Restrictive work practices in health

Mike Steketee in today's Australian analyses succinctly one of the major weaknesses of our health system:

In the days before labour market deregulation, unions would go on strike over a shearer being asked to pick up a fleece or a plumber asked to disconnect a piece of wiring. These days it is the Australian Medical Association that defends with religious fervour the exclusive right of doctors to issue prescriptions and to make or at least supervise any number of procedures that a junior nurse can perform. Even in remote areas where there seldom is a doctor in sight, woe betide any other health professional who suggests taking over some of their duties.

Health Minister Nicola Roxon wants to do something about a situation that discriminates not only against highly qualified nurses but also other allied health professionals such as physiotherapists, psychologists, dieticians, podiatrists and diabetes educators. It could be one of the most significant of the many health reforms on her plate, if she can carry it off.

Australia's health system compares favourably with that in many other countries but this is an area in which we are way behind the rest of the world. Greater workforce flexibility in health would increase efficiency and reduce costs in a sector of the economy that is looming increasingly large as medical technology advances and the population ages.

But Roxon has a fight on her hands. The AMA always has been a strong union but these days it arguably is the most powerful in the country. Most unions have suffered from a sharp decline in members, and from laws that greatly restrict their activities, including under a Labor government. But the AMA, representing a respected profession and with a tradition of articulate and very tough leaders, continues to fiercely defend the interests of its members.

In 2006, the Productivity Commission laid out in stark terms the case for reforming work practices in the health sector. It heard that the inability of physiotherapists to directly refer patients for diagnostic imaging cost taxpayers $1 million a year in 9500 hours of unnecessary GP consultations.

That is just one small example in one area of health. Physiotherapists and other allied health professionals cannot refer patients directly to specialists under Medicare: they have to go through a GP.

In the US, not generally held up as an example of world's best practice in health policy, podiatrists perform 80 per cent of foot surgery. In Australia, most of this work is carried out by orthopedic surgeons specialising in foot and ankle surgery. Although there are podiatric surgeons in Australia, they are not recognised as medical practioners, which means they cannot operate in public hospitals. Those who supply services to them, such as anaesthetists, pathologists and radiologists, cannot claim Medicare rebates for their services.

Radiographers cannot do the work of radiologists, even though the shortage of radiologists in hospitals creates problems when rapid results are needed, for instance in emergency departments. Only sonologists can prepare formal reports on ultrasound examinations, even though they often simply repeat the interpretation by sonographers. And so on.

Of course, the doctors have a justification for such restrictions. As AMA president Rosanna Capolingua argued at the National Press Club yesterday, "GPs are the pivotal gatekeepers: the people who select the services that each patient requires to get the best health outcome possible, in the most efficient and cost-effective way.

"Without appropriate medical diagnoses and supervision, patients' problems won't be dealt with properly in the first instance. Missed diagnosis, false reassurance, misdiagnosis, delay in care, all cost dollars and time and human expense." In short, see your GP or die.

Other countries, the Productivity Commission, and most Australian health experts - at least those outside the AMA - think that is a little extreme. Nurse practitioners and other allied health professionals working independently of doctors play significant roles in countries such as the US, Canada, Britain and South Korea.

The Howard government introduced Medicare rebates for practice nurses but they are not the same as nurse practitioners: they have fewer qualifications and can work only under the supervision of doctors, who are the ones who claim the payments from the Government.

Australia has just 300 of the more highly educated nurse practitioners and they are severely restricted in what they can do. Those limitations are all the harder to justify in rural and remote areas where it is hard to find a GP, let alone specialist doctors.

The Productivity Commission concluded that extending Medicare services to allied health professionals "would improve patients' access to quality care, enhance the convenience of care (and) lead to a more efficient use of the mix of skills in the workforce without compromising safety and quality".

This would mean Medicare funding a wider range of services but, to the extent that they substituted for those provided by doctors, it would save money. A study in Denmark of nurse practitioners working with elderly patients in the community found there were extensive savings.

The Productivity Commission recommended an independent committee look at the range of services covered under Medicare, together with referral and prescribing rights. Roxon announced something similar last week, despite the strident opposition of the AMA. A 13-member reference group will report by the middle of next year on, among other things, ways of "addressing the growing need for access to other health professionals".

It is yet another item on the list of Rudd reviews. If the results are not compromised out of existence, they have the potential to significantly improve the health system.

Public transport makeover promised for Adelaide

In his budget South Australia's Treasurer Kevin Foley has promised a radical overhaul of Adelaide's rail/ tram/ light rail transport system .

The Advertiser/ Adelaide Now reports:

The state's ailing public transport system has received a $2 billion injection described as the "single biggest commitment to public transport in the state's history" by Treasurer Kevin Foley. The centrepiece of the massive announcement is an extension of the Glenelg-city tramline to West Lakes, Port Adelaide and Semaphore at a cost of $162 million.

Over the next four years, $648.4 million will be spent on the first leg of the extension, the purchase of new light rail vehicles and buses, electrification of the rail network and a new ticketing system.

Speculation has been rife the Government would extend the tramline following the recently announced upgrade of AAMI Stadium.

Work will begin "immediately" on the first leg of the extension, to the Entertainment Centre, and trams are expected to be running on the new line by 2010.

A park-and-ride facility will be set up at the centre where western suburbs commuters can park their cars for a fee and commute by tram to the city.


To address capacity issues on the already overcrowded tram service, the Government has committed to buying or leasing six new or second-hand trams "immediately".

A further 15 hybrid tram-trains and 50 new electric trains will be bought and 58 diesel trains will be refurbished and converted to electric over the same period.

Mr Foley described the transport budget as a "blueprint for redeveloping our transport network that will help provide a framework for the future development of our city and state".

In the northern and southern suburbs, rail was the focus.

Electrification of the Noarlunga and Outer Harbour lines will begin at a total cost of $292 million and the start of concrete re-sleepering of the Gawler line will cost $116 million.

On the roads, an extra 80 buses will be added to the fleet over the next four years at a cost of $64.4 million.

This is in addition to the 133 replacement buses to be purchased under and $102.2 million program.

A long-awaited replacement for the more than 20-year-old Crouzet ticketing system has been promised with a commitment of $29 million to begin purchasing new machines.

For a map of the proposed changes see here.

Notwithstanding a question or two about details (eg how will standard gauge trams run on the broad gauge Port Adelaide rail track?) I'm obviously in favour of the proposals and look forward to seeing them implemented within Mr Foley's timeframe.