the university of auckland new zealand is there a role for doctors in future health workforces?...

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Is there a role for doctors in future health workforces?

Professor Des Gorman BSc MBChB MD PhD

Head of the School of Medicine

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Is there a role for doctors in the future?

Are current health workforces able to meet future needs?

How do we plan a health service for the future?

What is the rationale for doctors at all in a health service and what is the argument for a doctor-first health service planning process?

What could be the role of a doctor in the future?

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In the context of local health service quality and access, the first issue to consider is the adequacy of the status quo.

To paraphrase Jean-Paul Sartre, to do nothing and to “not make a choice” is actually to choose the status quo.

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New Zealand is chosen here to illustrate that even in perceptibly well funded health systems (about 10% of GDP) that problems exist in even meeting current health needs.

Is there equity in health service access and outcome in New Zealand?

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Disciplinary maldistributions of doctors

The utility of a cognitive and general scope of practice.

Baicker K, Chandra A. Health Affairs Data Watch, 07

April 2004

Woo, N Engl J Med 2006; 355 (9): 864-6

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The utility of a cognitive and general scope of practice. Woo, N Engl J Med 2006; 355 (9): 864-6

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In addition to a maldistribution of clinical service providers, there is also a shortage of academics in many disciplines. This is especially marked in Australia and New Zealand due to the relative “disinvestment” in health research.The bar graph is the annual per capita national public spend on health research (NZD exclusive of overheads).

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Cultural and demographic maldistributions of doctors

New Zealand and Australia are the most reliant countries in the OECD on overseas trained doctors.

The global medical market is not evenly distributed and shows a net movement to high expenditure health systems (i.e. the USA is the mouth of the Nile).

Bodenheimer, N Engl J Med 2006; 355 (9): 861-4

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WHO OECD Health Working Papers: Zurn and Dumont (2008)

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Cultural and demographic maldistributions of doctors

Māori comprise approximately 15% of New Zealanders, but only 2.7% of the medical workforce.Successful solutions to these inequalities will need to be Māori led.

Since 1972, over 200 Māori and Pacific doctors have entered the workforce through the University of Auckland Māori and Pacific Island Admission Scheme (MAPAS).

Asian/Indian35%

Māori10%Other

11%

P acific Islands6%

P akeha38%

Medical student ethnicity at the University of

Auckland 2008

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Projected personnel demand to maintain current health service

levels to 2021

NZIER predictions are based on three scenarios of population age and size, disease incidence and disability progression.

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NZIER (2005) NZ Population Projections by Age Cohort(Assuming medium population growth)

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Projected personnel demand to maintain current health service

levels to 2021

NZIER predictions are based on three scenarios of population age and size, disease incidence and disability progression.

Most likely optimistic case scenario = 69% more registered health professionals needed for 2021.

More likely is that there will be a doubling of need.

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Is the status quo of health service funding sustainable?

US Health System:16% of GDP.About 45 million have no real access to health care.Bureaucratic costs = 31% of total health spend.

Australian Health System:

9% of the total workforce.10% of GDP and increasing by 0.5% per annum (doubling in less than 20 years).

NZ Health System:Treasury forecast for $10 billion spend to double over next 20 to 50 years with fewer tax payers.

WHO forecasts:Robert Fogel (Nobel Laureate) prediction that “Western” health costs will be about 20% of GDP by 2020. 4.3 million shortfall in the necessary number of health workers in the decade 2006-16.

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Hypothesis: Unless Australian and New Zealand health services are extensively revised, the dichotomies and inequities already present in the system will be exaggerated and eventually match those in the USA.

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Hypothesis: The training, disposition and employed nature of current health workforces are inadequate in the context of meeting existing community needs, let alone those of the community in the future.

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Categories of solutions to the global crisis in health

workforces

Proposals unlikely to have utility.

The years of morbidity in later life could be compressed.

The percentage of the community employed in health services could be increased and/or greater output could be obtained from the current workforce.

Proposals likely to have utility.

The elements of the education and health systems could be better aligned with each other and with patient care needs.Identify and employ disruptive innovations.

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Categories of solutions to the global crisis in health

workforces

To these four categories of solution, a fifth over-arching consideration can be added; deficiencies in the Australasian health workforce will probably not be adequately addressed until there is a national non-partisan devised and complete reorganisation of the fiscal basis of the health system, including agreement on the balancing of private and tax payer contributions.

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The challenge of forming an effective health workforce





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The golden rule of health service planning

Given the uncertainty about what society might be like in 2021, let alone what the health needs and resources of that time might be, the only truism for planning the future health workforce is that that the planning will “almost certainly be wrong”.

The inevitable conclusion is that health professionals of the future must be able to be rapidly cross- and re-trained and re-deployed. Recognition of the intrinsic uncertainty and poor-predictability also supports the argument for an emphasis on generalist and inter-professional training in all health disciplines and the need for new educational models.

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Factors that will affect the predictive power of a community

health needs analysis

Cultural and social changes.Feminisation and both female and male work-life balances.Ageing of the community and other factors that can change the demand for health services.

Macro- and micro-economic changes.Biomedical technology changes and marketing.Changes in the balance of power between health “accountants”, public health advocates and clinicians.Changes in relative remuneration between and within the medical and other professional groups.

Successful trials of alternative health service models versus the power of established models and guilds.

Disciplinary distributions and task substitution.

Pharmaceutical and health-disease industry developments and marketing.International and private versus public recruitment changes.

Migration, recruitment and retention.

Changes in medical indemnity.Other changes in those factors that determine clinical decision making.

A change in the relative influence of Bayesian factors on clinical decision making (which may currently account for only about 15% of variance in primary care).

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How hard is it to plan for a future health workforce?

The medical student numbers in Australia have been increased from about 1,800 to 3,500.

Will this lead to the so-called Tsunami of doctors and unemployed medical graduates?

Is an excess of doctors in a first-World country a bad thing?

Will this allow medical self sufficiency and or a reduced reliance on overseas trained doctors?

Is any form of reliance on overseas trained doctors reasonable and sustainable?

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A future forecast of the Australian medical workforce

First, we should consider these questions of workforce in the context of the intrinsic uncertainties involved. Feminisation and both female and male work-life balances.

Every doctor in New Zealand working one hour less per week is equivalent to the loss of 300 doctors from the workforce given current workloads.

The relationship between the growing middle-class in India and Asia and the consumption of medical services (versus emigration to Australasia).

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A future forecast of the Australian medical workforce

If nothing else changes, then for Australia to have the OECD average number of doctors per capita and or to maintain current health service levels to 2025, then 50% of the medical workforce will have to be recruited from overseas.To reduce the reliance on overseas trained doctors to 25% of the total medical workforce, and again assuming that nothing else changes, then 20% of everything doctors currently do will need to be done by other health professionals.

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How hard is it to plan for a future health workforce?

The medical student numbers in Australia have been increased from about 1,800 to 3,500.

Will this lead to the so-called Tsunami of doctors and unemployed medical graduates?

Is an excess of doctors in a first-World country a bad thing?

Will this allow medical self sufficiency and or a reduced reliance on overseas trained doctors?

Is any form of reliance on overseas trained doctors reasonable and sustainable?

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What is the rationale for a doctor-first health service

planning process?

What is the key and or pivotal role in any health service?

How can we justify an element of the health service provider community that takes 15 years to train to individual competency and at a cost for each practitioner that might be as much as several million dollars?

Task substitution needs to be an active and not a passive process. Given the pivotal nature of doctors in patient differentiation, this requires the role of the doctor of the future to be defined.

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A doctor-first health service provider cycle

Identify the

outstanding shortfall

in health service

provision

Develop, prove

and implement alternative

health providers

and roles

Identify the role of the

doctor and

estimate the number

needed

Acknowledge intrinsic

uncertainty and

likelihood of getting

it wrong

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A thought on innovative disruptions

How do we test and prove new roles for already established practitioner groups and or novel types of health practitioner?

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Identify the


in health service

provision

Develop, prove


health providers

and roles


doctor and

estimate the number

needed


uncertainty and


it wrong

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An innovative health service provider cycle

Identify the


in health service

provision

Agree innovative

employment

models

Evidence based

implementation

of innovation

Develop responsive curricula

and conduct small

scale field

trials

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Identify the


in health service

provision

Develop, prove


health providers

and roles


doctor and

estimate the number

needed


uncertainty and


it wrong

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Some generic doctor “attributes” need to be agreed upon and must be sufficiently robust to stand the test of time. These have to be debated vigorously as they will determine learning outcomes and responsive curricula and pedagogies.

The doctor of the future should be:

professional;

re-deployable;

able to recognise and employ suitable innovative disruptions;

a physician-scientist;

resilient and sceptical;

have skills in health psychology, anthropology and sociology; and,

have a cognitive and general scope of practice.

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Is there a role for doctors in the future?





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Is there a role for doctors in future health workforces?

He wero tēnei mai Jean-Paul Sartre.

Tēnā rāwā atu koe.

Ka kite anδ.

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Hope springs eternal in the heart of the faithful.

the university of auckland new zealand is there a role for doctors in future health workforces?...

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