In mid December last year, a group of senior doctors, nurses, allied health professionals, hospital administrators and consumers in New South Wales publicly announced that they had had enough. So great was their frustration with the failure of the government to creatively confront the continuing workforce crisis in NSW public hospitals that they had banded together as the Hospital Reform Group to initiate open debate in the community and to find solutions. The media dubbed them the “health rebels”.1

Listed in the group’s manifesto is the statement:

In short, the group believes that public hospitals need to be dragged into the 21st century and their workplaces need to capitalise on current professional capabilities and not be bogged down by 19th century professional boundaries.3

The Hospital Reform Group workforce challenge follows closely on the back of similar calls from:

• the Australian Government Productivity Commission, which, in its draft report Australia’s health workforce (released in September 2005), called for an independent assessment of the opportunities to extend the role of some health workers so as to make best use of their skills while maintaining safety and quality.4

• the Health Workforce Innovation Conference organised by the University of Queensland and Queensland Health and held in Brisbane in November 2005.

A report of the conference is published in this issue of the Journal (page 105).5 Speakers from the United Kingdom and the United States described how their respective countries have responded to health workforce crises by introducing task transfer roles. These roles are played by nurse practitioners, physician assistants and a new professional species in the UK — the medical care practitioner. To the cynic, this is a watered-down version of a general practitioner. The UK speakers also outlined a new model for health care education — an education escalator, based on competence rather than time spent in training. Health care workers can “jump on” the escalator at different levels, depending on previous attainment of knowledge, skill and work experience, acquire further expertise, and then “jump off” the escalator at a higher level. The system’s apparent value is its capacity to encourage flexibility and multiskilling.

Australia is traditionally an importer of educational and health care ideas. There is no doubt that debate about the education escalator concept, along with the push for medical task transfer to other health care professionals, will escalate. This will be especially so if the Council of Australian Governments (COAG) endorses the major recommendations of the Productivity Commission’s report.

These developments should come as no surprise, as the drivers for changes have been with us for some time. These include:

• the prevailing shortage of doctors, exacerbated by the federal government’s cap on medical graduates in the 1990s, early retirement of doctors, shortened working hours, the feminisation of the workforce, and generational attitudes to work;6

• the continual increasing demands for medical services, driven by the increasing burdens of ageing and chronic diseases, along with new technology and the medicalisation of daily living;

• the ascendancy of multidisciplinary and multiskilled teams, which already blur some professional boundaries;7 and

• ever-narrowing subspecialisation, in which many medical tasks are reduced to discrete and limited knowledge and skill bytes which, it is argued, do not require a broad clinical perspective and have the potential to be undertaken by other health workers at lower costs.8,9

But there are deeper undercurrents. Sir Graeme Catto, President of the UK General Medical Council, recently observed that:

So how should the profession respond to the inevitable debate on task transfer? Most of the doctors who attended the plenary sessions of the Brisbane conference were surprisingly silent. Others were singularly dismissive of any encroachment by other health care professionals into the traditional domains of doctors. And the limited evidence for, and the value-laden opinions surrounding, task transfer came to the fore in the conference’s breakout sessions. It was the epitome of tribalism!

In this context, it is worth noting that:

And therein lies a problem. To be effective, the profession needs to speak with one voice and not in the babble of its many tribes. The latter will only be seen by the public as negative, defensive and self-serving. The profession needs to unite and develop a position that is evidence-based and has at its centre quality and safety for patients. In this debate, it is patients and the public who need to be convinced.