Systemic failures in health and other services

On Monday in a post on the New England Australia blog, Tamworth GPs close their books, I spoke of some of the workforce problems created by our current approaches to training doctors. This drew a very well informed comment from Martina.

The comment follows. Please read it. My own response follows at the end. 

We have been doing some very intensive research into medical workforce issues in rural Victoria and I would agree with the comments. The specialisation of the medical workforce means that there are no pathways to 'general' medicine which is what rural communities need most.

Hospitals need salaried medical staff but where do they get them from especially if they cannot provide enough supervision to employ PGY1+2 doctors straight out of university? If they are not in a District of Workforce Shortage (and many smaller rural centres are not classified in this way) they cannot even employ overseas trained doctors who are working towards full registration.

If they employ doctors who have not got a Medicare Provider Number, they cannot access Medicare funding and have to finance the doctor's salary themselves - and thats not going to be an attractive salary.
And if they do employ salaried medical officers, what is their career pathway? They can't really get full registration unless they are vocationally registered - or working towards vocational registration. So there is no other pathway than a specialist pathway (even for GPs).

The decision to require GPs to jump through the numerous hoops required by other "specialities" means that nobody can become an independent medical practitioner in less than 12-14 years - if my calculations are correct. That means that the GP has lost the key attraction it once held - that it was an easier and quicker pathway to becoming an independent practitioner. Without that edge, why wouldn't you become an opthalmologist, anaesthetist or cardiologist and get some real money and a lot more prestige?

With increasing feminisation of the workforce, the decision to require doctors to 'specialise' in General Practice (an obvious oxymoron) is a great way to ensure that we have less GPs.... Many women want to have families and don't want to spend 14 years getting their professional qualification....

Why can't we have some kind of Diploma in Family Medicine which can be done in two years and with less associated costs?

Martina points to some very real problems, problems that have been known of for many years and yet have not been addressed. Nor are these problems limited to medicine. In our obsession with "quality", "standardisation" and "professionalisation" we are creating systems that no longer work. This may sound extreme, but bear with me for a moment.

Whatever the general arguments may be about the overall standard of medical services in this country, it really doesn't matter a damn if you don't have access to a GP at all or if the centralised out patient service is not easy to access because of distance.

Similar arguments apply to specialist medical services or even to basic obstetrics and to dentistry. We have developed a two tier system in which the best treatment is very good, but in which availability of basic services is less than it was fifty years ago.

We have known for twenty years that these problems were coming, yet the actions taken have at best been band-aid, at worst have simply compounded the problem.

Australia has a housing shortage, yet we build fewer houses than we did in the past. I think that this is true in absolute terms at least in NSW, but it is certainly true in relative terms. Just look at how many people we housed after the Second World War.

The size and standard of the houses we build is higher, but the number is less because of the rules and regulations associated with both subdivision and building. That's fine if you can afford to build or buy, small compensation if you cannot.

Fifty years ago, those on low incomes could access social housing with the later possibility of purchase. Now social housing is limited strictly to those in greatest need. We worry about the creation of affordable housing to try to meet the expanding gap between the diminishing numbers eligible for social housing and those who can afford to buy or rent in a private market whose costs have been regulation increased. 

Turning now to food.

As I understand the numbers, the cost of food has increased faster than the CPI. Indeed, as an average the CPI increase has been held down because the real cost of certain manufactured goods has declined, while the cost of essentials has increased. This explains why so many lower income families feel worse off. They are!

Fifty years ago, the average household had access to home gardens including, in a lot of cases, chooks for eggs and meat. This is less and less true today.

Education.  

As with health, the gap between the best and worst education has widened. Debates about the My School web site or about overall standards of education do not have a lot of resonance when your school cannot get basic teachers.

Fifty years ago, a primary school teacher was two year trained, a secondary teacher four year including a Diploma in Education. Most teachers did more formal training, but this was generally done after graduation. Training times have increased, while the scholarships that used to be available have gone.

I could outline similar arguments for many other professionals including nurses, accountants and lawyers. In law, for example, there are major shortages in many country areas.

I am not arguing in this post for any particular solution. I am saying that if systems don't work, you change them. This includes simplification, clarification, acceptance of variety and multiple pathways. As part of this, we have to deal with what I call professional bracket creep.

Take nurses as an example.

To accommodate the professionalisation of nursing including increased training times, we have actually had to create new occupational groups to do some of the work that nurses used to do. With increasing doctor shortages, there is an increasing need in some areas for nurses to do the work once reserved for doctors. This has led to conflict over things such as prescribing rights. Professional bracket creep leads to professional boundary wars

I don't necessarily have a problem with any of this beyond the fact that things are clearly not working very well for particular and growing groups of Australians. If existing systems don't work, let's change the system.

It may be that we have to give up on the illusion that all Australians can have access to the same type of services and instead focus on the minimum level of service that must be supplied to all. It may be that we have to do away with certain standards and instead just focus on ensuring supply. It may be that it is time to review all professional structures and instead introduce a more varied approach. 

Postscript:

Since writing this post, The Australian has carried a story on the next stage in the creation of national standards for teachers. I quote:

The standards, which are expected to be released for public consultation this week, are the first step in a planned uniform system of teacher accreditation and registration, which will also provide national accreditation and standards for teacher education courses in universities......

The four levels of expertise in the proposed national standards are graduate, proficient, highly accomplished and lead.

Beginners must meet "graduate" standard to be registered and "proficient" a year later to qualify for a permanent licence. "Highly accomplished" and "lead" are open to all experienced teachers but not mandatory.

"The standards . . . support the collective responsibility of the profession to ensure that those who teach have the essential knowledge and skills," the draft says.

"By publicly articulating what is required of teachers at each level, they support improved access to quality teaching for all Australian students."

Back in August 2008 in Problems with teacher accreditation I spoke of my reservations about NSW plans to introduce a standards based accreditation system. The proposed national approach mirrors the same four step approach.

The difficulty I have with the national scheme lies in the way it mixes together different things.

One is the desire to professionalise teaching, something supported by many in the teaching profession. This is linked in supporter's minds not so much with standards as with improving the prestige of teaching. There is also the hope that the approach will make it easier to reward better teachers with higher pay, thus retaining more teachers in the system. Present pay structures with quite high starting salaries but limited top salaries do lead to loss of teachers after the first few years in the profession.

The second thing is the application of standards based approaches. As I have said before, standards deal with what we can call fit for purpose, the capacity to do at a specified level. This is quite a different concept to the common idea of a standard as in some ways a mark of excellence.

Whether such approaches actually improve performance depends critically on the size of the gap between the standard or standards and existing performance. By implication, the idea that the new system will in fact raise standards means that the existing system must be failing in some way across the spectrum set by the four levels of expertise as specified in the proposed national system. It is not clear to me that this is in fact the case.

What the proposed system actually does is to superimpose a new work based qualifications framework on top of existing educational qualifications. The dynamic effects of this are a little unclear.

On the surface, teachers classified simply as proficient will be disadvantaged in job terms, creating an incentive to move to the next level. Depending on the degree of effort required to meet the formalities, some teachers may not bother. In other cases they may actually leave the system. It is quite possible that we may end up with greater teacher losses and with schools now streamed by the proportion of their staff in the two higher categories, something easily measurable for the purposes of the My School web site.

The impact on formal postgraduate study by teachers is also unclear. Traditionally, many teachers have gone on to do further university courses in their key subject areas. Time is limited. Depending on the exact form of the new standard and of the associated assessment criteria and processes, the new approach may encourage more formal study or, alternatively, substitute for that study.

Finally, the actual impact on entry to the profession is unclear.

Just at present, we have a shortage of teachers. There is anecdotal evidence, I base this just on conversations that I have had, that existing structures discourage entry by people with required subject knowledge but who lack teaching qualifications as such. We have outwards mobility, inwards immobility. Depending on the way the new system works in practice, it may simply act to create a new barrier to entry.

Of itself, none of this means that we should not introduce the new national approach. However, we do need to recognise that we are adding a new level to an already complex system whose exact effects are unclear.

What we can be reasonably certain of is that the new system will not achieve the overall stated outcome: supporting improved access to quality teaching for all Australian students. I have added the bold.