 1995-2005 25.0% 20.0% 20.6% 22.1% 15.0% 15.1% 18.0% 17.9% 10.0% 5.0% 0.0% 19.0% 19.7% 16.1% 17.4% 10.4% 7.0% 12.8% 9.9% 7.6% 4.9% 9.8% 11.2% 15.0% 15.7% 12.1% 6.0% 18-24 25-34 35-44 45-54 55-64 65-74 >75 1995 2001 2005 Source: ABS publication National Health Survey (2004/05) Should the observed historical trends in the changing burden of disease and growth in contributing factors, such as the ageing population and obesity, continue for the foreseeable future (the next 10-20 years) demand for health workers (in particular specialities and geographic distributions) will also continue. It has been acknowledged that strategies are required to slow this growth demand given existing health workforce shortages and difficulties in meeting current demand. Most of these strategies have focused on both primary and secondary prevention. The National Preventative Health Taskforce is strongly advocating for workforce strategies to be part of a comprehensive preventative strategy and is specifically advocating the need for a skilled and motivated workforce, especially in the public health and primary healthcare sectors, will be essential to support delivery of health promotion and preventative health measures across the community. It also considers that this will have implications for the training of health care workers and how the different types of health care workers interact bringing primary healthcare providers such as general practitioners, community pharmacists, nurses, psychologists and other allied health professionals together for community-based training and 10 www.abs.gov.au, viewed 5 December 2008 11 National Preventative Health Taskforce (2008). Australia: the healthiest country by 2020. A discussion paper. Australian Government. National Health Workforce Taskforce - 6 May 2009 20

support, providing a way of ensuring a comprehensive and well-coordinated approach to preventative health care. Thus, there is strong advocacy not just for more health care workers but also for changing distribution, role and work practices of health care workers as part of a strategy to combat the growing burden of disease. 2.3 Changes in service delivery Changes in the way health services are being delivered has a consequential impact on demand for health care workers. This section looks at examples of how changes in service delivery are emerging within the health care system with regards to: The settings in which services are provided. The way services are delivered. 2.3.1 Service settings The settings in which health care services are provided and the configuration of those service settings continually change and impact on the type of health care workers and the roles of health care workers and also generate additional demand for them. Over recent years, we have seen, for example: An increase in same day facilities, both as part of existing institutions such as hospitals and as stand alone facilities varying in their focus from targeting specific conditions (eye clinics) to multi-purpose (surgical facilities). An increase in the delivery of services in the home ranging from hospital in the home programs to community care programs. An increased capacity and capability of primary health care services such as in general practice that with the advent of corporatisation has led to the establishment of service centres that have collocated diagnostic, imaging and interventional services in the one GP establishment. The development of multi-purpose ambulatory centres in the public health care sector to reduce the demand pressure on hospitals. Most recently, the establishment of virtual hospitals. 12 These trends for where services are delivered have an impact on workforce demand, for example the potential extension of nursing roles beyond what they normally undertake, a broadening of roles within the primary health care sector and additional demand for general practitioners services. 12 The Silver Chain Virtual Hospital proposal to the Western Australian Government 2008 National Health Workforce Taskforce - 6 May 2009 21

Two specific examples are discussed to illustrate the workforce implications. The first relates to the changing trends in hospital delivered services and the second relates to the changing role of GP based services. Hospital services Institution based settings, which include hospital and nursing home service delivery, are the most dominant health service delivery setting for health workforce employment (46 percent of the health workforce are employed in hospital and nursing home settings). 13 Community care services are the second largest source of health workforce employment with approximately 16 percent of the total health workforce employed in this sector. In the three years to 2012, the largest projected employment gains by setting are expected to be for Hospitals and Nursing Homes. Total hospital admissions have increased between 2001 and 2006 and totalled 7.6 million in 2006/07 (refer Figure 2.7). Figure 2.7: Public and private hospital admissions 2001-2006 8 7 Millions of admissions 6 5 4 2.4 2.6 2.8 private public 3 2 3.9 4.1 4.4 1 0 2002-03 2003/04 2005/06 Source: Australia s Health 2008, 2006, 2004, AIHW Public hospitals in Australia account for the majority of hospital admissions at 61 percent for 2005/06. Most hospital admissions were same-day stays, 50 percent in public hospitals and 65 percent in private hospitals. This was consistent with a long-term rise in the proportion of admissions that were same-day, from 46.3 percent in 1997-98 to 55.8 percent in 2006-07. As a result, the long-term rise in same-day admissions has driven a decline in average length of stay from 4.1 to 3.3 days over the same period. 14 This is likely to have been driven, in part, by a 13 Employment outlook for health and community services, DEWR, July 2008 14 AIHW, Growth in private hospital admissions outstrips public again, AIHW, http://www.aihw.gov.au/mediacentre/2008/mr20080530.cfm (accessed 30 May 2008) National Health Workforce Taskforce - 6 May 2009 22

number of initiatives currently in place across Australian jurisdictions, to decrease the average length of hospital stays, increase patient turnover and reduce procedure waiting lists. These initiatives include hospital in a home and early discharge programs. There is a growing list of well-defined conditions that have been shown to be manageable in home care, provided either as a complete alternative to hospital admission or to support early discharge from inpatient care. These include dialysis, cellulitis, chronic obstructive pulmonary disease and deep vein thrombosis. 15 Given the growing use of same day procedures in hospital settings, there is an implication that the demands on the health workforce will have an increasingly community-centric focus as ongoing care and support following procedures undergone in hospital will be required out in the community. In order to support the increase in same day procedures within the hospital setting, the health workforce requires enough resources and appropriate skills distribution to ensure the appropriate skills, not only undertaking the procedures but also ensuring safe monitoring and discharge procedures, are in place to manage demand. The role of GP based services has changed with the advent of a number of initiatives of federal and state health authorities in response to increasing prevalence of chronic conditions and the increase in demand for hospital services. General practices now employ/use a range of other health care workers including, practice nurses, specialised nurses such as diabetic educators and, in some cases, allied health workers. This trend will continue with, for example, ongoing initiatives such as the Australian Collaboratives that emphasise the use of other health care workers in a general practice to foster practice improvement. 16,17,18 There are also state based initiatives to expand the role of general practices to reduce the demand pressure on hospitals, such as the development of what is referred to as GP Plus centres in South Australia that will have clinical capabilities that go beyond the traditional role general practice with workforce implications. 19 These centres will require different types of health care workers and, in some cases, modified roles for existing types of health care workers. 2.3.2 Service delivery Changes in how services are delivered and the use of new service modalities impact on demand for health care workers. Changes in existing modalities and new modalities are a consequence of factors such as: New clinical technologies and new applications of existing technologies. 15 Hospital in a home: what next? Medical Journal of Australia, Volume 183, Number 5, 5 September 2005 16 Booth,A, A collaborative approach to mental health promotion in rural South Australia: A model of workforce development, Department of Human Services, South Australia 17 Queensland Primary Mental Health Care Collaborative (QPMHCC), www.gpqld.com.au (accessed 16 December 2008) 18 Australian Primary Care Collaboratives, http://www.rkdgp.com.au/site/index.cfm?display=37304 (accessed 16 December) 19 South Australia Health Care Plan, GP Plus Health Care Centres Fact sheet, www.health.sa.gov.au/desktopmodules/sssa_documents/linkclick.aspx? (accessed 16 December 2008) National Health Workforce Taskforce - 6 May 2009 23

New pharmaceuticals and new application of existing pharmaceuticals. New approaches to management of conditions such as use of medical rather than surgical approaches to intervention. Changing role of workforce groups in delivering the same modality of care. Two specific examples are considered, namely, imaging and diagnostic technology and surgical advancements. 2.3.3 Imaging technology During the past decade, there has been rapid growth in the use and availability of imaging and diagnostic technologies, such as computed tomography (CT) scanners, magnetic resonance imaging (MRI) units and positron emission tomography (PET) units, in most OECD countries. In Australia, the number of MRIs has increased from 0.6 per million population in 1990 to 4.9 in 2006, although these include machines eligible for Medicare reimbursement only and it is recognised that many MRI machines, ineligible for Medicare, are in operation in both public and private sectors. The OECD average was 10.2 MRI units per million population in 2006. 20 Whilst imaging capacity has been expanded through technology, nonetheless there are significant shortages of skilled radiologists to service this demand. A submission to the Productivity Commission by the Australian Diagnostic Imaging Association 21 noted that, to date, Australia has failed to train enough radiologists to meet the current levels of demand. 22 The 2001 Australian Medical Workforce Advisory Committee (AMWAC) report 23 on the specialist radiology workforce concluded that the radiologist workforce was inadequate, with a shortage of not less than 37 FTE specialist radiologists. Despite attempts to rectify the shortfall, the 2004 RANZCR Workforce Survey had found a significant possibility of some widening in the gap between supply and demand of radiologist services over next few years, assuming historical and predicted supply and demand trends continue. The degree to which productivity gains (for example, via digital image management systems) can continue to bridge this deficit over the next few years is unknown, but is possibly limited. 24 2.3.4 Surgical advancement As in most OECD countries, the number of hospital beds per capita in Australia has fallen over time. The number of acute care hospital beds in Australia was 3.5 per 1,000 population in 2005, slightly below the OECD average of 3.9 beds per 1,000 population. This decline has coincided with a reduction of average length of stays in hospitals and an increase in the number of surgical 20 OECD Health Data 2008 Report, www.oecd.org/dataoecd viewed on 9 Oct 2008 21 Productivity Commission, Health Workforce Submission from ADIA, 2005 22 Jones DN (2002), 2002 Australian radiology workforce report, Australasian Radiology 2002 September; 46(3):231-48. 23 AMWAC (2001) The Specialist Radiology Workforce in Australia: Supply, Requirements and Projections 2001 2011, AMWAC: Canberra. 24 RANZCR (2005) 2004 Diagnostic Radiologists and Radiology Trainee Report Australia, RANZCR: Sydney. National Health Workforce Taskforce - 6 May 2009 24

procedures performed on a same-day (or ambulatory) basis. 25 This demand for greater effectiveness of care, especially surgical interventions and reduction in average length of stays in hospitals, is due to the public demand for the best available care and demand by medical practitioners, such as surgeons for the best technologies to assist their patients. Surgical advancement and the growing use of medical technology depends on having access to appropriately trained medical professionals, like surgeons, theatre nurses and technicians. Having a developmental culture and work environment in which advancement and best practice is encouraged as part of day-to-day practice with support from qualified and experienced practitioners and trainers is also fundamental to providing best available care. The increase in the number of surgical specialists from 2,580 in 1995 to 3421 in 2005 (a 33 percent increase) 26,27 has facilitated the growth in new procedures and treatments being used to a greater degree than before. This has also led to an increased productivity of specialists, as new procedures such as minimally invasive techniques for eye surgery, hip and knee replacements have increased the amount of specific procedures that can be performed by specialists. As such, one of the main links between surgical and technological advancements and the requisite benefit to the community is the accessibility and proportion of well-trained specialists available to perform those procedures. 28 The resulting implication of changing technologies for the health workforce is that there appears to be an increasing demand for greater sub-specialisation, however in contradiction to this, a degree of flexibility will always be required in developing workforce supply solutions with the ongoing technology and procedural advancements. 25 OECD Health Data 2008 Report, www.oecd.org/dataoecd viewed on 9 Oct 2008 26 Australian Institute of Health and Welfare 2008. Medical labour force 2005. National health labour force series no. 40. Cat. no. HWL 41.Canberra: AIHW. 27 Australian Institute of Health and Welfare 2003. Medical labour force 1999. National health labour 28 Productivity Commission, Impacts of Advances in Medical Technology in Australia, Research Report, Melbourne 2005 National Health Workforce Taskforce - 6 May 2009 25

3 Characteristics of current health workforce in Australia This section describes the current characteristics of the Australian health workforce, providing detailed descriptions of a number of core professions, i.e. nurses and general practitioners, as well as examples of other professions to provide an indication of the general trends in key characteristics which the workforce is currently experiencing and will experience in the future. 3.1 The total Australian workforce The total number of Australians employed in the Australian workforce has increased between 1996 and 2008 from approximately 8.3 million to 10.7 million people. In that time, the proportion of those unemployed has fallen from 8.3 percent to 4.2 percent. Current forecasts estimate the total number of people employed in Australia will reach 10.8 million in 2016, suggesting a slow in growth of employed workforce. Figure 3.1: Total employed and unemployed workers in Australia 1996-2016 forecast 12,000 10,000 8,000 758 679 498 474 6,000 4,000 8,357 9,106 10,258 10,737 10,800 Total unemployed Total employed 2,000 0 1996 2001 2006 2008 2016 forecast Source: www.abs.gov.au, Labour force, cat. No. 6202.02, Canberra 2008 National Health Workforce Taskforce - 6 May 2009 26

Figure 3.2: Number of Australians employed in health workforce occupations as a proportion of the total Australian workforce 1996-2018 100% 3.4% 3.5% 3.5% 3.7% 90% 80% % 70% 96.6% 96.5% 96.5% 96.3% Health workforce Total workforce 60% 50% 40% 1996 2001 2006 2011 2016 2018 Year Source: www.abs.gov.au, Labour force, Cat. No. 6202, Canberra 2008 The number of individuals employed in the health workforce as a proportion of the total Australian workforce remained relatively stable between 1996 and 2006; it was approximately 3.5 percent of the total workforce. This is forecast to increase to 2016, at which point the proportion of those employed in the health workforce is estimated to be 3.7 percent. This suggests that those employed in the health workforce is growing at a faster rate than the total Australian workforce. 3.2 The Australian health workforce The number of individuals employed in the health workforce in 2006 was 360,400, which constitutes approximately 3.5 percent of the employed Australian workforce in 2006. In 1996, those employed in the health workforce was 3.4 percent of the employed Australian workforce. There were 61,085 medical practitioners, 96,085 miscellaneous health professionals and 203,231 nursing professionals employed in 2006. By 2018, there are forecast to be 409,300 Australians employed in the health care occupations with an average growth of 1.7 percent per annum. According to OECD research, Australia is ranked 10th of 24 member countries for number of doctors and 15th for doctors per 1,000 population. Australia has an above average medical workforce born overseas and below average medical students per 1,000 doctors. 29 29 International Migration Outlook, 2007. OECD National Health Workforce Taskforce - 6 May 2009 27

Figure 3.3: Number of Australians employed in health workforce occupations 1996-2018 250,000 200,000 Medical Practitioners (a) 150,000 Other Health Professionals (b) 100,000 Nursing Professionals (c) 50,000 0 1996 2001 2006 2011 2016 2018 Source: Access Economics, 2007 (unpublished data). Note: Access Economics developed the forecasts using a complex model which models changes in components of investment and consumption in relation to employment. It takes into account things such as exports/imports, public investment, private consumption, and government spending/consumption. For example, an increase in spending on the construction of housing will lead to a surge in the number of construction jobs. Note: Definitions for health workforce occupations (the reference numbers refer to category reference numbers assigned by the Australian Bureau of Statistics.): (a) Medical practitioners include: Specialist Medical Practitioners (2312) and Generalist Medical Practitioners (2311) (b) Other Health Professionals include: Dental Practitioners (2381), Pharmacists (2382), Occupational Therapists (2383), Optometrists (2384), Physiotherapists (2385), Speech Pathologists (2386), Chiropractors and Osteopaths (2387), Podiatrists (2388), Medical Imaging professionals (2391), Veterinarians (2392), Dieticians (2393), Natural Therapy Professionals (2399), Other health professionals (2399) (c)nursing Professionals include: Nurse managers (2321), Nurse educators and researchers (2322), Registered Nurses (2323), Registered Midwives (2324), Registered Mental Health Nurses (2325) and Registered Developmental Disability Nurses (2326) The growth forecast in number of health care employees varies by state and territory. New South Wales forecasts an average annual growth of 0.9 percent in medical practitioners to 2018, whereas in Victoria, the number of medical practitioners is forecast to decline by an average annual change of 0.2 percent and, in the Northern Territory, it is forecast to grow by 7.7 percent to 2018. The number of employed nursing professionals demonstrates a highly variable growth rate and is forecast to have an average annual growth of 4.5 percent in ACT, a 0.2 percent growth in Northern Territory and 2.1 percent growth in Queensland. Other health professionals are forecast to grow by 3.2 percent in Victoria, 2.1 percent in NSW and 4.6 percent in Northern Territory. National Health Workforce Taskforce - 6 May 2009 28

Other Health Professionals Other Health Professions (OHPs) refer to the segment of the health workforce whose professions lie outside the core medical fields of medicine and nursing. The number of OHP professionals in recent years has grown as a component of the total Australian health workforce, and is forecast to continue taking share of the total Australian health workforce to 2018. The three cases below provide more information on growth rates for three OHPs, Podiatry, Physiotherapy and Dentistry. Case Study 1 - Podiatry There were 1,820 employed podiatrists in 2003 30, a rise of 12.5 percent from 1,618 employed podiatrists in 1999. Between the period 1999-2003, there were varied rates of growth and decline within individual states for employed podiatrist numbers. These rose in New South Wales, Queensland and South Australia by 37.0 percent, 24.1 percent and 13.4 percent, respectively and decreased in Victoria and Tasmania by 4.2 percent and 18.2 percent, respectively. This highlights the growth in podiatrists but specific to geographic demands. Case Study 2 - Physiotherapy In 2002, there were almost 16,000 registered physiotherapists in Australia (excluding the Northern Territory). 31 This was an increase of 10.9 percent from the number registered in 1998. All jurisdictions, except Tasmania, experienced an increase in registrations over the four years between 1998 and 2002. Case Study 3 - Dentists The dentistry labour force has been increasing since 2003, and there has been a 4 percent increase in the number of practising dentists. However, the practising density of dentists varies by state and territory, from 31.2 dentists per 100,000 population in Tasmania to 75.4 in the Australian Capital Territory. Across geographic regions, the practising density of dentists per 100,000 population was higher in major cities (58.6) than in remote areas (19.8). 32 3.3 Description of health workforce characteristics The Australian health workforce characteristics have changed over the last 10 years. Below evidence is provided for the changing workforce characteristics of two of the core health workforce professions, namely general practitioners and nurses. There is limited published information available to undertake similar analyses for other health professions. Analysis of the 30 Australian Institute of Health and Welfare, Podiatry Labour Force 2003, Cat. no. HWL 36. National Health Labour Force Series no. 35 Canberra, 2006. 31 Australian Institute of Health and Welfare, Physiotherapy Labour Force 2002, Cat. no. HWL 37. Health Labour Force Series no. 36, Canberra, 2006 32 AIHW Dental Statistics and Research Unit, Dentist Labour Force 2005, Cat. no. DEN 172, Canberra, 2008. National Health Workforce Taskforce - 6 May 2009 29

general practitioners and nursing workforce provides a useful indicator or proxy for the current health workforce characteristics in Australia. 3.3.1 General Practitioner Workforce Characteristics The Australian Bureau of Statistics (ABS) data reveals a number of critical changes to the General Practitioner (GP) workforce. In the last decade (1998-2008), there has been a noticeable ageing of the GP workforce, for example there has been an increase of 8.3 percent of the number of practicing GPs over the age of 55years. There has also been an increasing feminisation of the GP workforce, currently 36.8 percent of the GP workforce is female, an increase of 6.8 percent since 1998. Ongoing local and international research continues into the impact of this commonly-termed feminisation of the workforce. Common findings of this research are that women tend to work fewer hours than their male counterparts, particularly during their child-rearing years and are more likely to retire early. However, the data varies as to the extent of the difference between male and female hours worked by GPs. While earlier studies estimated a female doctor will work approximately 60 percent of the productive hours of her male colleague 33, more recent Australian research places the number at just over 80 percent (37.6 compared with 46.7 hours per week) (AIHW, 2008). 34 There is substantial discussion about this topic with the OECD reporting that all things being equal. The supply of medical services will fall if female participation in the workforce increases. 35 Ongoing feminisation of the health workforce will have issues for the health workforce in the next decade, determining ways to address this requires detailed consideration. Approaches to addressing this could be adapted from private sector solutions, which have been addressing this issue and developing innovative approaches for at least the last 10 years. Other characteristics identified by the ABS, Figure 3.4, include an average decline of 8.1 percent since 1998, in the proportion of GPs working (and providing) more than 10 sessions per week. A decline of 11.7 percent since 1998 for GPs providing their own after hours cover was also observed. It has also been observed that the role of rural or remote GPs is often broader than that of their urban counterparts. This may be because of geographic and professional isolation and a lack of nearby supporting or complementary services such as medical specialists. In 2003, 22.1 percent of the rural and remote general practice workforce practised in at least one procedural field. 36 33 Brooks, P. Lapsley, HM. and Butt, DB. Medical Workforce Issues in Australia: Tomorrow s Doctor s Too Few, Too Far. MJA 2003; 179: 2006-2008. 34 Australian Medical Association, 2008, Media Release: Declining GP Supply a Major Concern 35 Simeons S and Hurst J, 2006 OECD Health Working Papers No. 21: The Supply of Physician Services in OECD Countries, Directorate for Employment, Labour and Social Affairs Group on Health 36 Australian Medical Workforce Advisory Committee, The General Practice Workforce in Australia: Supply and Requirements to 2013, AMWAC Report 2005.2, Sydney, 2005. National Health Workforce Taskforce - 6 May 2009 30

Figure 3.4: Summary of GP characteristics 1998-2008 90 80 70 60 % of GPs 50 40 36.8 30 33.5 33.2 2008 1998 30 20 10 0 30 Female 42.6 <45yrs 25.2 55 yrs plus 15.4 12.4 <6 sessions p/wk 10.9 19 >10 sessions p/wk 45.5 Own After-hours 11.3 19.3 Co-op after hours Source: 'General Practice Activity in Australia 1998-2008', AIHW The observed historical changes in the characteristics of the GP workforce between 1998 and 2008, if continued, will have an ongoing impact on the number of GPs required to meet current demand, let alone future increases in demand. At current rates of characteristic shifts, it would be anticipated that a significant increase in the number of GPs practicing in all regions of Australia is required. 3.3.2 Geographic and related age characteristics of the health workforce Market demands, government policy and personal circumstances drive the geographic distribution of the Australian health workforce. Higher numbers of health workers are present in the more densely populated cities and metropolitan regions versus rural and remote regions. In general Australia continues to experience health workforce shortages to a greater degree in rural and remote regions. The extent of these shortages varies by profession, which can be observed in analysing GPs versus the nursing workforce. One driver for this is the changing age characteristics of the workforce and how this is distributed by geographic region as analysed in Figure 3.5. The imbalance in the distribution of GPs between rural and city locations has become more accentuated in recent years. The imbalance of GPs by geographic region tends to be greater than for the nursing workforce for example, by 2001, 20 percent of the GP workforce were based in rural locations compared with 29 percent of the nursing workforce. The ageing of the GP workforce is also more accentuated than the nursing professions. Between 1986 and 2001, the percentage of rural GPs aged over 40 years rose from 40 percent to 60 percent compared to 43 percent to 57 percent for city GPs. In 2001, those born between 1946 National Health Workforce Taskforce - 6 May 2009 31

and 1964 made up 52 percent of the city GP workforce and 59 percent of the rural GP workforce. Figure 3.5: GP workforce in Australia 1986 and 2001 25 20 '000s 15 10 12.6 No. GPs 2001 No. GPs 1986 5 0 6.7 1.7 10.7 City Rural City Rural City Rural 1965-1974 1946-1964 1929-1945 4.4 3.0 3.7 4.5 1.0 1.3 Geography and birth years Source: Ageing of the baby boomer generation: how demographic change will impact on city and rural GP and nursing workforce, DJ Schofield, SL Page, DM Lyle, TJ Walker, Rural and Remote Health 6:64. 2006 Figure 3.6: Nurse workforce in Australia 1986 and 2001 140 120 100 62.8 '000s 80 60 No. Nurses 2001 No. Nurses 1986 40 20 0 24.3 10.0 City Rural 1965-1974 34.4 63.6 27.6 City Rural 1946-1964 Geography and birth years 10.7 6.1 23.2 11.5 City Rural 1929-1945 Source: Ageing of the baby boomer generation: how demographic change will impact on city and rural GP and nursing workforce, DJ Schofield, SL Page, DM Lyle, TJ Walker, Rural and Remote Health 6:64. 2006 Figure 3.7 and Table 3.1 below shows that there is also a growing proportion of the nursing and specialist health providers workforce which is ageing and that the rural workforce is ageing quicker than the metropolitan workforce. Specialists in major cities and, to a lesser extent, inner regional and outer regional are bucking this trend by decreasing in average age between 2002 National Health Workforce Taskforce - 6 May 2009 32

and 2005. The same is true for GPs in major cities who were also younger in 2005 compared to 2002. Figure 3.7: GP, Nurse and Specialist health workforce - average age 2002 and 2005 60 50 40 30 20 10 0 2001 2005 2001 2005 2001 2005 2001 2005 Major Cities Inner Regional Outer Regional Remote/Very Remote Region/Year General Practitioners Specialists Nurses There has been an increase in the number of hours worked by nurses in every region, particularly in outer regional and remote areas. However, specialists and GP workers have experienced a steady decline in average number of hours worked in the same period. Figure 3.8: GP, Nurse and Specialist health workforce - average hours worked 2002 and 2005 60 50 40 30 20 10 0 2001 2005 2001 2005 2001 2005 2001 2005 Major Cities Inner Regional Outer Regional Remote/Very Remote Region/Year General Practioners Specialists Nurses National Health Workforce Taskforce - 6 May 2009 33

Table 3.1: Nurse, GP and Specialist health workforce - average hours worked and average age 2001 and 2005 Nurse Average Hours Specialist Average Hours GP Average Hours Nurse Average Age Specialist Average Age GP Average Age Major Cities Inner Regional Outer Regional Remote/Very Remote 2001 2005 2001 2005 2001 2005 2001 2005 31 33.1 29.9 32.3 30.1 33.5 32.1 36.5 48 45.5 49.9 46.9 50.3 47 51 48.1 40.7 38.9 43.8 41.2 46.5 44.4 48.8 46.1 41.9 44.6 43.2 46.1 43 46 42.2 45.2 49.6 48.9 50 50.5 50.2 50 48.2 51.4 48.8 49.1 47.1 47.3 46.6 47.7 42.9 46.1 Source: (1) Australian Institute of Health and Welfare, Medical Labour Force 2005, National Health Labour Force Series no. 40. Cat. no. HWL 41, Canberra, 2008 (2) Australian Institute of Health and Welfare, Nursing and Midwifery Labour Force 2005, National Health Labour Force Series no. 39. Cat. no. HWL 40, Canberra, 2008 3.3.3 State and territory characteristics of health workforce Across all states medical practitioners, which includes both GPs and specialists, have all decreased the number of hours worked, but nurses have increased the number of hours on average worked between 2001 and 2005. National Health Workforce Taskforce - 6 May 2009 34

Figure 3.9: Average hours worked by nurses and medical practitioners by state and territory 2001-2005 45 40 35 30 25 20 15 10 5 0 NSW VIC QLD WA SA TAS ACT NT Australia State/Year Medical Practitioners Nurses The average age for nurses has uniformly increased across all states and territories between 2001 and 2005, whereas medical practitioners show considerable variation in age trends. New South Wales and Victoria experienced a declining average age for medical practitioners, but the Northern Territory had a much lower medical practitioner average age than in other states, but has experienced a slight increase between 2002 and 2005. Figure 3.10: Average age for nurses and medical practitioners by state and territory 2002-2005 60 50 40 30 20 10 0 NSW VIC QLD WA SA TAS ACT NT Australia State/Year M edical Practitioners Nurses Source: (1) Australian Institute of Health and Welfare, Medical Labour Force 2005, National Health Labour Force Series no. 40. Cat. no. HWL 41, Canberra, 2008 (2) Australian Institute of Health and Welfare, Nursing and Midwifery Labour Force 2005, National Health Labour Force Series no. 39. Cat. no. HWL 40, Canberra, 2008 National Health Workforce Taskforce - 6 May 2009 35

Historical trends indicate that the nursing workforce is ageing and working longer hours. Based on these current trends, it cannot be expected that this can continue at similar rates for a prolonged period of time into the future. This suggests that, if the nursing workforce continues to age, it will not continue to make a significant and growing contribution to the health workforce in the future as individuals retire. In considering a case for change for the health workforce, this needs to be factored in. Historical trends indicate that the medical workforce is also ageing, becoming more female and working fewer hours. If this continues a similar trend into the future, it requires consideration in a case for change for the health workforce. If historical trends continue, it suggests that more medical professionals will be required to satisfy current demand, let alone future growing demand, if a declining number of hours are being worked by an increasing number of medical professionals. 3.3.4 Other Health Professionals The number of OHP professionals in recent years has grown as a component of the total Australian health workforce, as per Figure 3.3. However, as per the general practitioner workforce, characteristics of the OHP workforce have been changing over time. These changes are quite specific to each OHP, and in considering a case for change this must be incorporated. The historical characteristic changes are demonstrated in the three case studies presented below which provide characteristics for the workforces in podiatry, physiotherapy and dentistry. The average age for podiatrists and physiotherapists has tended to be younger than for other health specialities, and this may be in part be due to the fact they are relatively new and developing specialities which tend to have greater opportunities for flexible working. Females dominate these two specialities. In contrast, the dentist workforce is on average older, but remaining relatively stable in recent years between 2003 and 2005. It is still a male dominated workforce, however this is changing over time. Case Study 1 - Podiatry The proportion of podiatrists that were male were less than 45 percent of working podiatrists with proportions ranging from 30.2 percent in Victoria to 42.3 percent in South Australia. 37 In the period 1999-2003, the podiatrist workforce aged slightly, with the proportion aged under 35 years decreasing (from 49.7 percent to 44.7 percent) and the proportion aged 35 44 years rising (from 27.1 percent to 30.9 percent). The proportion of podiatrists aged 45 years and older remained stable between 1999 and 2003 at 23.2 percent in 1999 and 24.3 percent in 2003. The ABS Labour Force Survey estimated the overall male proportion of employed podiatrists to be 33.1 percent. Podiatrists in Tasmania worked the highest total average weekly hours being 37 Australian Institute of Health and Welfare, Podiatry Labour Force 2003, Cat. no. HWL 36. National Health Labour Force Series no. 35 Canberra, 2006. National Health Workforce Taskforce - 6 May 2009 36

41.7 hours, followed by those in Victoria and South Australia, at 39.3 hours and 38 hours, respectively 38. Podiatrists with the lowest average weekly hours worked in New South Wales and Queensland (37.4hrs and 37.7hrs, respectively). These hours may be linked, in part, to the respective changes in total number of podiatrists available to practice within each state noted earlier. Case Study 2 - Physiotherapy In 2002, there were almost 16,000 registered physiotherapists in Australia (excluding the Northern Territory). This was an increase of 10.9 percent from the number registered in 1998. All jurisdictions, except Tasmania, experienced an increase in registrations over the four years between 1998 and 2002. 39 The average age of employed physiotherapists in the surveyed jurisdictions in 2002 was 39.1 years, with the Australian Capital Territory having the highest average age (41.5 years). Just over one-quarter (25.7 percent) of employed physiotherapists were male (ranging from 17.4 percent in the Australian Capital Territory to 28.6 percent in Victoria). The proportion of male physiotherapists was greater in the younger age groups, with nearly one-third (32.2 percent) of employed physiotherapists under age 30 being male, compared with only 22.1 percent of those aged 40 49 and 10.5 percent of those aged 60 years and over. This suggests that, over time, the feminine bias in this speciality may be declining. Case Study 3 Dentists The total number of dental registrations in 2005 was 11,868, a 4.1 percent increase from 2003 (11,404). The rate of practising dentists per 100,000 population also increased by 1.6 percent, from 48.7 in 2003 to 49.5 in 2005. The average age of dentists has remained stable between 2003 and 2005, at 44.5 years in 2005 compared to 44.6 years in 2003. In 2005, the largest proportion of dentists were in the 40 49 years age group (27 percent). Dentistry remains a predominantly male profession, with females comprising just over one-quarter (28.4 percent) of all practising dentists in 2005. This pattern was consistent across jurisdictions, ranging from 21.6 percent in Tasmania to 32.1 percent in the Northern Territory. However, the trend toward feminisation of the labour force is continuing. Between 2000 and 2003, there was a 3.4 percentage point increase in the percentage of female dentists (Teusner & Chrisopoulos 2006) 40 and, between 2003 and 2005, there was a 2.1 percentage point increase. On average, dentists worked 38.4 hours per week, a slight decrease from 38.7 hours in 2003. Males were working longer (40.3 hours) than females (33.5 hours). 41 38 Australian Institute of Health and Welfare, Podiatry Labour Force 2003, Cat. no. HWL 36. National Health Labour Force Series no. 35 Canberra, 2006. 39 Australian Institute of Health and Welfare, Physiotherapy Labour Force 2002, Cat. no. HWL 37. Health Labour Force Series no. 36, Canberra, 2006 40 Teusner DN & Chrisopoulos S, 2006. Australian dentist labour force 2003. Australian Dental Journal 51(3): 191 4. 41 AIHW Dental Statistics and Research Unit, Dentist Labour Force 2005, Cat. no. DEN 172, Canberra, 2008. National Health Workforce Taskforce - 6 May 2009 37

3.3.5 Generation Y Generation Y has increasingly been referred to as a stand-alone workforce characteristic. It is an emerging and controversial issue, which primarily focuses on a growing and broad trend for the desire to work reduced hours. Generation Y were born between 1979 and the 1990s, the Baby Boomers between 1946 and 1964 and Generation X between 1964 and the 1970s. The literature generally comments that the Baby Boomers and Generation X put a higher priority on career than the Generation Y workers (currently the youngest workers in the workforce). It is believed that Generation Y are more interested in making their jobs accommodate their family and personal lives. Financial reward is important to them, but maintaining work-life balance tends to outrank such financial considerations. In many cases, the opportunity to work for a company or in an environment that fosters strong workplace relationships and inspires a sense of balance and/or purpose outweighs that of earning high incomes. Generation Y workers tend to change jobs and relocate geographically more readily than their boomer parents 42, in fact some industries have already experienced over 30 percent churn rates in their Generation Y employees as they move to satisfy their values, career and life requirements. 43 Within the health profession there is limited research so far as to the effect of Generation Y on health workforces. However, literature from New Zealand for example, suggests that more than 80 percent of medical graduates indicate they will leave New Zealand (often spending 5-10 years abroad) within two years of graduation. 44 As already demonstrated, Australian figures show a decrease in hours worked by doctors from 2001-2005, in both total hours (45.4 to 43.7 hours) and in clinical practice (40.9 to 38.9 hours). 45 However, there is limited visibility as to the age groups contributing to this trend, and it cannot be entirely driven by the Generation Y cohort. Yet there is more qualitative discussion in the Australian literature that new doctors (Generation Y) will work fewer hours over the lives of their careers than doctors currently working. 46,47 Generation Y workers seek jobs with flexibility and technology options that allow them to work, yet at the same time give them the opportunity to leave the workplace temporarily to care for children. They see work as one component of a balanced life portfolio that includes family, 42 The Global Skills Convergence, issues and ideas for the management of an international workforce, Bernard Salt, KPMG. 2008 43 Beyond the baby boomers: the rise of Generation Y. Opportunities and challenges for the fund management industries, Bernard Salt, KPMG. 2007 44 Brooks PM, Lapsley HM, Butt DB 2003 Medical workforce issues in Australia: tomorrow s doctors-too few, too far, Medical Journal of Australia, Volume 179 45 Australian Institute of Health and Welfare, 2008, Life expectancy, accessed 9 October 2008 at http://www.aihw.gov.au/mortality/data/life_expectancy.cfm 46 Salsburg E, 2003 Physician Workforce Planning: What have we learned? Lessons for planning Medical School Capacity and IMG policies: The United States Experience, Centre for Health Workforce Studies, University of Albany, State University of New York. 47 Australian Medical Workforce Advisory Committee 2005, The General Practice Workforce in Australia; Supply and Requirements to 2013, AMWAC Report 2005.2, August. National Health Workforce Taskforce - 6 May 2009 38

friends, fitness, and fun. 48 However, while having a balanced life, Generation Y seek rapid career progression, diversity and challenge in their careers. In a survey undertaken by AMWAC, working hours and working flexibility options have emerged as a key issue of concern for medical professionals in recent years. The survey found: 71 percent of doctors thought they worked about the right number of hours. 28 percent thought they worked too many hours; with many comments at the end of the questionnaire expressing concern regarding working hours and many wanting to work part-time. 49 The demands and motivations of Generation Y have already been reflected in declining entries into particular specialities which historically have experienced work environments which are not generally conducive to Generation Y ideologies, such as Emergency Department physicians. In 2005, 108 new trainees entered first year accredited training positions. This was the same as in 2004, but 22 below the AMWAC target set in 2003. 50 The AMWAC report on the Australian specialist emergency medical workforce 51 recommended that advanced trainee intakes should increase to 130 per year as soon as infrastructure could accommodate this number, preferably from 2004 onwards. In 2004, there were a total of 471 emergency medicine trainees in Australia. This is a reduction of 131 training positions or 21.8 percent on the 602 training positions in 1997. Evidence for the Generation Y impact on health workforce issues is still limited, there is currently no definitive analysis which links Generation Y with explicit health workforce trends. It is currently little more than an academic model and conclusions on what this will mean in terms of the health workforce can at best be high-level and highly qualified. 48 Generation Y in the workplace, Cara Spiro: www.dau.mil/pubs/dam/11_12_2006/11_12_2006_spi_nd06.pdf viewed 16 October 2008 49 Career Decision Making By Doctors In Vocational Training. Proceedings of the Workshop Held to Consider the Findings of the AMWAC Medical Careers Survey 2002 and Possible Future Directions for Vocational Medical Training Convened on 3 November 2003. AMWAC Occasional Paper. 50 Health workforce planning and models of care in emergency departments, AMWAC, 2006 51 The specialist emergency medical workforce in Australia, AMWAC, 2003 National Health Workforce Taskforce - 6 May 2009 39

4 Supply drivers for shortages in the health workforce The majority of health workforce professions and specialities have seen actual growth in number of people practising, increasing from 282,645 individuals in 1996 to 360,401 in 2006 (an increase of 27.5 percent) 52, yet functional shortages still exist. Workforce projections for the health sector and the overall Australian labour market, highlighted in sections 3.1 and 3.2, suggest the proportion of the Australian labour market occupied by the health workforce will increase. The ability of the Australian labour market to meet the demand for health services and related health workforce in the future is likely to be constrained by current service and workforce models. There are a range of supply factors which are contributing to the current issue of health workforce shortages in Australia, which require consideration in formulating workforce strategies that address workforce structures, processes and education. These supply factors include: Competing demands for labour - Competition for labour is increasing, across the labour market for both undergraduate entry and for graduate professions, and within the health care labour market both internationally and within Australia across jurisdictions. A shrinking workforce pool - The Australian workforce pool is projected to decrease as a proportion of the total population over the next decade, driven by the ageing demographics of the workforce. Changing workforce intentions and availability - Workforce intentions indicate a move towards decreasing the hours for some categories of the health workforce and a increasing trend towards part-time employment. Reliance on international medical graduates - Australia is currently heavily reliant upon international medical graduates to supplement shortages in medical practitioners; ongoing global health workforce shortages mean this is an unsustainable model and cannot be considered a solution to manage workforce shortages in the long term. Education and training of health workforce professionals - Current system and structure of education and training is complex with insufficient capacity to satisfy current demand for trained health professionals. 52 www.abs.gov.au, Labour force, Cat. No. 6202, Canberra 2008 National Health Workforce Taskforce - 6 May 2009 40

Professional rivalries and morale. - Inter professional boundaries and tensions impact on the morale of individual practitioners that could lead to individuals leaving the workforce or changing their role in the workforce. This section discusses for each identified supply factor the current evidence and implications for the health workforce. 4.1 Competing demand for labour Australia, as every country, has a finite labour workforce pool shaped by a range of factors including, population demographics, health of the working population, employment legislation, government benefits system, immigration, migration and the education and training system. The proportion of those employed in Australia s health workforce is approximately 3.5 percent of the total Australian workforce (Figure 3.2). This proportion has been increasing for a number of years, faster than population growth and growth in the total Australian workforce. From an international perspective, Australia is not considered to have a critical shortage of health workers the number of people working in health occupations increased by 11.4% compared with an 8.7% increase in the total civilian workforce. 53 However, demand for services provided by the health workforce continues to exceed supply resulting in continuing health workforce shortages. This leads to an expectation that the proportion employed in the health workforce will increase at an even greater rate, based on current workforce practices and structures. At present, there are not enough doctors in the world to meet global healthcare needs. 54 The World Health Organisation (WHO) estimates the global need for more healthcare workers (including doctors, nurses and other health professionals) currently stands at approximately 4.3 million. 55 The three key reasons discussed in the international literature for this global shortage relate to: Policies on medical student places. Increased healthcare needs and expectations in countries supplying doctors. A trend towards a reduction in the productive hours provided per doctor. As shown in Figure 3.2, the Australian health workforce has been forecast to increase to approximately 3.7 percent of the total Australian workforce by 2016, an increase from 3.5 percent in 2006. This forecast is based on current trends, workforce practices and policies, 53 World Health Organisation, The World Health Report 2006 Working together for health, 2006. http://www.who.int/whr/2006/media_centre/06_chap1_fig10_en.pdf, (accessed on 28 October 2008) 54 Commonwealth, 2003 Commonwealth Code of Practice for the International Recruitment of Health Workers, http://www.thecommonwealth.org/, viewed on 12 December 2008 55 World Health Organisation, 2006, The World Health Report 2006 Working Together for Health, http://www.who.int/whr/2006/en/index.html, viewed on 12 December 2008 National Health Workforce Taskforce - 6 May 2009 41

such as the retirement age of 65 years. The question is whether the supply of the health workforce and the current structures and processes in place are sufficient to meet the expected growth in demand for the health services. Based on the global shortage for healthcare workers and an ongoing interest from other employment sectors (public and private) for those individuals who have trained and worked in health services, it can be inferred that, if these trends continue, there is likely to be increasing competition for existing healthcare resources from which Australia is not immune. Competing demand for health workers is not just an international issue. Australia s state based jurisdictional structure also means there is competition for resource between jurisdictions. The differing geographic, demographic and economic characteristics of the States and Territories and their individual policy directions can complicate the achievement of consensus and collaboration to achieve national workforce strategies. Discussions on national initiatives are commonly progressed through Ministerial Councils, usually based on consensus decisions, and as a result, the pace of any reform can be slow. 56 Added to that, where legislative change is required, eight and sometimes nine, parliaments must agree. This has led to a highly fragmented approach with variable degrees of success and limited national cohesion in addressing health workforce shortages. 4.2 Shrinking workforce pool The demographic analysis presented in Figure 2.1 projects that, between 2006 and 2021, those aged over 60 years will increase from 17.8 percent in 2006 to 22.9 percent in 2021. Today, Australia s demographic profile has approximately 27 percent aged between 20-49 years but, by 2021, this is expected to have dropped to between 19-20 percent 57 of the total Australian population. This introduces the possibility of a shrinking workforce pool in relation to the total Australian population, based on current employment legislation and trends that the majority of those over 65 years retire and leave the workforce. In addition to the expected shrinkage of the workforce pool, the workforce is ageing. Those working in health are currently among the oldest workers in Australia. While the average age of all Australian workers has increased by 2.8 years over the last two decades, the average age of workers in health services has risen by 5.5 years. 58 The ageing workforce population and ageing population as a whole will result in a lower proportion of the total population being part of the labour workforce pool and an increasing number of retirees out of the system. Based on current employment legislation which recommends retirement at 65 years, using current projections, the health workforce will experience greater impact driven by the higher average age of workers and resulting greater number of those eligible to retire than the general Australian workforce. 59 This is a significant supply problem for the health workforce. A key 56 Self Sufficiency and International Medical Graduate-Australia, National Health Workforce Taskforce, Peter Carver, September 2008 57 www.abs.gov.au viewed 5 December 2008 58 Kryger, T., Research Note: Australia s ageing workforce, Department of Parliamentary Services, 2005, http://www.aph.gov.au/library/pubs/rn/2004-05/05rn35.pdf, (accessed on 28 October 2008) 59 Kryger, T., Research Note: Australia s ageing workforce, Department of Parliamentary Services, 2005, http://www.aph.gov.au/library/pubs/rn/2004-05/05rn35.pdf, (accessed on 28 October 2008) National Health Workforce Taskforce - 6 May 2009 42

aspect in considering a case for change must consider this and ensure that changes in service and workforce models make the best use of available workers in a shrinking workforce pool. 4.3 Changing workforce intentions and availability 4.3.1 Medical practitioners - Exit from workforce The number of practitioners leaving the workforce, through retirement, migration or for other reasons, impacts the supply of medical practitioners. The AIHW s annual Medical Labour Force Survey provides estimates for the number of doctors not active in the medical labour force. The two primary outflows of doctors are through retirements and migration overseas (see Table 4.1). Table 4.1: Separation of doctors from the Australian Medical workforce Year Total Number of Australian Doctors Number of Australian Doctors Not in Medical Labour Force: Retired Number of Australian Doctors Not in Medical Labour Force: Overseas 2000 51 106 3399 2742 2001 53 384 2906 3181 2002 53 991 3131 3056 2003 56 207 3178 2781 2004 58 211 2519 2946 2005 60 252 2669 2947 Source: AIHW Annual Medical Labour Force Survey, Doctors 1999-2005 While retirement numbers currently appear to be declining, the population demographics and current employment legislation suggest that this will rapidly increase over the next 10-15 years as the numbers of those entering existing retirement age (65 years) significantly increases. The number of Australian trained doctors working overseas appears a relatively stable trend based on current data in Table 4.1. It represents a small proportion of the total doctors in Australia, but it has a magnified impact given ongoing workforce shortages. Drivers for doctors moving overseas consist of local, national and international factors including general economic conditions, opportunities for career progression (perceived or real), procedural experience, government policy (national and internationally) on training and education, workforce planning and work environments. For example, in the short term, Australia may feel the impact of current economic drivers such as the declining strength of the Australian dollar. Anecdotally, this may drive a greater proportion of Australian doctors to seek positions abroad compounding existing workforce shortages and conversely make Australia a less economically attractive place to work for international medical graduates. There is limited data or research which has been undertaken to understand the linkages between international government health workforce policies and economic factors on the number of health workers leaving the Australian workforce. These numbers are not significant at the National Health Workforce Taskforce - 6 May 2009 43

moment but, given global health workforce shortages, this may, in the future, become a more important factor requiring consideration within a case for change. With regards to future trends, a limited amount of research has been undertaken in terms of future health workforce intentions, those planning to leave the workforce and the related impact this may have on workforce supply. A number of states have undertaken some qualitative and quantitative research which estimates future workforce shortfalls. This is based on data collected during the annual AIHW workforce survey for medical practitioners and nurses. Typically an analysis of the data specific to those who have stated their intentions to leave the workforce to which a broad assumption that all those who have stated they will leave within the next 5-10 years are highly likely to leave. It balances this with current practicing numbers and those in training. This analysis has been fed into future workforce projections 60, calculating the estimated surplus and shortfall by speciality. The states which have undertaken this analysis have often calculated shortfalls by speciality in excess of 50 posts by 2016. Although the methodology applied is high level and has limited consideration for demand and supply drivers specific to the specialities, the analysis highlights estimated significant shortfalls in a wide range of specialities. It highlights specific speciality projected shortfalls in resource likely to be replicated (with jurisdictional differences) across Australia should the current workforce systems and processes continue. 60 Discussion with Maureen McCartney, National Health Workforce Taskforce, 15 December 2008 National Health Workforce Taskforce - 6 May 2009 44

4.4 Nurses 4.4.1 Exit from the workforce The number of nurses leaving the workforce, through migration or for other reasons, impacts the supply of nurses. The AIHW s annual Labour Force Survey provides estimates of the number of nurses not active in the medical labour force. The two primary outflows of nurses are through migration overseas and looking for work outside of nursing. Table 4.2: Separation of nurses from the Australian medical workforce Year Number Australian Registered Nurses in the Medical Labour Force Number of Australian Registered Nurses Not Looking for Work in Nursing Number Australian Registered Nurses Not in Medical Labour Force: Overseas 1999 186,170 14,934 3923 2001 189,671 15,248 4190 2003 196,091 18,194 4330 2005 206,873 21,779 1925 Source: AIHW Labour Force Survey, Registered Nurses 1999-2005 The number of registered nurses not looking for work in nursing has increased steadily between 1999 and 2005. This number can be further broken down by those not looking for work and those looking for work outside of nursing, however, the distribution between these two sub-categories remains at approximately 50:50 between 1999 and 2005, and therefore has not been represented here. The number of registered nurses overseas increased consistently between 1999 and 2003, but observed a significant drop in 2005. The movement of nurses overseas is likely to fluctuate over time driven by a range of factors beyond the direct control of the Australian health sector. In the short term, there may be an emerging trend for greater numbers leaving Australia driven by current economic factors such as the declining strength of the Australian dollar, and policies adopted by foreign governments to attract nurses internationally. Anecdotally this may drive a greater number of Australian nurses to seek positions abroad compounding existing workforce shortages. However, this can only be assumed as there is no conclusive data as yet, for 2008. As per the medical practitioner workforce, the numbers of registered nurses overseas is not a significant proportion of the health workforce so far but, given ongoing global workforce shortages, this may in the future become a more significant factor to consider in developing a case for change, including service and workforce models to make best use of available staff, how workers are remunerated and retained. National Health Workforce Taskforce - 6 May 2009 45

4.4.2 International medical graduates Australia is heavily reliant upon international medical graduates to minimise workforce shortages which has increased significantly in recent years, in part, as a consequence of government policy. In the 1980s, the Australian government made the decision to cap the number of entrants to Australian medical schools. This decision flowed from projections of the medical workforce which indicated that, as a consequence of previous rises in medical training levels and continued high migration of international medical graduates to Australia, the doctor-to-population ratio in Australia was deemed too high. 61 As a result of this medical school entrant capping, a shortage in medical practitioners subsequently emerged within the health workforce. These shortages were subsequently supplemented, primarily, by international medical graduates and more recently by increasing medical student intakes starting in 2000. 62 The number of publicly funded tertiary medical places has increased by more than 25 percent since 2000 increasing the number of publicly funded students completing university medical studies. This is projected to continue into the future, from approximately 1,300 students in 2005 to approximately 1,900 in 2010 an increase of over 45 percent. 63 An estimate of the current stock of international medical graduates suggest that approximately 20-25 percent (the average across the reporting states is 21.3 percent) of the practising doctors in Australia in 2005 obtained their degrees overseas. The most common qualification countries were New Zealand, UK/Ireland and South Africa. Of those jurisdictions that collected this information, Western Australia had the highest proportion of employed doctors who stated that they had obtained their first qualification in a country outside of Australia (34.5 percent), while Victoria had the lowest (17.5 percent). 61 Birrell, R, 2004 Australian Policy on Overseas-Trained Doctors. MJA 2004; 181 (11/12): 635-639 62 Self Sufficiency and International Medical Graduate-Australia, National Health Workforce Taskforce, Peter Carver, September 2008 63 The General Practice workforce in Australia, AMWAC, 2005 National Health Workforce Taskforce - 6 May 2009 46

Table 4.3: Employed doctors: country of first qualification, states and territories, 2005 Qualification Country NSW VIC QLD WA SA TAS ACT NT Australia N/A 13,050 7,524 3,095 3,777 1,056 980 N/A New Zealand N/A 311 243 159 104 39 54 N/A UK/Ireland N/A 683 704 688 236 150 73 N/A Asia N/A 705 358 320 517 N/A North America N/A 19 12 8 5 3 N/A South Africa N/A 188 210 62 N/A Other countries N/A 1,064 269 239 216 177 253 N/A Not Stated 21,730 19 46 158 18 11 719 Total 21,730 15,831 9,352 4,881 4,938 1,438 1,363 719 % Australian Trained N/A 82.5 80.9 65.5 76.8 74.0 71.9 N/A Source: Australian Institute of Health and Welfare, 2008, National Health Labour Force Series Number 40: Medical Labour Force 2005, Canberra, available at www.aihw.gov.au Note: Data for New South Wales (NSW) and the Northern Territory (NT) was not collected. A comparison between qualification countries in 1998 and in 2005 demonstrates how the supply countries have diversified.: While New Zealand trained doctors have increased in total numbers, the proportion has not increased (2.4 percent of the total workforce in both 1998 and 2005). The United Kingdom/Ireland remains a key supply region, but more recently has declined as a proportion of the total doctor workforce (8.3 percent in 1998 and 6.7 percent in 2005). The other countries category made up only 4.6 percent of the total doctor workforce in 1998 but, by 2005, it had increased to 7.2 percent of the workforce, suggesting that Australia is recruiting from a more diverse range of countries. Table 4.4: Country of qualification of doctors in medical labour force in Australia, 1998 and 2005 Qualification Country 1998 2005 Australia 38,526 47,391 New Zealand 1,196 1,450 UK/Ireland 4,043 4,039 Asia 2,942 3,028 Other Countries 2,227 4,343 Total 48,934 60,252 Source: Australian Institute of Health and Welfare, 2003, National Health Labour Force Series Number 24: Medical Labour Force 1999, Canberra, available at www.aihw.gov.au Note: The figures for 2005 were derived using the average percentages for the states that collected this information (Victoria, Queensland, South Australia, Western Australia, Tasmania, ACT) and multiplying this by the total number of doctors. National Health Workforce Taskforce - 6 May 2009 47

The role of international medical graduates in supplementing the supply of Australian health workers must consider both the increased international medical graduates entering Australia to practice and the increasing diversity of countries from which they come. A case for change must acknowledge the extent to which Australia is currently reliant upon international medical graduates and any future implications this may have, based on the worldwide shortages of medical practitioners as well as the supply countries future policies for retaining medical practitioners and attracting international medical graduates themselves. Consideration must be given to the service and workforce models needed to make the best use of available staff, as well as health system fundamentals such as regulatory schemes, educational accreditation, service accreditation schemes and training to ensure health workforce shortages are addressed. 4.4.3 Competition for existing resource Potential demand by professions outside the healthcare sector for those individuals with training and experience in the health care sector adds to the pressure on the supply of health workforce professionals. An analysis of the number of Australian doctors and registered nurses not in the medical labour force provides an indicative example of potential demand for health workforce professionals outside of the health profession. Unfortunately, this data does not show the proportion of those actually employed in other employment sectors, but it highlights that there is a large number of trained Australian doctors and nurses no longer in the medical labour force and that this has been a consistent trend. In particular, there has been a consistent growth in the number of nurses no longer looking for work in nursing and working outside of the profession. Table 4.5: Number of Australian doctors not in the medical labour force Year 2000 7,109 Number of Australian Doctors Not in Medical Labour Force: Total Number of Australian Registered Nurses Not Looking for Work in Nursing 2001 7,092 15,248 2002 7,283 2003 6,994 18,194 2004 6,495 2005 6,725 21,779 Source: (i) AIHW Labour Force Survey, Registered Nurses 1999-2005 (ii) AIHW Annual Labour Force Survey, Doctors 1999-2005 Anecdotal evidence and commentary has highlighted that there is and will continue to be a demand in other employment sectors for health workforce professionals, such as government policy units, management, pharmaceuticals companies, consulting firms and academic institutions. The attractiveness of these alternative professions and the resulting impact of individuals leaving the health workforce for these professions has not been fully analysed; it does however, remain a factor driving workforce shortages and must be considered in National Health Workforce Taskforce - 6 May 2009 48

formulating a case for change with respect to current workforce and service models and approaches to retaining staff in the health sector. 4.5 Workforce expectations and availability There are changing expectations amongst health care workers influencing the health workforce supply. Those specific to the health workforce have been categorised into a number of factors, defined as intrinsic, extrinsic and gender related factors. These factors will have different degrees of influence on each individual healthcare professional but must all be considered when understanding the current supply factors influencing health workforce shortages. Table 4-6: Intrinsic and extrinsic factors 64 Intrinsic Interest in helping people Intellectual content Appraisal of own skills and aptitude Domestic circumstances Job security Extrinsic Flexibility Atmosphere/job culture Work experience since graduation Opportunity for procedural work Hours Role models/mentors Table 4-7: Difference in factors stated 60 Female Hours Domestic circumstances Flexibility Type/variety of patients Number of years in training Interest in helping people Male Financial prospects Role models/mentors Intellectual content Work experience since graduation Prestige Cost of training 64 Attracting health professionals into primary care: strategies for recruitment, APHCRI, November 2007 National Health Workforce Taskforce - 6 May 2009 49

Those most influential extrinsic determinants of career choice for postgraduate doctors were work culture, opportunity to work flexible hours, hours of work typical of speciality and opportunity for procedural work. If these are met, doctors are more likely to remain in the health workforce. 65 In addition to the identified intrinsic, extrinsic and gender specific factors, there are a number of less tangible factors influencing career choices within the health workforce. There is for example, evidence in Australia of professional perceptions that some types of nursing practice are more legitimate than others, for example acute based versus community based. A limited focus on and exposure to non-acute and community based contexts of practice has limited the attractiveness of employment in these settings. 66 Career pathways with associated rewards are vital if particular areas of nursing practice, such as non-acute and community nursing, are to be attractive career choices for nursing professionals. There is also evidence that multi-country experience can enhance career progression. If there is demonstration of advanced knowledge and practice specific to the field of clinical expertise, this can be a strong incentive for nurses to remain in the workforce. 62 Evidence shows that, for many other health professions, high attrition rates are related to poor career paths. In order to achieve better career prospects, many experienced allied health professionals are choosing to move out of clinical areas into such fields as management and education, adding to the shortage of clinical practitioners. 62 While complex in nature, these factors are important to understand in considering a case for change with respect to current supply constraints. Changes in service and workforce models to make best use of available staff and retain staff are important considerations. 4.5.1 Changing approaches to careers Increasingly, individuals within the workforce have a different approach to their careers. The workforce literature often refers to there no longer being a career for life mentality. However, the figure below shows unexpected findings in the Australian labour mobility. Of employed persons, 24.5 percent had been at their current job for under one year in 1986. By 2006, this figure had decreased to 21.4 percent. This represents a proportional decrease of 3.1 percent over the 20 years to 2006. 65 Career decision making by postgraduate doctors, Key Findings, AMWAC, December 2005 66 Allied Health in Australia Priorities for health care reform, Feb 2008 www.ahpa.com/publications viewed 16 Oct 2008 National Health Workforce Taskforce - 6 May 2009 50

Figure 4.1: Duration of current job 1986-2006 <1 year 1-2 years 2-3 years 3-5 years 5-10 years 10-20 years >20 years 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 6.0 7.7 8.5 8.6 8.9 9.0 13.8 14.2 15.1 15.9 15.8 15.7 18.6 15.5 13.7 13.2 9.7 9.8 13.7 13.3 20.2 17 17.7 17.6 15 8.4 14 14.2 13.9 10.5 11.2 10.5 10.5 12.3 12.4 11.9 24.5 26.5 22.4 21.8 19.9 21.4 0% 1986 1990 1994 1998 2002 2006 Source: Labour Mobility, Australian Bureau of Statistics, 1994, 2000 and 2006. Analysis by Bernard Salt s demographics team The proportion of employees who had been at their current job for 20 years and over has increased between 1986 and 2006. In 1986, some 6 percent of employees had been in their current job for 20 years or more. By 2006, this figure had increased to 9 percent. This represents an increase of 3 percent. However, the number of people who leave a job within 2-3 years has increased. This could be as a result of an increasingly strategic approach being taken by individuals seeking to gain the experience necessary and stay at a job long enough to look relevant on a resume before moving on. Doctors and many other health professionals typically undertake far more training than Australian workers in general. They are therefore far more likely to stay longer in jobs and the health workforce to harvest the return on this investment. However, there are increasing changes to career intentions with respect to their future work practices. The AMWAC medical careers survey findings highlight a number of factors likely to shape future case for change for the health workforce. 67 On average, those questioned in 2004 were taking longer to complete vocational training than previously expected (48 percent), a greater adoption of part-time and taking time out were factors associated with slower progression. Of those respondents, 32 percent men and 53 percent women also planned to reduce their hours worked, 22.8 percent planned to work part-time in the 3-7 years and 49 percent planned to work less than 40 hours per week in the next 3-7 years. These are important considerations for future models of practice, if health workers are reducing the hours worked, then more staff are required to work to maintain existing service levels, based on existing workforce models and process. 67 Career decision making by postgraduate doctors, Key Findings, AMWAC, December 2005 National Health Workforce Taskforce - 6 May 2009 51

4.6 Education and training of health workforce professionals Education and training impacts on the supply of healthcare workers far beyond the simple fact that it is through education and training that individuals obtain the required qualifications to be health care professionals. The experiences and exposure trainees receive is understood to have a critical impact on their development as practitioners and the career choices they subsequently make. For example within nursing, limited exposure to practice environs beyond the acute care sector in undergraduate curriculum often shapes perceptions of alternative environments such as non-acute and community settings and can be hugely influential on student career choices. 68 There are a number of factors that impact on the capacity of the system to educate and train health care workers and on the time it takes for an individual to acquire their qualification including: Decisions regarding the number of undergraduate and postgraduate places. The availability of clinical placements. The models of education and training. The location of education and training institutions. The effectiveness of collaboration between the institutions, health care services and funders. The education and training of the health workforce and responsibility for the requisite policy direction, funding and delivery is spread across a broad range of stakeholders and providers including federal and state governments, universities, training and vocational education providers, specialist colleges, professional associations, accreditation agencies and health service delivery bodies. This results in a highly complex system with responsibilities spread across many levels of government and organisations. The plethora of education programs which currently exist reflects the ongoing complexity of the multi stakeholder structure of health care provision. As a result, there is a diverse range of programs, changes and initiatives ongoing to address the need for more health workers in the future. For example, historically, the trend with medical workforce supply has been a tendency to grow supply through ever increasing medical school intakes. 69 Since the late 1990s, other changes to education programs have included the decreased length of study required for medical degrees and the creation of graduate-entry medical programs (GMPs). 70 In its recent report, the Productivity Commission (2005) highlighted a number of key issues with respect to the current health workforce education and training approach in Australia. 71 The 68 Attracting health professionals into primary care: strategies for recruitment, APHCRI, November 2007 69 Productivity Commission, Australia s Health Workforce, Research Report, Canberra, 2005 70 Joyce C, Stoelwinder J, McNeil J & Piterman L, Riding the wave: current and emerging trends in graduates from Australian university medical schools Medical Journal of Australia 2007; 186 (6): 309-312 71 Australia s Health Workforce, Productivity Research Commission Report, December 2005 National Health Workforce Taskforce - 6 May 2009 52

Productivity Commission specifically noted the complexity, poor coordination between the education and training and the health delivery aspects of the system and the low responsiveness to changing needs. The health workforce skill needs are continually evolving as a result of the demand drivers discussed in section 2. Changes in the burden of disease, demographic shifts and advances in technology and modalities of treatment all impact and define the requisite skill requirements of those working in the health workforce. The responsiveness and capacity of the health workforce education and training system is particularly important when considering ongoing supply of the requisite health workforce professionals and accommodate students sufficiently to meet the service requirement in full. 4.6.1 Nurse education Nurses represent the largest health workforce profession in Australia. Nurses practice in diverse settings ranging from acute care environments to community based services that bridge the public and private sectors. Nurse education and training has experienced a significant change in the last 20 years - 1994 marked the end of the transition from an apprenticeship model of registered nurse training to an academic model of nursing education. Since 1994, all registered nurses in Australia have been educated to a bachelor degree level at university which typically has provided greater grounding in clinical sciences for registered nurses. In addition to requiring a bachelor degree in nursing, graduates must meet the Australian Nursing Council Incorporated (ANCI) competencies for registration in their State or Territory. The types of courses offered have become increasingly innovative in the ways in which they are delivered since the transfer to universities. Universities have attempted to be flexible in the delivery of courses to increase access for students wishing to undertake a nursing degree. The nursing vocational education system has also seen improvements in course structure which is competency based through greater consultation with stakeholders. 72 Undergraduate nursing programs are offered at 29 universities as well as one college (Avondale College). While universities in each state and territory are most likely to supply new graduates to that particular jurisdiction, this is not always the case. An increasing number of programs are offered by distance mode, and universities are sometimes contracted for the delivery of programs to students located in a different state or territory. Furthermore, new graduates are increasingly mobile, for example Western Australia and the Northern Territory both indicated during consultations into developing the National Review in Nursing Education 73 that they rely heavily on graduates from New South Wales and Victoria. In total, the number of nursing places will increase by 5,853 places from 2002 to 2010, meaning that by 2010 there will be 13,895 nursing training places. 72 Productivity Commission, Australia s Health Workforce, Research Report, Canberra, 2005 73 http://www.dest.gov.au/archive/highered/nursing/pubs/duty_of_care/doc5.html#8 (viewed 22 October 2008) National Health Workforce Taskforce - 6 May 2009 53

Nurse education focus on acute sector One issue related to nurse education and training which has been highlighted in the literature is the continuing focus on meeting the needs of the acute sector where nurse shortages continue to be most reported, despite the steady shift towards new modalities of care in the community and home. 74 This may in part be contributing to the relatively few nurses who are attracted to careers in general practice and community settings. Increasingly, practice opportunities for nursing are community based. 75 While there are undergraduate competencies established nationally for nurses that aim to provide nurses with basic skills to work in all settings, the challenge is to develop training programs for undergraduates and postgraduate levels which are timely and appropriate to ensure graduates can effectively function and provide the services required in new roles and domains of practice. To date, anecdotal evidence from the field suggests that the education and training system has not had sufficient flexibility or responsiveness to do so. 76 4.6.2 Doctor and medical education The Australian Medical Workforce Advisory Committee has identified current and emerging shortages in doctor training intakes. 77 These shortages have so far been addressed by two main supply sources. They are through graduates from Australian Medical Schools or via International Medical Graduates. Since 2000, there have been a significant increase in the number of Australian medical school places, which continues to rise, in response to workforce undersupply. The number of domestic graduates from Australian medical schools is set to increase by 45% in 5 years, from 1348 in 2005 to 1900 by 2010. 78 In addition, funding has been increasingly focused to address specific geographic areas of need and shortage. the allocation of a further 2,850 university places in medicine, nursing, mental health and other health related disciplines at Australia s universities this includes the establishment of a new rural medical programme involving a partnership between the University of New England and the existing medical school at the University of Newcastle - 80 medical places will be allocated to this new programme, 60 at the University of New England and 20 at the University of Newcastle A proportion of the new medical school places will be bonded to areas of medical workforce shortages. In addition, the Government is providing funding 74 Review of Primary and Community Care Nursing, APHCRI, November 2007 75 Review of Primary and Community Care Nursing, APHCRI, November 2007 76 Review of Primary and Community Care Nursing, APHCRI, November 2007 77 Australian Medical Workforce Advisory Committee (AMWAC) 2003, Specialist medical workforce planning in Australia. A guide to the planning process used by the Australian Medical Workforce Advisory Committee, AMWAC, Sydney. 78 Joyce CM, McNeil JJ, Stoelwinder JU. More doctors, but not enough: Australian medical workforce supply 2001 2012. Med J Aust 2006; 184: 441-446. National Health Workforce Taskforce - 6 May 2009 54

for 420 new mental health nursing places and 200 new clinical psychology places as part of the Government s contribution to the COAG Mental Health package. 79. However, increasing the number of university medical school training places for doctors, nurses and other health professionals is not the only driver which should be focused upon in addressing the health workforce shortages. Other factors to be considered include: The changing profile of entrants into the health education and training programs. The changing structure of education programs. Clinical training aspects of programs. Changing profile of entrants into education programs A substantial proportion of doctors working in OECD countries are now women, which represents a significant change over the past two decades 80. In Australia, 32.9 percent of the workforce in 2005 was female, compared with 30.7 percent in 2001. 81 The changing workforce demographics are being driven by changing profiles of the entrants into education programs, courses and training currently provided by higher education institutions, colleges and vocational providers. Females now make up more than 50 percent of the entrants into medical degrees in Australia. Entrants into medical degrees have also been getting older, for example those students over 25 years of age made up approximately 20 percent of the students commencing medical degrees in 2001 as apposed to in 1990 when they made up under 10 percent 82. 79 2,850 Medical and health places in Australia s universities, Department of Education, Science and Training press release, July 2006 80 Brooks, P. Lapsley, HM. and Butt, DB. Medical Workforce Issues in Australia: Tomorrow s Doctor s Too Few, Too Far. Medical Journal of Australia 2003; Volume 179 81 Australian Institute of Health and Welfare, Medical labour force 2005, National health labour force series no. 40. Cat. no. HWL 41, AIHW, Canberra, 2008 82 Joyce, CM, McNeil, JJ and Stoelwinder, JU. Time for a new approach to medical workforce planning. Medical Journal of Australia 2004; Volume 180 National Health Workforce Taskforce - 6 May 2009 55

Figure 4.2: Student characteristics entering higher education medical degrees 2005-2007 100% 99.54 99.32 99.46 80% 60% 55.26 55.23 55.09 %Full-time % Females 40% 20% 0% 2005 2006 2007 Source: www.dest.gov.au/sectors/higher_education As entrants into training programs become older and more feminine in profile, there are likely to be impacts on the way services are provided and resourced to maintain the same level of service provision, let alone increases in demand for services. 4.6.3 Specialist training Medical practitioners become specialists in specific fields with additional training, which takes place via vocational training and examinations as specified by the relevant colleges. For instance, GPs are required to train for an extra three years (which includes general practise posts and hospital posts) with the Royal Australian College of General Practitioners to be accredited as a GP. There has been a large increase in the number of specialist training placements in Australia with a 12.7 percent increase representing an additional 722 training placements (vocational training) from 1997 to 6,387 training placements in 2004. 83 However, there are currently limitations in the capacity and structure of the system which continues to limit sufficient accommodation of all students entering specialist training and, as a result, creates a barrier to training the number of specialists required. 83 Australian Competition and Consumer Commission & Australian Health Workplace Officials Committee, Review of Australian specialist medical colleges, ACCC & AHWOC, 2005 National Health Workforce Taskforce - 6 May 2009 56

The Phelan report and Productivity Commission have identified a number of issues with respect to the current system of education and training 84,85 and include a lack of placement availability for trainees, low levels of funding available for training placements, an identified lack of supervisors and availability of clinical environments for training and students. Issues specific to location of training and particular specialities were also identified, and included: Location - Comprehensive clinical experience cannot be provided for most specialist trainees in a single hospital, including large teaching hospitals. There is limited experience in ambulatory or longitudinal care of patients in many hospitals. A variety of conditions are now managed predominantly in the private sector and are not accessible to specialist trainees working only in the public sector. Specialities - The concentration of public psychiatry on managing people with serious mental illness has resulted in psychiatric trainees gaining little or no experience in managing patients with more frequently diagnosed mental health issues. Block periods of time in community based health services have become an important part of training in geriatrics, psychiatry, paediatrics and child health. Some experience in the private sector will be necessary for almost all trainees in ophthalmology, dermatology, radiology and pathology. A number of key barriers to addressing such issues for speciality training have been identified: The need to identify costs and attribute stakeholder responsibilities. Concerns about the potential impact on service provision in public hospitals. Medical indemnity and employment conditions for specialist trainees working outside the public hospital system. Access to appropriately trained trainers. Resources for accreditation of non-teaching hospital sites. The Council of Australian Governments (COAG) agreed that the Commonwealth and the states and territories establish, by January 2008, a system for specialist trainees to undertake rotations 84 Productivity Commission, Australia s Health Workforce, Research Report, Canberra, 2005 85 Peter Phelan Consulting, Medical Specialist Education and Training: Responding to the impact of changes in Australia's health care system. A Discussion Paper (Prepared for the AHMAC Working Party to Research Issues Relevant to Specialist Medical Training Outside Teaching Hospitals), February 2002 National Health Workforce Taskforce - 6 May 2009 57

through an expanded range of settings. This has started to occur in 2008. There have also been a number of state and territory announcements which have included funding for increasing the number of specialist training posts in Queensland, Victoria and Western Australia. 86 However, the detail on what these posts will look like is yet to be determined. It is too early to determine the likely impacts of these changes in specialist training. 4.6.4 Clinical training Clinical training for undergraduate and postgraduate levels is an important and essential component of most health profession training and education given the practical nature and need to see and experience a variety of symptoms and conditions. Clinical training placements have become a high priority for universities, health departments and health services for a number of reasons which include: Growth in the number of university places for health professionals has increased the requirement for clinical training places. This increase in university places has not necessarily been accompanied by planning for clinical placements or an increase in supervisor numbers. Clinical staff may be under pressure to meet higher workloads, at the same time as being asked to mentor and support students. Additional clinical training places are being sought for postgraduate clinical entry programs, overseas qualified pre-registration requirements for registrable professional groups and other health science courses, re-entry, refresher and certificate courses. Models of service delivery have changed, with length of stay and bed numbers decreasing and patient acuity increasing, particularly in teaching hospitals. Relative to the 2005 academic year, the planned growth in clinical placement requirements expressed in days is revealing 87 : By 2013 academic year, it is estimated that about 632,700 additional medical clinical placement days will be required per annum. By 2013 academic year, it is estimated that growth in demand for clinical placements of more than 613,750 additional nursing placement days will be required per annum. By 2013 academic year, it is estimated that over 82,988 additional other health clinical placement days will be required per annum. The assumptions for these calculations are set out in Appendix A. 86 http://www.health.gov.au/internet/main/publishing.nsf/content/work-edu-spectr-mstsc-rept-toc~work-edu-spectrmstsc-rept-app-d (viewed on 24 October 2008) 87 Growth in domestic students, unpublished, Peter Carver, National Health Workforce Taskforce, November 2008 National Health Workforce Taskforce - 6 May 2009 58

The majority of clinical training components of health courses involve public hospital placements, although some are provided in private hospitals and practices. The trainers are either salaried employees or Visiting Medical Officers (VMOs), primarily providing their time on a pro bono basis in addition to their day job. Payment and funding arrangements vary across professional disciplines. Public hospitals may receive some payment from universities for the use of their facilities for clinical training purposes in undergraduate courses, and there are some explicit clinical training components in the Government s contribution to medical and nursing course costs, but, for example, no separately identified clinical training component for allied health courses. There has been more recent emphasis on clinical training, specific to professions of need and funding provision made. For example, in the 2006-07 Budget, the Australian Government provided an increase in funding to support clinical training for nursing students, as part of the Government s contribution to the COAG s Health Workforce package as announced on 8 April 2006. 88 30 medical places will be allocated to the University of Melbourne and 30 to Monash University. In an example of exemplary cooperation, these two Victorian universities will work together to provide extensive high quality clinical training in northern Victoria with a particular focus on Bendigo. Students will enjoy extended training in a rural and regional setting to encourage their long term commitment to these regions. This cooperation between the two universities will avoid the significant problem of attracting scarce academic staff in the basic and advanced sciences which support medical training. It will also see more efficient use of scarce clinical placements throughout the northern Victorian region. 89 However, clinical training aspects of health workforce development is still heavily reliant on pro bono provision by more senior practitioners and with the increasing number of students on health related courses it is not clear how, where and by whom they and future postgraduate trainees will be clinically trained. 90 Issues are already becoming apparent with medical students who cannot acquire appropriate clinical experience because of the unavailability of patients in teaching hospitals, i.e. there are too many students chasing too few patients. 91 Specific access limitations have also been identified by universities and some jurisdictions in nursing clinical placements as highlighted in a 2005 report by AHWOC, Clinical Training Placements, analysis of responses to AHWOC, 92 and include: Nurses in specialty areas, such as midwifery, sexual health, mental health, psychiatric nursing, high dependency, paediatric and community health, drug and alcohol, maternal and infant care. 88 2020 New Higher Education places to boost the health workforce, media release, 9 May 2006 BUD 19/6 89 2,850 Medical and health places in Australia s universities, Department of Education, Science and Training press release, July 2006 90 Medical education in Australia: changes are needed. It is time for less talk and more action. Geoffrey W Dahlberg, Medical Journal of Australia, 2006; Volume 184 Number 7 91 Barriers to student access to patients in a group of teaching hospitals. LG Olson, SR Hill, DA Newby. Medical Journal of Australia 2005; Volume 183 92 Clinical Training Placements, analysis of responses to AHWOC, 2005 National Health Workforce Taskforce - 6 May 2009 59

First year students. Rural and remote places in mental health and psychiatric nursing, high dependency and acute nursing care. Undergraduate international students and migrant bridging students. Postgraduate international students places in critical, emergency and coronary care nursing. District and post acute care nursing. Some jurisdictions also indicated that student graduations were delayed to allow students to complete clinical placements. One jurisdiction indicated that disciplines where delays occurred included physiotherapy, podiatry, dietetics and clinical nutrition, pharmacy and speech pathology. 4.7 Workforce specialisation The health workforce has become increasingly diversified and specialised, in response to numerous factors such as professionalisation, scientific and technological developments, credentialing, changing models of care and identified needs. As the workforce has increasingly fragmented into sub-specialities, each group delineates and protects its own role through such mechanisms as controlling the entry criteria, registration, industrial action, and political influence. The greater control each group has, the greater its potential to influence the supply of its own discrete contribution within the health workforce. This trend towards specialisation contributes to workforce shortages in many and varied ways including: New sub-specialties create their own demand that eventually leads to a new area of workforce shortage. Demarcation across the sub-specialties has the potential to reduce flexible work practices requiring multiple practitioners to undertake functions that may previously have been undertaken by a single practitioner or at least preventing allied functions being undertaken by a single multi-skilled practitioner. Workforce shortages are a potential consequence where there are education and training capacity constraints, restricting supply of the specialist practitioner. Inter professional boundaries and tensions have the potential to occur, impacting on the morale of individual practitioners that could lead to individuals leaving the workforce or changing their role in the workforce. One example of inter-professional rivalries relates to obstetricians and midwives in the Australian context. Weaver et al (2005) discussed these issues and based on workforce survey information conducted by the Royal Australasian College of Obstetricians and Gynaecologists National Health Workforce Taskforce - 6 May 2009 60

(RANZCOG) the shortage of midwives was considered in part to be related to midwives perceptions of a lack of professional recognition, stress and workload issues, as well as limited opportunities for midwives to practice as primary carers and provide continuity of care to women. 93 Professional collegiate initiatives designed to overcome some of these professional boundaries have been introduced and one measure, the establishment of the Joint Committee for Maternity Services in 2002 occurred, with representatives from the RANZCOG, the Australian College of Midwives, the Royal Australian College of General Practitioners, and the Australian College of Remote and Rural Medicine, as well as consumer representation. The authors suggest that some progress has been made in a number of areas but that residual professional boundaries and tensions are likely to remain due to the underlying professional boundaries of scope of practice. Another example where inter-professional boundaries and tensions have had the potential to impact the morale of individual practitioners, which could lead to individuals leaving the workforce or changing their role in the workforce, is the impact on professional standing of General Practitioners within the medical profession. This was considered by Del Mar et al (2003). 94 The authors concluded that general practice is suffering from a crisis of status and that innovation to redress financial, power and academic imbalances within the medical profession are required. 93 Edward W Weaver, Kenneth F Clark and Barbara A Vernon Medical Journal of Australia 2005; 182 (9): 436-437 94 Chris B Del Mar, George K Freeman and Chris van Weel Medical Journal of Australia 2003; 179 (1): 26-29 National Health Workforce Taskforce - 6 May 2009 61

5 Emerging strategies The clear recognition of the workforce shortage problem in Australia has led to a number of initiatives over the last decade many with a focus on attracting, recruiting and then retaining individuals in the health industry. For example the significant increase in university places for health professionals and post-graduate education opportunities. Others have looked at new workforce innovations that have resulted in new types of health care workers and workforce models, for example same day hospital procedures, virtual hospital service delivery, physician assistants, assistants in nursing and nurse practitioners. Given that Australia is competing in an international environment for skilled healthcare workers where there is an international shortage that is likely to worsen, Australia will require a coordinated and integrated strategy that looks increasingly to workforce innovation as a sustainable solution and less on international recruitment. The recent economic events including the reduction in the Australian dollar in international currency markets will make it more difficult to recruit internationally. It is acknowledged that in the United Kingdom the National Health Service (NHS) 95 embarked on a comprehensive approach to workforce planning commencing in 1999 and concluded that the following key activities were required: Team working across professional and organisational boundaries. Flexible working to make the best use of the range of skills and knowledge which staff have. Maximising the contribution of all staff to patient care, removing barriers which require only doctors or nurses to provide particular types of care. Modernising education and training too ensure that staff are equipped with the skills they require in a complex changing NHS. Developing new, more flexible careers for staff of all professions. Expanding the workforce to meet future demands. The model that has been adopted by the NHS to achieve a comprehensive approach to workforce planning has been founded in service redesign and development, followed by education and training (skilling and re-skilling) activities. Alignment of workforce planning of all strands of health professional staff, a continued focus on skill-mix issues, responsiveness in curriculum development, new training programs for new types of staff, support for professionals who wish to change roles during a health care career, including those approaching retirement have all been priority action areas. Examples of some emerging strategies include: Extension of Nurse Practitioner roles in emergency departments and intensive care units. 95 A Health Service of all the talents:developing the NHS Workforce Consultation Document on the Review of Workforce Planning NHS National Health Workforce Taskforce - 6 May 2009 62

Extension of radiographer and sonographer roles in radiology. Extension of the use of allied health staff in emergency departments to take on care coordination. Increasing the skill levels of staff to enhance their capacity to manage patients with psychosocial and/or complex care needs. The use of the Liaison Nurse role to support both the intensive care units and medical wards in the hospital operating as a type of outreach service to medical wards. A number of new healthcare practitioners have been trialled or introduced in international modern health systems such as the United Kingdom, Canada and the United States. Australia is starting to embark on the introduction of these new roles, particularly as it relates to nurse practitioners, nurse assistants, physician assistants, allied health practitioner assistants and indigenous health care workers to name a few. A study by Jolly (2008) 96 considered the international experience and application of the physician assistant concept. The scope of practice included supplementing the services of doctors by undertaking routine and less complex care at both primary and tertiary care levels. In America, this includes prescribing rights, subject to limitations. In the United States, it was identified that there were 65,000 physician assistants in 2007 working across a number of medical practices and locations and their distribution related to general practice as well as acute hospital services such as orthopaedics, pathology, dermatology, endocrinology, urology, obstetrics-gynaecology, ophthalmology, gastroenterology and rheumatology. The paper highlights that research on physician assistants has been carried out in the United States since the 1970s and is uniformly positive about the benefits physician assistants have delivered to the United States health system. Future directions include the use of physician assistants to be used in telemedicine consultations and follow up post discharge from an acute care episode. Doctors are largely open to explore this option, but have stated that it should occur within the context of: Team care that synergises the different skills of doctors, nurses and other health professionals. Doctors retaining their central role. Increases in the capacity to extend medical services with efficiency gains. No loss of patient safety. 96 Rhonda Jolly, Social Policy Section, Department of Parliamentary Services Research Paper, Mar 2008;Health workforce:a case for physician assistants? National Health Workforce Taskforce - 6 May 2009 63

No fragmentation of care. 97 There are other examples of individual hospitals adopting a multi-dimensional strategy embracing new types of practitioners (nurses assistants) and new training methods (fast tracking accreditation and promotion through competency based systems) to overcome shortages in workforce and to increase retention of their workforce. 98 In order to navigate a satisfactory solution, a greater understanding of what workforce roles could mean for existing workforce professionals and levels of service is required. Experience from existing models in the US, UK and Canada can contribute to this, but the Australian context requires further consideration given the differing structure of its current health system. There have been many initiatives, seeking innovative solutions which have been adopted at the state, federal, health authority and individual professional group levels. All these developments in their own right are important and offer potential to help with workforce shortages and service delivery issues. However, there is no overarching framework or systems approach to address the fundamental issue which Australia is facing. If the principal objectives relate to a recognition of patient needs and preservation of high quality clinical care as the core driver then, a systems approach needs to consider: Improved linkages between health services planning, workforce planning and evolving models of care. Training systems and structures and how they complement the service delivery system. Considering traditional professional roles 99 and to direct strategic workforce planning toward new ways of working, which would challenge many traditional assumptions about work patterns and the organisation and performance of core clinical tasks. Building a repository of knowledge regarding initiatives and strategies, benefits and risks that jurisdictions, professional groups and other related stakeholders have already benefited from in terms of address workforce shortages. 97 Task substitution: the view of the Australian Medical Association, The Medical Journal of Australia, Choong-Siew Yong, MJA 2006;185 (1) 98 APHA Annual Congress, Professor Kim Walker, Professor of Nursing, St Vincent's Private Hospital Sydney, Presentation on Workforce Issues, 27 October 2008. 99 Losing patience, Sydney Morning Herald, Ruth Pollard. 30 August 2005 National Health Workforce Taskforce - 6 May 2009 64

Glossary ABS AIHW AMWAC APHCRI COAG DALY DEEWR DOHA FTE GMP GP NHS OECD OHP RANZCR VMO Australian Bureau for Statistics Australian Institute of Health and Welfare Australian Medical Workforce Advisory Committee Australian Primary Health Care Research Institute Council of Australian Governments Disability Adjusted Life Years Department for Education, Employment and Workplace Relations Department of Health and Ageing Full Time Equivalent Graduate Medical Program General Practitioner National Health Service Organisation for Economic Cooperation and Development Other health professionals Royal Australian and New Zealand College of Radiologists Visiting Medical Officer National Health Workforce Taskforce - 6 May 2009 65

A Clinical training placement calculation The estimated clinical training requirements by days and hours per professional category and year of course are set out in the following tables. Medicine 2005 2006 2007 2008 2009 2010 2011 2012 2013 1 st year 1,871 2,071 2,560 2,943 2,831 3,074 3,074 3,074 3,074 2 nd year 1,770 1,871 2,071 2,560 2,943 2,831 3,074 3,074 3,074 3 rd year 1,511 1,700 1,871 2,071 2,560 2,943 2,831 3,074 3,074 4 th year 1,470 1,511 1,700 1,871 2,071 2,560 2,943 2,831 3,074 Total Students 6,622 7,153 8,202 9,445 10,405 11,408 11,922 12,053 12,296 Days per year 1 st year 65,953 73,003 90,240 103,741 99,793 108,359 108,359 108,359 108,359 2 nd year 62,393 65,953 73,003 90,240 103,741 99,793 108,359 108,359 108,359 3 rd year 259,703 292,188 321,578 355,953 440,000 505,828 486,578 528,344 528,344 4 th year 252,656 259,703 292,188 321,578 355,953 440,000 505,828 486,578 528,344 Total 640,705 690,846 777,008 871,512 999,487 1,153,979 1,209,123 1,231,639 1,273,405 Nursing 2005 2006 2007 2008 2009 2010 2011 2012 2013 1 st year 9,675 10,246 11,093 11,298 12,395 13,895 13,895 13,895 13,895 2 nd year 9,265 9,675 10,246 11,093 11,298 12,395 13,895 13,895 13,895 3 rd year 8,541 9,265 9,675 10,246 11,093 11,298 12,395 13,895 13,895 Total 27,481 29,186 31,014 32,637 34,786 37,588 40,185 41,685 41,685 Days per year 1 st year 241,875 256,150 277,325 282,450 309,875 347,375 347,375 347,375 347,375 2 nd year 347,438 362,813 384,225 415,988 423,675 464,813 521,063 521,063 521,063 3 rd year 533,813 579,063 604,688 640,375 693,313 706,125 774,688 868,438 868,438 Total 1,123,125 1,198,025 1,266,238 1,338,813 1,426,863 1,518,313 1,643,125 1,736,875 1,736,875 Allied Health 2005 2006 2007 2008 2009 2010 2011 2012 2013 1 st y ear 5792 5919 6494 6494 6494 6494 6494 6494 6494 2 nd year 5919 5792 5919 6494 6494 6494 6494 6494 6494 3 rd year 5792 5919 5792 5919 6494 6494 6494 6494 6494 Total Students 17503 17630 18205 18907 19482 19482 19482 19482 19482 Days per year 1 st year 144,800 147,975 162,350 162,350 162,350 162,350 162,350 162,350 162,350 2 nd year 221,963 217,200 221,963 243,525 243,525 243,525 243,525 243,525 243,525 3 rd year 362,000 369,938 362,000 369,938 405,875 405,875 405,875 405,875 405,875 Total 728,763 735,113 746,313 775,813 811,750 811,750 811,750 811,750 811,750 National Health Workforce Taskforce - 6 May 2009 66

Explanatory notes for estimating clinical placements days The numbers of total clinical training hours by course and by year in each course are not nationally available for nursing, medicine and the allied health professions. The NHWT has sought information to confirm clinical training requirements through an initial request of jurisdictions, specific information from education providers through Universities Australia, public information about relevant courses and advice from accreditation bodies. Not only are the accreditation standards for clinical training in many cases not specific, where information is available on clinical training hours for courses, there is a significant variation across all universities in the actual hours required for each course. Given this large variation, the gaps in the information available and, as it is impossible to project which individual university might deliver any additional places, the NHWT has derived clinical training hours per year per course through an averaging process or, where possible, drawn on actual figures as provided. In some instances, an individual university has been used as a sample education provider and starting point. All figures therefore are notional. The calculation for the training requirements has been estimated in training hours and rounded up to training days. It is acknowledged that there is no standard training day; however, for this exercise, clinical training hours have been averaged as seven hours per day across all health professions to produce an equivalent, except for medicine which is calculated as an eight hour day. The calculation of clinical training requirements for each health profession has been limited in its accuracy and possible relevance given the lack of specific or standardised information. For some professions, the clinical training requirement is clearly and precisely stated in quantum and timing, whereas for others, it is competency based and/or may be left unspecified in its timing. Where the information is not comprehensive or detailed, individual university courses have been used to assume a starting point for calculation. For some health professions, there are a range of courses of variable duration. Detail as to how clinical training requirements for each professional group have been derived is provided below. Medicine The AMC describes the clinical training required for medical education as follows (Assessment and Accreditation of Medical Schools: Standards and Procedures, AMC, Canberra 2002 and revised accreditation standards which were in effect as of 1 January 2007): Standard 3.2 Clinical sciences and skills is an essential component of any curriculum, and a significant period of time is devoted to students personal contact with patients. This would normally entail the equivalent of at least two years spent primarily in direct contact with patients, as well as personal contact with patients during other parts of the course. The above standard has been calculated as 2,880 hours at four or more weeks in duration. This was computed based on 40 hours x 9 weeks/rotation x 4 week/rotations x 2 years (Human Capital Alliance for Victorian Department of Human Services, Accreditation requirements for clinical placements, July 2005). Medical Deans, through the MTRP Clinical Training Sub committee, have undertaken a project to gather data on clinical education and training requirements. The Draft Report of Medical National Health Workforce Taskforce - 6 May 2009 67

Deans does not identify the total number of hours required per year of a medicine course. The Medical Deans Report found that clinical training in the early years is often conducted in groups and sessions are of a short duration and that full-time clinical rotations are normally undertaken during the final two years of medical programs. The length of rotations varies between schools and disciplines, usually four, six or eight weeks. Further information is required in order to develop sound averages of clinical training hours required per year of a medicine course. The information available does indicate that (as identified in the Medical Deans Report) full time clinical rotations are usually undertaken during the final two years of a course. Some clinical training is undertaken during earlier years of a course. The average has been calculated using as four year course by taking an average of the total hours required by those courses where data was available. Further, the average split of those hours per year of course has been calculated on a national basis. Registered nurses The numbers of total clinical training hours by course and by years in each course are not nationally available for nursing. Contact was made with jurisdictions and with some registration boards to seek advice on the average number of total hours in each jurisdiction and by institution where that was possible. The approach used was to average the clinical training requirements for nursing across the three years on a 20/30/50 percent distribution given that advice supported the weighting towards the later years of training. Where an actual total of clinical training hours were provided and no distribution across the years of the course, this split was applied. Dentists There are national standards governing the clinical training requirements for each of these roles. Generally, there is minor placement time in the first two years with the final two or three years being heavily weighted towards undertaking clinical training hours. This is represented as an average amount as some universities measure through a points system and others reflect blocks. An approximate distribution commencing in second year is 12/12/26/50 percent with the majority being undertaken in the fourth and fifth years. Podiatrists The national standard is understood to be 1,000 hours over the life of a course and, based on advice from universities, this is applied across the second, third and fourth years of the course. Pharmacists The specifications for pharmacists vary across Australia however the trend appears to be that the majority of the relevant clinical training occurs in the final two years of the course, represented as 40/60 percent distribution across these two years. Physiotherapists There appears to be no national specification for registration and the breakdown of clinical training hours across the life of the course has been based on one university. Consistent with other allied health professions, the majority of the clinical training requirement appears to occur in the final two years of the course. National Health Workforce Taskforce - 6 May 2009 68

Occupational Therapists The national minimum standard of 1000 clinical training hours has been averaged as 15/15/30/40 percent distribution across the four years. Speech Pathologists The majority of clinical training is undertaken in the latter years with some focus occurring in the second year with the significant quantum being undertaken in the fourth year. Dieticians The national standard for professional practice or clinical training requirement is estimated to be 700 hours which is undertaken primarily in the final two years of a course. This is averaged as 350 hours per year. Social Workers This profession specifies 980 clinical training hours are required and these are generally undertaken in the final two years of the course, with the majority occurring in the final year. National Health Workforce Taskforce - 6 May 2009 69

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