12th Greek Australian Legal and Medical Conference
Samos, Greece 2009

“WHERE HAVE ALL THE HEALTH WORKERS GONE?” – FUTURE PROOFING A GLOBAL HEALTH WORKFORCE

James A Angus
Dean Faculty of Medicine, Dentistry and Heath Sciences
The University of Melbourne

Health Workforce and the Economy:

The health workforce is defined by the world Health Organisation as ‘Health Service’ providers that can be divided into the clinical provision of health by doctors, nurses, midwives etc and by the organisational infrastructure provided by health managers and support professions.

Whenever a crisis calls for clinical professionals, they are paralysed or severely hamstrung in their effectiveness unless the managerial professionals are on hand. This recognition of the partnership of the expertise of the health professional carers and health managers in the health workforce team is now essential in capacity building to deliver the benefit appropriate for the investment.

The health workforce is estimated to be 59 million health workers worldwide but the countries in most need have the least. The world health report noted that we were 4.3 million health workers short and most of these were in Sub-Saharan Africa. (1) In economic terms, USA spends 16% of their gross domestic product GDP on health care, yet of their 300 million population, 45 million have little or no access to health care. In Australia we spend 9.3% of GDP on health care and aged care and it is growing at 0.5% per annum.(2) The prediction is that by 2020, Western economies will be spending up to 20% of their GDP on health.

Causes of Health Workforce Shortage:

Why in 2009 is there such a health workforce shortage? First, declining fertility rates in many first world economies cause these countries to ‘backfill’ their declining youth from migrants. For example, in Korea the average is 1.1 children per couple, Japan, Italy and Germany 1.3, UK and Australia 1.8, and for New Zealand and USA 2.1 (3). Second, ageing first world populations with higher consumer expectation has increased the level of demand. Third, workforce maldistribution such as rural and remote communities struggle to attract adequate numbers of health workers, and in some countries, out migration such as in New Zealand, adds to an increasing workforce undersupply.

In Australia, State Governments nominated 2,739 medical migrants in 2003 in the ‘area of need’ category, while in 2008 this had grown to 6,500 per year. This scale of medical migration to Australia for physicians over 5 years (2001-6) was 7,596 mostly from India, UK/Ireland, Bangladesh, China and South Africa. Of these migrant physicians, 61-75% were in secure medical employment within 5 years of migrating to Australia. (4)

Australia has also responded by increasing its International Student enrolments in medical schools from 963 in 1996 to 2,304 in 2007, while nursing has grown from 762 to 4546 enrolments for basic courses.

Given the demand for migrant health workers by first world economies, it follows that young people will choose to migrate to move from disadvantaged countries, from rural to an urban lifestyle, seek a secure environment with stable law and order, quality healthcare, employment, and living conditions especially driven by opportunities in education and careers. A recent survey of overseas trained general practitioners in regional Victoria showed that International Medical Graduates (IMGs) were hypermobile i.e. moving from India to Dubai, to South Africa then to New Zealand, Queensland and finally Victoria. Indeed 60% of IMGs had five or more geographic moves.(5) With hypermobility, the quality of the medical training course, postgraduate experience etc, are matters of concern. At this time there are nearly 2000 known medical schools in the world and the Australian Medical Council is joining a WHO effort to develop a directory of education institutions for health professions.

The new ‘Avicenne Directories’ will be co-badged and sponsored by a collaboration of WHO and the University of Copenhagen to enable a comprehensive coverage, improved high quality detailed information and improved usability. Fields of data will include, by school, course of study, resources, quality assurance and contact details – useful for students, teachers, regulators or employing health authority (see http://avicenne.ku.dk).

There is real substance to optimism in health care given the revolution in ‘personalised medicine’ especially in the evolving field of cancer diagnosis and treatment, new technologies and advances in basic science. However, these opportunities to compress the years of morbidity to late in life are threatened by: i) the growing epidemic in obesity and diabetes; ii) the ‘worried-well’ demanding resource-intensive attention and in Australia; iii) the major gap in health care leading to 15-20 years shorter life span in Indigenous Australians compared to white Australia. Other factors affecting the undersupply of health workers relate to feminisation of Medical School intakes (now > 60%) and family work-life balance, practice safety (both limitations to scope of practice and hours on duty), unionism, graduation indebtedness, emigration and demographic attractiveness (or not) of rural, remote and outer metropolitan locations.

In a recent survey of doctors entitled “Medicine in Australia: balancing employment and life of 10,512 doctors including general practitioners, specialists, specialist trainees and hospital doctors, 47-56% wanted to reduce their working hours and 25% of all doctors were very or moderately dissatisfied with their hours of work. A total of 5,000 doctors mostly over 55 years old (12% GP, 13% Specialists) intended to retire in the next 5 years. This survey sharpens the focus on workforce training to ensure Australia has an appropriate and satisfied health workforce trained and willing to meet the demands of modern health care.(6)

Health Workforce -
The Medical School in the Australian Context:

First degree medical training provided by eighteen Medical Schools in Australia produces graduates ready, safe and competent for intern training and a broad range of medical careers.

Much debate surrounds the possible ‘streaming’ through medical school especially by ‘elective’ choice to allow the graduate some standing or recognition in a Specialist College training course. Given the long course of 5 or 6 years medical school from school leaver or three years plus four years for undergraduate science or biomedical science, followed by graduate entry medicine, then 3 years internship before entry into College courses makes for a prolonged program even without a period for research (PhD or MD).

The development of new Medical Schools in Australia, (Deakin, Griffith, Notre Dame (Sydney & Perth), Bond, University of Wollongong, University of Western Sydney, James Cook University, has caused pressure on recruiting suitably qualified teaching staff, building a research base and raised issues of what is the appropriate modern clinical teaching model, to include primary care physicians and simulation. State Health Departments in consort with competing Medical Schools are cooperating to distribute clinical sites appropriately.

The Commonwealth Government has led the push to double the medical training places often in outer metropolitan areas and rural settings to meet the maldistribution of training places and hopefully in the medium term to address areas of workforce need. Major capital investments for teaching spaces and student accommodation mainly in rural settings together with a large budget for staffing Departments of Rural Health and Rural Clinical Schools has occurred since 2000. Twenty five percent of a medical school cohort must spend one year training in a rural setting to be eligible for these Commonwealth grants. Despite an initial strong retaliation by medical students against rural placements, these rural settings are now highly valued as offering lifestyle change from a city life, excellent supervision and opportunity for ‘hands on’ experience compared with the competition for access as a student in metropolitan teaching hospitals. Attributes for a graduating medical student in modern medicine have the following characteristics:

A doctor entering internship should display professional, exemplary conduct, be redeployable, innovative, a physician-scientist, resilient, sceptical of evidence/data, have skills in health psychology and a leader and willing participant in care teams. The greatest shortage of doctors overall is in the ‘generalist’ category or specialist General Practitioner. Remuneration may be a driving factor in career path choice since for over 70 years the Commonwealth has funded medical units of practice not time expended. As technology advances and risk dissipates, it is a concern that the price for cataract surgery has not been reduced.

The increase in graduating medical student numbers should increase the popularity for generalist and primary care workforce numbers in rural/remote Australia. The Medical Student Outcome Database run by Medical Deans Australia and New Zealand in partnership with the Commonwealth should be a valuable data set for planning career profiles and predict workforce shortages especially required for our rural and remote communities.

New Technologies – eHealth Record:

The most exciting step change in health care delivery and safety should be achieved with the development of the electronic health record (eHR).

Patient-owned, anywhere, anytime access to an electronic health record will provide diagnostic data, prescribing information and a hospital discharge summary. Incorporated with this eHealth super highway would be decision-support for the attending physician or health care worker, and the potential for health surveillance of what treatments work and don’t – offering clinical trial and health economic data of immense research value for policy and clinical treatment benefit. Moreover, patient safety and quality of care efficiencies should be delivered. The easier eHealth rollout has occurred in discreet locations such as within a city where hospitals are under one governance, including community clinics as at Vanderbilt University Hospital in Nashville, Tennessee. With the scanning of paper records, digital online imaging and pathology reports, it will not be long before all records are available electronically. In Australia the take up of this technology from GPs is large, while specialists, especially in single practice environments, are slow adoptees. The major issues holding back eHR are ownership of data, rival software, lack of connectivity, and privacy/access laws. Given Australia’s vast distances, eHR on a UBS stick owned and carried by the patient would be a most useful start.

Access to expert medical advice for those most in need may well happen because of the mobile phone, satellite phone – where images and other diagnostic material could be assessed by volunteer doctors abroad with telemedicine and advice being transmitted back to the treating doctor on the ground. Recently software has been developed to scan the internet looking for words or phrases from ‘chatter’ communication that can pinpoint hot-spots or ‘rumour registering’ to alert pandemic flu outbreaks for example. So, clever internet surveillance may help to monitor the over-servicing of the rich, while providing much needed access for the poor in undeveloped countries through telemedicine and the mobile phone.

In the USA, only 20% of doctors offer eHR, compared with 100% in Denmark, where they have a sophisticated health grid. The USA forecast suggests that if 90% of USA hospitals were to adopt health information technologies, there would be a $77billion in efficiency gain and a further $77billion for health and safety outcomes, a total saving of 6% of the current $2.6trillion expenditure on health.(7) President Obama has just announced the expenditure of $19billion for eHR to create a national health information network. For our own health workforce, the establishment of an eHR network harmonised by the Commonwealth with established standards and privacy protection could add enormous benefits to safety and efficiency and to the health economy. The recent Broadband venture and our vast distances with a sparse population demand we take this opportunity. To delay will further cripple the delivery of a competent health workforce and our community will be poorly served.

New Technologies – Personalised Medicine:

The ability to sequence a patient’s total genomic DNA for less than $10,000 is becoming available. Specific gene targeted sequence data can provide rapid diagnosis especially in cancer and result in optimised targeted therapy. This ‘personalised’ medicine can help in the diagnosis of single amino acid defects in ion channel gating mechanisms causing epilepsy. In patients with schizophrenia, the co-discoverer of the structure of DNA, James Watson, is collecting 3,000 patient DNA sequence data to look for common mutations that might help confirm the diagnosis of his schizophrenic son. The explosion of the ‘omics’ revolution from genomics to proteomics to metabolomics will provide the scientific basis for diagnosis and treatment. But what about the promises for today’s patient?

Has the promise been oversold and under delivered? If you know the information, what can or should you do? How will insurance companies react, your employers, your family? One example is that at the Mass General Hospital in March 2009, where all patients admitted with a tumour were screened for 110 point mutations in 13 cancer related genes. This high speed sequencing was essential to optimise target therapy. But the aberrant genetic signature may or may not generate the tumour protein. How this protein is metabolised is also an essential piece of the equation. So, the world turns; science advances, translation into patient diagnosis and therapy becomes key through clinical trial and evaluation.

Values and Behaviours:

In my view a global health workforce is influenced by both external forces such as the large ‘ethical’ Pharmaceutical Industry and internal forces such as the innate behaviour and values of the individual doctor and managers of health care. What is the report card today in this arena?

First, the Pharmaceutical Industry. I would give just two recent examples of where ‘big Pharma’ have been found wanting and second an exemplary record in innovation. The US based Pharmaceutical Company Merck had an exemplary record in ethical behaviour in providing the world with ethical, block buster drugs with proven safe and effective records. I would remind the reader of the Ivermectin Story, where Merck developed and paid for the most effective treatment for ‘river blindness’ in Africa – for communities stricken with this tiny worm that destroys the sight in young adulthood – but these communities had no ability to pay.

Merck gave the drug away for free – against the best economic principles of business-practice-and the Merck share price rose. You can imagine then when Merck’s Vioxx, a trade name for an effective anti-inflammatory drug, was found to be causing cardiac infarction and death, yet the company went, apparently, to extraordinary lengths to suppress the side-effects data and continue to reap large profits. In a recent class action against Merck we heard evidence of the very dark side of ‘the business’ – ghost writers of scientific papers supporting evidence of safety, we heard of the company suppressing clinical reports of unsavoury side effects from both the doctors prescribing the drug and the regulatory authority – the US Federal Drug Administration (FDA). This ‘business’ and profit-driven motive at any cost must not prevail for medicines – the separation of best ‘business’ practice for consumer goods from medicines must be rigorously championed. The community, the patients, the governments and insurance companies paying for these treatments must demand the highest ethical standards of marketing, pricing and surveillance of side effects.

Second Glaxo Smith Kline (GSK) has recently announced a 4 step approach to help the world’s 50 poorest countries. First, 20% of profit from the sale of medicines in the least developed countries (LDC) will be invested in local technical expertise such as Universities, local partnership companies, or the public sector. Second, small molecules, IP, or process of manufacturing patents for neglected tropical diseases will be made available for the LDC patent pool enabling development of medicines utilising known intellectual property. Third, the maximum price of a medicine in the LDC will only be 25% of the developed world price – a significant change to allow discrimination of pricing on the ability to pay. Fourth, GSK will open its research and development facilities to partners private or public, to develop new medicines for LDC country diseases such as malaria and TB.

Thus the developing world hobbled initially by their tropical disease burden could set the stage for a new paradigm of ‘Global big Pharma’ helping the third world.

I now turn to the individual professional health worker. Australian doctors can be employed under a variety of conditions such as fulltime salaried positions in a public health service, or have a part-time private practice, or have a salaried academic position with a University for teaching and research. However, one issue is, does each employer know the extent of the doctor’s earning capacity in all sectors and is there a rigorous performance accountability? What may occur if the doctor also has shares in a diagnostic service to which he refers his patients and perhaps has also an interest in his private hospital (i.e. shares). Does this ‘conflict of interest’ lead to malpractice? In the USA, a surgeon, Atui Gawande, has compared the spiralling average cost of health care in a rural town in Texas, McAllan, with other towns in the USA, with half the per capita cost.

His analysis points not to the overuse of expensive technology, quality of care or other usual culprits but simply overuses of medicine across the board driven largely by the “culture of money”, in various forms, “profit-centres”, ‘churn’, ‘kickbacks’, ‘business of high versus low margin work’.

His article entitled ‘The Cost Conundrum’ (8) leads to the compelling idea that the professional doctor must separate the clinical decision making process and disinterested cost-benefit analysis from personal remuneration. This goes to the crux of the professionalism of the individual – their integrity and being able to manage this conflict of interest. This, in my view, is not envy of highly paid individuals – it is simply getting a handle on transparency of health service provision and a better undertaking of health costs.

Stop Press:

The National Health Workforce Taskforce has just released a detailed analysis of Australia’s Health Professional entry requirements from 2009-2025. The report uses the current policy framework and supply of health workers to “predict future service provision”. For each of 14 health professions, variables such as a feminisation of the workforce, hours worked, population growth and ageing, hospital separations etc were set. For Medicine, international migration rate was set at 1500 per annum. The modelling showed that to achieve a balance of supply and demand by 2025, Australia needs to graduate an extra 356 doctors per annum, an extra 5,319 registered nurses and 80 dentists. In allied health, 808 physiotherapists, 1323 social workers, 1357 psychologists, 1412 ambulance paramedics would be required as an increase each year. For medicine this means two new Medical Schools opening per year for the next 15 years! Again, the model of training needs to change and the academic workforce enlarged. These figures are a ‘call to arms’ for Governments and the wider community to properly plan and replan our strategy in delivering a quality sustainable health workforce over the next 15 years. It will require bold and bipartisan decision making, an end to the Commonwealth/State divide, cost shifting and ‘blame game’ and still unfortunately rely on employing overseas trained doctors to make up 25% of our medical workforce.

References:

  1. The World Health Organisation. Working together for health. WHO World Health Workforce Report Geneva : WHO, 2006
  2. The Australian Institute of Health and Welfare, Australian Health 2006, Canberra : AIHW, 2006, P.315.
  3. Global Fertility Rates : OECD 2007 “Health at a glance”
  4. Australian Government, department of Immigration, Multicultural and Indigenous Affairs.
  5. Hawthorne L., Birrell B., Young D., Factors influencing the retention of overseas trained general practitioners in regional Victoria. Rural Workforce Agency Victoria, Melbourne, 2003.
  6. Scott T., Medicine in Australia : Balancing employment and life. No.1, May 2009. www.mabel.org.au
  7. Vaitheeswaran V., Medicine goes digital, The Economist , special report 18 April 2009, P 3-16.
  8. Gawande A., The Cost Conundrum : What a Texas town can tell us about health care. The New Yorker, 1 June 2009, P 1-8.

Acknowledgement:

I thank Professor Lesleyanne Hawthorne for much material and discussions.

I thank Rita Costas for secretarial assistance.