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.