In this issue, an interesting article appears concerning the role of the industrial unions in the development of the salaries and award conditions for Australian dietitians working in publicly funded healthcare. Australia has a complex health system composed largely of publicly funded hospitals and community health centers which constitute the majority of facilities, and a minority of private hospitals and health facilities which are operated for profit or "not-for-profit" entities; Ambulatory healthcare for individuals is provided by private medical and allied health practitioners. The funding of the healthcare system in Australia is by agreement between the State jurisdictions and the Commonwealth of Australia's national government. The Commonwealth provides funding to the States to operate the public hospital sector and provides rebates to private medical providers as part of the universal right to healthcare "laws." A moderate proportion of Australians also hold private insurance to assist in paying for healthcare in the private sector.
In this total system, unions undertake what we in Australia call enterprise bargaining on behalf of groups of workers in the public and private sectors. The unions have been successful in achieving better career pathways and more equitable pay scales. The unions have brokered agreements that vary between States in both the range and amount of salary available, often as a result of the cost of living, the total number of professions involved, and the structure of the local hospital sector (see Table 1). The awards negotiated for both conditions of work and salary do not automatically apply to the private sector, although many private hospitals try to stay in line with the State awards. However, they are not bound by them, and some private hospitals even pay above the salaries awarded by collective bargaining in order to attract staff and some pay less.
The Dietitians Association of Australia (DAA), the professional association, has never entered into salary negotiations. Rather, as a professional association, its interest lies in supporting and advancing the role of the dietitian in a way that develops and expands the role and therefore opportunity in a general way leading to increased remuneration as a result of expertise. Members work in many settings, both traditional and nontraditional. The Advanced Practitioner and Fellow programs, introduced this year and defined by Tapsell in this issue, have been modeled in such a way that they can be used synergistically with the state-based awards. Some of the states have awards that allow for progression on clinical expertise rather than through management, and the advanced practitioner program will be able to provide dietitians with the evidence they need to demonstrate this higher-order expertise. The variability within the publicly funded hospital dietetics sector can be seen in the table. The table shows that while commencing salaries are roughly similar, the number of grades and most senior remuneration scales vary between the states.
DAA does, however, operate on a wide front to advocate for dietetics broadly. A major advance in 2004 was DAA's successful proposal for the inclusion of dietetic services in the government funded "Medicare" system when it was extended to some allied health services. For the first time, patients who see private practitioners are eligible to receive rebates for the services provided, provided certain conditions have been met, rather than directly paying or receiving private insurance refunds. This was a major achievement in two ways. First, to be named as one of the limited numbers of eligible allied health practitioners was important, and second, to be the only nonregistered practitioners included was solely as a result of DAA, its programs, and interventions. Dietetics in Australia is self-regulated, and DAA was able to demonstrate to the government that the Accredited Practicing Dietitian (APD) program was sufficiently robust that it has been accepted as equal to registration. For dietetics, the number of funded rebates under this scheme has risen from 72 in the first month of operation, July 2004, to 4425 in December 2004.2 For a small profession, this is an enormous growth and has stimulated private practice across the country. Indeed, in terms of absolute numbers of use, dietetics is currently second, but in terms of size of the profession, dietetics stands first. This increased access has allowed dietetics to develop new services and to increase its profile. At present, the private practice/consultant group is the fastest growing sector of DAA members, it is now nearly 20% of the total membership.1
In addition, DAA proactively seeks to lobby the health insurers to provide more and better refunds for dietetic services. This has been successful in terms of increasing the benefits payable for dietetic services as well as increasing the fees that the Commonwealth government provides for services to war veterans.
In considering how various organizations assist the profession, it is important to return to the question of the role that industrial or trade unions play in improving salary and conditions. Undoubtedly, unions have been instrumental in achieving better salaries and conditions and protecting workers from abuses of various kinds. Union membership is now voluntary in Australia, and has fallen over the last decade in particular. The capacity to gather data, therefore, is not as good as it once was, and DAA has been able to assist those members in unions with information that might be useful. In particular, workforce data and comparative salary rates are collected and made available. Members, whether they are in the public hospital sector or the private sector, can then see how they fare and can develop their own or a collective case to contribute to enterprise bargaining or a workplace agreement.
It is of critical importance for any profession that the various aspects of industrial relations are well covered and that the profession develop and grow, no matter where the specific work setting. In the climate that currently prevails, various organizations can contribute. DAA is one such organization that has made considerable progress towards positioning dietetics as a dynamic and important profession.
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