Does 'unleashing the potential for the health workforce' lead to efficiency, effectiveness or anarchy? 

The federal Health Minister the Hon Mark Butler has announced a review designed to “unleash the potential for our health workforce”.

The Unleashing the Potential of our Health Workforce Review will be led by Professor Mark Cormack and will looking at optimising Australia’s “health workforce across a stretched primary care [sector, to] improve health access and equity across all communities” (here).

The review was recommended by the Strengthening Medicare Taskforce.

The use of the word “unleashing” is an interesting way to frame the problem of plummeting general practice capacity (as outlined by Deloitte here).

The idea of “unleashing” tends to evoke images of dog parks, with all their chaos, unpredictability and threat, which isn’t exactly a pleasant metaphor for health professionals. So why is it being used?

Who applied the “leash” in the first place?

The argument for nurses, allied health professionals and pharmacists extending the range of clinical activities they are able to do relies on two key ideas: that they will be working “at the top of their scope” because they are already “highly trained professionals” and that any objections to their extended roles is simply a protectionist attempt by patriarchal medicine to restrict access to lucrative activities in the health care landscape. In other words, medical guilds are merely protecting their turf (as was claimed in this news article). The Australian Nursing and Midwifery Federation has said that nurses and midwives should be supported to work to the full extent of their skills and training, stating that “Nurses and midwives, who comprise the majority of the healthcare workforce, have the capacity, expertise, and education to vastly improve health equity and access for people living in all areas of Australia.”

The idea is that there is a vast landscape of fully qualified health professionals ready, willing and able to undertake the work that GPs do, if only the “leashes” applied by the medical guilds could be removed and we could allow them to do their jobs. Indeed, I believe the capacities of nurses have been underutilised and their expertise has not been respected the way it should have been. In recent years, there has been a strong push by the professional guilds to correct that discrimination, particularly in nursing and pharmacy. The assumption is that if regulations could be relaxed, the workforce crisis could be solved.

It is an interesting argument that breaks down on close inspection. Firstly, some of the activities that are proposed are clearly beyond the “top of scope”. There would be no additional training required for pharmacists to prescribe if that skill was already within their scope. The trials in several states enabling pharmacists to prescribe antibiotics for women with symptoms consistent with urinary tract infection (UTI) are expanding, despite concerns from the Australian Commission on Safety and Quality in Health Care. In North Queensland, the National Aboriginal Community Controlled Health Organisation (NACCHO) withdrew from the Steering Group over concerns that the trial placed Aboriginal and Torres Strait Islander communities at risk. “Our communities deserve the highest quality care,” wrote Dr Jason King, Gurriny Yealamucka Health Services Aboriginal Corporation senior medical officer. “The pilot project fragments health care for some of the most vulnerable. It undermines the decades of work the ACCHO sector has done to bring us closer to closing the gap in health amongst Aboriginal and Torres Strait Islanders.” In this case, the pharmacy trial was unleashed on the community without their consent — a worrying precedent.

Secondly, there are workforce shortages in many disciplines, including nursing, so shuffling them around doesn’t fix the problem. Thirdly, there is some evidence from the United Kingdom that although multidisciplinary teams are popular and effective for single-disease integrated care, they have less evidence of benefit in a GP setting, particularly if their focus is on diagnosis and not just management. In Scotland, multidisciplinary teams did not decrease GP workload or increase GP capacity.

General practice is inherently challenging and complicated. Patients do not announce complexity on the way in the door, so any patient with an undifferentiated illness could need urgent life-saving treatment or just simple reassurance. Meningitis and a common cold can look frighteningly similar in a sick child. It is a surprisingly difficult task to distinguish the patient with serious disease among the clutter of ill-health.

It is this inherent uncertainty that makes primary care the most difficult part of the system to organise and regulate. There is no evidence-based protocol for undifferentiated illness, so it is difficult to measure the value of the work or its outcomes. GPs are obviously not infallible, but our more than ten years of training make us the best trained experts in diagnostic uncertainty Australians have. A number of current initiatives, such as nurse-led clinics and pharmacy prescribing, attempt to replace the GP at the diagnosis stage. Replacing GPs with algorithms (such as the UTI pilot in pharmacy) or protocols in nurse-led clinics [SH1] means there is more chance a rare or serious diagnosis will be missed.

The challenges of diagnosis

Diagnostic uncertainty is a difficult skill to master. GPs know this as we have over a century teaching it. Unconscious incompetence is dangerous and it’s the reason supervision of GPs in training is so difficult. Assuming a less trained health professional will call in a more senior colleague when they are “stuck” is not safe. Supervisors know a GP registrar may not realise there is a problem at all, and blithely mismanage a complex issue with an inappropriate simple solution.

In hospitals, there are teams surrounding the patient, meaning there is more chance of detecting an outlier. In a nurse-led clinic or a pharmacy with no GPs, the safety net of the experts in diagnostic uncertainty is completely absent. Pharmacists, nurse practitioners and allied health practitioners often argue they don’t need medical supervision to practise “top of scope”. The hardest question is whether we will know if the standard of care drops.

Primary care is the most challenging environment in which to measure and evaluate outcomes. Many of the new models of care are evaluated with measures such as waiting times, numbers of patients seen and patient satisfaction. Although these is a valid outcome measure, they cannot be used to measure the quality of care.

In discussing the challenges of primary care outcome measurement, one team writes about how traditional outcome measurement is challenging because it assumes there is a definitive and measurable correct answer to any clinical problem. “In contrast, primary care physicians often deliver high-value care by doing the best they can with the patient care cards they are dealt, knowing that perfection will never be achieved.” In that uncertain environment, excluding the experts from care seems a very brave decision.

What are the ethics of unleashing lower trained workers so they can do higher status work?

There are also hidden ethical choices in the argument for unleashing primary care professionals. Most patients will be diagnosed and treated appropriately if algorithms are used. However, algorithmic health care can increase inequity and outliers can be harmed. Are we happy, as a community, to accept the harm to a few to justify the benefit for many? Are we also happy to see the average training of a primary care health professional drop so precipitously?

There are other less obvious ethical concerns. We cannot consider power, status and the funding of health workforce without taking into account past injustice to women health workers, particularly nurses. Part of the reasoning behind nurse-led clinics and nurse practitioner roles must be to remove the legacy of nurses being classified as “handmaidens”. It is understandable that highly trained professionals resent this understanding of their role and want to increase their autonomy and agency. However, past injustice towards nurses, in particular, can make appropriate debate about the governance of primary care challenging. It is easy to case genuine clinical concern by doctors as a “turf war” that disrespects the expertise of other craft groups.

The paediatricians who suggested leashing Lucy Letby should have had their legitimate concerns heard, rather than being accused of bullying and intimidation themselves. We should not be correcting for past inequity by simply shifting power from one guild to another.

Are we using “leashes” from medical guilds to “protect our turf”?

Guilds are old institutions, that were designed to control the market by regulating access to knowledge, training, certification and even equipment. Guilds regulated fees and created environments of scarcity that drove up prices by creating a competitive market. Famously the accoucheurs of the 16th century hid their forceps in an elaborate box, and delivered babies in a locked room to protect their discovery from others who may take away their market advantage.

Medicine has had powerful guilds since medieval times and have always been accused of protecting their turf. However, over time, medical autonomy has eroded, particularly in general practice. Legitimate concerns about public safety should not be confused with attempts to “leash” our multidisciplinary colleagues.

GPs are crippled by over-governance. Our numbers in training are regulated by governments, rebates by Medicare, and our curriculum by the Australian Medical Council. The Medicare Benefits Schedule and the Pharmaceutical Benefits Scheme regulate what subsidised investigations we can perform and the drugs we can prescribe. GPs can no longer make a diagnosis on a disability support pension form, or organise a subsidy for a patient’s insulin equipment (but nurses can).

GPs face the carrots of subsidies and the sticks of audit threats, nudging us towards the preferred behaviours the federal government would like to see. Governments harvest our data, scrutinise our practice and restrict our scope of practice. The appropriate balance of the rights and responsibilities of all health workers is an ethical question that should not be answered by a professional guild alone. However, loss of autonomy can also cause harm.

I believe that while other primary health professionals may be gaining autonomy, GPs are choking on the leashes of over-governance. Costs of over-governance include the untimely deaths of doctors under investigation by AHPRA and attrition of the workforce due to moral distress. It has also meant the emptying of rural obstetric facilities of their GP obstetricians.

Do all health professionals need a “leash” to keep the public safe?

In 2004, Samanta wrote that “somehow, a balance must be struck whereby the public can be confident that doctors practise competently, with due regard to ethical and technical standards, yet the regulations are not so overwhelming as to represent a sword of Damocles permanently hanging over doctors’ heads.”

I would argue that we may be losing the safety net of governance, by granting autonomy to the powerful guilds who gain significant benefits from being “unleashed”. Unleashing health professionals has sometimes gone very badly, which is why AHPRA have re-leashed the cosmetic surgeons.

GPs are leaving because they can’t survive the choke collars around their own necks. Before we unleash the lot, I think it is time to consider what an appropriate governance system might look like that balances autonomy and agency, and apply it to everyone working in primary care, regardless of the discipline. Otherwise, we create a free-for-all system with little accountability, and that is health system anarchy. Australians deserve better.

Dr Louise Stone is a Canberra GP with clinical, research, teaching and policy expertise in mental health. She is Associate Professor in the Social Foundations of Medicine group, Australian National University Medical School.