Background
Allied health comprises the largest clinical workforce in primary health care in Australia, however access to allied health workers is inequitable with shortages in rural and remote areas [
1]. Podiatrists’ earnings have an important influence on workforce supply and sustainability, including the attraction and ability of the workforce. These dynamics ensure the healthcare needs of all Australians can be met. Yet little is known about earnings and debt within the profession in Australia or more broadly in the international podiatry community.
Podiatry has been described as a career that offers diversity in workload, opportunities to upskill, flexible working arrangements and excellent employability in public and private settings [
2,
3]. Earning capacity is related to these settings, and remuneration methods (either salaried or contracted) and bargaining agreements can impact workforce dynamics. In Australia, the taxation law outlines the differences between employees and contractors [
4]. Therefore, salaried employees are remunerated based on their award or negotiated employment arrangement, whereas contracted podiatrists are self-employed and take an agreed amount and/or a percentage of income from patient fees. This secondary model requires sufficient throughput or services of different client types to generate adequate fee-for-service income. Salaried employment arrangements include access to leave (paid and unpaid) as well as minimum mandatory contributions paid by the employer to a superannuation scheme as set out by the Australian Government [
5]. In contrast, podiatrists who are contracted typically work as sole traders and are responsible for making their own contributions to a superannuation scheme [
6], and do not always have access to leave entitlements. A recent study of Australian podiatrists identified that 16% (180 of 1,129) work in these contracted arrangements and 51% (573 of 1,129) are salaried employees [
7].
Little is known about podiatrist remuneration and any relationship to workforce dynamics, but it is hypothesised that income could impact workforce dynamics. In a recent qualitative study of six student podiatrists exploring the question “why study podiatry?” [
2], one participant focused on remuneration. Another recent study within the United Kingdom identified financial pressures related to the removal of the National Health Service bursary, financial support provided by the United Kingdom government, being a key deterrent for students choosing podiatry as a career [
8]. Whilst these studies explored motivations and barriers towards podiatry as a career, the impact of debt related to education is a workforce dynamic consideration.
In Australia the average retirement age is 55 years [
9], but the age at which people are eligible to access the government funded age pension is 66 years and 6 months [
10]. This access to pension funds is set to increase to 67 years from 1
st July 2023 [
10]. The average age that podiatrists retire in Australia is unknown, but currently 18% of the Australian podiatry workforce are aged between 50–64 years and 2% are aged over 65 years [
11]. In a study of nurses, financial security was found to be associated with early retirement [
12] and intent to leave was linked to ‘maximum superannuation benefits reached’ and ‘optimal taxation situation’ [
13]. Whilst data exists in the nursing profession, most of whom work in salaried arrangements, it may not be transferable to allied health professions with different training pathways, training subsidies, employment structures and awards through which they are remunerated.
The 10 year Primary Care Plan [
1] and the Strengthening Medicare Taskforce Report [
14] identifies the need to fast track work to improve the supply and distribution of allied health professionals including podiatrists as a key component of health prevention and primary care system development. In the current economic climate, it is timely to consider financial security and its predictors as a potential component impacting podiatry workforce dynamics. Therefore, the primary aim of this study was to describe the financial characteristics of podiatry work and the factors relating to a sense of financial security.
Discussion
This is the first known study to explore podiatrists’ financial characteristics and perceptions regarding financial security as a potential factor related to workforce dynamics, including overall workforce attraction and retention. This research is fundamental to building solutions to ensure workforce sustainability in the podiatry profession. If podiatrists perceive they don’t have adequate financial income and secure prospects for more income, relative to debt accrued from studying and the costs of running a business, they may choose to retrain or seek employment outside of direct clinical care. How podiatrists are remunerated and employed is modifiable, often through awards and mutual negotiation through the employer and employee/sub-contractor. Therefore workforce planners should strongly consider the findings within this study to address business support, superannuation, and debt reconciliation These factors have potential to impact workforce dynamics.
The association between regular contributions to a superannuation scheme and participants agreeing that they will have enough to live on when they retire is unsurprising. Superannuation contributions in Australia has been compulsory for employers since 1992 and has been legislated to rise incrementally each year until it reaches 12% in 2025 [
23]. However, a subset of podiatry positions are contractual in nature such that podiatrists are sole traders for tax purposes and therefore individually responsible for making their own superannuation contributions [
6]. The Australian Tax Office has identified the challenges with this business model for business sustainability (25% Australian workforce is self-employed contractors working under this arrangement) [
24]. Regarding the podiatry profession, the policy regarding superannuation for contractors is a key factor for self-employed podiatrists preparing for retirement. Lower superannuation contributions over a working life would mean lower superannuation balances at retirement and the need to continue working for more years [
24]. Overall, this may underpin the finding that 38% of the podiatrists in this study did not perceive financial readiness for future retirement.
This study provides insight into educational debt and earnings related to podiatry. Podiatrists who did not have debt related to education and training were more likely to agree they would have enough to live on when the retired. In the Australian context, government subsidised loans are available to pay for study when podiatrists are enrolled with an approved higher education provider [
25]. The government financial support for allied health degrees in Australia is provided to education providers at a fixed rate, which has received little increases in the last 20 years. This has resulted in universities having increasing course fees to remain viable [
26]. 2021 saw the most recent impact on university fees in for health care education. This impact saw a change in Commonwealth Supported Places, where students paid a reduced fee or acquired a smaller debt compared to previous years [
26]. These changes saw the greatest impact on nursing, with limited changes to medical and allied health education [
26]. Further steps to support nursing training were taken by some Australian state and territory governments as a result of the COVID-19 pandemic. Most recently, the Victorian Government implemented a bursary of $9000 for enrolled nursing students, and an additional $7500 on graduation. This financial contribution would clear any enrolment debt if a nurse went on to work in the public health system for two years after finishing their course from 2023 [
27]. Few bursaries are available to podiatry students in Australia and completion of a pre-registration degree will cost a student between $33,000-$120,000. Subsidies for allied health education have been shown to be successful in increasing university intake numbers in the United Kingdom [
8].
This study further highlights that skills in business management and viability are a key factor related to financial security of podiatrists. Podiatrists are trained in tertiary institutions to deliver podiatry care and there is limited compulsory curriculum in how to run a profitable business. Podiatrists who run a business may have to obtain skills and qualifications through professional associations, tertiary institutions, or government education programs. At the time of data collection, the average wage podiatrists earned was consistent with the average Victorian wage, and greater than the average health worker wage [
28], highlighting the earning potential for podiatrists. Despite podiatrists reported earnings, education investment and practice debt podiatrists appear to accrue, workforce planners should consider partnering with education providers to build business skills for podiatry students including how they enable superannuation, HECS-HELP debt repayments, ensure leave provisions and manage profit, loss and long-term business growth, as factors related to sustainable financial security of podiatrists. Peak bodies may also consider providing support to new graduates in business and financial literacy. This is a key recommendation set out by the Rural Health Commissioner as a potential enabler of allied health capacity building to support service access in rural locations [
29].
When interpreting the findings of this study, the limitations should be considered. Whilst the data provides an accurate representation of the Victorian podiatry workforce, results may not be generalisable to the entire Australian podiatry workforce. The data was also collected prior to the COVID-19 pandemic, in a time of relative economic security. This means it is important to consider what the findings would look like now if they were collected again following the pandemic with low growth and lower numbers of students than in the past [
30]. As this was a singular cross-sectional study design, the research team investigated the predictor variable and outcome measure of podiatrists at the same time and therefore it is difficult to derive causal relationships between actual retirement and podiatrists leaving the profession [
31].
Attitudes towards financial security can change over time and are based on significant external factors therefore, further research is required to explore podiatrists’ perceptions regarding their financial status and its impact on retention within the profession. A mixed-method approach using longitudinal data would provide more comprehensive information in both stable and unstable economies about how podiatrists perceive their financial security and how it impacts workforce decisions.
Conclusion
This study is the first to explore financial characteristics and financial security of podiatry work. In 2017, Victorian podiatrists’ average annual gross income was $79, 194, with 36% of podiatrists having $36, 629 average debt related to education or training. Financial security, as indicated by belief that podiatrists would have enough to live on when they retired, was related to being an owner or partner of a practice, having grown up in a rural location, not having debt related to education or training and having access to regular contributions into superannuation. Workforce planners and the Australian Government should strongly consider strategies around debt reconciliation, business management support and superannuation to enable financial security in the profession as a possible factor influencing workforce dynamics Further research could assist in understanding how earnings and debt impact intent to leave the profession in both stable and unstable economies.
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