On-off doc­tor sup­ply no real an­swer

The Weekend Australian - Travel - - Health -

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.

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