Addressing Health Workforce Shortages in Rural and Remote Australia through the Provision of Physician Assistants

By Ankur Verma

Ankur attended the 2015 OECD Forum in Paris. 

Abstract

The context of global and Australian health workforce presented in this research paper has been used to guide the introduction of Physician Assistants (PAs) into Australia as a national health care recommendation. The scope of practice, employment potential, prospective impact on the Australian health system, and contribution to the productivity and quality of health care services[1] offered by the Physician Assistant model, as it is referred to, is discussed in support of the recommendations presented in this paper. Alternative rural and remote training pathways and better access to health care through even workforce distribution have been selected as two broad themes for this research paper. Health Workforce Australia’s (HWA) review on the globalisation of PAs in the United States (US), has also been used to guide the need for professional registration for PAs with the Australian Health Practitioner Regulation Agency (AHPRA), and accreditation with the Australian Medical Council (AMC). PAs’ access to the Medicare Benefits Schedule (MBS) and the PBS (Pharmaceutical Benefits Scheme) has also been recommended evidenced by their role in the Australian health workforce context, so they can be utilised to their full potential including contributing to General Practitioner (GP) supervised primary care services, especially in rural areas. 

Recommendations

The review undertaken is based on the support of Australian College of Rural and Remote Medicine (ACRRM):[2]

  • Recommends national registration for Physician Assistants through the Australian Health Practitioner Regulation Agency (AHPRA), ideally under the direction of the Medical Board of Australia.
  • Recommends access to the Pharmaceutical Benefits Scheme (PBS) and the Medicare Benefits Schedule (MBS) for PAs to make a sustainable contribution to primary health care services, and enable ‘collaborative arrangement’ between PAs and medical practitioners.
  • Recommends the implementation of ‘mid-level’ health care personnel including the Physician Assistant role in regional, rural and remotes areas of Australia as a general approach to address the shortages of General Practitioners (GPs), and stabilise health care services in those areas.
  • Physician Assistants should be adopted as part of the national health workforce with an intent of introducing PAs in all States and Territory jurisdictions across Australia, using the accreditation standards for professional training developed by the Australian Society of Physician Assistants (ASPA).
  • Recommends Medical Board of Australia, Australian Medical Council (AMC), and ACRRM to establish a model of accredited tertiary educational programs nationally for Physician Assistants, ideally housed within medical schools.

Introduction

The aim of the Organisation for Economic Co-operation and Development (OECD) is to promote policies that will improve the economic and social wellbeing of people around the world. [3] An important aspect of increasing the economic and social wellbeing of all people is to review and implement effective health policies addressing the rural and remote health workforce. The purpose of this research paper is to highlight relevant data and provide references to key health workforce data and health outcomes.[4] The aim is to provide evidence on ways of improving access to healthcare and services for the Australian population, and to produce improved health outcomes across the country by introducing PAs into Australia’s health care team, especially in rural and remote areas.[5] For the purpose of this paper, the term ‘health workforce’ refers to medical practitioners (general and specialists), nurses (registered and enrolled) and midwives, and certain allied health practitioners; and health workforce is discussed in both global and Australia’s context.

Based on the findings, key recommendations to Australia’s health system and policy makers relevant to the PA workforce model are presented in this paper. The development of PAs in other OECD countries has been used to inform Australia’s health care system to consider its national accreditation and registration by AHPRA. Globalisation of PAs in a range of health services around the world (Canada, United Kingdom, United States and others) have also been linked with positive health outcomes, which suggests a need for innovative models of primary health care funding and delivery in Australia. Consequently, the recommendations proposed may serve as a guide for both the State and Federal Governments to consider the implementation of PAs as a solution to improve the healthcare training pipeline, and as a medium-long term reform of health care systems.

Role of a Physician Assistant (PA)

The term Physician Assistant (PA) has been defined as someone who assists the physician in the provision of medical services.[6]-[7] The PA-profession training is based on the ‘medical model’, and was first created in the USA in the 1960s. PAs practice medicine under the direct supervision of a doctor.[8]

PAs can learn to provide any type of services that GPs can deliver, and add a new level of flexibility to primary care in areas with too few GPs. A systematic review was undertaken by the Anthropology Department at University of Texas that assessed the scope of practice of Physician Assistant in rural health.[9] Out of the fifty-one papers which were identified, twenty eight papers had a primary focus on research and specified PAs in a rural setting. The study findings revealed that PAs provided cost-efficient and supplemental medical services in underserved populations.[10] They were found to be highly valuable, with a large scope of primary care practice as a rural PA.  

PA’s role in Primary Care and Specialist Services

Primary care is often the first point of entry for patients into the health care system. Therefore, early training programs are designed to prepare PAs for roles in the primary care sector.[11] Skills which a PA may apply include taking patient histories, physical examinations, knowledge of signs and symptoms, and recognising emergencies, though this list is not exhaustive. This further enhances the role of PAs in educational, acute and chronic care management settings, along with providing care in the community by linking patients with services and resources.[12] The HWA’s second report on the potential role of PAs in the Australian context highlighted that the scope of practice of PAs extended to 61 specialist fields in the US, including paediatrics, obstetrics, gynaecology, surgery, and surgical subspecialties, to mention only a few. The report also highlighted that PAs in surgical care performed assistant roles in order to maximise the surgeon’s time to perform more complex procedures.

PAs possess a wide range of clinical skills in the Emergency Departments of hospitals in the US. A meta-analysis of 66 studies on the role of PAs in Emergency Departments by Doan et al (2010) found that approximately 66 percent of US academic medical centre hospitals used PAs in the Emergency Departments.[13] The study also found that the quality of care provided by PAs was comparable with that of the physicians and senior residents, with an ability to deal with 62 percent of the Emergency Department cases.

Globalisation of the Physician Assistant model

Due to shortages of doctors (especially in rural areas), as well as rising health care costs and increases in physician costs, some OECD countries like Canada, England, the Netherlands and Taiwan have adapted the PA concept as one of many solutions to their medical workforce problems.[14] For example, Canada faced doctor shortages and access to health care for many of its citizens, and introduced PAs in the health workforce as a partial solution.[15] Similarly, the Netherlands faced an ageing population with comorbidities and increased costs of health care issues. This was also actioned by the introduction of the PA profession as a strategy to improve the provider-to-patient ratio, and reduce the cost of health care.

Similar health workforce issues and poor health outcomes have been associated with countries like Australia, where workforce shortages in rural areas and underrepresentation of Indigenous health care providers are prevalent.[16] Therefore, Australia has now turned its interests to developing a US-modelled PA practitioner to work closely with doctors and improve access to care. However, the implementation of PAs is still not effective, and needs coordinated action by the Commonwealth and State governments.

Issues Impacting Global Health

The Global Health Education Consortium (GHEC)[17] released a module that undertook an initiative to understand the disparities in global health and in the health workforce. The module suggests that there is an ongoing challenge for public health services to allocate health resources effectively, to reduce major causes of disease burden globally, and to decrease health disparities between poor and affluent populations.18 One of the major global health issues identified by the World Health Organisation (WHO) includes chronic disease, which is highly associated with social determinants of health, such as low income, and ageing population. Chronic diseases such as diabetes and cardiovascular diseases are amongst the top ten causes of morbidity and mortality in high income countries like Australia. The most influential factor related to these health outcomes is the higher rates of poverty among the older persons in most OECD countries than the population average, which has detrimental effects on nutritional status, work environment, living conditions, access to healthcare, and availability of healthcare providers. [18]     

In contrast, a deficient healthcare workforce is recognised as a more significant issue by the WHO, as it is a more serious obstacle to implementing treatment plans.[19] This trend is further understood from life expectancy data, which indicates that political leadership, adequate financing, and a comprehensive plan must be in place in order to expand the health workforce. An example of this is reflected in the life expectancy of those in the United States, which is listed as 24th amongst the OECD countries. This suggests a need for lessening health care disparity and a well-planned workforce expansion.

Other challenges for global health include the ageing population in industrialised nations. For example, the older population in less developed regions is growing faster than in the more developed regions. The United Nations projects that by 2050, nearly eight in ten of the world’s older population will live in the less developed regions.[20] Due to ageing populations, the developing countries are facing a high burden of health care costs attributable to chronic conditions, as well as health workforce issues due to the retirement of providers. Consequently, because of the increase in prevalence of chronic conditions such as diabetes and heart disease in developing countries, and healthcare budgets already strained, nations are being faced with hard decisions regarding where to place the health care dollar.

Industrialisation is an important determinant responsible for these health outcomes that exists globally. The cyclic process of industrialisation across countries has caused an unprecedented amount of migration since the early 1990s.[21] As a result, influxes of immigrants, refugees, and internally displaced populations are faced with increased health risks related to poverty, personal danger, and mental health issues. Globally, providing health care for these at-risk populations has been difficult and costly. Therefore, a new paradigm in management of humanitarian crises is emerging, encompassing a change in skills needed by healthcare providers, and with greater emphasis on infectious diseases, tropical medicine, chronic diseases, cultural sensitivity, and global health in medical education. Consequently, the change has been implemented by experimenting the concept of PA profession in 13 countries to meet the specific health needs and skills required for populations at-risk, and enable the PA profession to be an alternative approach to addressing access in global health.

Challenges of Global Healthcare Workforces

Such global health challenges have raised a need for international action to increase healthcare workforces. This was effectively summarised by Dr. Margaret Chan, Director-General of the WHO during the welcoming address in Geneva, Switzerland, 2007, when introducing a new international Task Force to address the global health workforce shortage:

The simple fact is that the world needs many more health workers. The world faces global as well as local threats to health. Infectious diseases have staged a dramatic comeback, and chronic diseases are on the rise. We cannot improve people’s health without the staff to deliver health care.

The WHO recognises that health workforce challenges are driven by health needs (changing demographics and disease burden), health systems (financing, technology, and customer preferences) and context (education and globalisation).[22] Some of the global health workforce challenges recognised by the WHO include shortages of health workers, misdistribution in rural and urban areas, and lack of effective working conditions and workplace safety. Therefore, given the magnitude of challenges, health workforce shortages are a global phenomenon, and Australia is no exception. Australia, like most other developed nations, is experiencing workforce shortages across a number of health professions, especially in rural and remote areas, despite a significant and growing reliance on International Trained Graduates (IMGs).[23] However, as the PA model is experiencing expansion and implementation in nations with similar health systems to that of Australia, implementing a PA model in Australia could potentially also address workforce shortages and health service misdistribution.[24]

Australia’s Health Workforce Context

The 2015 Intergenerational report states that the Australian Government health expenditure per capita is projected to more than double over the next 40 years,[25] with an increment from 4.2 percent of GDP in 2014-15 to 5.5 percent in 2054-55 under the ‘proposed policy’[26] scenario. Such increments are validated with Australia’s growing and ageing population, needing increasing chronic care, and a decreasing supply of the health care professionals to supply that care, particularly in rural areas.[27] Similar health care and workforce challenges are faced by other OECD countries who have trialled the PA role as a partial solution to these needs. Therefore, the effective contribution of a PA in rural areas warrants a need for growth and change in the Australian health care system over the next forty years.[28]

Australia has the longest life expectancy in the world, 29 which is indicated by the future projections of life expectancy at birth as 95.1 years for men and 96.6 years for women in 2054-55, compared with 91.5 and 93.6 years today.[29] This growth has important implications on the demand for primary health and aged care services. Such concerns were raised from the results of the 2011 Productivity Commission[30] when aligned with the future projections of demand and supply. The supply pressures were indicated by a small example of uneven distribution of health workforce, indicating that only 27 percent of GPs and 23 percent of medical specialists live outside major cities.[31] Moreover, demand pressures were indicated by the ageing and diverse populations of Australia, including 70 percent of Aboriginal and Torres Strait Islander peoples who live outside major cities.[32] The statistics above indicate that the geographic distribution of health workforce remains uneven. This finding is significant, because it matches a disparity in health outcomes for communities in regional and rural Australia.[33]

Burden of Chronic Diseases on Australia’s Health Workforce

With an ageing population, and the diversity of communities accelerating the demand on the health workforce, there is a growing prevalence of chronic illness.[34] The 2007-08 National Health Survey recognised the burden of chronic diseases as highly prevalent among the Australian population accounting to cancer (2%), diabetes (4%), asthma (10%), long-term mental or behavioural conditions (11%), arthritis (15%) and heart disease (16%).[35] The increase in chronic diseases has implications not only for the number of health workers required, but also the skills mix and different models of care required for optimum treatment. Therefore, mounting burdens of chronic disease demanding heavy workloads in emergency departments has led to the creation of mid-level and advanced clinical roles for nurses, midwives and allied health workers.[36] Among the supply of health workers, the research findings also indicate that multidisciplinary and team-based care is becoming increasingly important to the management of many chronic diseases.[37]

However, there is still a wide gap in the degree to which health consumers have access to information about preventative health and health maintenance.[38] The current trend relies on the significant demand for specialised acute health services with less effective and costly results; when investments in primary care, health promotion and disease prevention would produce better health outcomes.38 For example, if PAs were used to bring the lowest-access rural and remote Medicare local areas up to the 20th percentile target, this could save patients almost $5 million a year in fees, given that GP fees are currently a serious barrier to care.[39]-[40] This would mean that PAs would have to bulk bill Medicare. Therefore, it is recommended that the Commonwealth Government allow PAs to access MBS, and referral billing systems (for diagnostic images and tests).

It is evident that resource allocation, necessitated by cost challenges and exacerbated by long distances, has resulted in Australia’s continuing struggle to provide equality of access to primary health care (PHC) services.[41] Therefore, it is important for the State and Commonwealth governments to consider regulatory changes for a smooth transition of PAs by enabling National Registration with AHPRA under the direction of Medical Board of Australia, accreditation of training program by the Australian Medical Council, harmonising legislation across states and territories allowing them to prescribe, and access MBS and PBS for Medicare and pharmaceutical benefits. [42]

Solutions to Transform Models of Care

Training

According to HWA, the projected balance of supply and demand for doctors to 2025 indicates that Australia is in a training bottleneck, as shown by the lack of 800 hundred GP training positions last year.[43] The deficit in training pipelines warrants a need for thousands of specialty positions to be funded and accredited to fill the gap that Australia will have by 2030.41 However, training takes a long time to produce independently practicing vocationally trained specialists, and once completed, doctors typically have a long medical career. These facts mean that adjusting medical student numbers is not an effective means to deal with imbalances between supply and demand for doctors.[44] Rather, these pressures provide a validity for the creation of the PA workforce that offers a route into expanded, flexible, and clinical careers[45] that can not only be the solution to rural doctors and specialists misdistribution, but can also assist with the retention of health professionals who might otherwise be lost to the health care system due to deficits in training pipelines.

Innovation and Reform

The key findings from the HW2025 report recommend that Australia needs a variety of innovation reforms to facilitate the necessary transformation of the existing health system.[46] The PA role is suggested as the future workforce solution that can make a significant contribution to the rural and remote health workforce of Australia.[47] The introduction of PAs, as part of the framework strategy[48], focuses on supporting and extending the career span of existing rural and remote health workforce (with the PA profession as an advanced career option for Aboriginal Health Workers) and providing medical services in regional, rural and remote areas of Australia where attracting and retaining Australian-trained doctors is difficult, and supporting health care services for Indigenous Australians through multidisciplinary teams.

There is substantial evidence [49] that PAs can expand the care available in under-serviced areas, without compromising quality or safety, and at an affordable cost. The findings of a study undertaken by the Grattan Institute support the need to expand access to GP services in rural and remote areas ‘by redesigning and redistributing the way doctoring and nursing are provided.’[50] Therefore, PAs, based on strong evidence, have been suggested as the major solution to the imminent loss of experience in the medical workforce.[51]

Development of Physician Assistant Role in Australia

The delegated nature of the PA role, its flexibility and potential breadth in the scope of practice have responded to the needs of a rural practice. This was reflected in the two independently-evaluated PA pilot programs in South Australia and Queensland in 2010 which resulted in successful outcomes in regional and Aboriginal communities. The pilot programs were small with consistent and encouraging results concurrent with overseas experiences, including shorter waiting times, improved safety and clinical outcomes, and very high levels of patient satisfaction.[52]  The PAs recruited in both locations primarily worked in the Emergency Department, Outpatient clinics, and Primary Health Care Centres (PHCC) such as Aboriginal Health Services. The key roles of a PA are discussed as a brief example in Table 1 to summarise the health outcomes for Aboriginal communities.

Table 1: The table describes the key Findings from Queensland AHS PA trial against several Domains of Quality.[53]

Table 1: The table describes the key Findings from Queensland AHS PA trial against several Domains of Quality.[53]

The above outcomes of the pilot programs suggested that PAs enabled more equitable care by providing access to additional clinic times along with a medical practitioner. This was further evidenced through patient survey results from Cooktown and Mount Isa, which found that the care provided to them was ‘a lot better’ than usually provided.[54] The Queensland pilot also identified the importance of e-health (electronic record system) that facilitated communication between health professionals, and allowed review of the basics of internal medicine for PAs to become part of the team.[55]

‘Delegated practice’ of PAs in the Queensland Health system has intended to fill the health service gaps in underserved populations, extending to urban and suburban populations as well as Indigenous settings. A recent example was the launch of three PA positions under the Queensland health systems at Townsville Tertiary Hospital (TTH) in the Emergency department, where the role of recent James Cook University PA graduates involved specific skills working under a new ED model called SIFT (Senior Intervention from Triage). A recent graduate described the delegated practice working with Emergency Department registrars and consultants as ‘supportive’, as the graduate gained an opportunity to extend specialist services by taking on routine assessments, pre-and post- procedural care, and follow-up and outreach to free specialists for complex cases.[56]

The Economic Outcomes of Physician Assistants

Table 2: The table shows the Medicare billing on a typical day caring for an average of nine patients at Mulunga Aboriginal Health Service (AHS) in Mareeba, Queensland.[57]

Table 2: The table shows the Medicare billing on a typical day caring for an average of nine patients at Mulunga Aboriginal Health Service (AHS) in Mareeba, Queensland.[57]

The Intergeneration Report 2015 highlights productivity as the most important driver of Australia’s economic growth. Productivity was defined as ‘working more efficiently or producing more or better quality services.’[58] The evaluation of the two Australian pilot program supports PAs contribution to the productivity and quality of health care provided.16 Based on the evaluations of the pilot trials, findings suggest that PAs contribute to the improved functioning of service delivery that is safe, clinically effective and acceptable to patients.

Medical college representatives stated that the productivity of PAs is likely to be greatest in rural areas.[59] This is further evidenced through the Medicare items (Table 2) utilised in Mulunga Aboriginal Health Service (AHS) for generating income to pay both the doctor and PA salaries.

The current health workforce costs two-third of the current spend on health care, which alone makes a strong case for supporting the implementation of PAs that supplement future workforce needs and take measures to keep supply and demand close to equilibrium.[60] This is evident in this systematic follow-up built into the Medicare scheme (Table 2) where patients at Mulungu AHS had the opportunity to ask questions, initiate discussions about problems, prevent gaps in medication regimes, and formulate solutions more effectively. The PA’s contribution further resulted in additional time for doctors to treat more complex patients, and other leadership duties including administration, clinical data review and teaching of medical students.[61]

Development of the PA model beyond its pilot program has been consistent with the support of several peak organisations such as The Royal Australasian College of Physicians (RACP) and ACRRM. Their submission to the National Health and Hospitals Reform Commission in 2009 has supported and encouraged task transfer and delegated practice as an evolving way of taking roles in patient management, and extension to training approaches in form of medical service (doctor/physician) extenders rather than substitutes or replacements.[62] Therefore, doctors who understand the benefits that PAs bring to health care, and want to progress with implementation of the role, should raise concerns to AHPRA and Medical Board of Australia in regards to the provision of professional registration for PAs as without it, their skills are not fully utilised.

Conclusion

Improvements in workforce distribution requires the Physician Assistant (delegated care) model to increase efficiency and effectiveness of the avaable health workforce.[63] Introduction of PAs in the patient-centred, team-based approach (components of medical model) has proved to be effective in chronic disease management.[64] Through the collaboration of PAs with medical practitioners at primary and tertiary care institutions, patient acceptance of this holistic model and positive health outcomes have been effectively highlighted in Australian pilot programs. Pilot programs in Queensland and South Australia, and the experiences of other OECD nations exemplifies the potential that the PA model presents. The doctor/PA partnership is a non-competitive, time-efficient and cost-saving model that improves access for more patients to high quality care. Therefore, the PA profession should be implemented as a ‘mid-level’ health care personnel, predominantly in regional, rural and remote areas of Australia as a guide to general approach to address the workforce shortages, and then ease its integration into the Australian health care system nationally. Reductions in doctors’ fatigue and isolation, and increases in productivity, are key advantages of this partnership, which consequently affect the retention rate of doctors, especially in rural and remote communities. From the trials undertaken, a few recommendations have been drawn to establish training programs for locally trained PAs and students, enable professional registration arrangements by AHPRA through national regulation, and enlist the PA profession as part of the National Registration and Accreditation scheme by Medical Board of Australia, and its accrediting body, Australian Medical Council (AMC). Given the strong evidence provided on the successful implementation of PAs associated with improved health outcomes and access to health care both in Australia and other OECD countries, it can be recommended that the State and Federal governments action the implementation of PAs into the health workforce as one strategy to addressing the deficits in healthcare training.

Full Footnotes and Bibliography can be found here or by copying the following URL into your browser: http://bit.ly/AnkurVerma