Recent writers, such as Menadue, Duckett and Goulston, have drawn our attention to the need to reform the health workforce. They are quite right to highlight the deficiencies in the health (and health education) industry in order to make headway with the issue of health reform. There are also daily reports in the media of ‘health workforce shortages’ and continuing cries of ‘a health workforce in crisis’.
So what is the ‘health workforce’? In reality, there is no such beast. ‘Health’ presupposes that the focus is on the wellbeing of individuals, families and communities, but the system actually focuses almost entirely on the provision of treatment services. ‘Workforce’ presupposes a relatively homogeneous group, when in reality it consists of as many professional and trade groups as exist in the total workforce. We therefore talk about reforming something that doesn’t actually exist and wonder why we continue to fail.
What is required is sustainable human resource development that meets the ever changing needs of the community. Firstly there is a need to acknowledge that the demand for health services will always outstrip the supply. Secondly, there is a need for human resources that contribute to the delivery of effective, affordable, quality and safe care and are responsive to planned service development. Finally there is a need for leadership contributes to the retention of our human resources.
The health human resource pool will never be sufficient to meet all potential demands for health care in Australia. Our aim should be to create the largest, strongest and best trained health human resources possible given funding constraints. The objective cannot be to have sufficient human resources to meet all demands but to create a best fit between the available human resources and the population’s health needs. This requires prioritising particular health needs and adjusting the size, composition and skill-set of the health human resource pool in order to meet service priorities. For example, this often means choosing between: decreasing investment in outpatient clinics or increasing investment in hospital avoidance programmes; maintaining services in multiple locations or consolidating services; and providing a mental health programme or a palliative care programme.
When confronted with a number of options it is useful to have a quantitative methodology to support one’s decision making and to have community engagement in the process. But more often than not there is media and/or political intervention preventing any quantitative assessment and debate regarding the marginal benefit to the community. There is an urgent need for community education, discussion and debate on where best to invest the limited finances and human resources we have.
Effective & Efficient Health Services
Responsive, Flexible Human Resources: Structural imbalances within and between occupational groups and a lack of the appropriate skills to meet local needs and changing circumstances continue. Skill mix issues arise where the skills and competencies possessed by an individual, the ratio of senior to junior staff within a single discipline, or the mix of different types of staff within a multi-disciplinary team are inappropriate for local conditions. Changing the skill mix of health human resources is one option which can potentially improve the efficiency of the health care system. This will require new, flexible approaches such as: extending the role and/or skills of individual workers; substituting one type of worker for another (particularly across professional divides); delegation of tasks within and between staffing categories, and particularly making more effective use of traditional medicine, allied health, personal care support, administrative and management staff; creating new jobs or new types of workers; moving the provision of service from one type of care to another (e.g. From hospital to community care); and improved liaison between types of workers, (eg. Specialists providing support and education to General Practitioners).
Appropriate Utilisation of Skill: Clarity about service and staff skill needs and requirements is necessary to ensure the delivery of effective and efficient services. Current human resource planning and development arrangements inhibit multi-professional planning and do not support creative use of existing staff skills.
Health care would better utilise the skills of its human resources if the following work practises were adopted: flexible working arrangements to make the best use of the range of skills and knowledge of staff; doing away with barriers which dictate that only doctors or nurses can provide particular types of care; developing more flexible careers for staff of all professional groups; more flexible deployment of staff to maximise the use of their skills and abilities; and workforce planning and development based on the needs of patients, not of professionals.
A Balance of Service Delivery Models: Despite the need for and proven efficacy of preventive and primary health care, the system continues to have a reliance on acute treatment, particularly in hospitals. The focus on treatment in hospitals is reinforced by historically based budget processes, emphasis on the curative model of care in training programs and increasing specialisation.
Governments, communities, health authorities and services providers come to equate ‘hospitals’ with ‘health’ and give high priority to their development and maintenance. Training programs focus on treatment and prepare students for placement in hospitals. Health care workers increasingly select highly specialised career paths to further promote treatment options. If we are to change the way health care services are delivered, placing greater emphasis on collaborative practice, teamwork and networks of providers then traditional scopes of practice will need to change. This indicates the need for new roles for nurses, general practitioners, pharmacists and allied health practitioners, as well as the potential for new health professions to emerge.
Health care institutions have been the slowest to embrace many of the ideas inherent in contemporary leadership models.
That is not to say that leadership does not occur. Many health professionals lead daily within their practice roles, however not many are involved in high-level leadership across multi-disciplinary groups with political, policy and decision-making powers. The issue for health professionals has been an entrenched reluctance to accept that leadership is inextricably bound to the use of power and that leadership involves influencing others in the achievement of certain ends. The only overt example we see of leadership is through the health professional unions. These unions, often under the guise of professional associations, focus almost entirely on protecting their profession. The most recent example is the opposition to the development of a ‘generic health worker’.
The traditional traits of fear and apathy in the workforce as a result of an outmoded and unacceptable ‘military’ model of leadership pose enormous challenges to those health professionals working in outdated heavily bureaucratic health care systems that appear to youth as decidedly unattractive as places of work.
Getting it right
Yes, there is a need to address skill mix issues, there is a need to reform the health (and health education) industries, but more importantly there is a need to look after the human resources we have.
Continuing to focus on the ‘health workforce’ will result in continued focus on shortages and therefore the demand for more health professionals. This oversimplifies the issues and distracts policy makers, planners and managers from the real work of reforming the system so that it supports the right staff, with the right skills, in the right place, at the right time.