Task transfer: the view of the Royal Australasian College of Physicians

Task transfer or role evolution has a long history in medical care. Forty years ago, nurses did not take blood or suture lacerations in the emergency room. Over the past 20–30 years, nurses have developed increasingly high-level skills in acute care, taken a very active role in such areas as oncology, intensive care, and renal dialysis, and also taken an active role in prevention and health promotion, for example, as diabetes nurse educators. Nurse practitioners have become increasingly independent and numerous in Australia, following a longstanding lead in the United States.1 In the United Kingdom’s National Health Service, some specialist nurse practitioners are soon to be given full prescribing rights for all except controlled drugs.2

Like many countries, Australia has responded to health care workforce shortages and geographical workforce imbalances in a number of ways. Nurses may be the only health care practitioners in small country towns, and Aboriginal health workers play an increasingly sophisticated role in remote Aboriginal communities.

In the US, physician assistants (PAs) have developed as new health professionals over the past 30–40 years.3 Most practise in primary and emergency care, but they also contribute to care in some medical specialties such as oncology, and as surgical assistants. PAs work under the supervision of physicians, and as part of a team.

With the rapid changes that are occurring in health service delivery, the Royal Australasian College of Physicians (RACP) is committed to training physicians and paediatricians who meet the evolving health needs of the community, and is grappling with a range of task transfers, both internally across its specialty groups and externally with other health care practitioners.

The new RACP Educational Strategy, under development and soon to be implemented, is underpinned by a professional qualities curriculum, which emphasises the importance of communication, teamwork and leadership skills.4 These are extremely important for the emerging models of care which contribute to the need for task transfer.

The RACP is concerned that the balance between generalist physician and specialist physician skills has moved too far towards the latter. The College has been in discussion with senior health department bureaucrats in all states and territories about their future requirements for employment of physicians with generalist skills in acute care settings. These include general physicians and specialist physicians with a continuing role in generalist care. An action plan, Restoring the balance, has been developed with the Internal Medicine Society of Australia and New Zealand.5 The strategic actions include:

• promoting departments of general medicine (or combined departments of general medicine and other subspecialties) and acute medical wards in teaching hospitals;

• improving physician training and continuing professional development in general medicine;

• improving outer metropolitan, regional, rural and remote services in general medicine; and

• raising the incentives for non-procedural physician practice.

The concept of task transfer is not new to physicians and paediatricians, who have long worked with general practitioner colleagues on a day-to-day basis to share patient management and the associated tasks. Further, the development of basic training curricula and competency-based assessments provides the basis for the RACP’s growing capacity to train in a cross-disciplinary fashion. For example, we are in early discussions with the university sector about developing a training program in partnership for Career Medical Officers, who deliver a considerable amount of acute care, particularly in regional and rural hospitals.6

The RACP is also beginning work on appropriate and more specific task transfer to other health professional team members in areas of chronic disease management, particularly for diseases that are highly prevalent in the community. Principles of safety and quality of care and maintenance of high standards of health are the basis of this work.

The RACP trains physicians and paediatricians to provide care on consultation, particularly in complex cases and chronic illness management. The responsibilities of diagnosis, differential diagnosis, development of management plans and prognosis at this level of expertise are not easily shared. However, implementation of management plans, specific tasks to be performed, and working with community-based teams are already, and will increasingly be, shared.

Many physicians also practise highly skilled procedures. The RACP will work closely with specialty groups, health bureaucrats and regulatory authorities if there is a good evidence base for the safe and cost-efficient transfer of some of these procedural tasks to others.

The RACP is also committed to patient-centred practice, whereby personal case management and monitoring of health becomes, as much as possible, the responsibility of the patient and his or her carers. With adequate communication systems in place, this may be the most efficient task transfer of all.

The RACP is very supportive of the development of team-based care where appropriate task transfer offers the opportunity of more efficient health care. However such task transfer must also be safe and facilitate best patient care. Medical leadership is essential in many of these team-based care pathways.