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Innovation in allied health: an evidence-practice mismatch?

Much of the Western world is facing a health workforce and skills shortage, while at the same time having to deal with numerous challenges on how best to care for the population, which is ageing. In addition to the ageing population, health care stakeholders are also confronted with the need to provide services which are underpinned by quality elements, such as safety, effectiveness, timelines, equity, efficiency and patient centeredness to complex patient presentations. While there have been innovative means to address these challenges, such as newer models of care and use of technological solutions, the health workforce continues to play a crucial role in helping meet these evolving challenges. However, the World Health Organisation (WHO) estimates that there is currently a shortage of 4.3 million health workers around the globe. There are a number of factors which seem to influence the health workforce supply. They include changing demographics of the workforce with gradual feminisation of the workforce (43% in 1979 to 59% in 2009), changing working patterns and mobility such as reduction in total number of working hours (36 hours in 1979 to 32 hours in 2009) and higher rates of part time work (18% in 1985 to 30% in 2009).1 To increase supply, there has been a concerted effort to increase the number of training places, supporting education and training and improve retention rates, but this has been moderated by health professionals leaving the workforce.

It is in this context, I was recently asked to present at a conference about allied health workforce to an audience which consisted of health care professionals, consumers, managers, academics, policymakers and administrators. During my presentation I highlighted the numerous challenges which confronted health workforce generally, and allied heath more specifically, including inadequate skill recognition, poor quality workforce data, lack of clear workforce structure and career progression, the diverse workforce participation, distribution and stress, burnout and isolation. I also highlighted the "identity crisis” that confronts allied health, as many diverse health professions with different education standards, registration requirements and legislative controls and variable practices are grouped under the umbrella term "allied health."4 This can lead to definitional confusion and ambiguity with regards to "who” constitutes allied health.

As a way of moving forward, I suggested that rather than merely just increasingly supply, health care stakeholders should also consider the current allied health workforce and the opportunities for redesigning. I highlighted some examples where this could be possible and presented research evidence where these had been operationalized. After my presentation, one of the audience members came up to me and, while commending my presentation, also challenged me regarding the evidence underpinning allied health workforce redesign initiatives. While my presentation parameters did not allow me to delve into the evidence underpinning allied health workforce redesign initiatives, as a health services researcher with strong interest in evidence based practice, I was intrigued as to what the evidence actually was. So, after the conference and upon returning to my work, I set out to find the evidence for two most common allied health workforce redesign initiatives, the advanced and extended scope of practice and the allied health assistant.

The allied health advanced and extended scope of practice has traditionally emerged in response to local health services needs and models of care. They have been purported to reduce workload of existing staff and improve patient care (reduce waiting time, access to appropriate care pathway) in a cost and time efficient manner. In recent times, there has been a proliferation of advanced and extended scope of practice projects across the globe. In allied health, these include physiotherapy, speech pathology, medical radiations, occupational therapy and multi-disciplinary and trans-disciplinary services. While these initiatives have continued to proliferate, surprisingly, the evidence to support these, at best, is equivocal. While searching the literature, I came across a systematic review published by McPherson and colleagues published from New Zealand.3 This review identified that much of the evidence on advanced and extended scope of practice came from a handful of studies (n = 21) which were predominantly low level evidence. Furthermore, collectively, the body of evidence indicated that while allied health professionals could learn specific skills and apply them in clinical care, the impact of these advanced and extended roles were limited to improvement in access to patient care. There is little evidence on patient outcomes and cost effectiveness. McPherson and colleagues also highlighted that many of these initiates were developed adhoc and in an opportunistic manner.

The allied health assistants’ role in health care has also seen a radical transformation. While historically, allied health assistants have played a role, increasingly they are considered as an important "piece of the puzzle” in allied health workforce redesign. It is thought that as allied health professionals take on more advanced and extended roles, allied health assistants can help fill this void. However, while increasingly complex roles are proposed for allied health assistants, very few systematic approaches on the current evidence base was identified. This lead to the undertaking of a systematic review by Lizarondo and colleagues on allied health assistants’ role in the current health care environment.2 This systematic review identified a meagre evidence base (n = 10) of low level research studies. While there were some positives (such as positive changes to the process, improved patient satisfaction and increased opportunities for allied health professionals to work with more complex patients), there was little evidence on patient outcomes, cost effectiveness, how the allied health professionals were now used and what, if any, were the outcomes from such endeavours. Lizarondo and colleagues also highlighted the variability in the training and education of allied health assistants as they were encouraged to take on the roles traditional undertaken by allied health professionals.

While allied health workforce specifically, and health workforce more broadly, continues to face a number of challenges, it is clear that new and innovative approaches to address these challenges are likely to be advocated. While innovation in allied health needs to be encouraged, we must also recognise that some innovations in allied health, such as the advanced and extended scope of practice and allied health assistants, are plagued by key evidence gaps. It is imperative that these evidence gaps are addressed so that these innovations can be tried, tested, improved to meet the current and future challenges confronting health care. Without such evidence and ongoing reflection, it is likely that precious time and resources may be wasted, which ultimately could result in poor quality and safety of health care.

References

  1. Leach, M., Segal, L., May, E. 2010, Lost opportunities with Australia’s health workforce, Medical Journal of Australia, vol. 193, pp. 167-172.
  2. Lizarondo, L., Kumar, S., Hyde, L., Skidmore, D, 2010, Allied health assistants and what they do: A systematic review of the literature, Journal of Multidisciplinary Healthcare, vol.3, pp. 143-153, DOI 10.2147/JMDH.S12106.
  3. McPherson, K., Kersten, P., George, S., Lattimer, V., Breton, A., Ellis, B., Kaur, D., Frampton, G, 2006, A systematic review of evidence about extended roles for allied health professionals, Journal of Health Services Research and Policy, vol.11, no.4, pp.240-247.
  4. Turnbull, C., Grimmer-Somers, K., Kumar, S., May, E., Law, D., Ashworth, E, 2009, Allied, Scientific and complementary health professionals: a new model for Australian allied health, Australian Health Review, vol. 33, no.1, pp.27-37.

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