Health workforce reform is clearly on the agenda of health policy makers in Australia. It has been the focus of discussion at the Council of Australian Governments which requested the Commonwealth to initiate further research in this area, operationalised by the Treasurer commissioning the current research study by the Productivity Commission http://www.pc.gov.au/study/healthworkforce/index.html
. There are a number of immediate causative factors for this heightened policy attention, most notably contemporary perceived shortages of most categories of health professionals. Increasingly, health policy makers and health service managers are also recognising that the current structure of the health workforce is probably not suitable for 21st
century healthcare delivery. [1
Australia is not unique in facing workforce shortages [2
], nor in recognising the inadequacy of current workforce structures [4
]; the World Health Organisation is highlighting workforce issues internationally by making them the focus of its 2006 World Health Report http://www.who.int/hrh/whr06_consultation/en/
. Although the headline problem is usually couched in terms of workforce supply, problems in flexibility of the workforce and workforce planning also confront policymakers.
The focus on workforce flexibility
is in part a response to perceived overspecialisation of the health workforce. Specialisation, which in part was seen to be associated with higher quality, is now seen as possibly detracting from continuity of care and hence may have a deleterious impact on quality, especially in the context of the increased salience of chronic diseases in the health sector. Although all the benefits of specialisation should not be lost, the current assignment of roles for health professionals is perceived to be inefficient either because more staff are employed than would be required in an efficient organisation of roles, or staff at higher pay classifications being used to perform tasks which could be performed by staff at lower pay levels. The inflexibility of contemporary workforce structure also inhibits service delivery because of shortages of staff to perform key roles. Policy attention is therefore being directed towards strategies about workforce substitution [5
] and to develop skills "escalators", that is to make it easy for existing health professionals to acquire additional skills to enable them to perform additional tasks.
Table shows some of the task substitutions which could potentially take place in Australia. In some cases the substitution is already occurring and the potential is for expansion of this practice. In other cases, substitution will require:
Examples of potential (or current) task substitutions
• Identification and clarification of the precise range of tasks to be substituted;
• Protocols to identify the types of patients for whom the substitute professional or assistant is relevant;
• Clarification of the nature of supervision, and reporting and regulatory arrangements (if any);
• Negotiation of payment/salary arrangements.
Obviously new substitution arrangements need to be carefully planned and monitored, but over time as health agencies (and patients) become more confident and familiar with substitution, expanded roles and task substitution will become a recognised and routine part of service delivery.
The possible substitution examples outlined above mostly involve changing the scope of practice of existing professionals. Substitution can also occur through creation of new categories of professionals or assistants. [6
] The more prevalent substitution becomes, the more there will be challenges to our contemporary conception of the definition and place of a "nurse" or "physiotherapist". This will not be an issue for members of health care teams who work closely or regularly with team members working in extended roles, but transient team members (such as agency staff or staff with only irregular or peripheral contact with the team) may not be fully aware of the team's skill mix and may make inappropriate referrals or consultative decisions. Consumers may also have different expectations of the treating team membership, and this too will need to be addressed.
The importance of addressing workforce flexibility and the associated issue of workforce substitution cannot be underestimated, particularly as predictions of future workforce requirements need to make some assumptions about the mix of tasks that will be performed in the future by the health professionals under review [7
]. If the tasks undertaken by physiotherapists, for example, are expanded, then more physiotherapists will be required, but if tasks currently undertaken by physiotherapists are able to be delegated to other categories of the health workforce, then the number of physiotherapists required in the future will be reduced. For this reason, the term 'skills shortage' is preferred to 'workforce shortage' to describe the contemporary problem. The latter term focuses on particular professions, thus channelling policy attention into traditional professional structures, rather than recognising workforce flexibility and the potential for changed skill mix.
A second cluster of problems relates to health workforce planning. The legal aphorism, res ipsa loquitur, is relevant here. The existence of skills shortages damns current workforce planning efforts. Although there are technical problems with workforce and demand projections, a critical inhibiting factor is the lack of effective formal structural links between the health and education sectors. Figure shows the current relationships.
Organisational relationships between health and education sectors.
A health agency, for example, relates most closely in organisational terms to the State Health Department. The State Health Department has an overview of the needs of the health agencies within a State and State Health Ministers may be politically exposed to shortages in particular health professions which lead to problems of service delivery.
State Health Departments have two sets of relationships which are of relevance here. One is to the Commonwealth Health Department structured through organisational arrangements such as the Australian Health Ministers' Conference and the Australian Health Ministers' Advisory Council. The other is to the parallel State Education Department. Relationships between state health and education departments are not always close and rarely involve structured joint planning arrangements. These somewhat looser relationships are indicated by dotted lines in the figure. The Commonwealth Health Department has links to the Commonwealth Education Department, which in turn has links to State Education Departments and to universities. At the bottom of the figure we note that health agencies have direct relationships with Faculties of Health Sciences within universities, for example, in terms of placement arrangements.
The mechanisms for a health agency or a State Health Department to influence the admission or curriculum decisions of universities are very indirect, typically progressing up and down the chain, mediated by the Commonwealth Departments. The longer the links in an implementation chain, the more the policies are likely to be attenuated or distorted. [9
] The mechanisms for implementing health workforce decisions are very indirect and this could be predicted to be relatively ineffectual, which they are.