Workforce Plan for the Health Workforce of the ACT 2012-2017 Discussion Document

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Contents

1. Request for feedback...........................................................................32. Executive Summary.............................................................................43. Introduction..........................................................................................64. Health workforce demographics..........................................................75. National Workforce Issues...................................................................146. Additional issues impacting the ACT region.........................................187. ACT Government Health Directorate staff and program feedback......208. Recruitment & retention.......................................................................229. Feedback from other Health Services in the ACT................................2610. High Risk Professions..........................................................................3111. Informal carers and self-carers............................................................3212. What’s already happening to meet the health workforce challenge?

3313. Key Strategies for further exploration..................................................4414. Glossary...............................................................................................4815. Bibliography.........................................................................................50Attachment 1: List of Submissions received to assist preparation of the Discussion Paper.......................................................................................56Attachment 2: Achievements & Initiatives related to 2005-2010................57Workforce Plan...........................................................................................57Attachment 3: Health Directorate workforce distribution by.......................59classification June 2011.............................................................................59Attachment 4: Health Directorate workforce distribution by age range......60Attachment 5: Related ACT Government Health Directorate Service Plans and strategies...................................................................................61

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1. Request for feedback

This discussion paper collates key national and local workforce issues and considers strategies that may help to resolve or improve these issues.

The paper will be used to inform the development of the Workforce Plan for the Health Workforce of the ACT for the period 2012-2017.

It is noted that some of the suggested strategies may already be occurring in some sectors. The new workforce plan will incorporate additional current and projected health workforce data.

The Workforce Planning team would like to thank all the clinicians, and service managers who have provided input from across ACT Government organisations; non Government organisations; aged care facilities; general practice; unions; professional associations; tertiary institutions and private providers. A full list of contributors is provided in Attachment 1.

The team would also like to apologise for the delay in releasing this discussion document and advise that this relates to a significant increase in the Workforce Policy and Planning workload following the commencement of other National health workforce initiatives.

The new Workforce Plan has an expected release date of end July 2012.

Contact Details for Feedback

Please send feedback to WorkForcePlan@act.gov.au by 17 July 2012.

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2. Executive Summary

In 2005 the ACT Health Workforce Plan 2005-2010 set the direction for building a sustainable ACT Health workforce. Its purpose was to ensure that high quality health and community care services continued to be delivered to the people of the ACT and the surrounding region to the year 2010. It also aimed to provide long term workforce planning guidance under four key objectives, including:

workforce profile; responsive workforce; education and training partnerships; and effective linkages.

This Plan has contributed to a large number of successful initiatives (See Attachment 2) and provided a good foundation for the next plan; however, a new health workforce plan is now required to guide broader sustainability of our local health care system.

The main focus of the new Plan will be on health professionals and health support workers employed within ACT Government Health Directorate (Health Directorate). However, the ACT public health sector is part of a complex interrelated health system and so many of the strategies identified will also be relevant to other health sectors in the ACT.

The Australian population is ageing and the health workforce is ageing faster than the general working population. By 2050 there will be only 2.7 people of working age to support each Australian aged 65 years and over (compared to 5 working age people per aged person in 20101). Competition for labour is increasing for both undergraduate and graduate entry professions, and within the international and Australian health care labour market. The ACT’s high workforce participation rate means that skilled health workers often need to be sourced outside the Territory.

Demand for health services is increasing due to our ageing population and an increase in complexity of needs related to multiple chronic disease prevalence. It is reported that increased service demand is impacting on services to less urgent client groups and that clinicians are spending increasing time on essential administrative duties impacting on the number of services they can provide.

Increasing numbers of people are providing informal care to family members or friends, with around 2.9 million Australians providing 1.3 billion hours of informal care in 2010.2

It is reported that lack of integration/collaboration between health services is leading to inefficient practices such as duplications, gaps, multiple referrals and inconsistencies in services delivered.

1 Commonwealth of Australia: Intergenerational Report: Australia to 2050:future challenges 2010 2 Access Economics: Caring Places- Planning for aged care and dementia 2010-2050

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A gradual change in workforce skill-mix has led to a significant increase in the proportion of vocational trained workers employed in the residential aged care sector while the proportion of registered nurses (RN’s) to enrolled nurses (EN’s) in the acute sector is higher than the national average.

To address these and many other health workforce issues in the ACT, there needs to be a sustainable increase in productivity combined with a focus on improving the health of the population to reduce the long term demand for health services through prevention and early intervention measures.

A number of national initiatives are already underway to help meet current and future workforce challenges and improve and sustain health services. Local initiatives include a substantial redevelopment of health facilities in the ACT, part time nursing graduate positions, GP workforce initiatives, role extension, new support positions and innovative service changes.

Workforce planning and retention strategies must be cost effective, resilient, proactive, ethical, equitable, accountable and appropriate and provide the right service to the right person at the right time and in the right place. Consumer and population needs must provide the main driving force for workforce change.

Proposed strategies to deal with these workforce pressures include: increased collaboration between organisations; service redesign; lifting the workforce participation rate; increasing client self care options; improving care of the health workforce to reduce absenteeism; and a greater emphasis on succession planning and retention.

The ACT is collaborating with the national workforce reform program to meet the health workforce needs into the future so the proposed strategies have been based on a combination of the local input provided to this paper, the findings from the literature and national workforce reform strategies. Strategies have been aligned under the five domains for action provided in the National Health Workforce Innovation and Reform Strategic Framework for Action 2011-2015.

The aim is that these strategies will also assist other ACT based health services in identifying potential workforce planning activities.

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3. IntroductionIn 2005, the ACT Health Workforce Plan3 set the direction for building a sustainable ACT Health workforce. Its purpose was to ensure that high quality health and community care services continued to be delivered to the people of the ACT and the surrounding region to the year 2010. It also aimed to provide long term workforce planning guidance under four key objectives: workforce profile, responsive workforce, education and training partnerships and effective linkages.

The ACT Health Workforce Plan 2005-2010 has contributed to a large number of successful initiatives (See Attachment 2) and provided a good foundation for the next plan. However, a new health workforce plan is now required to guide broader sustainability of our local health care system.

The ACT public health sector is part of a complex interrelated health system, so while the main focus of the new Plan will be on health professionals and health support workers in ACT Government Health Directorate (Health Directorate -formerly known as ACT Health), this discussion document also highlights issues experienced by other health providers across the ACT and it is expected that many of the strategies identified could be applied across health sectors.

This document will be used to steer the direction of the new plan.

Greater competition for workers will be accompanied by a rising demand for health services related to an increase in total population, our ageing population and an increase in chronic diseases such as Type II Diabetes. For example, by 2014, in addition to current service levels, it is projected that 1500 extra ACT residents will require home and community care services and 200 more will require community aged care packages.4 The increasing prevalence of chronic conditions is driving the need to move a greater proportion of health workers into primary health care and is influencing the role of health workers.

Without significant changes in the way health care is delivered into the future, rising demand, combined with reduced workforce supply presents a real risk to maintaining a sustainable health system and a multi-faceted and coordinated approach will be needed. The health sector needs to find ways to increase productivity in a sustainable way but there is also a need to focus on improving the health of the population to reduce the long term demand for health services through prevention and early intervention measures.

Discussion Points:

1. Are there other issues that you believe are facing the health workforce that are not covered above?

3 ACT Health: ACT Health Workforce Plan 2005-2010 4 Access Economics: Caring Places- Planning for aged care and dementia 2010-2050

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4. Health workforce demographics

National By 2050, there will be only 2.7 people of working age to support each Australian aged 65 years and over (compared to 5 working age people per aged person in 2010).5

Approximately 3.6 percent of the employed Australian workforce works in the health sector. By 2018, there are forecast to be 409,300 Australians employed in the health care occupations with an average growth of 1.7 percent per annum.6

Between 1985 and 2005, the average age of workers in health services rose by 5.5 years; almost double the average of 2.8 years for all industries.7

In 2008, 20.6% of male and 14.6% of female health workers were aged 55 years or older and approximately one-third of health workers reported being born outside Australia. In 2008, 35% of nurses were aged 50 or older.8

75.7% of the Australian health workforce is female and 50% of females employed in health work less than 35 hours per week, compared with one-fifth of males. 9

ACT Government Health Directorate WorkforceThe 5898 employees of Health Directorate make up approximately 27.5% of ACT Public Service employees.10 The average worker is 42.2 years old, and is female, has worked for Health Directorate for 7 years, and works full time in a permanent position.11 The average Health Directorate staff member takes 11 days of personal leave per annum as compared to an average of 9.6 days taken across the ACT Government (see Attachment 3).

Almost 30% of the Health Directorate workforce are aged 50 or older and 15.6% are aged over 55 (see Attachment 4). The average retirement age in Health Directorate is 61 for males and 59 for females and 7.4% of employees permanently separate from Health Directorate each year.10

15.4% of Health Directorate employees have a first language other than English, 0.6% identify as Aboriginal or Torres Strait Islander and 1.8% have a disability.10.

For the purposes of this document Health Directorate workers have been grouped into 8 classifications (ordered by number of employees): Nurses, Administration, Allied Health (including Dental), Medical Officers, Support services, Technical, Miscellaneous professionals and Executives.

5 Commonwealth of Australia: Intergenerational Report: Australia to 2050:future challenges 2010 6 NHWT: Health Workforce in Australia and factors for current shortages 2009 7 Parliament of Australia; Australia’s Ageing Workforce 2005 8 AIHW: Nursing & Midwifery workforce 20089 AIHW: Health and community services labour force 2006 (Published 2009)10 ACT Government: ACT Public Service Workforce Profile 2009-201011 ACT Government Health Directorate Workforce reporting data derived from Chris 21, June 2011

(attachment 4)

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Medical Workforce The medical workforce includes medical officers, post graduate fellows, registrars, specialists and senior specialists. In ACT Government Health Directorate, there are 720 Doctors filling 621 full time equivalent resident positions. 57% are male. Doctors have the youngest average age of any classification (39 years). Only 15% work part time and only 30% are permanent employees. The average length of tenure for doctors in the Health Directorate is 4 years.12

There was a 10% increase in medical practitioners in Australia between 2001 and 2006.13 The demographics of junior doctors have changed significantly over the last 20 years. This has been influenced by increasing feminisation, a move to graduate entry and the entry of Generation Y Doctors to the workforce. In a 2007 Australian Medical Association (AMA) work-life flexibility survey, 85% of respondents indicated that they would need some form of flexible working and training arrangement over the following 10 years and it was noted that hospitals with the most family and employee friendly arrangements will increasingly become employers of choice.14 The ACT Government Health Directorate reports increasing requests from doctors for part time employment and 5% of resident medical officers and registrars are currently working part time.

In 2010, the ANU Medical school had 355 Medical students spread across 4 years15 and by 2014, graduating doctor numbers will have increased by 132% compared to 2006.16 The increase in medical student intake requires increasing numbers of clinical placements and these placements require supervision.

Discussion Points:

1. Are there other matters relating to the medical workforce that you believe could account for these figures?

Nursing & Midwifery WorkforceThe nursing and midwifery workforce includes enrolled nurses, registered nurses, registered midwives and nurse practitioners. The nursing and midwifery workforce is the largest group of employees in the ACT Government Health Directorate, comprising 40% of the Health Directorate workforce with 2363 individuals covering full time equivalent 2009 positions. This group has the highest percentage of female employees with 90% being female. They also have the highest percentage of part time workers with 44% working part time and the highest number of workers in permanent positions (86%). The average length of tenure for nurses and midwives in the ACT Government Health Directorate is 7.77 years. 8.8% of the nursing and midwifery workforce permanently separate from ACT Government services each year.17

12 ACT Government Health Directorate Workforce reporting data derived from Chris 21, June 2011 (attachment 4)13 AIHW Health Workforce: accessed 10/05/201114 AMA: Work-Life flexibility Survey report of findings 200715 Medical Deans Australia & New Zealand: 2010 Medical Students Statistics16 Medical Deans Australia & New Zealand: Media Release: Keep Medical Student Numbers on hold 13th April 201017 ACT Government Health Directorate Workforce reporting data derived from Chris 21, June 2011

(attachment 4)

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The ACT has a higher ratio of RN’s to EN’s than the national average. In 2007 the national ratio of RNs to ENs was 4.26:1 while the ACT ratio was 5.25:1. Victoria and South Australia have ratios of 3.16:1 which suggests that there is potential to employ higher percentages of diploma level ENs in the ACT workforce and use nursing workforce skills more cost effectively.18

The University of Canberra has approximately 340 Bachelor of Nursing students and 80 Bachelor of Midwifery students enrolled across three years.19 Registered nurses are also trained at the Australian Catholic University and enrolled nurses are trained at Canberra Institute of Technology.

Between 1991 and 2008 the number of Australian nursing workers declined from 1415 to 1115 per 10,000 population. Employment of personal carers and nursing assistants grew by around six per cent per annum and the ratio of registered nurses to enrolled nurses also grew. There was a 16.3% increase in registered nurses and 0.5% decrease in enrolled nurses between 2001 and 2006.20

By 2008, for every RN under 35 years of age there were two RNs over the age of 50, part time work had increased in popularity, there was an increasing trend to specialisation in nursing, 5% of nurses had qualified overseas and over 9% of registered and 10.5% of enrolled nurses were not employed as nurses and were not seeking work as nurses. This does not include nurses who had let their registration or enrolment lapse and moved into alternative occupations.21

Discussion Points: Are there other matters relating to the nursing & midwifery workforce that you believe could account for these figures?

Allied Health Workforce (Health Professionals)The Health Directorate defines a 'health professional' as one who diagnoses and/or treats physical and mental illnesses and conditions, and recommends, administers, dispenses and develops medications or treatments to promote, restore or manage good health. Included in this definition are science and engineering professionals who perform analytical, conceptual and practical tasks in the health environment.22

In order to ensure that all health professional groups are represented at an executive level, the Allied Health Adviser in the Health Directorate provides advocacy for any health professional group under the allied health banner that is employed by the Health Directorate and does not fall into a medical or nursing category. There are approximately 30 health professions who meet this criterion in the Health Directorate.

955 allied health professionals fill 837 full time equivalent positions in the Health Directorate, 28% work part time and 83% fill permanent positions. The average 18 AIHW: Nursing & midwifery workforce 200819 University of Canberra: Faculty of Health: Nursing and Midwifery (Accessed 09/05/2011) 20 AIHW Health Workforce: accessed 10/05/201121 DEST: The Nursing Workforce 2010, AIHW: Nursing & midwifery workforce 200822 ACT Health Directorate: Allied Health Salary Information Accessed 10/05/2011

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length of tenure for allied health professionals in the Health Directorate is 7.06 years.23 Allied health is increasing in size faster than nursing and medicine in Australia, with a 22% increase in allied health workers between 2001 and 2006.24 Allied health is comprised of a diverse group of small professions, but as a group they comprise 16.19% of the Health Directorate workforce (the second largest clinical workforce). 9.1% of the health professional workforce permanently separate from ACT Government services each year.25

Only a few of the allied health professions are trained in the ACT, these are physiotherapy, clinical psychology, pharmacy, dietetics, social work, pathology, and occupational therapy. Allied health assistants are trained at the Canberra Institute of Technology (CIT) crossing the professions of Physiotherapy, Occupational Therapy, Speech Pathology, Nutrition and Podiatry.

Discussion Points: Are there other matters relating to the allied health workforce that you believe could account for these figures?

Administrative Workforce Administration is the second largest group of employees in the Health Directorate; this classification includes administrative service officers, senior officers, information technology officers, public affairs officers, clinical coders, dental receptionists, graduate administrative assistants and cadets. 1179 workers fill 1086 full time equivalent positions. 80% are female, and 17% work part time. The average length of tenure for the administrative workforce in Health Directorate is 7.2 years.26

Support Services Workforce Support Services includes officers servicing stores, kitchens, sterilisation services and other essential facilities. There are 442 employees in the Health Directorate filling 397 full time equivalent positions, 58% are male. Support services have the lowest number of temporary employees (7.47%). The average length of tenure for support service workers in Health Directorate is 7.16 years.26

Technical Workforce The technical classification includes technical officers in the Health Directorate, assistants in nursing and health care assistants. There are 202 employees filling 159 full time equivalent positions, 73% are female, 24% work part time. There are more casual technical officer employees than in any other classification (26%). The average length of tenure for the technical workforce in the Health Directorate is 5.5 years.26

In 2008, the US Bureau of Labor Statistics developed a list of the ‘30 fastest growing occupations’ as forecast to 2018. This includes eight occupations that relate to 23 ACT Government Health Directorate Workforce reporting data derived from Chris 21, June 2011 (attachment 4) 24 AIHW Health Workforce: accessed 10/05/201125 ACT Government: ACT Public Service Workforce Profile 2009-201026 ACT Government Health Directorate Workforce reporting data derived from Chris 21, June 2011 (attachment 4)

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health assistants or health aides, with a 30-50% increase forecast in these positions by 2018.27

1500 people were in training in community services and health Industry courses in the ACT in September 2010.28

Executive WorkforceThe executive workforce in the Health Directorate includes 20 full time employees, 60% are female. This workforce has the highest average age of 49 years and the highest number of contract employees (70%). The average length of tenure for an executive in the Health Directorate is 11.5 years.29

Miscellaneous Professional WorkforceThe miscellaneous professional workforce in the Health Directorate includes 17 professionals working in research, information technology and teaching positions. 76% are female, 29% work part time and 59% are temporary employees. The average length of tenure for a member of this workforce in the Health Directorate is 7.6 years.29

Other Health Services Workforces in the ACT

General Practitioners (GPs)The number of ACT GPs has remained static since 2007 at around 67 GPs per 100,000 people. This compares with 90 GP’s per 100,000 people in other urban areas of Australia.30 The average Canberra GP is in the 50-54 year age-range.

ACT GPs are increasingly working part time and taking on multiple roles across different sectors e.g. hospital or university roles.31 However, it is suggested that ACT GPs working part time are able to cope better with complex care and psychiatric issues if they are not dealing with them every day. They may also have better links with other parts of the health system if they are working across different areas.32

SpecialistsThe only data identified around average specialist supply in Australia is for surgeons. In 2009, there were 68 active surgeons in the ACT, with10% aged under 40, 26.5% aged 40-44, 34% aged 45-54 and 29% aged 55 years or older. There were 1.5 surgeons per 1000 population which conforms to the national average,

27 United States Department of Labor: Bureau of Labor Statistics News Release: The 30 fastest-growing occupations, 2008-1828 Community Services and Health Industry Skills Council: Environmental Scan 201029 ACT Government Health Directorate Workforce reporting data derived from Chris 21, June 2011 (attachment 4)30 Productivity Commission: Report on Government Services 201031 ACT GP Taskforce: General Practice and Sustainable Primary Health Care — the way forward: Final Report, 200932 Dwan, Kathryn, Douglas, Kirsty, Forrest, Laura and Res, Sonia: Part time GP’s: scourge or saviour of general practice?: Poster

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however per head of population, the ACT had fewer general surgeons and urologists than the national average. ACT based surgeons were more likely to be taking part in medico-legal work and less likely to be taking part in research and pro-bono work.33 33% of ACT patients feel that they wait longer than acceptable for a specialist appointment, compared to 21.2 % of patients nationally.34 However, it is unclear whether this relates to a longer than average wait time or a lower tolerance to long wait times in the ACT population.

Community ServicesIn 2009, there were 197 Community Service outlets in the ACT with an estimated 1282 people working in disability services, 181 in child protection and 776 in the general community services sector. This data includes both Government and non-government services,35 however there are other community services sectors in the ACT that are not included in this profile.

Residential Aged Care Sector (RAC)The RAC resident population is increasingly ageing and developing more complex needs. This change in demographics has been accompanied by a change in skill mix of the RAC workforce. Between 2003 and 2007, the proportion of registered nurses (RNs) fell from 21% to 17% and ENs fell from 14% to 12.5%. Allied health workers also fell from 7.6% to 6.6% while personal carers rose from 57% to 64% of staff36. There are 23 Aged Care facilities in the ACT.

Private Practitioner Sector (other than Medical sector)There is no publicly available data around the sole or small practice private practitioner workforce in the ACT. However a survey of the 2010 ACT Yellow pages identified approximately 50 pharmacies, 23 occupational therapy businesses, 42 physiotherapy businesses, 13 podiatry businesses, 127 dental businesses, 36 clinical psychology businesses, and 11 rehabilitation businesses. There were also small numbers of private practitioner businesses offering pathology, medical imaging, speech pathology and audiology services. Disciplines not employed within the Health Directorate were not included in the search.

Private Hospital SectorThere is no publicly available data specifically around the private hospital workforce in the ACT37 but there are 328 beds across three private hospitals in the ACT.38

Non Government Organisations (NGOs)

33 Royal Australasian College of Surgeons: Australian Capital Territory Surgeons 2009 Census34 COAG Reform Council: National healthcare Agreement Performance Report for 2009-10 201135 National Institute of Labour Studies: Who works in Community Services? 201036 Access Economics:Nurses in RAC 200937 ABS: Private Hospitals Australia 4390, 201138 AIHW: Australian Hospital Statistics 2009-10

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The NGO sector is growing strongly showing an average annual growth of 7.7 per cent between 1999 and 2007.39

Commonwealth sectorThe Commonwealth has a number of key agencies based in the ACT that employ health professionals. The Department of Health and Ageing had 5061 employees in 2009-10, the Australian Institute of Health and Welfare (AIHW) had 352 employees and the National Health and Medical Research Council (NHMRC) had 257 employees.40 Only a small proportion of these employees are health professionals. Additional health professionals are also employed in Defence, however there is no accessible data available which identifies the proportion of Defence employees working in health services.

Informal CarersIt was estimated that around 2.9 million Australians would provide 1.3 billion hours of informal care in 2010.41 While data around informal carers is sparse, there were at least 2300 primary carers in the ACT in 2003, the majority of whom were females in the 35-54 year age range.42

392 Access Economics: Caring Places- Planning for aged care and dementia 2010-2050 Productivity Commission Research Report: Contribution of the Not for Profit Sector 201040 Australian Government: State of the Service report 2009-1041 Access Economics: Caring Places- Planning for aged care and dementia 2010-205042 ABS: 4430.0 - Disability, Ageing and Carers, Australia: Summary of Findings - State Tables for Australian Capital Territory 2003

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5. National Workforce Issues

The issues outlined below have been identified as impacting on the health workforce nationally.

Competing demands for labour Competition for labour is increasing for both undergraduate and graduate entry professions, and within the international and Australian health care labour market.43 Where health professions in shortage are employed in both the ACT public and private sectors there is intense competition for this workforce between sectors.

Issues have been raised by the private sector regarding their investment in training staff that then leave to work in the public system. The ACT Government may be competitively advantaged to attract staff due to its ability to offer public service conditions such as salary packaging and by the wide variety of work it can offer. However, since Commonwealth Government departments and New South Wales (NSW) Health services are also competing for the health professional workforce in the ACT, each service needs to maximise the advantages of their sector in order to attract and retain their workforce.

Discussion Points:

1. Are there other competing demands that you think should be considered in this section?

2. Are there other aspects of the ACT that you believe make this a competitive market for attracting labour?

Ageing workforceThe Australian workforce pool is projected to decrease as a proportion of the total population over the next decade, driven by the ageing demographics of the workforce.44 In 2008, 18% of the Australian health workforce was aged 55 years and over (compared with 13% in 2003). While many health workers are replaced by new entrants, there is concern that the rate of workforce replacement is not keeping up with the increased demand for health-care services as a result of the ageing population.45 It is, however, possible that the changing age distribution will have less of an impact than expected as workforce participation rates are increasing, partly due to changes in policy such as superannuation rules and an increase in workforce participation by women.46

43 NHWT: Health Workforce in Australia and factors for current shortages 200944 ABS: 4430.0 - Disability, Ageing and Carers, Australia: Summary of Findings - State Tables for Australian Capital Territory 200345 AIHW: Australia’s Health 201046 Segal & Bolton: Issues facing the future health care workforce: the importance of demand modelling, Australia and New Zealand Health Policy, 2009

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Changing workforce intentions and availability There appears to be a move towards decreasing the hours for some categories of the health workforce and there is also an increasing trend towards part-time employment.47

Reliance on international medical graduates Australia is currently heavily reliant upon international medical graduates to supplement shortages in medical practitioners. Ongoing global health workforce shortages mean this is an unsustainable model and cannot be considered a solution to manage workforce shortages in the long term.47 There are indications that Australia may be moving into a situation where international medical graduates are oversupplied in Australia.

Professional rivalries Inter-professional boundaries and tensions may impact on the morale of individual practitioners and this could lead to individuals leaving the workforce or changing their role in the workforce.

Lack of integration/collaboration between sectorsLack of collaboration between organisations, departments and individual practitioners can lead to issues with efficiency and quality such as duplications, gaps, multiple referrals and inconsistencies in service delivery. A number of barriers make collaboration difficult to achieve including, differences in administrative boundaries, laws, rules and regulations, budgets and financial streams, IT systems and databases, professional and organisational cultures, values and interests and commitment of the individuals and organisations involved.48 Collaboration is raised as an issue across the ACT in relation to both inter-agency and interdepartmental integration. Cooperation between the public and private sector in the ACT is considered in workforce planning due to the close proximity of service facilities and finite resources available.49

Workforce specialisation The health workforce has become increasingly diversified and specialised, due to professionalisation, scientific and technological developments, credentialing and changing models of care and identified needs. As increasing sub-specialities are developed, there can be protection of roles by controlling entry criteria, registration, industrial action, and political influence. The more control a group has, the more likely it is to influence the supply of its service within the health workforce.50

This can contribute to workforce shortages by, creating demand for new sub specialties that may be in short supply, reducing flexible work practices so that 47 NHWT: Health Workforce in Australia and factors for current shortages 200948 Axelsson & Axelsson: Integration and collaboration in public health- a conceptual framework 200649 ACT Health Directorate Critical Care Services Plan 2007-2011 (internal document)50 NHWT: Health Workforce in Australia and factors for current shortages 2009

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multiple practitioners are required to undertake functions that may previously have been undertaken by a single practitioner, preventing care being provided by a single multi-skilled practitioner, restricting supply of the specialist practitioner through constraining education and training capacity and increasing inter-professional boundaries and tensions which impact on the morale of individual practitioners leading to individuals leaving or changing their role in the workforce.51

Absenteeism and ill healthAIHW states that in a survey of working-age people, 96% report at least one of the following risk factors: smoking, risky alcohol consumption, obesity, physical inactivity, low fruit or low vegetable consumption, high blood pressure, or high blood cholesterol. 75% of the respondents report multiple risk factors.

The authors found that people with three or more risk factors had significantly greater odds of not being in the labour force compared with those without risk factors and that absentee rates were significantly greater for males and females (4.0 times and 2.5 times as high, respectively) among those with at least one risk factor and at least one chronic disease, compared with those with no risk factors or chronic disease. In addition, the net annual loss due to absenteeism associated with these risk factors was more than that for chronic disease (112,000 and 57,000 full-time person-years, respectively).52

Job strain has been found to double a workers future risk of depression and depression is estimated to cost more than $8000 per affected person per annum in lost productive time and job turnover/employee replacement. Recommendations to combat workplace depression include investment in ‘mentally healthy workplace’ studies, and a need for new workplace health promotion approaches to target job stress.53

A recent Cochrane review found that interventions which increase employee control by offering worker-orientated flexibility (specifically self-scheduling and partial/gradual retirement) are likely to be associated with health improvements including improvements in physical health, mental health and general health. In contrast, interventions that were motivated or dictated by organisational interests, such as fixed-term contract and involuntary part-time employment, found equivocal or negative health effects.54

Initiatives such as increasing the number of child care facilities co-located with health workplaces, offering extended hours of child or elder care and offering more flexible working hours to support existing part time workers to increase their hours, may also increase options for people to extend workforce participation. Classification

51 NHWT: Health Workforce in Australia and factors for current shortages 2009 52 AIHW: Risk factors and participation in work 201053 Victoria Health: Estimating the economic benefits of eliminating job strain as a risk factor for

depression 201054 Pabayo et al: Flexible working conditions and their effects on employee health and wellbeing

(Cochrane Review) 2010

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In the next five to ten years it is anticipated that new classifications will be required as additional health professions become recognised and accepted, new professions emerge or strengthen and others undergo role redevelopment, redesign or extension.

It is noted that industrial relations, law and practice can impact negatively as well as positively on workforce reform.55 Changing classification is a slow process that impacts on the introduction of new or extended roles. In the Health Directorate, industrial agreements usually cover a three year period, which makes it difficult to introduce changes to classifications in a timely manner impacting on the introduction of new roles.

Classification has been raised as an issue within the Health Directorate, with some respondents believing that their positions are under classified for the level of work that they perform and some indicating that classifications are inconsistently applied across programs.

Following a review of the classification structure in the ACT Public Service, Chief Minister and Cabinet Directorate is currently looking at options to create a new vocational stream and a single salary spine.56

55 National Health Workforce Innovation and Reform Strategic Framework for Action: National Consultation: In draft56 ACT Health Directorate: General Enterprise Agreement 2010-2011

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6. Additional issues impacting the ACT region

Sustainability is identified in the Health Directorate Corporate Plan as a key performance area,57 however sustaining the health workforce in the ACT is a significant challenge compounded by a number of issues specific to the region.

In July 2010, the national workforce participation rate was 65.3% as compared to the ACT rate of 72.9%. The national unemployment rate was 5.2% and the ACT rate 3.4%.58 The financial crisis has triggered a rise in the number of people employed in community services and health across Australia,59 however the ACT has less potential than most states and territories for increasing workforce participation levels in the existing population and must look outside the territory boundaries for additional skilled workers.

In the Commonwealth Public Service, 52% of ongoing Senior Executive Service (SES) and Executive Level (EL) employees will be eligible for retirement in the next 10 years. 76.5% of all SES and 62.3% of all EL employees are employed in Canberra so this could have a significant impact on the ACT.60

While the ACT has the most educated population in Australia, 32% of people in the ACT still have a level of literacy below the accepted standard needed to work in a knowledge-based economy.61 A lift in workforce participation in semi-skilled health-based occupations would require increased provision of basic core skills training such as adult language, literacy and numeracy as well as vocational skills.62

As of 2012, people who complete Year 12 studies in NSW but study at interstate universities are no longer guaranteed medical intern placements in NSW hospitals.63 The ACT may be too small to be able to offer sufficient variety of placements to deliver the breadth of experience required by an intern, so there is potential for this decision to impact on student choice of university and potentially on the diversity of the internships available to ANU graduates.

Lack of local new graduate supply and limited training facilities makes recruitment to many allied health professions extremely difficult in the ACT.

57 ACT Health Directorate: Corporate Plan 2010-201258 ACT Government Labour Force- July 201059 Community Services & Health Industry Skills Council: Environmental Scan 201060 Australian Government: State of the Service report 2009-1061 Australian Bureau of Statistics (2008), 2006 Adult literacy and life skills survey , Australia, 4228.062 HWA: National Health Workforce Innovation and Reform Strategic Framework for Action 2011-201563 NSW Health Priority List for Intern Allocation 2012

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Commencements in vocational education courses grew in all states and territories except the ACT between 2005 and 2010, the ACT maintained an average commencement rate of 1200 students per quarter across all vocational training courses.64 Corporate support services have a critical role in underpinning core health services business and assisting delivery of services and maintaining a reliable supply of vocational educated workers to deliver these services is vital.

Discussion Points:

1. Are there additional issues impacting the ACT Region that you feel should be included here?

64 NCVER Australian vocational education and training statistics: Apprentices and trainees: September quarter 2010

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7. ACT Government Health Directorate staff and program feedback

Submissions were sought to identify the key workforce issues of concern in the ACT (see Attachment 1). A number of issues were raised by the Health Directorate staff and divisions which are not noted as national key workforce issues. These are outlined below.

Community based Nursing servicesThere was an 18% increase in occasions of community based nursing services delivered between 2007-08 and 2010-11. One of the suggested reasons for this increase is that community based clients are increasing in complexity. Since 2006, routine personal care has been referred for delivery by non government organisations, so only people with the most complex needs are seen by community based nursing services. Community nursing services introduced a number of new community based services such as weekend and specialist clinics in 2009-201065 in an attempt to meet demand.

Allied Health servicesSome allied health services report increased demand for their services which impacts on the level of service provided to less urgent client groups which they feel leads to reduced satisfaction, reduced clinical efficiency, an impact on provision of clinical training to students and a reduction in time available for non client contact activities such as leadership, policy development and development of new models of care.

There are currently no national standards available around allied health acute staffing ratios. Although some work is in progress66 lack of standards is reported as impacting on acute areas and future service planning. There are local staffing standards available to guide allied health in some services.67

Increasing student numbers and the commencement of new local health training schools, e.g. the new occupational therapy school, are recognised as essential to assist recruitment and develop sustainability of the allied health workforce. However, it is noted that delivering supervision to increasing numbers of students is a major challenge for the allied health workforce in the ACT and new training programs need tutors and supervisors for clinical placements which may need to be sourced from the existing workforce.

Medicine

65 2011 report Community Care Program Nursing Workload 2008-2011 (Unpublished)66 Health Workforce Australia: Workload Measures for Allied Health Professionals accessed 16/06/201167 ACT Health Directorate: Operational Support: Standard Operating Procedure Acute Support Allied Health - Caseload Allocation (internal document)

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It is noted that improvements in rostering for junior doctors in 200868 has resulted in safer working hours. However in March 2011 the Health Directorate had 15 vacant junior doctor positions and junior doctors were working overtime to backfill these vacant positions while the positions were being readvertised. This situation has now improved and junior doctor recruitment for 2012 is now finalised with 100% recruitment achieved.

Administrative servicesWhere administrative staff are not available, or are under classified for the tasks required, clinicians are spending increasing time on essential administrative duties and this inevitably impacts on the number of services provided by clinicians.

Career pathwaysLimited clinical career structure is raised as an issue within some allied health professions, where it is reported that there are very few clinical opportunities beyond Health Professional (HP) 3 level. This means that clinicians need to move into a management career path in order to advance. This is an issue usually documented in rural areas,69 however the small size of the ACT means that there may be limited opportunities for local promotion within discipline, especially in small professions. Some professions, such as speech pathology have advised that there are significantly better career opportunities available in NSW and this can impact on retention.

Practice nurses and health promotion professionals currently have no formal career path at all; health promotion is not classified as profession in its own right which makes it very difficult to develop a career pathway.

It is reported that people employed in support services have limited opportunities for skills education, development and articulation to higher studies.

68 ACT Health Directorate: Annual Report 2007-0869 Schoo et al, A conceptual model for recruitment and retention: Allied health workforce enhancement in Western Victoria, Australia: Rural & Remote Health (Online) 2005

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8. Recruitment & retentionIt is noted that recruitment and retention of experienced staff is a particular issue in the ACT, as the size of the ACT restricts career opportunities in some professions. High house prices and inflexible hours in some sectors are also cited as contributing to this issue. Locally trained new graduates are easy to attract, however they may move on when they have gained 1-2 years of experience. Staff leaving for other sectors are generally more experienced and are more difficult to replace.

New graduates trained interstate can be hard to attract to the ACT and this impacts on professions without a local training school. New graduates are more likely to stay working in their profession if they feel well supported so an investment in graduate support programs is essential.

A survey of 246 new Canberran’s by the ‘Live in Canberra’ team70 indicates that work and lifestyle are the main influences behind choosing to move to Canberra, NSW was the most common state to immigrate from and the UK was the more common overseas location. Most people attracted to Canberra have partners and 41% are families with children.

It is noted that compliance with the mailed request for provision of exit data in Health Directorate is poor. Consistent provision of data detailing staff reasons for leaving is invaluable for planning retention incentives. Other methods such as electronic surveys may have a higher take-up rate. An incentive may also encourage greater compliance.

Medical SpecialistsRecruitment to specialist and some trainee positions in the ACT public sector has been a particular issue in geriatric medicine, anaesthesia, plastic surgery, emergency and palliative care, with positions staying vacant between three to 12 months and longer in some cases.

Executives and managersRetention of executives and managers is raised as an important priority within the Health Directorate. Volatility at this level is highly undesirable as it makes it difficult to progress initiatives, or to maintain a secure, supported workforce.

70 Live in Canberra Program Welcome to Canberra Events Survey 2006-2010 (Unpublished)

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Mature aged workersDepending on the financial situation, Commonwealth Superannuation Scheme (CSS) members may find that they have a significant financial incentive to retire at 54 years and 11 months and it is estimated that 40% of CSS members of that age choose to retire. The CSS stopped taking new members in 1990 and there are now only 275 CSS members in the Health Directorate (including 130 nurses) so they only represent 4.6% of employees (5.5% of nurses). Special employment agreements are available to help retain these experienced staff members by offering increased superannuation payments to remove the gap between the standard pension (taken after age 55) and the deferred pension (taken at 54 years, 11 months). This option can be limited to selected employees but must be negotiated before the employee starts to implement retirement plans. This strategy can also be used where an employee prefers a ‘staged retirement’ moving to part time or lower level employment. However the employee would need to be aware that superannuation contributions would be based on their former (full time) salary and so would result in a lower take home salary while employed. The employee benefits by gaining from further growth of the salary that their final benefit is calculated on and by the reduced pension discount because they retire at an older age.71

The Health Directorate General Enterprise Agreement72 allows the Director General to approve additional remuneration benefits for eligible mature aged employees, instead of employer superannuation where the employee has knowledge, skills and experience that are essential for the agency to retain. This allows key staff members to be offered position retention without financial disadvantage to the staff member.

Graduated retirement options may assist in retaining some executives and managers beyond retirement age. Part time options for recently retired workers may include retaining involvement in training and supervision.

In addition to the key workforce issues above, the issues outlined below were also of concern to Health Directorate staff and divisions.

Small ProfessionsSmall professional groups report feeling professionally isolated in the ACT and state that this impacts on retention and professional credentialing for their groups. Local peer support networks may be implausible due to low numbers. The smaller professions, such as speech pathology and orthotics / prosthetics, are not trained in the ACT so there is no home grown source of these professionals and it can often be difficult to fill vacancies locally. Members of small professions seldom have the benefit of backfill to allow them to take time to do research, develop new models of care, and trial new clinical practices. This makes it difficult for these professions to introduce changes that may benefit their service. There are difficulties with succession planning in professions or specialties where there may only be one or two practitioners and small professions may also need additional travel and inter-professional support in order to meet credentialing, up-skilling and quality improvement requirements.

71 Australian Government: Management Advisory Committee: Report on Organisational Renewal, 200372 ACT Health Directorate: General Enterprise Agreement 2010-2011

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Slow growth in Assistant RolesWhile assistant roles are slowly increasing in number within Health Directorate, limited resourcing is impacting on the creation of new roles.

Assistants in Nursing (AINs) are not currently classified as nurses despite being paid and recognised under the Nursing Collective Agreement and, as non nurses, they sit outside the nursing hours per bed day calculation of workload determination. This means that AINs are unlikely to be employed as additions to current staffing levels. As "nurse equivalents" they would be included in total nurse numbers creating industrial concerns about lowering the skill mix. However, there are also concerns that as scopes of practice have moved up the continuum, basic care activities such as showering, toileting, feeding and routine pressure care are being increasingly impacted.

A stage 2 pilot of assistants in nursing (AINs) occurred within the Health Directorate in 2009/10, however these roles have not been continued following the trial.

Changing TechnologiesNew technologies are increasingly influencing workforce needs, requiring increased need for technician resources. As monitoring and treatment services are increasingly conducted remotely in the community it is expected that the Health Directorate will need to set up home based equipment services and technicians will be required to deliver these services. These technicians may not be used to working with clients so some may require additional training.

Increasing use of IT in specialised areas may require targeted development of specialist IT roles such as Laboratory IT support- where the support person has basic training in pathology as well as IT skills. Staff will also need support to change the way they do business.

Where changes in technology have reduced care complexity, there is a need to explore reallocation of tasks to less skilled workforce members. Technology may also improve the safety of some interventions making it more feasible to re-locate affected tasks outside the tertiary hospital campus.

Despite the fact that 82% of ACT residents have home internet access73 a lack of approved IT encryption currently prevents the use of email as a route of communication with patients.

Proposed mobile health worker electronic record technologies are expected to save significant time, enable additional services to be provided and enhance community based worker safety by remotely identifying their location; however there are issues around privacy that will need to be addressed to support these changes.

73 ABS: Household Use of Information Technology Australia 2008-09

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It is noted that while new technologies can be significant time savers, they can also lead to increased staffing requirements where new treatments are offered for conditions that would previously have been untreatable or where treatment outcomes are significantly improved by a new more labour intensive technology.

Discussion Points:

1. Are there other recruitment and retention issues facing the Health workforce that you feel should be included?

2. What are your suggestions for improving recruitment and retention throughout the Health Directorate?

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9. Feedback from other Health Services in the ACTSubmissions were sought to identify the key workforce issues for health services in the ACT other than Health Directorate. Please see Attachment 1 for a list of all the submissions received.

Key issues shared across multiple external health services

Training, supervision & mentoring supportSupervision and mentoring requirements vary between professions, and there are a range of support models for the provision of supervision in the Health Directorate.Smaller health services in the ACT do not have sufficient numbers of health employees to support significant training infrastructure which impacts on their ability to provide appropriate training to staff.

While cross sectoral training is offered by the Health Directorate, this is delivered for a fee to cover costs incurred by the Health Directorate. Health Directorate’s Staff Development unit advise that there is no profit margin included in this fee, however the fee is referred to as a barrier to training access for some services.

Lack of supervision and mentoring support is reported to be an issue across sectors, particularly where people filling these roles are relatively isolated, such as practice nurses.

Some training needs are reported as not currently being met in the NGO sector, including disability awareness, mental health training and multicultural awareness training. NGOs note that in some circumstances, employing people with lived experience, such as people with experience of alcohol or drug dependence assists them to deliver more relevant and meaningful services to clients, however there may be barriers to their employment through normal selection procedures. These workers may also face unusual difficulties in completing qualifications in order to enter into the workforce and may require significant additional support such as language support, longer timeframes to complete units, affordable child care, and scholarship support.

Better support may also be required for health workers returning to the workforce in the NGO sector. NGOs also report difficulty for workers in accessing supervision and debriefing support to reduce the stress encountered whilst working in very demanding environments.

Salary InequityHealth Professionals working for the ACT Government Community Services and Justice and Community Safety Directorates are not entitled to the same level of salary packaging as those in ACT Government Health Directorate and this potentially impacts on recruitment and retention of health professionals in these agencies. This also impedes the ability for staff to rotate seamlessly across the sectors.

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Salary inequity has significantly impacted on the attraction of NGO staff and has discouraged skills development through higher education, with employees leaving the sector for better-paying jobs in the public sector.74

A Fair Work Australia Equal Remuneration Case for community services workers recently found that there is not equal pay in the non Government sector for work of equal or comparable value by comparison with state and local government employment and that employees are generally remunerated at a level below that of state and local government employees who perform similar work. Work is now commencing to determine what changes will be introduced following this decision.75

The significant wage differential between residential aged care (RAC) nurses and other nurses is resulting in shortages of adequately trained nursing staff and is leading to problems with nurse retention and turnover rates.76 Low salaries in the RAC industry make it increasingly difficult to attract workers.

A number of issues were raised which were specific to individual sectors and are documented by sector below.

The ACT Government Sector (other than Health Directorate)

Slow growth in assistant rolesDisability ACT does not currently have assistant roles but believes that disability assistants could be used to support health and nursing professionals in the disability sector. Therapy ACT would also be interested in exploring the use of psychology assistants to support families to implement interventions.

Non Government Organisations

Recruitment & RetentionNGOs are often subject to funding arrangements that do not guarantee recurrent or ongoing funding. This limits their capacity to plan adequately for the future, especially in terms of service provision and staffing. Due to funding uncertainty, short term contracts are usually offered which impacts on recruitment and retention as employees prefer the security of a longer contract. Average staff turnover across Australian community sector agencies was equivalent to 29% in 2010.77 As a comparison, Health Directorate has an average permanent staff turnover rate of 7.4%.

Staff turnover is expensive to an organisation, with resignation of a staff member incurring significant expenses including separation, replacement, training, lost

74 Community Services & Health Industry Skills Council: Environmental Scan 201075 Fair Work Australia Decision- Equal Remuneration Case: Australian Municipal, Administrative, Clerical and Services Union and others 201176 Access Economics: Nurses in RAC 200977 ACOSS: Australian Community Sector Survey Report 2010: Volume 1- National

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productivity and lost business costs. Labour turnover costs may range from between 50 to 130 percent of an incumbent's annual salary.78

The Productivity Commission notes that NGOs are usually required to subsidise the costs of services delivered on behalf of Government agencies and that this has led to salaries being squeezed to the point where many NGOs find it difficult to attract or retain experienced staff79 and this means that some NGO workforces are increasingly weighted with inexperienced staff. NGOs note that, in some circumstances this can lead to inexperienced clinicians being promoted beyond their skill level.

Career pathwaysNGO staff turnover is particularly impacted by lack of career paths. The small size of many NGOs means there are few career opportunities, and, even where employees undertake training, funding structures are often insufficiently flexible to accommodate employees with higher level qualifications. The current absence of career paths, and associated financial recognition linked to training, can reduce the incentive for employees to invest in their own training. This, along with funding constraints, means that many NGO employers are unable to sufficiently invest in training their staff. In addition, staff training expenses are often not regarded by funding bodies, or the public, as a necessary part of service delivery.80

Service demand / High workloads / burnoutThe NGO sector reports that it is providing much of the basic community service intervention and this work continues to grow.

Workplace flexibilityNGOs identify a need to increase the flexibility of their working hours to attract more staff, including part time options.

Residential Aged Care Sector The rate and number of residential aged care places in the ACT increased in 2009-1081. The demand for aged care workers is also expected to significantly increase as a result of the increasing number of older Australians requiring care and support and a decline in the relative availability of informal carers.

78 Council for Equal Opportunity in Employment (CEOE) survey cited by The Australian Governments Equal Opportunity for Women in the Workplace Agency79 Productivity Commission Research Report: Contribution of the Not for Profit Sector 201080 ABS: 4430.0 - Disability, Ageing and Carers, Australia: Summary of Findings - State Tables for Australian Capital Territory 200381 COAG Reform Council: National healthcare Agreement Performance Report for 2009-10 2011

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Staffing skill-mixNurses in RAC have to spend much of their time on non clinical activities and supervision, rather than providing clinical care. This affects work satisfaction as well as reducing the amount of direct care provided to RAC residents by nurses, and the quality of overall care.82

Dependence on overseas residents to fill personal carer positionsIn the ACT, increasing numbers of personal carers are international students or spouses of international students. Poor English language skills and differing cultural backgrounds can lead to communication difficulties with demented and frail residents.

These workers are not entitled to government financial assistance with vocational training and the cost of training in 2010 was $5,550 for a 6 month Certificate III in Aged Care.83 This equated to almost 18% of the annual entry level FTE minimum carer salary of $31,512.84

Regulation of personal carersDue to low salaries and high rental costs, many personal carers are working in multiple RAC locations and may be rostered for consecutive shifts in different places. There is no registration of personal carers so regulation is difficult and there is the potential for unsuitable people to remain in the industry by moving to an alternative employer.

GP AccessThe aged care sector reports acute issues with accessing GP services, with few GPs able or willing to take on clients in the RAC sector as home visits are poorly reimbursed and time consuming. Some RAC facilities have approached this problem by arranging for a GP to hold a regular weekly clinic in the facility and see any patients who require a consultation, however in order to take advantage of this option, residents need to transfer to this GP. The remuneration for GPs taking on this work is also impacted, as under the current remuneration structure GPs are paid decreasing amounts for each additional patient seen in the duration of the visit.

A lack of consulting rooms and computer facilities is an issue for GPs when seeing RAC clients.85 A few GPs have very large numbers of aged care patients and these are predominantly older GPs so there will be a substantially negative impact when one of them takes leave, retires or moves out of the ACT. After-hours and weekend GP cover is also seen as a major issue in the RAC sector, although the Canberra after-hours Locum Medical Service does provide cover.

Palliative care services82 Access Economics: Nurses in RAC 200983 CIT International Student Section- telephone advice 20/09/1084 MA000018 - Aged Care Award 201085 ACT GP Taskforce: General Practice and Sustainable Primary Health Care — the way forward: Final Report, 2009

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A palliative care nurse provides services to RAC facilities in the ACT, however it is sometimes difficult to get urgent prescriptions written by GPs in a timely manner. Clients requiring palliative care may be best served by remaining in a familiar environment if their palliative care needs can be met there so there is the potential for aged care palliative care nurse practitioners to work within or across RAC facilities to improve this service. As of 1 November 2010, nurse practitioners can access the Medicare Benefits Schedule and provide pharmaceutical benefits scheme medicines in the community and this may assist in improving the timeliness of medication changes to the aged requiring palliative care.

Medical PractitionersIn 2009 a GP Taskforce was set up in the ACT to investigate GP workforce issues. The predominant challenges identified by the Taskforce were the GP workforce shortage, and the provision of care to older residents.86

International Medical GraduatesThe ACT Division of General Practice (ACTDGP) (now the ACT Medicare Local) flags that access to training placements for International Medical Graduates (IMG) can be difficult and note that the current GP training model is inefficient for IMGs.

GP practices that source a suitable IMG to work with them, have a six to nine month time lag before the IMG can be approved to commence work. Extensive paperwork, appropriate medical registration and an appropriate visa must be obtained for the position offered. IMGs are then subject to Medicare provider number restrictions that affect where they can work in Australia, with IMGs who take up permanent residency or citizenship in Australia being unable to obtain a Medicare provider number for 10 years unless they work in a district of workforce shortage.87 Some outer metropolitan parts of the ACT are currently included as districts of workforce shortage, however this status has the potential to be revoked on review. In March 2012, the House of Representatives Standing Committee on Health and Ageing tabled its report on the inquiry into the registration processes and support available to overseas trained doctors in Australia88. This report includes 45 recommendations to increase the transparency of the National Scheme’s accreditation and registration processes for IMGs, and to reduce the administrative burden on IMGs by improving efficiency.

The Medicare Local has stated that they would like to explore the potential for medical and physician assistant roles but they are impacted by funding limitations.

86 ACT GP Taskforce: General Practice and Sustainable Primary Health Care — the way forward: Final Report, 2009

87 Department of Health & Ageing: Doctor connect Website- Provider number restrictions 200788 Parliament of Australia- House of Representatives: Lost in the Labyrinth

Report on the inquiry into registration processes and support for overseas trained doctors 2012

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10. High Risk ProfessionsA number of health professions are cited as being at, or near, crisis level in terms of a declining workforce numbers and in attracting people to train in these professions. Nationally the health professions that are identified as being in shortage or having recruitment difficulties are sonographers, optometrists, occupational therapists, physiotherapists, podiatrists, audiologists, speech pathologists, midwives, registered nurses, psychologists, medical laboratory scientists, social workers and welfare workers.89

Within the ACT the professions being identified as requiring immediate intervention are pathology (including medical laboratory scientists, cytologists venepuncturists, and pathologists), biomedical engineers, specialty nurses (such as ICU and emergency department nurses), medical physicists and radiation therapists.

The US Bureau of Labor Statistics lists Medical Scientists as the 6th fastest growing occupation in the USA, with an expected increase of 40.4% between 2008 and 2018.90 A review is currently being undertaken of ACT Pathology medical laboratory scientists.

A recent survey of the Australian pathology workforce91 indicates that, compared to other states and territories, the ACT has the greatest proportion of permanent full time workers (77.0%), the highest number of workers who regularly work for more than 50 hours per week (15% compared to 8% nationally), the highest number intending to reduce their hours (36.1% compared to 20.4%) and the highest number of workers planning to leave the pathology workforce within the next three years (50%) with many citing their intent to leave to improve work/life balance. 39% of pathology workers in the ACT are aged over 50.

Both private and public sector pathology services agree that a variety of approaches are required to increase the pathology workforce in health, including attracting more students to take up clinical placements in health and improving the training through increased industry involvement.

Medical physicists and biomedical engineers often require overseas recruitment to fill positions.

Biomedical Engineering Technicians (BMETs), work under the guidance of professional clinical engineers in clinical settings and with patients / clients and have the technical skills, knowledge and experience to enable them to effectively maintain clinical technology, taking electrical safety and patient safety into account. BMETs are also equipped to manage and mitigate the risks associated with ‘hospital in the home’.

89 DEEWR : Skill Shortage List, Australia 201190 Bureau of Labor Statistics: Fastest Growing occupations 2008-2018 (USA)91 DOHA: Survey of the Pathology Workforce: 2011

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Discussion Points:

1. Are there other factors that you think contribute to high risk professions?

2. Do you have suggested mitigation strategies?

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11. Informal carers and self-carers

Where a client is receiving long term treatment and they, or their carer, are willing and able to do so, they can be trained to deliver their own treatment, monitor progress, react to changes and call for professional assistance when required.

There is an increasing move towards self management of health and self management of chronic diseases, for example, the Diabetes Services Strategic Plan92 includes the need to promote active self management approaches to assist people in meeting their targets for control of blood glucose, lipid and blood pressure. Clients are already delivering 12% of their own haemodialysis in Australia (21% in NSW). 93

Benefits include better control over timing of treatments to fit around client’s work or social events, reduced travel requirements and clients may have less adverse incidents due to closer self monitoring.93

Clients and carers may require a high level of initial support, however there is potential for a longer term reduction in professional intervention required for these patients.

Informal carers are more likely to be unemployed or not participating in the paid workforce than those who are not carers so the availability of informal care for aged and disabled people is expected to be impacted by increasing workforce participation.94 It is, however possible that the ageing population will create a larger pool of informal carers of retired age.

Discussion Points:

1. How do you believe the balance between increased prevalence of self managed care and decreased participation in the workforce (for informal carers) can be achieved?

92 ACT Health Directorate: Diabetes Services Strategic Plan 2008-201293 Kidney Health Australia: Home Haemodialysis- A Treatment Option94 ABS: 4430.0 - Disability, Ageing and Carers, Australia: Summary of Findings - State Tables for

Australian Capital Territory 2003

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12. What’s already happening to meet the health workforce challenge?

National initiativesA number of national initiatives are underway to help meet current and future workforce challenges and improve and sustain health services:

National Health reformA Heads of Agreement on National Health Reform was signed by all states and territories in February 2011 and the full National Health Reform Agreement was signed in August 2011.

The purpose of the health reform measures are to improve health outcomes and ensure the sustainability of the health system. Under this agreement the states and territories maintain management of public hospital services and have a lead role in public health while the Commonwealth will increase its contribution to growth funding for hospitals to 50% from 1 July 2017 and an independent national funding body will administer hospital funding from 1 July 2012.95 The Commonwealth is developing a national approach to employment structures as part of its health reform package.96

Local Hospitals Networks (LHNs) have been established by all states and territories. The ACT Government has implemented a single LHN for the ACT, initially confined to the geographic borders of the ACT. This is a networked system that will hold service contracts with the Health Directorate and is comprised of the Canberra Hospital, Calvary Public Hospital, Clare Holland House (CHH) and the Queen Elizabeth II Family Centre (QEII). The ACT and NSW Governments have both agreed to undertake a further planning exercise to examine the feasibility of developing a regional LHN model.97

Medicare Locals are new primary health care organisations that have been set up by the Commonwealth to better integrate health care and improve the responsiveness to the needs of the local community. The boundaries of the ACT Medicare Local and the ACT LHN are aligned. The ACT Division of General Practice formed the ACT Medicare Local as of 1 July 2011. The ACT Medicare Local is developing an expanded range of services to the wider primary health care community in the ACT, so that Canberran’s can access better coordinated and integrated primary health services and preventive health programs.

The ACT Medicare Local aims to bring together primary health care professionals and organisations to deliver quality services to the ACT population. General practice will remain central to the ACT Medicare Local service delivery.

95 Heads of Agreement- National Health Reform 201196 COAG: National Partnership Agreement on Hospital & Health Workforce Reform 200997 ACT Government: A Local Hospital Network for the Australian Capital Territory 2011

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Priority activities for the ACT Medicare local are to: Continue as a key partner in developing the ACT Primary Health Care

Strategic Plan 2011-14 in the context of COAG health reforms; Develop a dedicated GP portal enabling GPs to access relevant patient

clinical information; Expand on e-Health capacity including e-Discharge summaries and e-

Referrals and participate as a member of a consortium which has been selected for the second wave of e-Health records, and is working on furthering other e-Health projects;

Promote good governance throughout the primary care sector; Work towards developing a highly sophisticated population health capacity

sourced through national data sets; Identify groups of people missing out on general practice and primary health

care or services that a local area needs and respond to those gaps by better targeting services; and

Work with Local Hospital Networks to assist with the transition of patients out of hospital and if required, into aged care.98

Health Workforce Australia (HWA)HWA is a key national agency, established in early 2010. HWA’s mandate is to provide leadership in addressing the health workforce issues facing Australia. It is aiming to ensure that we have a skilled, flexible and innovative health workforce that meets the needs of the Australian community.

To achieve this, HWA is developing policy and delivering programs across four main areas including research and data, workforce innovation, clinical training and international recruitment. This focus aligns closely with the objectives of the first Health Directorate Workforce Plan.

HWA is progressing a raft of initiatives including:

a National Health Workforce Data Set containing national supply and demand data;

a profile of the supply and demand projections for the aged care and Residential Aged Care (RAC) sector nursing workforce (RNs, ENs and AINs) and the acute care nursing workforce;

a methodology to support mental health workforce planning for the non-government community mental health sector;

increasing supply and demand of health workforce professionals to meet both anticipated future demand and to overcome any existing shortages;

initiatives to increase clinical training placements; a review of supervision and simulated learning environments; a map of health workforce competencies and a taxonomy for competency

based standards in health education and training; evidence based options for competency based career frameworks for the

Australian health workforce;98 ACT Medicare Local Website: Accessed 17/05/2012

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alternative approaches to health workforce planning; a review of major shifts in the aged care workforce to improve the future

supply and adaptability of the workforce for the care of older Australians; options for data sources for measuring workload/productivity of the allied

health workforce; and oversight of the National Health Workforce Planning and Research

Collaboration.99

Integrated Regional Clinical Training Networks have been set up in every state and territory to support a collaborative focus on student placement and a forum to explore additional opportunities for cross sectoral integration and collaboration around clinical education and training for staff. These networks may support initiatives such as inter-agency placements, rotations and expansion of shared staff training in the region.

In November 2011, Health Workforce Australia published the National Health Workforce Innovation and Reform Strategic Framework for Action 2011-2015.100 This provides a framework of the following five domains for action:

1. Health workforce reform for more effective, efficient and accessible service delivery;

2. Health workforce capacity and skills development;3. Leadership for the sustainability of the health system; 4. Health workforce planning; and5. Health workforce policy, funding and regulation.

These domains will also provide the framework for the Workforce Plan for the Health Workforce of the ACT 2011-2017.

E Health

The national e-health initiative will deliver personally controlled electronic health records, and a national e-health records system and is expected to be implemented by September 2012.101

E-health is expected to improve the quality and safety of health care by allowing better flow of information between all parties involved in a healthcare event. It can replace many of the current paper-based processes and improve access to relevant information through enabling 24 hour a day 7 days a week access. It can also overcome fragmentation and duplication of services, give individuals / carers better management and control of their personal health outcomes and provide better access to health care services in remote, rural and disadvantaged communities. However, new technologies may also open up opportunities to offer additional

99 HWA Website http://www.hwa.gov.au/ 100 HWA: National Health Workforce Innovation and Reform Strategic Framework for Action 2011-

2015 101 E-Health website http://www.ehealthinfo.gov.au/

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services of value to the community and additional workers are then needed to deliver these new services.102

From a workforce perspective, e-Health can significantly improve health service efficiency by reducing staff time spent accessing paper based records, reducing duplication of services such as pathology tests, and speeding up the flow of communication between health professionals providing services to a client.101 However significant training and management of change is required to support the introduction of these initiatives.

Training incentivesIncentives to choose nursing degrees are being offered by the Commonwealth Government, whereby nursing graduates who go on to work in the nursing profession have their compulsory HECS HELP debt repayments significantly reduced.103

Aged Care reformThe Commonwealth Government has announced that it will assume full funding and policy responsibility for aged care and it has allocated more than $310 million over four years for a combination of workforce programs, including additional nursing places and scholarships, incentive payments for the aged care workforce to undertake additional training and/or upgrade qualifications and the introduction of the Aged Care Nurse Practitioner Program. In response to this funding announcement the budget review notes that complementary strategies are also required such as offering positive remuneration to draw practitioners to areas where skills are most needed.104

The Productivity Commission released a report on ‘Caring for Older Australianss in June 2011’ which recommended proposals to assist with workforce issues in the aged care sector including, scheduling prices for aged care to enable fair and competitive wages to be paid to the workforce, expanding accredited courses to increase skills, expanding ‘teaching aged care services’ to promote the sector, providing appropriate training for personal carers, medical, nursing, allied health students and professionals and reviewing delivery and outcomes of aged care related vocational education and training courses by registered training organisations.105

Succession planningWhile succession planning has traditionally focussed on executive and senior management positions, it can also be extended to all levels of an organisation.Organisations that have embraced succession planning have found that it helps identify management talent and capabilities, establishes a broad base of leadership ready to take on new challenges, and avoids the disruption that can result from ill-timed promotions and inadequately prepared managers. Succession planning also

102Australian Health Workforce Advisory Committee and Australian Medical WorkforceAdvisory Committee: Technology & Health Workforce Planning, 2005

103 Commonwealth of Australia: Transforming Australia’s Higher Education System 2009104 Parliamentary Library: Budget Review 2010-11105 Productivity Commission: Caring For Older Australians 2011

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addresses both sides of the recruitment and retention equation, drawing people to the organisation and making it easier to fill senior positions from within.Succession planning can be approached as replacement planning, in which managers identify and help groom their replacements before moving on to another position themselves. Leadership transition planning focuses on planning for the transition of the top two or three positions in an organisation, and continuity or leadership development planning takes a broader assessment of management talent throughout the organisation without attempting to identify single individuals to fill specific positions.106

Local InitiativesThe first Health Directorate Workforce Plan (2005-2010) has already initiated a large number of successful initiatives (See Attachment 2).

Health Infrastructure Program: ‘investing in Canberra’s Health’The ACT Government is currently overseeing a major redevelopment of health facilities in the ACT. These initiatives will require a mix of additional staff, additional skills and workforce redesign including new models of care.

The Health Infrastructure Program: Investing in Canberra’s Health is a comprehensive range of services, including hospitals, community health, mental health, cancer services, aged care and rehabilitation services. This includes provision of home based and remote monitoring and use of technologies to support mobile health workers. The implementation of new technologies is expected to lead to safer treatment with improved quality of care for patients and better communication and collaboration between clinicians and services. It is anticipated that better organisation of workflow and significant time savings will result from the introduction of mobile nurse call systems and laboratory service alert systems.107

Expanded facilities are necessary to meet the future needs of the ACT community. New facilitates completed or underway at the Canberra Hospital (TCH) include an Adult Mental Health Unit, a Mental Health Assessment Unit, a Adolescent and Young Adult Mental Health Inpatient Unit, a new Neurosurgery Suite, a 16 bed Surgical Assessment and Planning Unit and a new Women and Children's Hospital.

Future planned developments include a new acute services building which will include an Emergency, ICU /High Dependency Unit (HDU) and acute inpatient units, and a Centre for Health Teaching, Training and Research. The development will also include the expansion of of diagnostic and treatment services which include new Medical Imaging, expanded interventional suites and development of a digital mammography system.

A sub-acute hospital is also planned to be built on the north side of Canberra.108

106 Rollins, G.: Succession planning: Laying the foundation for smooth transitions and effective leaders in Healthcare Executive Vol 1(6),2003107 The Nexus Consortium: ACTGHD: Digital Health Enterprise Technology Strategy and Implementation Plan Version 1.2 2010108 ACT Government Chief Minister: Media Release: New North Side Hospital, May 2011

38

Within the community, planning includes a new community health centre at Gungahlin, redevelopment of the existing community health centres, potential for Walk in Centres (WICs) in community health sites, expansion of two health centres into enhanced community health centres including expanded clinical, diagnostic, acute and post acute services, and an upgrade of Brian Hennessy House Rehabilitation Centre.

The ACT is investing in new technology to support the Health Infrastructure Program with planned integration of information and communication technologies and medical equipment, including clinical systems, communication systems, clinical devices, controls over the physical facilities, imaging services and information management. This integration will extend across all services and will include home based and remote monitoring and technologies to support mobile health workers.109 This e-health program will further complement and connect with the computerisation of GP services. The new technology is expected to enable secure and coordinated information sharing and teamwork between the different parts of the health system, resulting in improved quality of care and improved patient outcomes.110 Detailed planning is currently underway for the integration of technology into future health service delivery.

Part time Nursing GraduatesWith increasing numbers of new nursing graduates, the Health Directorate is offering new nursing graduates the option to work part time.

109 The Nexus Consortium: ACTGHD: Digital Health Enterprise Technology Strategy and Implementation Plan Version 1.2 2010

110 ACT Government media release: Electronic Transfer of Prescriptions (ETP) way of the future 2010

39

GP InitiativesThe GP Taskforce recommendations have led to the commencement of the following initiatives:

A GP Marketing Support Officer position has been established; Education Infrastructure Support Grant payments are being offered to support

GPs teaching undergraduate medical students; Scholarships are being offered to provide incentives to train in general

practice; The GP Prevocational Placement Program supports junior doctors to

experience general practice as one of their medical rotations; A GP Development Fund is providing one-off incentive payments to GP

practices for initiatives to attract staff, enhance practices and establish new services;

A business-hours GP aged day service has commenced to assist GP practices to provide care to people who cannot travel easily (such as residents of aged care facilities) and reduce pressure on after-hours services and ACT emergency departments.

Models of CareService growth offers opportunities to review and change work practices to use existing staff more efficiently, develop new work flow practices, develop new roles, extend existing roles and review skill mix requirements. The Health Directorate has progressed a number of initiatives including role extension, support positions and innovative service changes.

Role extensionRole extension is being increasingly explored and implemented to meet client needs, reduce workforce pressures and improve clinical career structures. Non-physician clinicians working as substitutes or supplementing physicians in specific roles have been found to maintain, and sometimes improve the quality of care and the outcomes for patients. Revision of roles appears to be acceptable to patients and physicians.111

The Health Directorate has conducted several projects to trial, implement and assess extended scope roles across the health sector, including nurse practitioners who are registered nurses educated and authorised to function autonomously and collaboratively in advanced and extended roles. This role includes assessment and management of clients using nursing knowledge and skills and may include direct referral of patients to other health care professionals, prescribing medications and ordering diagnostic investigations.112 Following successful trials, the number of nurse practitioners has grown in the ACT and the number is likely to continue to expand.

Extended Scope of Practice (ESP) Physiotherapy trails are being conducted in the Orthopaedic and Emergency departments at TCH.

111 Laurant et al: Revision of professional roles and quality improvement: a review of the evidence, 2010112 Office of the Chief Nurse, Nursing & Midwifery, ACTGHD Nurse Practitioners in the Australian Capital Territory: The Framework, 2008

40

In the orthopaedic trial, new referrals are triaged and referred to physiotherapy, a multidisciplinary specialist clinic, or, where the problem has resolved or been treated elsewhere, they are removed from the waiting list. The Orthopaedic ESP physiotherapist provides independent caseload management and has undergone training to order and interpret medical imaging, prescribe limited analgesia and inject joints. Preliminary data is showing reduced waiting times for outpatient orthopaedic appointments, improved access to appropriate care for patients and that these extended scope interventions have been shown to be safe and effective and accepted by patients and colleagues. The project has also proved cost-effective, supporting better utilisation of consultant skills by ensuring that they only see clients who are most likely to require their specialised services.113,114

In the emergency department trial, the ESP physiotherapist is managing musculoskeletal injuries and simple fractures, interpreting x-rays, prescribing simple analgesia and injecting local anaesthetics for relocation of small joint dislocations. Preliminary data indicate that 94% of patients referred to the ESP physiotherapist are treated and leave the ED within 4 hours and that the productivity of the ‘in scope’ physiotherapists working in ED is also enhanced.115

Support Positions

The number of allied health assistants in the Health Directorate is rising slowly and most assistants now have formal qualifications. The literature is sparse, but there is some evidence that allied health assistants have increased access to care for some clients, reduced length of stay, led to faster improvement due to additional rehabilitation input and increased the percentage of patients able to be discharged straight home instead of being discharged to a high level care facility. Allied health professionals have also been freed up to undertake a greater range of services and to concentrate more on providing complex treatments to a greater range of patients.116

In the Health Directorate, assistants are being used to run group sessions for groups of people assessed as having the same needs. In one instance it was found that changing to a class based intervention for post operative exercise needs for total knee replacements (TKR) led to an overall 36% improvement in staffing efficiency compared to standard practice in treating TKR and specifically led to a 79% reduction in physiotherapist hours spent treating clients with TKRs117 and the classes were well accepted by clients. This type of initiative has the potential for expansion to other treatment groups and disciplines where appropriate and assists in making better use of the skill mix available.

113 Morris et al: Effectiveness of a physiotherapy-initiated telephone triage of orthopaedic waitlist patients; Patient Related Outcome Measures 2011 114 Gilmore et al: Skills escalator in allied health: a time for reflection and refocus; Journal of Healthcare Leadership 2011115 Morris, J. PowerPoint presentation (unpublished) May 2012116 ACT Health Directorate: Evaluation of the impact of up skilling ACTGHD Technical Officers working in Speech Pathology, Physiotherapy and Occupational Therapy 2009117 Quality Improvement Activity Report for 'Implementation of Circuit Class for Post Total Knee Replacement (TKR) Patients referred to Continuing Care Physiotherapy' July 2009 (Unpublished)

41

In 2011-12 Therapy ACT will be piloting a new model of service using therapy assistants for students with disabilities in schools.118

Innovative service changesA number of innovative service changes are occurring within the Health Directorate, including:

The new WIC is staffed by nurses who provide free one-off advice and treatment for people with minor illness and injury;

The ‘Care around the Clock’ project recently examined current services, staffing and demand at the Canberra Hospital and analysed and proposed services, systems and staffing across 24 hour service delivery. The findings are being used to inform future improvement work and rolled into an overall plan for the Canberra hospital campus;119 and

The Rapid Assessment of the Deteriorating Aged at Risk program (RADAR) is a rapid response program to support older people in the community, when they are becoming unwell and their own GP requires assistance with medical management.120 In 2009-10 the RADAR service helped to potentially avoid admission to hospital for 78% of all patients seen by the service. Patients that did require admission were directly admitted to the Medical Assessment and Planning Unit, or into the private hospital system under the care of a geriatrician, thus avoiding admission to the Emergency Department. The service has been expanded by the recruitment of an additional staff specialist geriatrician, an additional RN and an occupational therapist. Access to the service has also been broadened to include referrals from RAC facilities, providing the GP has consented.121

As part of the ambulatory planning process, suitable Health Directorate services currently based at a hospital will be gradually relocated into community health centres. The aim is to provide tertiary level services on hospital grounds and non tertiary/non-acute services in the community setting.

Developing and supporting the consumer, carer and volunteer workforceThe mental health sector is building their consumer and carer workforce including establishing a scholarship program for consumers to study certificate IV in mental health and supporting consumers and carers to take on valued paid and volunteer roles in all areas of planning, development, governance, management, delivery, and evaluation of services across the mental health sector. It is anticipated that the consumer and carer workforce will offer additional support options not reliant on specialist professionals.122

118 ACT Government Community Services Website 07/11/2011119 ACT Health Directorate: Care Around the Clock project (Accessed 02/12/2011)120 ACT Government (Health) RADAR Web Page 2011121 ACT Health Directorate Annual Report 2009-10122 ACT Health Directorate Mental Health Services Plan 2009 - 2014

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Where viable and appropriate, Health Directorate workers in the community can provide education, support and training for carers who choose to provide care including technical care.123

Chronic disease self-management (CDSM) is the active participation by people in their own health care. A joint Health Directorate and Arthritis ACT program offers training for people with chronic diseases on living a healthy life with long term conditions.124

Volunteers enjoy an increased sense of belonging to their community, as well as opportunities to use their skills, to make a difference to the organisation’s work, and to learn and develop. Volunteers also find that volunteering assists them to find paid employment. The available supply of suitable volunteers and limited organisational capacity are the most common barriers to involving volunteers reported by organisations. There is also a need to introduce new and different approaches to promoting volunteering.125

Discussion Points:

1. Do you believe there is enough investment already underway to meet the health workforce challenge?

2. Are there other areas of the workforce challenge that you believe needs closer attention?

123 ACT Health Directorate Support & Training for Carers policy (internal document)124 ACT Health Directorate: Chronic Conditions- Living a Healthy Life with long term conditions accessed 17/06/2011 125 Volunteering Australia : National Survey of Volunteering Issues 2010: Preliminary Findings – Summary

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13. Key Strategies for further explorationOverarching principlesWorkforce planning and retention strategies should be cost effective, resilient, proactive, ethical, equitable, accountable and appropriate and support provision of the right service to the right person at the right time and in the right place. Consumer and population needs must provide the main driving force for workforce change.

The following overarching strategies are aligned under the domains provided in the Health Workforce Australia National Health Workforce Innovation and Reform Strategic Framework for Action 2011-2015. The ACT will be collaborating with the national workforce reform program to meet the health workforce needs into the future.

These strategies are recommended to provide a framework for workforce planning and retention within the Health Directorate. The strategies are based on the local input provided to inform preparation of this paper, the findings from the literature and the national workforce reform strategies.

These strategies may also assist other health services based in the ACT in workforce planning activities.

Workforce planning strategies

Domain 1: Health workforce reform for more effective, efficient and accessible service delivery.

Objective: Reform health workforce roles to improve productivity and support more effective, efficient and accessible service delivery models that better address population health needs.

Strategies under Domain 1 Introduce more efficient technologies;

Develop strategies to meet service gaps;

Increase use of volunteers and use volunteers more effectively;

Provide time and support for planning and change management;

Support inter-professional collaboration;

Increase productivity and retention of the existing workforce;

Support all health disciplines to work to their full or extended scope of practice;

Utilise the assistant and support workforce more efficiently;

44

Collaborate with national initiatives to investigate models of workforce reform, policy and funding options that are inclusive of private and NGO providers;

Collaborate with national initiatives to develop cross-discipline guidelines for regulation of redesigned roles, expanded scopes of practice and accreditation of supporting training programs.

Domain 2: Health workforce capacity and skills development.

Objective: Develop an adaptable health workforce equipped with the requisite competencies and support to provide team-based and collaborative models of care.

Strategies under Domain 2

Make better use of skills in the workplace; Empower consumers and expand client self-care options; Collaborate with national initiatives to increase education and training

options including inter-professional strategies, articulation across education programs, increased re-entry points to training and career paths;

Promote health careers and build programs in schools and workplaces;

Work with tertiary institutions to ensure that education and training programs prepare the workforce to deliver culturally appropriate and safe health care in all settings;

Facilitate the uptake of technologies that enhance workforce practice and productivity with an emphasis on underserved communities and populations;

Expand clinical training placements in underserved and non-traditional settings.

Domain 3: Leadership for the sustainability of the health system.

Objective: Develop leadership capacity to support and lead health workforce innovation and reform.

Strategies under Domain 3 Make succession planning part of core business; Encourage continuity of leadership; Collaborate with the development of national health workforce leadership

competencies; Support the leadership capacity of the Aboriginal and Torres Strait Islander

workforce; Support, promote and sustain inter-professional practice and workplace

learning.

45

Domain 4: Health Workforce Planning.

Objective: Enhance workforce planning capacity, taking account of emerging health workforce configuration, technology and competencies.

Strategies under Domain 4 Develop targeted retention and attraction strategies for small and hard-to-find

professions; Drive workforce change based on consumer and population needs; Develop incentives for retired workers to return to part time employment; Improve the capacity and accessibility of workforce information among

managers and staff; Collaborate in the development of a national health workforce planning

approach and national health workforce tools; Contribute health workforce data to a National Statistical Resource.

Domain 5: Health workforce policy, funding and regulation.

Objective: Develop policy, regulation, funding and employment arrangements that are supportive of health workforce reform.

Strategies under Domain 5 Lift the workforce participation rate by encouraging and supporting more

people to enter, re-enter, extend working hours and remain in the workforce; Support the capacity of the tertiary education sector to deliver skills training; Develop a partnership approach to workforce development between

government, industry and private enterprise; Facilitate increased collaboration between organisations; Revise exit data collection methodology; Encourage and support bottom-up workforce change initiatives; Utilise the new Integrated Regional Clinical Training Network to improve

training opportunities; Make care of the health workforce part of core business; Work with HWA to identify system wide changes required to achieve a

balance between generalism and specialism; Identify policy, financial and non-financial mechanisms which enable the most

cost-effective, efficient deployment of the health professional workforce; Work with HWA to maximise retention of clinical training supervisors across

disciplines by addressing policy, regulatory and other mechanisms;

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Collaborate with national legislative and regulatory reforms to facilitate appropriate mobility of the health workforce across professions and the implementation of expanded scopes of practice;

Collaborate with national legislative and regulatory reforms to address legislative, regulatory, industrial and other barriers to minimise inefficiency and duplication and to achieve greater workforce ability to respond to the health needs of the community;

Collaborate with national legislative and regulatory reforms to address remuneration, payment arrangements and terms and conditions to support workforce models that increase accessibility, improve workforce retention and productivity and encourage inter-professional practice.

Discussion Points: 1. Do you agree with these strategies?

2. Are there other strategies that you believe should be considered?

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14. Glossary

AIN: Assistant in Nursing

ACT: Australian Capital Territory

ACTGHD: ACT Government Health Directorate

AIHW: Australian Institute of Health & Welfare

ACTDGP: ACT Division of General Practice

CSS: Commonwealth Superannuation Scheme

CCU: Coronary Care Unit

EN: Enrolled Nurse

EL: Executive Level

ESP: Extended Scope of Practice

FTE: Full Time Equivalent

GP: General Practitioner

HP: Health Professional

HDU: High Dependency unit

HWA: Health Workforce Australia

ICU: Intensive Care Unit

IMG: International Medical Graduate

NHMRC: National Health and Medical Research Council

NSW: New South Wales

NGO: Non Government Organisation

RAC: Residential Aged Care

RADAR: Rapid Assessment of the Deteriorating Aged at Risk

RN: Registered Nurse

SES: Senior Executive Service

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TCH: Canberra Hospital

TKR: Total Knee Replacement

VET: Vocational Education & Training

VMO: Visiting Medical Officer

WIC: Walk in Centre

49

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Attachment 1: List of Submissions received to assist preparation of the Discussion Paper

Written Submissions

External Health Directorate ACT Ambulance Service ACT Chief NurseACT Council of Social Services (ACTCOSS) Health Directorate Speech PathologyACT Division of General practice (ACTDGP) ACT Lyphoedema ServiceAustralian Health Promotion Association (AHPA): ACT Branch

Calvary Public Hospital

Australian Nurses Federation (ANF) Capital Region Cancer ServiceAustralian Salaried Medical Officers Federation (ASMOF)

Continuing Care Nutrition

Capital Pathology Continuing Care NursingCanberra institute of Technology (CIT) Information ManagementCommunity & Public Sector union (CPSU) Interprofessional Learning CoordinatorDisability ACT Patient Safety & Quality UnitHealthcare Consumers Association (HCCA) Staff Development UnitMental health Community Coalition (MHCC) TCH PharmacyRoyal College of Pathologists of Australia TCH PsychologySpeech Pathology Australia TCH Social WorkTherapy ACT Transitional Therapy & Care Service

Verbal Feedback

External ACTGHD ACTCOSS Acute supportHCCA Aged care & Rehabilitation ServiceMental health Community Coalition (MHCC) Business & InfrastructureMorsehead RAC facility Clare Holland House (Palliative Care)Private Speech Pathologist Government Relations, Planning &

Development UnitWomen with DisabilitiesYouth Coalition of the ACTACT & Southern Tablelands Regional Committee & DONs meeting

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Attachment 2: Achievements & Initiatives related to 2005-2010Workforce Plan

The 2005-2010 Workforce Plan supported ACTGHD to:

Initiate a range of research projects on workforce redesign, extended job roles and extended scopes of practice within the allied health, nursing and midwifery disciplines

Establish Nurse Practitioner Roles

Establish Allied Health Assistant Roles

Introduce new workforce practice models for enrolled nurses

Introduce safe working-hours arrangements for the medical profession

Introduce more versatile roster hours for nurses

Conduct an Occupational therapy workforce review

Conduct a Radiation Therapy Workforce Review

Collaborate with the Canberra Institute of Technology (CIT) to develop and implement Certificate IV programs for Occupational Therapy Assistants, Physiotherapy Assistants and Speech Pathology Assistants (2006-07)

Explore Nutrition & Podiatry Allied Health Assistants roles and participate in developing a Certificate IV course for these groups

Participate in the CIT Advisory Committee and Program Reference group to develop new curricula for enrolled nurse training

Participate in establishing an accelerated program for articulation from EN to RN at the Australian Catholic University (2006)

Work with local higher education institutions to better align courses with workforce needs

Conduct a feasibility study for the establishment of a Skills Development Centre including simulation environments

Use the Special Employment Arrangement provisions for hard-to-recruit professions, offering scholarships to students who agreed to work in ACT Health upon graduation

Collaborate with the University of Canberra initiative to provide access to Clinical Educators to undertake a Graduate Certificate in Tertiary Education (2008)

Commence Prevocational General Practice Placements Program (2008)

Establish Health Day Out careers day (2007)

Pilot a Mentoring Program for Early Career Researchers in the Allied Health Professions

Establish an accredited medical specialist training program in paediatric surgery and partnerships with the private sector for vocational training programs in Psychiatry, general surgery and community rehabilitation and aged care

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Support building the Allied Health School at the University of Canberra

Commence a trial of extended scope physiotherapy roles (2010)

Enhance partnerships with the tertiary education sector

Develop a rigorous learning and development strategy

Review the Health Directorate orientation program (2008-09)

Develop the Capabiliti training management system (2007-08)

Review the performance management system learning and development strategy, resulting in streamlined training activities (2007-08)

Fund scholarship support to nurses, & midwives and (from 2007) allied health professionals

Introduce Apprenticeships & Traineeships for Allied Health Assistants

Introduce a Leadership & Management development program (2008-09)

Introduce team development exercises

Establish the Medical Appointments and Training Unit (2006)

Establish the Student Clinical Placement Unit (2008)

Develop and launch the Student Placements Online Database

Commence a Managers Orientation Program

Commence a Stepping Up Program (2008)

Establish the Inter-professional Learning Coordinator and Program (2005)

Commence a Graduate Midwife Program (2006)

Commence an EN Graduate Program (2006)

Revise the EN Professional Development Program (2009)

Commence the Clinical Development Nurse/Midwifery Program

Provide support and resources for Diploma and Certificate courses in Nursing and Midwifery

Introduce refresher programs for registered nurses/midwives

Introduce an overseas-qualified nurse program

Introduce a Paediatric non-health professionals programs

Introduce the Positive Professional Development Scheme

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Attachment 3: Health Directorate workforce distribution byclassification June 2011

Nurses Admin Allied Health

Medical Officers

Support Services

Technical Executive MiscellaneousProfessionals

TOTAL

Head count 2363 1179 955 720 442 202 20 17 5898

FTE 2009.18 1085.59 837.25 620.65 397.03 158.91 19 14.99 5142.6

% Female 90% 80% 80% 43% 42% 73% 60% 76% 76.55%

Average age 43 42 40 39 42 43 49 41 41.5

% Part time 44% 17% 28% 15% 20% 24% 0% 29% 30%

% Permanent 85.99% 82% 83.35% 30.14% 78.28% 62.37% 30% 41.1% 76.21%

% Casual 5.5% 4.83% 2.61% 1.11% 14.25% 26.2% 0% 0% 5.6%

% Temporary 8.51% 13.31% 14.03% 68.75% 7.47% 11.38% 70% 58.82% 18.09%

% of total workforce

40.06% 19.99% 16.19% 12.21% 7.49% 3.42% 0.34% 0.29% 100.00%

Average tenure (years)

7.77 7.20 7.06 4.02 7.16 5.48 11.47 7.59 6.97

16.

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Attachment 4: Health Directorate workforce distribution by age range

Age Range <20 20_24 25_29 30_34 35_39 40_44 45_49 50_54 55_59 60_64 65+

Grand Total

Female 21 256 579 522 532 528 579 615 429 191 48 4300Male 8 61 122 183 213 176 145 155 112 70 19 1264Grand Total 29 317 701 705 745 704 724 770 541 261 67 5564

<20 20_24 25_29 30_34 35_39 40_44 45_49 50_54 55_59 60_64 65+0

100

200

300

400

500

600

700

Female Male

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ACTGHD Workforce distribution by age range as at 22/09/10

Attachment 5: Related ACT Government Health Directorate Service Plans and strategies

ACT Health Directorate Corporate Plan 2010-2012

Health Directorate Sustainability Strategy July 2010

Critical Care Services Plan 2007-2011 (Under review)

Digital Health Enterprise Technology Strategy and Implementation Plan Version 1.2 2010

Diabetes Services Strategic Plan 2008-2012

Mental Health Services Plan 2009-2014

Renal Health Services Plan 2010-2015

Towards a Healthier Australian Capital Territory: A Strategic Framework for the Population Health Division 2010–2015

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