Utilising the umbrella term 'allied health' to represent the various health disciplines, excluding doctors and nurses, is a relatively new concept. The use of the term allied health was coined in the 1990s and has been increasingly used at service delivery and policy levels. The impetus to utilise the term and to be viewed as a 'collective profession' was seen as important in the drive to gain greater autonomy and influence for allied health disciplines in strategic leadership, and by symbolising integration within the health system.
There is no one definition which prescribes the disciplines considered as allied health. At the meeting of the Council of Australian Governments (COAG) in July 2006, agreement was reached to establish NRAS for health professionals, beginning with the ten professional groups registered in all jurisdictions, of which seven fall under the allied health banner: chiropractic care, optometry, osteopathy, pharmacy, physiotherapy, podiatry, and psychology (refer to Chapter 3).
A further four allied health professions joined NRAS on 1 July 2012: Aboriginal and Torres Strait Islander health practitioners, Chinese medicine practitioners, medical radiation practitioners and occupational therapists. A description of the above disciplines included under NRAS is outlined in Chapter 2.
In some cases oral health practitioners are considered to be part of the allied health workforce, however in this chapter the oral health workforce has been discussed earlier.
In very broad terms, allied health professionals provide services to enhance and maintain function of their patients (clients) within a range of settings including hospitals, private practice, community health and in-home care. There is an emphasis on healthy lifestyle and on independence; whether that is physically, psychologically, cognitively or socially. The allied health workforce works across the spectrum from acute to primary care and aged care. Allied health professions also have a large role in the management of people with disabilities from childhood to adult.
At a time when health economics is driving the need to look for increased productivity in the health system, the effectiveness of allied health interventions needs to be evaluated in terms of client health outcomes. There is a paucity of evidence for the effectiveness of some particular allied health interventions; both as a collective and within single discipline interventions. With allied health being a part of the primary health care team with a focus on prevention and maintenance of function in the community, it is important that health outcomes from allied health management are better understood.
For the most part, each allied health discipline has its own professional organisation which provides advocacy and policy development. They also provide a platform for professional development opportunities, with some organisations providing accreditation/credentialing of their professionals. However, there are also a number of overarching professional bodies that represent the allied health workforce generally.
Four key professional bodies representing allied health disciplines are outlined briefly below. Of these bodies, DoHA provides funding support to the Services for Rural and Remote Allied Health (SARRAH), CRANAplus and Indigenous Allied Health Australia (IAHA) (Refer to Chapter 5 and Chapter 9).
Allied Health Professionals Australia (AHPA), formally called Health Professions Council of Australia, is a professional stakeholder based organisation which represents allied health professions and their representative bodies. Collectively, organisations within AHPA represent about 50,000 health professionals. AHPA's membership comprises a number of allied health professional associations including audiologists, chiropractors, dietitians, exercise physiologists, occupational therapists, orthoptists, orthotists and prosthetists, osteopaths, hospital pharmacists, podiatrists, psychologists, sonographers, social workers and speech pathologists. The Diabetes Educators and Practice Managers associations are associate members.
One of AHPA's key priorities is to ensure that allied health professionals are heard on issues affecting health care in Australia.
promote and support allied health workforce development.
SARRAH describes itself as a grass roots organisation and undertakes a significant amount of lobbying nationally for issues facing rural delivery of services but also has a strong focus on network support for rural and remote allied health. SARRAH is not a member organisation of the AHPA as it is not regarded as an allied health professional organisation.
supporting the administration of Government-funded scholarship programs.
SARRAH also administers the allied health element of NAHSSS on behalf of DoHA.
Indigenous Allied Health Australia (IAHA) is the peak body in Australia representing Aboriginal and Torres Strait Islander allied health professionals and students. IAHA receives funding through the Aboriginal and Torres Strait Islander Health Workforce Training Package.
Four allied health organisations announced the formation of the Australian Allied Health Alliance (AAHA) at the SARRAH conference in September 2012. The organisations involved are IAHA, SARRAH, AHPA and the National Rural Health Students' Network. The aim of the alliance is to form a cohesive group for championing and lobbying allied health to Government.
the poor access to relevant educational courses.
In 2010, the core funding for CRANAplus was included in the National Rural and Remote Health Stakeholder Support Scheme, managed by the Primary and Ambulatory Care Division of DoHA.
In the last ten years, a number of specific initiatives have been implemented by the Commonwealth targeted at allied health professionals. These initiatives have primarily been directed at improving access to allied health services for the management of chronic disease and improving the health status of Australians in rural and remote areas.
Medicare provides public health insurance for the cost of medical and hospital treatment, which is clearly demarcated from non-medical, allied health services. Exceptions exist however, in relation to dentists and optometrists. For instance, optometrists have provided services under the Medicare Benefits Scheme (MBS) since 1975 and, in accordance with their training, are able to perform the same refractive tests and bill for items as well as ophthalmologists.
Another precedent in current Medicare arrangements is the provision allowing oral surgeons to undertake similar (prescribed) procedures to those undertaken by medical practitioners; and for the same rebate. Without this proviso, a potential anomaly in the system would otherwise be that particular procedures performed by a physician would be covered by Medicare but the same procedures would not be covered when performed by a dentist.
The Enhanced Primary Care (EPC) MBS items were introduced in 1999-2000 to improve the health and quality of life of older Australians, people with chronic conditions and those with multidisciplinary care needs. The EPC items provided a Medicare rebate for GPs to undertake or participate in health assessments for older people, and care planning and case-conferencing services for patients with chronic conditions and complex needs.
Chronic Disease Management (CDM) items were introduced in 2005 to replace the existing EPC care planning items. The Medicare allied health initiative allows chronically ill people who are being managed by their GP under a CDM plan to access Medicare rebates for allied health services.
In 2006 MBS items for GP mental health plans and associated psychological therapy items were introduced as part of the Better Access to Psychiatrists, Psychologists and GPs program to improve consumers' access to high quality primary mental health care.
Access to Allied Psychological Services (ATAPS) - enables GPs to refer consumers to allied health professionals who deliver focused psychological strategies.
GP Psych Support - provides GPs with access to patient management advice from psychiatrists.
More Allied Health Services (MAHS) was funded through the (then) Divisions of General Practice (now generally subsumed as Medicare Locals). The objectives of the program were to provide allied health services to rural populations and to improve local linkages between allied health care and general practice.
Divisions were able to fund a range of suitably qualified allied health professionals to increase the number and range of services available. The program was reviewed in 2007 and it was found there was overwhelming evidence that MAHS was meeting a rural workforce need and was increasing team work, communication and shared knowledge amongst Divisions. In 2004-05, there were 169 allied health professionals funded under the program. MAHS was consolidated into the Rural Primary Health Services (RPHS) program in 2008.
The RPHS program's aim was to improve access to a range of primary and allied health care services and activities for rural and remote communities. The RPHS program gives community-based primary health care services greater flexibility in the range of services they can offer, including health promotion and preventative health activities.
The Better Access initiative provides better access to mental health practitioners through Medicare. The initiative was introduced in November 2006 in response to low treatment rates for common mental disorders (e.g. anxiety, depression and substance use disorders).
The Better Access initiative increases community access to mental health professionals and team-based mental health care, with general practitioners encouraged to work more closely and collaboratively with psychiatrists, clinical psychologists, registered psychologists and appropriately trained social workers and occupational therapists.
Part of the Better Access funding has been allocated to education and training for health professionals. Understanding the requirements relating to Medicare Benefits Schedule item numbers, referrals and patient health care planning, as well as how mental health professionals can work together in a multidisciplinary treatment team, is fundamental to treating people effectively under the Better Access initiative.
The Better Access initiative is part of the Commonwealth component of the COAG National Action Plan on Mental Health 2006–2011.
This program is a component of the Australian Government's health reform initiatives funded in the 2010-11 Budget: National Health and Hospitals Network – Workforce – rural locum scheme for allied health professionals; National Health and Hospitals Network – Workforce – rural locum scheme for nurses. These were subsequently combined to create the Nursing and Allied Health Rural Locum Scheme (NAHRLS).
Improve access of rural and remote communities to nurses, midwives and allied health professionals.
The Commonwealth allocates funding for a variety of allied health education and training support schemes to assist allied health students and practitioners with their studies and continuing professional development (CPD). As mentioned above in 8.1, the education and training support schemes include the NAHSSS, NAHRLS, RHCE Stream Two, Rotary scholarships and PHMSS. In addition to these schemes, pharmacy has two scholarship schemes dedicated to its discipline, the Rural Pharmacy Scholarship Scheme (RPSS) and the Aboriginal and Torres Strait Islander Pharmacy Scholarship Scheme (ATSIPSS).
Eligibility varies for each of the schemes (above) and may be restricted to a selected group of allied health disciplines or in the case of the pharmacy scholarships restricted to one allied health discipline. Some scholarships and support programs are only available to Aboriginal and Torres Strait Islander people studying in health disciplines, such as the Rotary scholarships program, PHMSS and ATSIPSS. Eligibility may also be prioritised according to location, and in some cases focus on providing support to a wide variety of allied health disciplines in rural and remote areas. The scholarship and other education and training support programs are dealt with in more detail in Chapter 3.
Allied health practitioners work in various settings in both the public and/or private sectors. The majority of allied health practitioners employed in the public sector work in acute care, the community care sector, and in community services. Within the public sector, particularly in the acute setting, allied health practitioners tend to work in discipline departments with a senior of their discipline. However, there has been a move towards a more multidisciplinary approach to health service delivery in the public sector, with allied health disciplines taking on a more prominent role.
There has been a significant increase in private allied health practitioners over the last ten to twenty years. Optometrists, physiotherapists, podiatrists, chiropractors, osteopaths, pharmacists and psychologists are the disciplines with significant private practice opportunities.
Within the private sector, the most common service delivery model for allied health services is a small (or solo) practice of the same discipline. Larger allied practices which may be co-located with medical practices and other health disciplines are becoming more common. However, for the most part, allied health disciplines continue to operate in a siloed manner.
Allied health practitioners working in a private capacity do not require a referral from a medical practitioner and many allied health services are funded by private health insurance 'general treatment' policies. However, allied health disciplines do form collaborative relationships and develop referral pathways to and from medical practitioners as well as other allied health disciplines. Various submissions indicated the potential for better collaboration and referral processes between allied health and other health disciplines, particularly between private providers and the public sector.
As mentioned above, collaboration and communication in patient care between allied health disciplines is crucial, particularly given the increased focus in recent years on a more multidisciplinary approach to patient/client health care. The move toward co-located health disciplines is one way to encourage and increase partnerships and collaboration activities of health practitioners.
A lack of private practitioner services in rural areas means that rural communities tend to have limited ability to access Commonwealth MBS items or any value in purchasing private health insurance for allied health services. Models need to be explored which strengthen collaboration between all services (health and disability sectors), including private and public and in smaller communities.
Medicare Locals and local health networks (LHN) could play an important role in attracting more allied health to rural locations by having an integrated approach to employment of allied health practitioners. Rights of private practice and/or collaboration between Medicare Locals and LHN could see more attractive positions developed for allied health in a possible shared public and private service.
In the current service delivery model (within the acute sector) patients/clients are often assessed and managed by a number of different allied health practitioners. For example, a patient who has suffered a stroke is likely to receive care from a number of allied health professionals including physiotherapists, occupational therapists, speech pathologists, dietitians and social workers. It is therefore important to continuously review models of care to ensure maximum coordination of client care (including with nursing) and to reduce any unnecessary overlap.
There have been some models developed in the acute sector where health professionals (including doctors, nurses and allied health) are managed at a service level rather than by discipline. This model has been used in orthopaedic services and neurological services, with a professional supervision matrix structure for supervision and support through a discipline senior. This shift is driving enhanced interdisciplinary practice and client-based care. Models of multidisciplinary care involving allied health professionals have been utilised successfully in the community health and disability sector, where allied health practitioners are more likely to be employed in multidisciplinary roles.
Further investigation into the overlap of roles/skills between allied health disciplines, and indeed with nursing, should be explored when developing new models of care. The use of allied health in specific areas of extended scope of practice in interdisciplinary teams also merits further work.
Since the acceptance of allied health as a professional grouping, some jurisdictions have established senior allied health positions in the public sector. There has been a trend in recent years for health services (local health networks) to create allied health leadership positions in some major hospitals. The roles of these types of positions can vary depending on the service delivery structure of the particular health service. However, the main purpose is to provide better direction and coordination of the allied health workforce in health service delivery.
A significant number of leadership positions have been established by state and territory governments to support allied health policy development at a jurisdictional level. Allied health leadership and management positions within service delivery and government are important as they provide allied health disciplines with a "voice" in policy decision making as well as impetus to continue to work towards integrating allied health services into core health service delivery.
Allied health organisations have been advocating for a Chief Allied Health Officer in DoHA for some years. Additionally, in the recent Senate Inquiry into factors affecting the supply of health services and medical professionals in rural areas, one recommendation included the development of a rural allied health officer role in DoHA.
On 13 March 2013, the Minister for Health announced that the Government would establish the Commonwealth's first Chief Allied Health Officer to further support allied health professionals and provide advice on how best to strengthen their role in the Australian health system.
The role of the Chief Allied Health Officer is envisaged to be the provision of enhanced liaison and consultation with the allied health workforce, thus enabling better informed health workforce and service delivery policy making. While the predominant focus of this position will be on improvement in the delivery of allied health services in rural and remote areas, it should also assist in providing a more integrated health workforce.
The Commonwealth has a more limited and less direct role in funding and employment of allied health professionals than the state and territory jurisdictions and the role of a Chief Allied Health Officer will therefore carry a different emphasis than is the case in those jurisdictions. The function of a Chief Allied Health Officer at a Commonwealth level should be to elevate (to a senior executive level within DoHA) the possible role of allied health professionals in relevant health workforce and service delivery policy, data and planning processes at a national level.
On the basis of submissions made to this review, the establishment of a Commonwealth Chief Allied Health Officer position within DoHA is supported. It will be important for DoHA to consider and liaise with relevant areas to determine the scope of this role and the type of representation that is necessary across disciplines.
Consideration should also be given to a Coalition of National Nursing Organisations (CoNNO) type model where allied health stakeholder representatives would meet on, for example a quarterly basis. It is possible that the new Australian Allied Health Alliance (discussed earlier) could play a role in this regard.
Regular consultation would enhance the Commonwealth's ability to liaise and consult with the allied health disciplines. This type of approach would allow DoHA to present new or emerging policy/program implementation plans and where indicated, ask for relevant committee representation. This would also allow allied health stakeholders to present issues and proposals for discussion with relevant areas of DoHA (including the Chief Allied Health Officer) and other Commonwealth agencies where necessary.
Both the Chief Allied Health Officer and the proposed CoNNO-type model provide the opportunity for allied health stakeholders to be more involved in DoHA discussion relevant to allied health and would assist in building allied health stakeholders' understanding and involvement in Commonwealth policy development.
Recruitment of allied health practitioners is generally not problematic in metropolitan areas but in rural and especially in inland areas, there can be recruitment difficulties to long-term vacancies. While reliable data is not available at the national level, there is a well-recognised mal-distribution of allied health professionals in rural and remote areas, in both the private and public sectors.
There can often be long-term vacancies and often positions in public health will 'disappear' with the fiscal restraints of the public health system. This means that some rural and remote communities can have limited or no services for specific disciplines. Smaller rural and remote communities also often rely on outreach service provision from larger centres, however these services are often irregular and dependent on staffing levels at the larger centres.
Certain health areas are likely to experience higher demand for allied health services over the coming years. For example, a significant number of allied health professionals work in the area of disability, managing clients from childhood through to adult. The recently announced National Disability Insurance Scheme (NDIS) is likely to increase demand for allied health services in this sector and this may have an impact on health services staffing.
There is a limited number of allied health practitioners employed in aged care services. The disciplines that are employed in this sector are mainly diversion therapists and physiotherapists. The latest aged care workforce census and survey 2012 has for the first time included a category for both allied health assistants and professionals. With both of these together, data indicates that both the head count and FTE for allied health has reduced over the past three years.
Professionals and their families who relocate to rural areas will often be challenged with living in a small and sometimes isolated community. However health practitioners also deal with professional isolation, increased workloads and more complex work. Many small communities are unlikely to provide sufficient business to sustain a private health practice.
Allied health practitioners in private practice are generally only funded through private health insurance where that is available, or by direct patient payments. Allied health practitioners in rural areas are not always financially viable for funding by state and territory jurisdictions as there is not always enough patient throughput to justify the costs of these positions. The argument has been made that funding for certain allied health professions will be critical to the future better management of chronic disease in the community.195 This argument has merit, but the provision of core allied health services to patients living with chronic disease is unlikely to be affordable in rural and remote locations without exploration of alternate service delivery models for allied health disciplines.
With the recognised shortage of allied health services, many rural areas have been developing processes and frameworks to support the development of trained allied health assistant roles to assist service delivery. In 2007, a Certificate IV in allied health assistance was included in the new nationally recognised Community Services and Health Training Package. This qualification allows trained assistants to work with allied health professionals, allowing the professional to work to the full scope of their licence and have an allied health assistant to complete more routine tasks, under supervision.
Rural allied health professionals and local managers appear to be supportive of allied health assistant roles. However, advocacy and peak groups for the sector appear to be far less supportive. At the consultative Allied Health Roundtable for this review there were in fact strongly expressed views in favour of increased specialisation in some allied health disciplines and opposition to any erosion of professional boundaries, including the use of allied health assistants.
The allied health assistant role is one possible solution to increase access to services in rural and remote communities. Research into the clinical effectiveness and safety of allied health assistants needs to be conducted, to see efficiencies and productivity gains as well as increased access to services. If an allied health assistant model works in rural areas and is shown to be safe and cost-effective, this could also be considered in metropolitan locations, although this will not occur without the support of the relevant professional associations.
Enhanced service delivery to areas previously underserviced or receiving no services i.e. improved access.
Increased job satisfaction of professional staff.
While long standing vacancies exist for professional staff, allied health assistant positions are keenly sought after positions by the local community who are keen to stay in the area and who know their community.
Allied health professionals are generally educated in the university sector with bachelor degrees, usually three to four years duration. However, in a development common to other health professions, there is an increasing move to postgraduate degrees, for example an initial generic undergraduate science degree followed by a Masters in an individual discipline. The postgraduate stream lengthens training to a minimum of five years. Opinions are divided as to whether this is a positive development.
Of note, psychology and pharmacy are the only allied health disciplines that have a compulsory postgraduate training requirement. Issues have been raised about the barriers this further training places to rural and remote practice, particularly psychology. Dentistry, conversely, takes pride in the fact that its graduates are "work ready" and registrable upon graduation.
At the practitioner level, ongoing professional development can pose particular challenges for those working in rural and remote communities. The isolation experienced by these practitioners can often include a lack of supervision and support and limited opportunities to access CPD training. This creates difficulty where clinicians do not have the contemporary skill sets, limiting their capability and capacity to work in new models of care, but may also prevent them meeting mandatory registration requirements where their profession is included in NRAS.
A continued focus on allied health networking, adequate supervision and access to CPD for allied health practitioners is vital in providing quality health service delivery based on contemporary practice in rural and remote areas. Professional supervision is particularly difficult in the more rural and remote areas. Private practitioners in these areas are even more isolated than their counterparts in the same locations but in the public sector. As an example, in the consultations for this review, rural and regional stakeholders expressed strong concerns about the rigidities of the compulsory psychology postgraduate training and its impact particularly upon women in rural areas seeking qualification.
Members of some particular professions urged that their respective boards should keep this in mind so as to ensure that training requirements are as flexible as possible to meet the needs of rural and remote practitioners. All standards should be reassessed from this perspective.
Alternative service models may be of benefit to communities where they build on health delivery structures which are already in place. MBS rebates for Telehealth consultations have been available since July 2011, with payments applicable for both a remote specialist medical practitioner and the GP, nurse, midwife or Aboriginal and Torres Strait Islander health practitioners with the patient during the real-time consultation.
Expanding the list of eligible Telehealth support practitioners to include health practitioners like optometrists is an option that should be explored. In this example, expanding the current consultation rebates would assist rural communities to access ophthalmological consultations more rapidly, with the support of a practitioner specialised in eye health.
Innovation in Telehealth and online training as well as development of professional networks for support is required. Inspirational leadership in allied health is required to move services from traditional service delivery to innovative interdisciplinary approaches.
The consultations as part of this review highlighted the frustration of allied health peak bodies at the lack of allied health workforce data and priority of data analysis. There is limited data available on the allied health disciplines, especially those who fall out of the registration scheme of NRAS.
Currently, there are no reliable data sources that indicate the level of employment of the allied health workforce across the different sectors and settings. Better data collection across settings should provide useful information for policy development. This is particularly important in regard to the disability sector, with the establishment of the NDIS, as well as in aged care.
Arguably, service sector workforce planning – looking at community needs for care and utilisation of allied health disciplines rather than a population-based planning approach – would provide more meaningful information to assist not only with supply and demand for the different allied health professional groups but this approach would also assist in looking at best practice models for service delivery including interdisciplinary care and the use of allied health assistants.
To combat the lack of data on the allied health workforce, HWA is to commence workforce modelling of 'selected allied health disciplines' in the near future. HWA's 2012-13 work plan indicates that it will be commencing workforce modelling by service sector. Noting the complexity and diversity of functions of the allied health disciplines across sectors (including disability), this type of approach may provide more meaningful data to assist in workforce planning rather than looking at a population-based approach for allied health as has been utilised in Health Workforce 2025 – Doctors, Nurses and Midwives.
The Government's recent announcement of the establishment of a Commonwealth Chief Allied Health Officer is supported. This new position should play an important role in providing advice on policy and allied health workforce reform. Nil Short term – this appointment is likely to commence in 2013.
The Commonwealth should consider options aimed at enhancing its ability to liaise and consult with the allied health disciplines. This could be pursued through supporting the development of a Coalition of National Nursing Organisations type-model, where allied health stakeholder representatives would meet regularly with senior representatives of the Department, including the Chief Allied Health Officer. Nil – new secretariat funding, potentially through the Health Workforce Fund. Short term – linked to the appointment of the Chief Allied Health Officer.
The Commonwealth should consider providing seed funding to establish allied health networks and professional hubs in rural areas. This would assist in peer support, ensuring adequate supervision of students and new practitioners, and access to continuing professional development. This is essential to ensure service delivery is based on contemporary practice and is more sustainable (particularly in the private sector).
The Commonwealth should explore the possibility of expanding the list of eligible Telehealth specialist support items to include specific allied health services, including optometry. Close consultation with the Medicare Benefits Division in regard to the feasibility of the recommendation is essential. MBS Medium term – subject to discussions with MBD and available funding.
Regionally based agencies such as Medicare Locals and local health networks (LHN) could play an important role in the development of an integrated approach to the employment of allied health professionals.
Options for the Medicare Locals and LHN networks to address the lack of allied health private practitioner services in rural areas (with the resultant current limited ability to access private health and Commonwealth MBS items) should be explored further. Although comprehensive HWA data is not yet available, it seems clear that rural communities have significantly less access to private allied health services when compared to metropolitan areas.
195 Senate Community Affairs References Committee, The factors affecting the supply of health services and medical professionals in rural areas, Parliament of Australia, Canberra, 2012, p 19–22.