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Task substitution is a folly we cannot afford
Evan Ackerman more by this author
PROFESSOR Peter Brooks’s article, ‘Try task substitution – it could set you free’ (MO Opinion, 9 March) requires balance and examination.
Professor Brooks argues that task substitution provides the solution to increasing health costs and demand. This is a far too simplistic and inaccurate view.
Professor Brooks needs go no further than his state of Queensland and the Patel inquiry to realise that the mix of cost pressures and task substitution is a dangerous cocktail.
‘Task shifting’ or ‘task substitution’ is a fashionable phrase for reassigning delivery of healthcare interventions and services from one practitioner to a less highly trained and paid health provider. The supposition is that similar quality outcomes will be achieved for less costs.
The evidence to support GP task substitution by nurses, though achievable, is quite limited, with the strength of recommendations being quite low.
The assumption that task substitution reduces costs cannot go unchallenged. Evidence on GP task substitution has never found an economic benefit. Current evidence again is sparse but nurse practitioner costs are reportedly equivalent or higher than GPs.
In the real world, high use of Level C consultation item numbers by Australian nurse practitioners, and the high cost per patient of the Canberra walk-in centre, testify to the expense of nurse practitioners. Yet task substitution remains the darling of Australian health workforce planners.
As a further recent example, Professor Brooks should review Health Workforce Australia’s report on non-medical prescribing to examine the ridiculousness of task substitution proposals.
Most of the experience for non-medical prescribing comes from the UK.
A recent systematic review found there are substantial gaps in the knowledge base required to help evidence-based policy making in this arena.
Health Workforce Australia in 2009 commissioned work to explore the likely nature and contingencies for non-medical prescribing in Australia.
The report proposed there was a barrier to healthcare provision, namely access to prescriptions and medications. This was based on an assumption that access to GPs was poor due to workforce shortage and maldistribution, and because of this there was a medication access problem.
Despite the lack of evidence or actual presentation of a health problem, the proposed solution to this access block was widening prescribing to multiple non-medical practitioners.
In essence, Health Workforce Australia was proposing a solution (i.e. non-medical prescribing) to address a problem that does not exist.
It is not surprising then that the medical profession reacts with such scepticism and resentment.
Health provision is not a collection of small tasks or business-like transactions that can be provided by any health provider.
Evidence shows the more health providers involved in a patient’s care, the more likely the occurrence of an adverse event.
Rather than task shifting or substitution, the emphasis should remain on improving continuity of high quality care.
There is ample evidence that Australian primary care ranks with the highest quality and most efficient in the OECD.
The cost of primary care, particularly that provided by GPs, has been stable for many years.
If cost reductions are to be the true goal, health workforce programs that lead to savings in medication and hospital expenditure should be the priority. This is not the case.
It seems the cause of task substitution has captured the nation’s health planners, and enthusiasm for broad implementation without evidence or justification seems the norm.
It’s a folly that the nation cannot afford.