Dr Eileen Willis of the School of Medicine at Flinders is co-author of Workplace reform in the healthcare industry: the Australian experience, a book which examines the changes brought about by workplace and industrial reforms, and assesses their effects.
Dr Willis said the health sector and its workforce had been required to adjust to a double dose of reform.
In addition to general reforms such as enterprise bargaining and a raft of measures that aimed to increase productivity, there were specific measures aimed at the health sector built into the Federal government's Medicare agreement with the States.
The States also implemented the concept of casemix, which shifted health funding from its historical basis to a formula based on levels of "outcomes".
"Each patient had a diagnosis, and the diagnosis had an amount of money attached to it, and that amount of money was linked to the length of time the patient was in hospital," Dr Willis said.
At the same time in South Australia and Victoria, financial failures had ushered in Liberal governments intent on pursuing an agenda to curtail public spending.
The two governments not only introduced casemix, but began a program of privatisation which saw previously publicly funded radiology and pathology hospital-based services pass into private hands. Dr Willis said that the Federal national competition policy meant that governments ultimately had little alternative but to outsource or privatise.
The impact of the reforms was variable, Dr Willis said. One area in which they were felt strongly was the country, where the closure of hospitals and privatisation of health services meant that both services and employment were lost directly and through the loss of flow-on business.
On the other hand, the introduction of higher levels of casual work, initially seen as detrimental to women workers in particular, turned out to be seen as positive. A policy of upskilling saw cleaners and kitchenhands in some states retrained to become Personal Service Attendants, undertaking more specialised functions in the wards, while their basic work was outsourced.
Enterprise bargaining, touted by governments as a way to increase productivity, made almost no nett gains in efficiency, Dr Willis said.
"What the government took away through privatisation and casualisation, the unions were able to claw back in terms of conditions through enterprise bargaining," she said.
Dr Willis said there have been some negative effects, notably a shortage of health care professionals.
"Since 2000, there has been a scramble to attract nurses into the profession, and in the case of salaried medical officers, enterprise bargaining has created a disparity in income between the states resulting in a drain of young interns to New South Wales and Victoria," she said.
Dr Willis said the current era of reforms has moved away from governmental industrial measures to notions of evidence-based medicine.
"Now you have huge Commonwealth funding into clinical governance, which can be seen as a fight-back by medicine to regain control over clinical decision-making, but also as taking on the government's agenda of efficiency and productivity," she said.
Dr Willis said the balance between clinical considerations and managerial directives was more healthy, but that tensions remain.
There are also new trends to be considered: Dr Willis said that developments such as off-shore outsourcing of the diagnosis of pathology and radiology tests, already common in the United States, may be the next area of debate.
Dr Willis said the effect of streamlined hospital stays - down by as much as a third since the early 1990s - remains a point of issue among doctors and nurses.
"The general view of health care professionals is that quality of care has gone down - from the nurse's or the doctor's point of view their work is intensified and they only see the patient at the height of their illness," Dr Willis said.
"There has been an increased division of labour in the treatment.
"While it's called 'seamless care', meaning that there is care for the patient along every step of their trajectory, each health care professional is only caring for the patient for one narrow time-span.
"Their perception is that it is less satisfying, less holistic and that patients are discharged at each step along the production line too quickly."
Workplace reform in the healthcare industry: the Australian experience by Dr Eileen Willis, Associate Professor Pauline Stanton and Dr Suzanne Young is published by Palgrave Macmillan.
