Our health care systems in Australia have faced enormous challenges in recent years. The challenges posed by COVID-19 have received much of the attention since 2020, but even before many health care systems were stretched.
Prior to COVID, in my home state of Tasmania, “Bed Block” and ambulance “Ramping” were an outward sign of a Public Hospital system under stress. The increase in elective surgery waiting times, an external manifestation of system malaise. Perhaps, even then, the system was close to losing its’ “fitness for purpose”.
Pre-COVID, hospital managers had identified the need for Occupational Medical advice for Heath care Workers at the front line due to the mental health challenges posed by Bed Block & ramping, but little was done at that time.
The precursors of this “decompensation” of our health care systems have been present for some time:
- an ageing population;
- increasing incidence of mental health disorders; and
- escalating chronic disease rates associated with obesity and type 2 diabetes.
In the background I suspect there is an assumption that our society should be able to provide universal health care irrespective of cost. This assumption, combined with the historical perspective that a primarily hospital-based system attuned to provision of acute care could deliver such care. This places a high level of expectation on the public health-care system.
An additional Tasmanian factor is regional parochialism, creating pressure to duplicate facilitates regionally, despite major improvements in emergency transport negating this need for emergency medical care.
Governments at both a State and Federal level have shared funding including various short-term quick fixes, targeting electorally visible problems, but a more general system overhaul is overdue to target underlying trends and issues that are the genesis of this emerging lack of “fitness for purpose”. Dual accountability for funding dilutes responsibility for planning, service delivery and outcome analysis.
Doctors, allied health staff and their support staff are the very essence of the healthcare system, but are now at risk.
Central to this evolving crisis is the dwindling resource of the health practitioners themselves. Metropolitan:Regional, Rural & Remote (RRR) workforce imbalances, significant shortages of GPs along with what has become known as “burnout” of frontline hospital staff has compounded the difficulties with planning and service provision.
The health of our health workforce is at serious risk!
Our news feeds are increasingly filled with stories about health care worker shortages, burnout and dissatisfaction. The keynote address at WorkSafe Tasmania’s Annual Conference, by Dr Amy Imms was entitled “Workplace Burnout: Prevent, detect, manage”. This presentation highlighted the impact on individuals, workplace and the community generally from the high incidence of workplace burnout. The aim of the presentation was to raise awareness of the burnout phenomenon, and provide relevant skills to people in the workplace.
Tasmanian Premier and Health Minister Jeremy Rockliff recently announced financial and employment-related measures to address healthcare workforce shortfalls with incentive payments and guaranteed employment for newly graduated nurses, but will these measures address the underlying factors causing the shortage?
The problem is not confined to the health sector, with teachers and other critical service providers affected.
Professor John Wilson quoted in a recent ABC News article,
“It’s at a stage now where practitioners, not only in medicine but also in nursing and allied health, are all thinking, ‘Why am I doing this? It’s not actually good for my health, and may in fact be dangerous,'”Fears of mass exodus of hospital workers as doctors and nurses face burnout
What is Occupational Health?
According to the ILO and WHO, occupational health is “the promotion and maintenance of the highest degree of physical, mental, and social well-being of workers in all occupations by preventing departures from health, controlling risks and the adaptation of work to people, and the people to their jobs.” This definition reinforces the importance of prevention rather than reliance on reactive strategies i.e. treatment and rehabilitation.
The Australasian Faculty of Occupational & Environmental Medicine (AFOEM) expresses its purpose in the following terms:
“To promote the health and well-being of workers, healthy workplaces and good work”
Many of the current challenges facing health care organisations are person centred relating to individual health or interactions with others, rather than relating primarily to ‘traditional’ physical, chemical or ergonomic risks within a workplace. Current challenges include:
- degenerative disease related to ageing and pre-existing conditions:
- unsatisfactory or stressful interpersonal interactions in the workplace contributing to mental ill-health; along with increased workplace demands; and
- the increasingly blurred line between personal and work-related conditions
To address these issues requires a greater emphasis on health of the worker in their occupation to complement management of workplace risk with advice from safety professionals.
Occupational Health Services
The health and well-being of healthcare workers (or any other occupational group for that matter) is primarily an occupational health issue. This is best approached by a fundamental re-appraisal though an health-focused lens of relevant individual, workplace and societal factors. This can include analysis of accident/injury and absenteeism rates, measures of productivity, psychological health & satisfaction surveys and appraisal of workforce turnover rates with emphasis on direct involvement in the workplace. To develop appropriate strategies requires not only information about the problem but a deep understanding of mechanisms of disease and ill-health and application of the principles of managing risk and ill-health. Like any workplace strategy, it has to be lead from the top and utilise the right expertise, summoning the power of workforce consultation to fully understand the actual issues in each workplace.
Relevant strategies to enhance occupational health include both prevention and management of the health issues facing the healthcare workforce coupled with effective monitoring systems to evaluate the measures put in place.
Examples of “Health-First” initiatives include:
- Development of non-adversarial clinical pathways to manage injury and illness causing work incapacity (irrespective of cause)
- Programmes to improve the health and resilience of the workforce (both physical and psychological)
- Investigation and management of specific occupational risks, whether “burnout”, infection risk or a specific physical or ergonomic hazard.
Who has the background, qualifications and expertise to lead?
ILO Recommendation R171 spells out the expertise required for occupational health services. Multidisciplinary teams are critical important:
- In accordance with national law and practice, occupational health services should be made up of multidisciplinary teams whose composition should be determined by the nature of the duties to be performed.
- Occupational health services should have sufficient technical personnel with specialised training and experience in such fields as occupational medicine, occupational hygiene, ergonomics, occupational health nursing and other relevant fields.
- The occupational health services should, in addition, have the necessary administrative personnel for their operation.
Medical Practitioners trained in Occupational Medicine have the expertise to solve the problems facing healthcare workforces with a holistic “Health First” approach, reversing recent trends giving priority to claims reduction or artificially separating psychological and physical factors and seeming to prioritise legal strategies over health. There is a need to turn thinking on its head i.e. we shouldn’t be asking how we can best reduce numbers of claims rather:
“How can our various systems, including Employee Support and Rehabilitation Services, Human Resource Policies, Personal Leave Systems and Work-related Compensation Schemes best support recovery and return to work?”
Who better to lead strategy development and provide guidance to a health-care system than medically-qualified occupational experts?
Specialist Occupational & Environmental Physicians – Fellows of the Australasian Faculty of Occupational & Environmental Medicine (AFOEM) within the Royal Australasian College of Physicians (RACP)] are the most highly-qualified experts in the field, best placed to lead teams including occupational therapists/ergonomists, hygienists, nurses, physiotherapists, rehabilitation counsellors and safety practitioners.
Why haven’t many organisations heard about Occupational & Environmental Physicians?
I am most familiar with the situation in Tasmania, but the trends observed locally have been mirrored around Australia (and overseas too). Focus on cost-cutting and efficiency by government and private organisations, combined with a lack of obvious new occupational health threats (at least until recently) are important factors. A colleague recently suggested that OEPs are victims of their own success with an overall reduction in workers compensation claim numbers (although claims durations and the numbers of stress claims have risen significantly in the same period).
Over my 30 year period of practice, I have observed:
- WorkSafe Australia no longer employs in-house occupational medicine specialists
- Government organisations rarely retain in-house medical advice of any sort
- The Defence Department no longer funds Occupational & Environmental Medicine (OEM) training for its doctors
- There is no hospital-based training for Occupational & Environmental Physicians (the traditional location for most specialist medical training)
- Government Funding to train specialists in non-hospital settings (STP Funding) is virtually non-existent or allocated to other specialities
- Very few Government hospitals retain Occupational Physicians
- What OEM expertise exists is diverted to determine liability in cause-based compensation systems rather than research, strategy development, prevention, educational and treatment activities.
It is critical that Occupational & Environmental Physician-led, Occupational Health Units be re-established within government organisations to provide a focus for training of relevant specialists, raise awareness about how such expertise can provide solutions to Occupational Health challenges facing healthcare and the workforce more broadly and provide relevant clinical services.
My next article will makes the case for re-establishment of Occupational & Environmental Medicine (OEM) expertise within Government at both a Federal and State level, using Tasmania as a case in point.