Iain Beith, Head of School of Rehabilitation Sciences / Associate Dean for Practice Education, Kingston University and St George’s University of London
During 2015-16 I have been one of four Florence Nightingale Foundation /Council of Deans of Health leadership scholars. Lucky man (more on the whole programme in a future blog.)
As part of the scholarship I visited Australia in February 2016 to explore partnership working between higher education institutions (HEIs) and health and social care providers. The trip followed the announcement in the Comprehensive Spending Review (CSR) of the move from bursaries to loans for new nursing, midwifery and allied health professional students in England from September 2017. Interestingly Australia moved to a student loans system in 1989 and has incrementally deregulated student numbers entering university since 2000. So exploring the effect of a move to loans and deregulation of student numbers became an extra agenda item for my visit and discussions.
I visited five HEIs in all: La Trobe and University of Melbourne in Melbourne; UTS, Western Sydney University and University of Sydney in Sydney. Most visits included liaison with some of the health and social care providers who work in partnership with the HEIs in both cities, including on site. I met with academics and clinicians from a wide range of disciplines. I also linked in with Professor Ian Wronski and Robyn Adams of the Australian Council of Pro Vice-Chancellors and Deans of Health Sciences (ACPDHS), a member organization of HEIs providing healthcare education, comparable to CoDH. This gave a whole country view. Last but not least, I linked in with the network of Allied Health Leaders from all states.
I’ll start by outlining the facts as presented to me, and then give some overview from my own perspective.
Australia’s journey started with student fees being paid in the 1970s and 1980s and a move to loans in 1989. The current higher education contribution system (HECS) consists of a 30% contribution by the student and 70% by the government (this percentage varies by subject cluster). Increased student numbers and engagement with higher education over that period suggest this is well accepted and embraced by Australians.
The increase in student numbers has also been facilitated by three small step changes in the regulation of student numbers, phased in since 2000. In the early 2000s HEIs were allowed to reallocate student numbers internally between different programmes. This saw an increase in the numbers on healthcare programmes, and the number of healthcare programmes. In 2010 there was a partial lifting of the cap on student numbers entering an HEI, and in 2012 the cap was lifted completely.
In the late 1980s there were five pre-registration physiotherapy education programmes in each of the five main cities in Australia. There are now 21 programmes with a 22nd opening in 2017, and none have reduced numbers. There are similar stories of growth for other professions.
The overall result? There was a healthcare workforce crisis in Australia in 2005. There isn’t now.
On the face of it “pseudo” marketisation has provided the answer to workforce planning. Taken at face value the move to loans and opening up what market there is, has worked. Does this mean hope for the UK? I would argue yes but with caveats. Firstly the Australian loan system HECS is a 30% contribution system, and secondly the changes were phased in. In all five HEIs that I visited, staff were confident we will benefit from the changes to loans. No-one raised a desire (or even mentioned) a wish for a commissioned system such as the one we are now losing.
Of course the short term risks with the big step like change to loans in England in 2017 are acknowledged by everyone. But the Australian experience suggests the direction of travel seems right, as does the introduction of a full loan system in USA where there has also been increased engagement.
The one area which feels most uncertain is placements (or “work integrated learning” as one university calls it), an integral and mandatory component of healthcare programmes. Interestingly, where the physiotherapy provision has increased in Australia, all programmes have enough placements, though no-one seemed to know how they have managed it! And there are some pinch points. The competition seems more pronounced in Sydney (New South Wales) than Melbourne (Victoria).
The Australian government at national level (with promised support from the states) created an organization call Health Workforce Australia (HWA) in 2012 primarily to manage the increase in numbers and placements. HWA was closed in 2014, partly due to politics between central and state governments, and lack of matched funding from states (Australian States are relatively autonomous and powerful). So an attempt to control and manage placements via an intermediary body between HEIs and the health and social care sector was unsuccessful. And this left a legacy of raised expectations within providers, especially about payment for placements.
A small pot of centralised money has been retained to address what the Australians call “maldistribution”; inequitable resource allocation between rural and metropolitan areas and to some extent between different ethnic groups. (I don’t usually like judgmental words but in this case maldistribution might be worth adopting, if only to draw attention to inequity.)
My own view
Ever since the introduction of fees in 2012 I have watched and seen the small initial dip in student numbers bounce back. I have become convinced by student behaviour that the shift to student fees going through the student’s bank account, albeit retrospectively, is good for the sector and to motivate learning. The increase in numbers entering higher education in Australia and the USA who have both moved to loans, supports this. Of course student expectations have been raised and so they should be. It means more engagement, ironically one of the key characteristics of a competent professional.
Being part of the Council of Deans of Health’s Executive over the last three years I have observed the Benchmark Price negotiations with Health Education England (HEE). It hasn’t been easy, and increasingly highlighted the unsustainable nature of the funding for pre-registration fees. Little wonder the question of a different system, giving more freedom for growth was raised in the year or two prior to the CSR in November 2015.
As an example the reduction in Allied Health Professions commissioned student numbers in the 2016-17 flies in the face of the accepted need to move care from secondary to primary/community settings, where AHPs do some of their best work. I suspect HEE will say they had no choice and had to prioritise. If that’s right, then bring on loans. I don’t want my family, or friends or quite frankly me, to be left without enough appropriately educated healthcare professionals as we move towards our senior years, purely because there wasn’t enough money to pay for them.
What I saw in Australia convinced me a loan system taking out the commissioning middle man, has delivered enough healthcare workers. I came back to South London where there are trusts with 20% nursing vacancy rates. This is three years after the nursing commissioned student numbers for three year programmes were reduced by 20%! That data suggests a constrained workforce planning and implementation system centrally and locally hasn’t worked, and doesn’t work.
So when I look at all the evidence both here and overseas I find myself being more of a marketeer on loans for healthcare students. Which is strange as I am not a natural marketeer in life.
It isn’t a complete conversion though. One of my day jobs is Associate Dean for Practice Education. It’s been a fascinating three years. Placements need careful management between HEIs and placement providers; stronger bilateral partnership working and there is real value in the stability of a national tariff. I would be wary though of an intermediary body being part of the process. There does need to be a process to manage inequity, in the same way as we are all lobbying to build equity into the loan system. That wouldn’t have to be managed via an intermediary body. The failure of Health Workforce Australia to manage placements is a salutary lesson.
- Let the market dictate via the loan system for health and social care professional development. Give the public choice. It seems to pay dividends. Remember there is now no healthcare workforce crisis in Australia. There was in 2005.
- Be careful with placements. Let the HEIs and placement providers build better partnerships, and work it through.
- We all recognise the quick move to loans carries risks. This is probably most true for nursing, and metropolitan areas may be more at risk. However let’s not forget there is also risk for some of the smaller professions. These risks need to be managed in the new system. I’m confident they can be.
Finally, thank you once again Florence Nightingale Foundation and the Council for the leadership scholarship. A truly life changing programme. And I got to go to Australia!