The system and interrelationships between the broad range of stakeholders involved in health workforce training, policy development and health service delivery is notoriously complex. When, as the result of a tranche of health reform, new authorities, agencies and administrative units are created, it can be important over time to take the opportunity to clarify or rationalise relationships with existing agencies.
For this reason, it is timely for this review to attempt to make some contribution toward mapping out the existing roles and responsibilities in the arena of health workforce between DoHA – in particular, HWD – and HWA, bearing in mind, as outlined below, that further broad reviews of activity in this issue may occur in the future.
Health Workforce Division, Department of Health and Ageing
The Department provides the Australian Government, through the Minister, with policy advice and implements programs to address workforce capacity, supply and training needs in the medical, nursing, dental, allied and Indigenous workforce sectors. DoHA also supports the implementation of Council of Australian Government (COAG) projects including a nationally consistent assessment process for international medical graduates, health workforce reforms under the National Health and Hospital Reform Partnership Agreement and the National Registration and Accreditation Scheme.
HWD, as is detailed in earlier chapters, administers a range of programs specifically targeting workforce in medicine, nursing, dental, allied health and Aboriginal and Torres Strait Islander health. These activities include, but are not limited to, scholarship programs, training programs targeting distribution in rural areas or specific health professions, rural incentive programs, and the development of new workforce groups such as Aboriginal and Torres Strait Islander outreach workers.
While HWD has responsibility for the majority of workforce programs, other areas of DoHA, such as mental health and aged care, also have workforce programs. This presents some challenges, both within the Department and externally, in obtaining a coherent workforce response.
In addition, the Department has had oversight of implementation of key commitments under the 29 November 2008 COAG agreement on Hospital and Health Workforce Reform, for example, increasing the number of vocational training places under the AGPT and STP programs, establishing HWA and managing the transition of funding and functions and associated investment in infrastructure to expand the capacity to train more entry-level health students.
In 2011, HWD acquired many of the workforce distribution arrangements, particularly those focused on rural general practice services including the Overseas Trained Doctor (s. 19AB and s. 3GA) programs, General Practice Rural Incentives Program (GPRIP), and GP procedural grant initiatives. This was to enhance the Division’s capacity to provide more complete advice on distributional pressures in workforce.
The Division also established a policy branch that provides a strategic overview of ‘workforce’ rather than the current split by professional fields. The policy branch is also the main point of liaison with HWA.
Health Workforce Australia
On 29 November 2008, COAG announced its $1.6 billion health workforce reform package.200 At that time, the Commonwealth committed $1.1 billion, with the states and territories committing to $540 million in funding. A component of the reform package was the establishment of HWA.
The Australian Government, through the Department, provides funding for HWA through a funding agreement totalling $781 million over four years. The National Partnership Agreement (NPA) which governs the allocation of funding to HWA is scheduled to expire at the end of June 2013. HWA activities are outlined at Schedule B of the NPA. A broad review of the overarching NPA is planned and would include some consideration of the delivery of HWA’s key activities specified in Schedule B, as described further below.
States and territories have not provided funding directly to HWA.201 The Department has advised that these jurisdictions indicated subsequent to the 2008 COAG agreement that they would provide their $540 million contribution to HWA’s broad objectives through in-kind arrangements related to historical clinical training provided to undergraduate students through the public hospital system.
HWA was established to manage the majority of initiatives announced as part of the 2008 COAG commitment to health workforce. HWA’s explicit charter is to operate across educational and health sectors and jurisdictional responsibilities to develop national, integrated solutions to workforce planning and policy in support of health reform. Seventy per cent of HWA’s total allocation ($547 million over four years) is to deliver a range of programs that aim to expand capacity in undergraduate clinical training and supervision across all health sectors, including simulated learning environments. Box 9.1 describes the key programs delivered by HWA.
The establishment of HWA provides the ability to significantly expand complementary activity in workforce that draws on the best available evidence, state and territory arrangements and improved workforce planning. Much of this reform activity is likely to take place in areas likely to be highly contested, either between states and territories (due to their differing service platforms – for example the rural generalist model which exists in QLD but not in all other states at this time) or by professional and industrial organisations where new professions or scopes of practice are proposed (such as nurse endoscopists).
HWA has a complex governance structure requiring it to report to all Health Ministers. The CEO of HWA reports to the board consisting of a chair, three independent members and nominees from all jurisdictions. Following approval of the board, HWA then seeks approval from all Health Ministers through the Standing Council on Health for major pieces of work, resulting in a cumbersome and slow process.
Arguably, there has been an element of drift from the original concept of HWA as a joint Commonwealth/state (national) agency where jurisdictions partner to lead reform, improve national workforce planning, facilitate innovation and increase clinical training capacity. This concept was enshrined in legislation and forms the basis of the COAG fund allocation. Some possible options for future governance arrangements are outlined below.
Stakeholder feedback in the course of this review was not specifically sought on the role and function of the HWA, or on the outcomes generated by its specific funding activities. However, where stakeholders have commented on the impact of HWA involvement in particular programs or policy areas, this has been appropriately reflected in the body of the report.
Following the expiry of the NPA at the end of June 2013 it will be timely to reassess both the governance structure of HWA and the broad achievements of HWA’s programs in addressing Australia’s emerging health workforce issues.
If changes are contemplated possible options would be to amend the board membership so that it is comprised of skills-based representatives, removing the jurisdictional nominees, or making HWA a portfolio agency of the Commonwealth Health Minister. Removal of jurisdictional representatives from the board, however, may affect the ability to influence national, long-term health workforce reform, making HWA effectively a Commonwealth agency.
Relationship of HWD and HWA
During 2009 and 2010, advice is that the relationship was in transition as HWA was being established. HWD was responsible for ensuring HWA was established including funding arrangements and in some circumstances functions, such as the International Recruitment Program, where the Commonwealth had started activities under the NPA.
From 2010, once HWA’s work plan was well developed and in the implementation phase, and in particular with the commencement of rollout of funding, there has clearly been increased potential for demarcation issues to arise between the agency and the department.
HWA is an independent agency responsible for the delivery of a number of projects under the NPA, on behalf of COAG, and other items as directed by Health Ministers. HWA is limited to this function by its legislation.
The Department's role is to provide advice to the Australian Government and the Minister for Health and Ageing. The Department also directly funds a number of specific workforce programs (as above). Given that jurisdictions do not provide funding directly to HWA (despite what was originally envisaged in the model) there is an understandable imperative for the Commonwealth to seek greater involvement in HWA activities. The expenditure of Commonwealth funds is involved, and the delivery of Commonwealth policy outcomes is to an extent contingent upon appropriate targeting of these funds.
There is no legislative or other basis for the Minister or her Department to seek to direct HWA in its operations. Its operational accountability is to its board.
It is clear that this issue has resulted at times in some tensions between relevant sections of DoHA and HWA. This, in itself, although no doubt at times irritating for those involved in both organisations, would be insufficient grounds to consider large scale structural or governance reform. The real question for future consideration will be whether the current structural arrangements facilitate or impede the delivery of good policy and operational outcomes in ensuring that Australia has a health workforce which is well qualified, capable and flexible to meet the needs of Australian communities.
A number of factors will assist Government in making decisions around the function of HWA and that of HWD.
· The outputs and outcomes of the NPA through which HWA was established will be reviewed in coming months. This broad-based review will include some consideration of Schedule B (Workforce Enablers), which includes the establishment of a National Workforce Agency (now HWA), increased funding for clinical training across the health disciplines, funding to develop supervision capacity, consolidated international recruitment, workforce redesign strategies and support for the development of simulated learning environments. In addition to these HWA functions, the NPA review will entail consideration of Commonwealth investments in postgraduate medical training linked to increasing medical school places (as discussed in earlier chapters).
· The Productivity Commission has identified its intention to undertake a follow-up inquiry to its 2006 report on Australia’s Health Workforce. If this inquiry proceeds in the medium term it is likely to include the key areas of productivity improvements, geographic and professional distribution, workforce attraction and retention, and the efficiency and effectiveness of clinical training. This inquiry has the potential to highlight issues within the health workforce and provide recommendations for reform which will likely impact on the programs of the two organisations.
As already mentioned, this current review of Commonwealth health workforce programs has not been designed to include a specific analysis of each of HWA’s activity areas, or duplicate the broader consideration of the overarching NPA review. However, it is inevitable that this review process has identified some factors which impinge upon HWA and its work.
Given the substantial investment by the Commonwealth in HWA’s activities it would be sensible to consider a further independent evaluation process that would more closely scrutinise the delivery of key HWA functions and assess their impact in terms of efficiency, effectiveness and integration with other health workforce measures.
Clinical training funding: the role of jurisdictions and HWA programs.
This program has provided funding to tertiary education institutions, jurisdictions and the private sector to support the growth in clinical placements required to meet the increase in undergraduate health students. Currently, it is not clear if jurisdictions have increased or decreased funding in this area. However there is contention between the tertiary institutions and the jurisdictions about this funding. The funding provided by HWA may be used to ‘top up’ jurisdictional funding and therefore the Commonwealth may be funding activities that have historically been jurisdictional responsibilities. As there appear to be few clear deliverables related to this funding stream except for reporting of additional clinical placements, it is hard to track the expenditure and outputs. Possible future changes to be considered may include:
· HWA loses the function and the additional Commonwealth clinical training could be managed via the Department or could be included on base funding paid to training institutions through DIICCSRTE; or
· HWA maintains the function with possible amendments to ensure adequate Commonwealth visibility of the expenditure of Commonwealth funds; a national approach to managing funding of training in the public health sector through the Independent Hospital Pricing Authority is being developed for implementation in 2018. This option would develop a price on clinical training and identify funding sources and responsibilities.
· Modification of the HWA governance structure, noting that the NPA is scheduled to expire on 30 June 2013.
With the Commonwealth being the only direct funder there is certainly a case to argue for another structure which would allow greater Commonwealth influence of HWA/workforce initiatives and at the same time allow the agency to be in a position where it can provide more innovative and bold leadership in reform.
Amendment to HWA’s operation
There are three broad changes that could be made to HWA’s operation that could be considered by Government in the context of the NPA review.
1. HWA operations remain the same.
HWA’s current arrangements continue with HWA having responsibility for both program and policy development. Following the expiry of the NPA Health Ministers and the board would provide strategic oversight and direction setting for HWA’s work. However, the current governance arrangements have created a number of issues during HWA’s operation. The requirement to report to all Health Ministers has resulted in a cumbersome process requiring HWA to report to a variety of ‘masters’. This is despite HWA being fully funded from the Commonwealth.
2. HWA becomes a ‘think tank’ and does not manage programs.
HWA’s programs could be managed by the Department which would enable HWA to focus on its data analysis and policy development work. This would enable HWA to be more innovative and bold in its approach to workforce reform, having more time to focus on the emerging issues. This is the aspect of HWA’s work which has been most highly valued and validated by stakeholders in the course of this review, and it would justify investment of time and resources.
Under this option HWA would retain a budget for innovation and reform; to support innovative ‘pilot’ approaches which may be, if successful, applied more broadly through DoHA program funding. In this option, the best approach would be to remove HWA’s program delivery as there could potentially be conflicts with HWA setting the policy and then setting funding priorities without having a transparent, open process.
HWA programs could be returned and managed by the Department, for example the Clinical Training Subsidy, or (preferably, for stakeholder management reasons) be funded by the Commonwealth through other organisations, for example funding Rural Health Workforce Australia (RHWA) to manage the International Health Professionals Program or delivering other funding via the Rural Clinical Schools. This would reduce some of the overlap and confusion currently created, for example, by the fact that both HWA and RHWA undertake overseas recruitment of medical practitioners.
3. HWA takes over the management of selected DoHA programs
A contrasting argument would be that now HWA is more established, it could take over responsibility for the management of a number of DoHA programs to ensure synergies in program management and policy and presumably some efficiencies.
There are a number of programs (described in earlier chapters) that could be transitioned between the two organisations. For example, the HWA Clinical Training Program and HWD’s Rural Clinical Training and Support (RCTS) program could be combined and refocused to rural-specific initiatives. This would ensure continuity and reduce duplication of funding to universities. It would also assist in attracting and retaining students to rural areas. It may be timely to mention here the Integrated Regional Clinical Training Networks funded by HWA which have been singled out by Medical Deans, among others, during review consultations as being particularly valuable.
The Specialist Training Program (STP) is another program that could transfer to HWA with potentially minimal impact on participants. STP is a Commonwealth-funded initiative targeted to specific priorities (agreed by the Minister for Health) which are updated annually. STP funds specialist training in areas where the states are not funding posts, mostly in the rural and private sectors.
It should be noted, however, that the RCTS program and STP are part of the HWF. The Minister, as the decision maker, currently has the flexibility to utilise funding to meet arising priorities. This capacity would be lost if programs currently managed by HWD were to transfer to HWA. Also, the transfer of programs moved from the Department to HWA would need to be subject to reform of the current HWA governance arrangements already mentioned.
It is worthy of note at this point that in the course of this review, while many stakeholders praised the data and policy work of HWA, and particular innovative funding projects, there were critical comments about the general capacity of HWA to deliver funding. Mention was made of an extremely onerous compliance based contracting model, and in particular there was criticism of the way in which growth funding for medical places had been delivered.
No response has been sought from HWA as part of this review so it is unclear whether these issues with funding and contracts are inherent in the governance structure of HWA or the inevitable issues encountered when establishing a new agency.
|Recommendation number||Recommendations||Affected programs||Timeframe|
|Recommendation 9.6||This review has identified legitimate stakeholder concerns about the lack of clarity defining the respective roles of Health Workforce Australia and DoHA, as well as inconsistencies in the delivery of Commonwealth funding between the two agencies. It is likely that current arrangements are less than optimal.
This issue needs to be addressed to ensure the Commonwealth gains the best value from its investment in HWA and departmental programs.
Issues raised in the course of this review may inform the forthcoming overarching review of the National Partnership Agreement on Hospital and Health Workforce Reform (NPA), which will include consideration of Schedule B of the NPA and those items relating to HWA functions.
There are three broad changes that should be considered by the Commonwealth in this area:
Option 1 – HWA becomes a specialist data and policy agency ‘think tank’ and does not manage mature programs
HWA’s programs could be managed by the Department which would enable HWA to focus on its data analysis and policy development work. HWA would retain a budget for innovation and reform; to support ‘pilot approaches’ which may be, if successful, applied more broadly through DoHA program funding.
Option 2 – HWA takes over the management of selected DoHA programs
HWA could take over responsibility for the management of a number of DoHA programs to ensure synergies in program management and policy. Examples include the consolidation of HWA Clinical Training Program and HWD’s Rural Clinical Training and Support program; and the transfer of the Specialist Training Program.
In the event that the overarching NPA review does not provide sufficient analysis to inform these options, it may be necessary to undertake a specific independent analysis of HWA’s activities and governance arrangements, building on information gathered in the course of this review and in the NPA process to inform future directions for the national health workforce agency.
Option 3 – HWA operations remain the same
HWA’s current arrangements continue with HWA having responsibility for both program and policy development.
However, if this ‘status quo’ option is pursued, at a minimum, the roles and responsibilities of both agencies will need to be clarified for the benefit of stakeholders and more effective communication channels need to be established at the program management level to enhance collaboration.
|Health workforce training programs and HWA funding programs.||Longer term – reform would need to be pursued on the expiry of current long-term funding agreements and be linked to the completion of structural reviews of both HWA and the larger health workforce environment.|
200 COAG, The National Partnership Agreement on Hospital and Health Workforce Reform, 2009 accessed at http://www.coag.gov.au/node/337
201 The HWA Annual report 2011-12 does not show any income from outside the Australian Government, see Page 69.