THE AUSTRALIAN
ORTHOTIC PROSTHETIC ASSOCIATION
Joint Standing Committee on The National Disability Insurance Scheme
Inquiry into NDIS workforce
AOPA | Submission for The Joint Standing Committee on NDIS workforce 1
Orthotics and Prosthetics in Australia
Orthotist/prosthetists are tertiary qualified allied health practitioners who assess and treat the physical and functional limitations of people resulting from disease, illness, trauma and disability, including limb amputation, using orthoses (external braces or splints) and prostheses (artificial limbs). Orthotist/prosthetists work in a range of settings that include clinical, academic, managerial and policy domains. As autonomous practitioners, orthotist/prosthetists work closely with other medical, nursing and other allied health practitioners to deliver evidence‐based care to clients in order to improve mobility, function and quality of life.
Orthotic/prosthetic students complete their training alongside other allied health students including physiotherapy, podiatry and occupational therapy, and complete training at an Australian Qualification Framework level 7 to practice in Australia.
The Australian Orthotic Prosthetic Association (AOPA) is the peak professional body for orthotist/prosthetists in Australia and is responsible for regulating the profession. Certified practitioners currently represent 89% of the total workforce. AOPA Certification is required for the provision of clinician services for many federal, state and third-party payors, such as the National Disability Insurance Scheme, Department of Veterans affairs and Private Health Insurers. The Commonwealth Government recognizes AOPA as the assessing authority for skilled migration skill assessments for orthotist/prosthetists
AOPA is a founding member of the National Alliance of Self-Regulating Health Professions (NASRHP) and a full member of Allied Health Professions Australia (AHPA)
Contact
The Australian Orthotic Prostetic Association P.O. Box 1132 Hartwell, Victoria 3124 (03) 9816 4620 | www.aopa.org.au Leigh Clarke – Chief Executive Officer leigh.clarke@aopa.org.au
Executive Summary
In response to the Joint Standing Committee’s inquiry into Currently the national prevalence of orthotist/prosthetists the National Disability Insurance Scheme (NDIS) workforce, the Australian Orthotic Prosthetic Association (AOPA) is pleased to provide the following insights focused on the Australian orthotic/prosthetic workforce.
Workforce data presented in this submission reflects the body of AOPA Certified Practitioners as of August 2019. A large proportion of Certified practitioners provide services for NDIS participants. In Australia, AOPA certification is required to provide most, but not all patient care. AOPA Certified Practitioners represent 89%1 of the total Australian orthotic/prosthetic workforce.
Orthoses and prostheses are used by people experiencing a broad range of medical and disability-related conditions, extending across the lifespan. Common conditions include diabetes, congenital deformity, trauma, foot ulcers, cancer, stroke, post-polio syndrome, scoliosis, lymphoedema and arthritis. For example, a pair of ankle- foot orthoses may be worn by an infant living with spina bifida to prevent contractures at the ankle and improve their ability to stand and walk; a lower-limb prosthesis will allow an adult to continue participation in activities that bring joy and meaning to life, such as work and recreation.
As the population ages and increased rates of disability and comorbidity are experienced2 3 orthotist/prosthetists will be increasingly relied upon to meet the growing healthcare need. Increasing demand for orthotic/prosthetic services is particularly problematic as workforce data suggests a workforce shortage already exits4.
Currently the national prevalence of orthotist/prosthetists is 1.62 per 100 000 population. This falls well below the only published recommendation of 3.0 orthotists per 100,000 population5. There is also substantial geographic maldistribution across states/territories with only 14% of the orthotic/prosthetic workforce providing service to areas outside of major cities. Since 2007, the orthotic/prosthetic workforce has also become significantly younger and more feminized4, which suggests issues for adequate mentoring and supervision, and an increased demand for flexible or part time work arrangements. Collectively these factors are likely to cause delay in access to orthotic/prosthetic services for NDIS participants.
Most recently, the impact of the COVID-19 pandemic on the Australian orthotic and prosthetic workforce, has been immediate and severe. Many orthotic/prosthetic service providers will struggle to maintain financial viability during the time of quarantine restrictions which will decrease future access to services for NDIS participants.
AOPA provides evidence and subsequent recommendations regarding orthotic/prosthetic workforce development for the Joint Standing Committee’s consideration. We hope the recommendations contribute to the efforts to grow and secure the orthotic/prosthetic NDIS workforce, with the ultimate objective to improve NDIS participant access to quality orthotic/prosthetic services.
AOPA will gladly take questions or provide further workforce data as the Joint Standing Committee requires.
The current size and composition of the NDIS workforce
The Australian orthotist/prosthetist workforce it currently experiencing complex change. There is a substantial workforce shortage and the profession is becoming more feminized and younger
AOPA Certified orthotist/prosthetists
Given the characteristics of the orthotic/prosthetic workforce, AOPA highlight three key workforce issues that are likely to have a significant impact on the NDIS orthotic/prosthetic workforce and the delivery of orthotic/prosthetic services to NDIS participants.
- Workforce shortage
- Orthotist/prosthetist workforce gender distribution
- Workforce age
Therefore, the characteristics of the workforce data presented herein reflect the characteristics of the NDIS orthotic/prosthetic workforce.
Currently the Australian orthotic/prosthetic workforce:
- Comprises of 410 certified practitioners
- Has a mean age of 38 years (median 35 years)
- Is 49% female
- Has an average practitioner prevalence of 1.62 orthotist/prosthetists per 100 000 population
- 46% of the workforce is concentrated in Victoria where there are 2.85 practitioners per 100 000 population (Figure 1)
- The states/territories with the lowest practitioner prevalence are New South Wales (0.99) and the Northern Territory (0.81)
| ACT | NSW | NT | QLD | SA | TAS | VIC | WA | AUS |
|---|---|---|---|---|---|---|---|---|
| ■ 2007 ■ 2012 ■ 2019 |
Figure 1. Number of orthotist/prosthetists per 100 000 population
Only 14% of practitioners work outside of major cities (NB: this 14% includes all of Tasmania and the Northern Territory)
Workforce shortage
The Australian orthotic/prosthetic workforce does not meet recommended practitioner to population ratios and has high variability across the states and territories.
The most recent workforce data shows that Australia has a low prevalence of 1.64 orthotist/prosthetists per 100 000 population$^6$. This is 50% of the international recommendation for orthotists only, of 3.0 orthotist per 100 000 population.$^5$
Victoria and Tasmania have the highest prevalence of orthotist/prosthetists per 100 000 population ($\text{Victoria} = 2.85$, $\text{Tasmania}=2.43$). Victoria alone represents 46% of the orthotic/prosthetic workforce. The remaining states/territories are likely underserviced with practitioner prevalence rates as low as 0.81 and 0.99 per 100 000 population in the Northern Territory and New South Wales respectively.
Given 74% of Australia’s population live in the states/territories other than Victoria,$^6$ it is likely that nearly three quarters of the Australian population do not have adequate access to orthotic/prosthetic services.
Workforce gender distribution
Since 2007, the Australian orthotic/prosthetic workforce has become significantly feminized (p<0.05)$^{4}$ with the proportion of female orthotist/prosthetists shifting from 30% in 2007 to 49% in 2019 (Figure 2).
Gender
| Year | Male | Female |
|---|---|---|
| 2007 | ||
| 2012 | ||
| 2019 |
Flexible working arrangements required by the female orthotic/prosthetic workforce are particularly relevant for the states with a very high proportion of female workforce such as South Australia and Tasmania where 71% and 62% of orthotist/prosthetists are female respectively and expected to increase.
Workforce age
The Australian orthotic/prosthetic workforce has become significantly younger over time. For example, the mean age reducing from 42 years in 2007 to 38 years in 2009 ($\text{p}=0.008$) $^4$. In 2007 nearly half (44%) of the Australian workforce was aged under 40 years; in 2019 this proportion increased to nearly two thirds (63%) $^{4}$. In 2007 17% of the workforce were aged 55 or older dropping to 12% in 2019.$^4$
Younger and less experienced practitioners rely on the mentoring and skill sharing of experienced practitioners in order to increase their own clinical expertise and provide safe and effective orthotic/prosthetic services. The current orthotic/prosthetic workforce has seen an influx of younger practitioners, and with the reduction in
proportion of practitioners over 40 years of age, the
experience, skillset and support required for their clinical capacity for mentoring is reduced. This is problematic for younger practitioners who may not have the required support required for their clinical role, particularly in a complex clinical environment, such as the provision of NDIS supports.
6 AOPA | Submission for The Joint Standing Committee on NDIS workforce
Challenges in attracting and retaining practitioners to
regional and remote communities
Challenges in recruitment and retention in rural and remote communities exacerbate the issues with orthotist/prosthetist geographic dispersion.
It is well known that recruitment and retention of allied Professional isolation, poor access to supervision and health practitioners in regional and remote areas presents continual professional development have been identified a challenge to state and federal government with as a common extrinsic negative motivators impacting job responsibility for workforce planning. Like many other satisfaction and retention, in regional and remote allied allied health disciplines, there is a lack of workforce data health practitioners. examining workforce retention and attrition in orthotic/prosthetics in regional and remote areas.
Example: Abdul’s new career troubles
Despite a lack of data, it is likely that retention and attrition in regional and remote areas will be no different for orthotist/prosthetists than they would be those in the Abdul graduated with a Master in Clinical medical, nursing and wider allied health fields. In fact, Orthotics and Prosthetics 2 years ago and given the small and specialized nature of the works in a clinic in regional South Australia. of the 410 Australian certified practitioners, there are 31 in South Australia but only 3 outside of Adelaide. Abdul works with two part‐time senior practitioners and often practices with minimal supervision. Abdul leaves this position after just 6 months and looks for another job where he feels more supported and can receive regular supervision.
In addition to the small absolute Certified Practitioner numbers available for supervision in regional and remote areas, the influx of young inexperienced practitioners puts further strain on the few experienced practitioners who are available.
Professional isolation
There are 59 orthotist/prosthetists, or 14% of the workforce servicing regional/remote areas of Australia including all of Tasmania and the Northern Territory. This gives a low 0.84 practitioners per 100 000 population, compared to 1.92 servicing metropolitan areas of Australia4.
Access to Continuing Professional Development and Mentoring
Example: John can’t keep up
personal expense (e.g., travel, overnight accommodation, alternative arrangements for family responsibilities) and reduced clinical hours (e.g., lost time due to travel).
John is a certified orthotist/prosthetist The lack of access to continuing professional development affects a practitioner’s skillset and knowledge. Without maintaining current knowledge and skill a practitioner is unable to ensure the services they offer are the most up to date and safe and effective.
John has over 45 years’ experience across 4 major clinical areas. John is looking forward to reducing his clinical hours to part time, so he is able to spend more time with his grandchildren.
John has started mentoring younger practitioners, however the strain of mentoring young practitioners, whilst trying to reduce to part time work means John is having less time to keep up with his own clinical load. This stress causes John to make plans to retire earlier than he had anticipated.
Example: Harry’s difficulty upskilling
Harry is an Orthotist based in Perth. He is hoping to attend the AOPA congress held in Melbourne this year. Harry has looked over the program and is excited to note a number of presentations and workshops are relevant to the services he provides Unfortunately, as the congress is in Melbourne, Harry is unable to attend as he cannot cover the costs of flights and accommodation, and the two days off work.
Access to continuing professional development and mentorship is essential in a hands-on profession such as orthotics and prosthetics.
For certified orthotist/prosthetists practicing in regional and remote areas, the opportunity to attend such professional development only exists at the cost of
Impact of orthotist/prosthetist workforce challenges on NDIS
participants
Poor geographical dispersion, increasing feminization and the problematic atio of younger practitioners to experienced practitioners, will impact the provision of services to NDIS participants.
There is currently a shortage of orthotist/prosthetist in
Australia. Coupled with challenges in dispersion across Example: Molly needs to travel 8 hours
for service
states and territories and the changing workforce
demographics, the workforce profile will impact NDIS
participants. Primary areas of impact include accessibility
of services, delays in service access, and the availability of specialist and complex services
a new pair of ankle foot orthoses with modified footwear to help her walk at school, at her part‐time job and around the community. Unfortunately, Molly lives 8 hours away from her nearest orthotist. This means Molly’s mother needs to take two days off work to drive Molly to her appointment and back. As it is such a long trip, Molly and her mother also must stay overnight for this appointment. Molly and Her mother will need to make this trip again for a fitting appointment in 4 weeks’ time, and again in another 2 weeks for a review.
Workforce shortage decreases access to services
Australia’s orthotic/prosthetic workforce operates at a shortage with regional and remote practitioner numbers being particularly low. People in regional and remote locations are already at risk for worse health outcomes11. Unfortunately, the workforce shortage and distribution issue disproportionately effects people living in rural and remote areas, particularly those outside of Victoria. For example, in Rockhampton (MM2 location), there is one clinic operating two days per month servicing prosthetic clients only, with the closest orthotic clinic located in Bundaberg, 288km away, and operating 2 days per month.
The professional isolation experienced by many Access to services in these regions requires innovative orthotist/prosthetists is a likely factor in retention in rural solutions. Currently there are barriers to the provision of and remote regions. Poor retention contributes to low services into rural and remote regions as satellite or fly-in practitioner numbers causing NDIS participants in some fly-out clinics due to the arrangements for claiming travel cases to travel large distances to receive their services. support. The already stretched metropolitan workforce will require the removal of barriers in order to promote the
11 Australian Institute of Health and Welfare (AIHW). Australia’s health. 2012. Canberra: AIHW; 2012.
AOPA | Submission for The Joint Standing Committee on NDIS workforce 9
Workforce Shortages in Orthotic/Prosthetic Services
Delivery of services into rural and remote areas, therefore Samantha is less likely to ambulate in the increasing accessibility of orthotic/prosthetic services.
The workforce shortage delays access to services resulting in reduced physical activity, social interaction, volunteerism and work output.
Given orthoses and prostheses are regularly relied upon for mobility and completion of activities of daily living, the The changing workforce profile will reduce access to impacts of poor access to orthotic/prosthetic services will complex clinical services be serious for many NDIS participants. Many participants require their orthosis/prosthesis in order to maintain their The shift in the workforce profile towards an increasingly independence, safely ambulate and interact at work, care younger workforce will impact the availability of mentoring for others and engage in the community. Children in of younger practitioners. This will result in the younger and particular will be affected, given they are constantly less experienced workforce managing complex case-loads growing and require frequent adjustments to maintain earlier in their career. Younger practitioners may not have orthosis/prosthesis fit, as well as more frequent provision the required skill set and support to manage complex of a new orthosis/prosthesis. cases and therefore it is likely that either ineffective servicing will occur or access to services will be restricted.
Delays in accessing orthotic/prosthetic services will also increase the overall demand for health care, bringing additional costs to funding bodies as well as societal costs from reduced activity and participation throughout recovery times. For example if a child cannot access an appropriate orthosis to help maintain muscle length, they are more likely to require tendon lengthening surgery at a later date; if an adult with post-polio syndrome can’t access services for the repair or replacement of her knee- ankle-foot orthosis she must use a wheelchair for mobility, decreasing her physical condition and mental wellbeing. If NDIS participants are to access orthotic/prosthetic Example: Trinh’s needs to wait services in a timely manner, it is vital that key stakeholders collaborate to address the barriers to growth and Trinh is a transfemoral amputee living in retention of the orthotic/prosthetic workforce. regional NSW. She requires a new prosthesis to help her ambulate at her work and around her garden. Trinh’s Case Example: Samantha’s goal is to prosthetist is trialing a piece of new e keep on walking technology which should help the fitting process substantially making everything more efficient. Unfortunately, Trinh’s Samantha is an NDIS participant with post‐ prosthetist works by themselves and is polio syndrome. She uses a Knee Ankle Foot building their own expertise regarding this Orthosis (KAFO) to walk safely in the new piece of technology, without oversight community. She cannot walk without her or access to colleagues with whom they KAFO. Samantha’s goal is to continue her can share experiences and knowledge. If current level of walking ability around Trinh’s prosthetist had adequate mentoring home and the community. Currently her and the ability to work with more KAFO is 12 years old and needs to be colleagues on the new piece of technology, replaced – the plastic is experiencing Trinh’s prostheses may have been fitted stress-fatigue and is at increased risk of earlier. Unfortunately, Trinh had to wait fracture. A workforce shortage would make longer than anticipated and as a result, it likely that Samantha will be placed on a Trinh had to take time off work as she did lengthy wait list before assessment, not feel safe to ambulate on her old prescription and fitting of a new KAFO can prosthesis. occur. This places Samantha at risk for falls as her current KAFO is now unsafe.
Considerations for governments and stakeholders for NDIS
workforce planning
AOPA is pleased to summarize the following information factors affecting the retention of allied health for federal and state governments, as well as other key practitioners in regional and remote locationsError! stakeholders, for consideration when planning for future Bookmark not defined.. However, access to continuing professional development and professional support structures (e.g., supervision) are successful retention strategies for retaining allied health practitioners in rural locations, specifically, in the disability sector.13
Retention
It is integral for workforce planning to consider the
substantial retention issues faced by the Stakeholders should consider supporting innovative
orthotic/prosthetic workforce. It is equally important to training models for regional and remote practitioners.
consider retention in its three specific forms: Through innovative training models practitioners can
receive continuing professional development, allowing
- Retention in regional and remote locations them to upskill, feel supported, and assist in practitioner
retention. - Retention of experienced practitioners to
balance the influx of the younger workforce Echoing the Victorian speech pathology workforce data,
- Retention of the increasing female workforce the weight of service demand upon practitioner
retention in rural locations suggests the use ofThe orthotic/prosthetic workforce shortage reflects alternative service delivery modes like telehealth to helppractitioner retention challenges. These challenges are meet service demand needs13. Althoughalso experienced by other allied health workforces such orthotic/prosthetic services have not traditionally beenas speech pathology. Victorian speech pathology delivered through telehealth, there is an opportunity toworkforce data identifies a number factors influencing innovate in this area, which may assist practitioners inretention including; maternity leave (especially for a regional and remote areas to better triage and reviewhighly feminised young workforce), limited opportunities participants and their needs. Further to this, telehealthfor career progression, and stress from the inability to also offers the opportunity to improve multidisciplinarymeet a community need with available service care in rural and remote regions and provide practitionerresources12. These retention issues are already well- support and mentoring.known and likely lay ahead for the orthotic/prosthetic
workforce. Stakeholders may consider ways to support telehealth to
address workforce shortages in regional and remoteRetention in regional and remote locations areas, allowing participants to gain access to their vital
orthotic/prosthetic services whilst allowing practitionersProfessional isolation, lack of supervision and poor to reduce burden on service demand. This support mayaccess to continuing professional development are clear be the provision of clear pathways and information for
12 Victorian State Government. Speech Pathology Workforce report. July 2016.
13 Lincoln M, et al. (2014) Recruitment and retention of allied health professionals in the disability sector in rural and remote NSW, Australia, Journal of Intellectual & Developmental Disability, 39:1, 86-97
AOPA | Submission for The Joint Standing Committee on NDIS workforce 11
Recommendations to strengthen and retain
the orthotic/prosthetic NDIS workforce
The orthotic/prosthetic workforce requires both experienced and younger practitioners to reduce workforce shortage; with an increasingly younger workforce, the retention of experienced practitioners is vital for clinical supervision and mentorship opportunities to be accessible for younger practitioners.
Younger practitioners must be adequately supported and provided with supervision to allow for their skills and experience to build. This also reduces the risk of younger practitioners leaving the workforce, as they feel adequately supported with experienced practitioners providing mentoring and supervision.
Specific data on retention of experienced orthotist/prosthetists is severely lacking. The South Australian Allied Health Workforce Survey noted a slight dip in job satisfaction mid-career (10-20 years qualified) compared to early and late career practitioners combined$^{\text{14}}$. The survey also noted career advancement remained high on the list of reasons for leaving the allied health workforce$^{\text{14}}$.
e should consider ways to increase job satisfaction, particularly develop various opportunities for career advancement for mid-late career practitioners in the orthotic/prosthetic workforce. Career advancement may look different in various roles and settings, but clear pathways for promotion and professional advancement would assist in supporting orthotic and prosthetic retention.
Retention of the feminized workforce As females typically work fewer hours per week7 9 10 it is important for an increasingly feminised workforce like the Australian orthotic/prosthetic workforce, to have flexible working arrangements and part time employment opportunities. If the Australian orthotic/prosthetic workforce continues to feminize as it has in the past 13 years, majority of the workforce is soon to be female and more likely to require part time or
AOPA is pleased to provide the following recommendations to the Joint Standing Committee to address the current workforce shortage issues and support development of the future workforce in line with community needs:
- the NDIS establish a transparent process for NDIS providers to claim for remote and very remote travel,
- the NDIS seek to establish contractual arrangements for the provision of remote and very remote clinic services,$
- explore innovative service models, including telehealth and alternative modes of service, to address access issues in rural and remote regions,$
- investigate opportunities to improve practitioner mentoring in rural and remote regions, including the use of telehealth for peer supervision,$
- adopt innovative training models to improve regional and remote continuing professional development,$
- ensure NDIS provider registration requirements are sufficiently flexible for the needs of the changing workforce (e.g., National Quality Safeguards Commission requirements)
The Impact Of The Covid‐19 Pandemic On The Australian Orthotic/Prosthetic Workforce
The current covid-19 pandemic is having a substantial impact on the orthotic/prosthetic workforce. Aopa estimates the majority of orthotic/prosthetic service providers will experience financial hardship with many services reducing service capacity. It is expected that there will be a loss of practitioners from the workforce.
Aopa expects the majority orthotic/prosthetic providers will operate with reduced staffing levels which will make it difficult for ndis participants to access immediate and timely orthotic/prosthetic services. Drivers for reduced staffing levels include:
- increase in operational costs (e.g., purchase of ppe, stringent sanitization measures when handling orthoses and prostheses),
- concern regarding transmission and infection within the service due to the challenges in securing sufficient ppe,
- staff electing to self-isolate due to personal risk factors for covid-19,
- a reduction in services offered and/or accepted by participants due to personal risk factors for covid-19,
- fencing – where staff are divided into two teams so that if one team is affected by covid-19, services can be provided by the alternate team,
- a reduction in employment as borders are closed and interstate/international recruitment is heavily impeded
Aopa acknowledges and are grateful for the ndis support in the delivery of services using non-traditional means as well as financial support for ndis providers.
Although it is clear that the ndis workforce is affected by the covid-19 pandemic, data is not yet readily available to demonstrate the significance and reach of the impact.
THE AUSTRALIAN
ORTHOTIC PROSTHETIC
ASSOCIATION
The Australian Orthotic Prosthetic Association P.O. Box 1132 Hartwell, Victoria 3124 (03) 9816 4620 | www.aopa.org.au
14 AOPA | Submission for The Joint Standing Committee on NDIS workforce