On-off doctor supply no real answer
MAJOR changes occurring in the medical workforce have serious implications for the future provision of health care in Australia. Over 50 per cent of medical graduates are now women; the generation of ‘‘ baby boomers’’ is approaching retirement, and many young doctors don’t want to run a business — they just want to be a doctor. This will reduce the size and availability of the medical workforce at a time when demand is increasing. Medical workforce shortages are most acute in remote and rural areas.
Although these trends are known, doctor shortages and surpluses always, in many countries, seem to creep up without anyone noticing. Imbalances arrive by stealth, and when it is finally apparent that a shortage exists, it is usually too late to fix it quickly. Since health professional labour markets are very inflexible, they cannot respond in the short term as it takes around 10-15 years to train a doctor.
The people who ultimately lose are patients, who face rising co-payments and reduced access to health care. Doctors themselves also lose out as workloads increase and job satisfaction falls. This can impact on quality of care as doctors have less time to spend with each patient, and is also likely to exacerbate the shortage as overworked and stressed doctors reduce their hours of work further, take time out, and even leave medicine as medicine becomes a less attractive career.
What usually follows is an example of reactive policy making that does not solve the problem and may make it worse. First, there is a rush to implement increased fee rebates to doctors to increase the bulk-billing rate. This can be costly and its effects uncertain.
Second, a relatively easy way for politicians to be seen to address the health workforce crisis is to announce more funded training places for doctors and/or fund new medical schools. For example, in response to the current shortage that began to emerge from about 2001, seven new medical schools have been established across Australia and existing medical schools have increased the number of places offered. There was also a raft of ‘‘ tinkering with Medicare’’ initiatives to try and increase the bulk-billing rate, and reviews and fee reform to reduce administrative workloads of GPs. Although the bulk-billing rate has since increased, we do not know what caused this.
The major problem is that this kind of politically driven policy gives rise to, and may exacerbate, long-term cycles of shortages and surpluses that are not matched to patient needs for health care. Both economists and meteorologists know how difficult it is to predict the future, and cycles of large increases (or reductions) in doctor numbers every 15 years can have potentially damaging effects. In 10-15 years time there will be a tsunami of doctors rather than a shortage, and this will prompt the education and training cycle to start again with reductions in medical school places. Too many doctors can lead to potential problems of overservicing and increases in healthcare costs.
Perhaps a constant expansion of graduate numbers that matches annual GDP growth may be more sensible for reducing these potentially damaging cycles, but this is unlikely to be a short-term vote winner.
To stop the reactive policy responses to doctor shortages and surpluses requires a much more evidence-based approach to medical workforce policy. One of the major and persistent barriers to developing effective policies to support the medical and health workforce is a lack of evidence about what works and what does not work. Current government data collections are driven by the need to count health professionals, rather than the need to understand and support the medical workforce.
There is very little research about why doctors are reducing the hours they work in the face of increasing demand, or about how to solve the shortage of doctors in rural and outer-urban areas or in less affluent areas. Are doctors happy at work, or is morale falling? How does this influence patient care and doctors’ working patterns? What factors influence morale and job satisfaction?
Such research needs to be longitudinal so we can measure changes over time, and understand what is happening why. Only this way can effective policies be designed to support the medical and health workforce. Otherwise, the constant reactive and ‘‘ muddling through’’ approach to health workforce policy will continue to solve nothing, and may in fact exacerbate longer term cycles of shortages and surpluses.
Despite its political attractiveness, it is clear that health workforce shortages cannot be solved in the long term by increasing doctor numbers alone. The solution lies in a much broader re-alignment of the incentives and structure of the healthcare system in which doctors practise and showing how this can be changed to improve population health, whilst maintaining and improving work satisfaction, morale, recruitment and retention amongst doctors and other health professionals. Professor Tony Scott, of the University of Melbourne, is lead investigator on the MABEL (Medicine in Australia: Balancing Employment and Life) longitudinal survey of doctors funded by the National Health and Medical Research Council.