In the following article, we delve into the critical challenge of enhancing workforce flexibility in the health sector, addressing the barriers that hinder the workforce from optimally serving population needs. The crux of the issue lies not just in workforce shortages but also in constraints set by professional boundaries, funding models, and therapeutic partitions.
These constraints often inhibit the ability of health professionals to fully utilise their skills, access necessary technologies, and offer comprehensive services. Moreover, they can increase clinical transactions and costs, further hampering responsiveness. As innovative models of care emerge, this paper presents six groundbreaking principles aimed at bolstering health workforce flexibility.
While some of these principles may challenge traditional norms surrounding health-care delivery, they also hold promise in paving the way for a more responsive and efficient health system. The implications of these proposed reforms and their potential to reshape patient-centric care, state regulations, and healthcare efficiency will be explored in depth.
The full text of this article is available here Six principles to enhance health workforce flexibility.
Background
The health workforce is the most expensive part of health service delivery. Rising health-care costs and increasing workforce shortages, means there is a pressing need for innovative solutions for efficient workforce use1 2 3.
A flexible workforce can enhance healthcare accessibility and efficiency, however the health system has traditionally focused on reinforcing traditional professional roles at the expense of flexibility4 5 6.
A truly flexible workforce could provide more timely care, minimise training times and expenses, and allocate health resources more effectively to meet patient needs. Although the concept of workforce flexibility is gaining international attention, most changes are localised and within existing professional frameworks7 8 9; large-scale, systemic changes in workforce flexibility are still under-researched10.
Most examples of workforce flexibility have been unintended an driven by large-scale events, such as outbreaks of disease, war, and major policies shifts such as the European Working Time Directive 11 12 13 14. Other drivers of workforce flexibility include economic drivers 15 16.
How professions protect their boundaries
While many different practitioners can deliver similar services with the right training and support 17, the health workforce has evolved from a position that certain types of services should be delivered only by specific professions 18. Professions have historically defined their roles and safeguarded their unique identities through a principle called social closure which allows them to claim ownership over certain skills and knowledge19 while stopping others from performing the same roles.
The success of professions in maintaining those boundaries largely depends on state protection through regulation and the ability of the professions to influence others 18 20 21.
Inflexible healthcare delivery and ‘therapeutic partitions’
Often, a single health practitioner (or team) may lack access to a complete set of skills or technology to fully meet patient needs. Instead, patients need to seek input from multiple different practitioners to achieve their single healthcare goal, referred to here as a therapeutic partition.
Sometimes therapeutic partitions are appropriate and recognise the specialised input of particular professions, or are a way of rationing access to certain diagnostic tests or treatment. However other partitions are historic, or an artefact of inefficient funding models. Such partitions can be more expensive22, more time-consuming, and introduce risk in some areas17.
Examples of factors that contribute to therapeutic partitions include:
- Regulatory restrictions, like limited prescribing rights.
- Health financing models, creating inefficiencies by promoting cost-shifting between agencies, not always in the patient’s best interest18 23.
- Funding models that restrict service reimbursements based on referrer type. For instance, only certain professionals might be reimbursed for specific tests like radiographs24, or MRI referrals25.
- The referral system itself, which adds another clinical transaction with associated costs. In some regions, even first-contact practitioners require referrals, adding extra steps and costs19 26.
Efforts to counter therapeutic partitions include integrated service models27 and interdisciplinary teamwork28 29. However, sometimes the solution might be a single trained practitioner or a well-organised team, rather than complex role negotiations.
Six principles to enhance workforce flexibility
Six key principles to boost health workforce flexibility:
- Measure health system performance from the perspective of the patient.
- Minimise training times.
- Regulate tasks (competencies), not professions.
- Match rewards and indemnity to the levels of skill and risk required to perform a particular task, not professional title.
- Ensure that practitioners have all the skills they need to perform the tasks required to work in the environment in which they work.
- Enable practitioners to work to their full scope of practice delegate tasks where required.
Principle 1: Measure health system performance from the perspective of the patient
Health care efficiency is typically measured from the perspective of the health system, rather than the health user. For example, telehealth reduces patients’ travel time and costs30 but as travel costs are largely borne by patients, the overall efficiency savings introduced by telehealth will be underestimated if only service costs are calculated 31.
Another example is the use of allied health professionals to triage surgical waitlists. There is good evidence that allied health can provide a range of different support to decrease waiting times for elective surgery, allowing surgeons to deal with more critical or appropriate cases 32. While service efficiencies might arise, we rarely consider the societal advantages of faster treatment time, such as the reduction in short and long term disability and further deconditioning 10.
To truly improve, we need consistent metrics that capture the results of these workforce changes 10 on patients rather than just services.
Principle 2: Minimise training times
One way to increase workforce supply during times of workforce shortage is to increase the number of trained practitioners. However, as we outline in this article, formal, university based training is time consuming and costly. Ironically, the length of time it takes to train a health practitioner has increased for many professions while health workforce shortages have increased.
There are now an increasing number of flexible training models that focus on the incremental achievement of competencies to meet the needs of the population or respond to specific local needs, or provide training in-situ. Examples include step-on, step-off programs that provide multiple exit points, ensuring quicker acquisition of marketable skills33 34; the growth of micro-credentials; and degree apprenticeship programs.
Principle 3: Regulate tasks (competencies), not professions
The regulation of professions, rather than specific competencies, reduces flexibility in two ways. First, individuals must demonstrate competence in a large number of domains before they are deemed fit for practice as a “professional”, which prolongs training times. Yet, the achievement of some competencies, incrementally, may provide individuals with skills that are marketable well before they achieve their professional status (such as micro-credentials).
Second, when the bundled competencies become part of a professional repertoire, role boundaries are generally dictated by professional politics and history rather than patient needs. State regulation of professions provides a stamp of legitimacy over the jurisdictional claims of the professions, reinforcing their professional branding.
This principle obviously brings into question the nature of professionalisation – and whether professions are simply a collection of competencies, or whether those competencies are integral to a more unifying professional philosophy – and whether those competencies can be disentangled from the professional repertoire and still provide valuable health care.
By focusing on specific competencies, the workforce can adapt to contextual needs, as shown by Australia’s rural health generalists who possess a mix of competencies across professions to cater to local demands35.
This doesn’t mean all tasks are for everyone. High-risk tasks, for example, need to undergo rigorous scrutiny, emphasizing quality, efficacy, and cost over just a professional title36. Many regulatory frameworks embrace this approach – where scopes of practice are not regulated, with the exception of certain high-risk tasks (such as surgery and prescribing).
Principle 4: Match rewards and indemnity to the levels of skill and risk required to perform a particular task, not professional title
This principle builds on the concept of recognising competencies, rather than professions, and reimbursing levels of skill and risk as opposed to a traditional professional repertoires, as opposed to the existing regulatory and insurance systems that are largely profession based.
In other words, lower risk, less skilled tasks should attract a lower fee and therefore be performed by lower cost workers. Such a model would rapidly fragment health work so that skills and risks were matched by the appropriate level of worker and reimbursement. Similarly, risks and indemnity levels would need to match specific tasks which would subsequently be reflected in pricing.
Funding models such as diagnosis-related groups that draw on a bundle of attributes surrounding a diagnosis or procedure that is not directly linked to professions, have the ability to reward and influence health-care quality and could lead to efficiencies through role redesign by looking at more efficient and effective ways to deliver a certain service.
Principle 5: Ensure that practitioners have all the skills they need to perform the tasks required to work in the environment in which they work
If a health practitioner lacks the skills or resources to deliver their healthcare effectively, it results in therapeutic partitions (outlined above).
A truly patient-centred model ensures that patients have access to all the skills necessary to treat and support their needs, rather than having those skills devolved across a wide range of professional repertoires. Such a model can occur with multidisciplinary teams of practitioners skilled to deliver the specific tasks or, more efficiently, ensure that a single practitioner has the skills necessary to address the majority of patient needs (a multidisciplinary practitioner). The task sharing approach developed by the rural allied health practitioners may be an appropriate model in this context.
Principle 6: Enable practitioners to work to their full scope of practice delegate tasks where required
An efficient workforce ensures that practitioners are largely employed to perform tasks that require their more specialised skills and not performing tasks that can be delegated to other practitioners.
The Queensland Health Ministerial Taskforce identified a number of administrative barriers that prevent allied health practitioners from working to their full scope of practice 24 37. These included preventing the ordering of radiographs and other diagnostic tests by practitioners for whom this is a normal part of their scope of practice and an inability to make direct referrals between practitioners.
Conclusion
The six principles presented in this paper propose that the 21st century workforce could be more flexibly and appropriately arranged around specific tasks that are organised in ways that meet the needs of the population, not the professions. Additionally, the revolving door between GPs, diagnostic, therapeutic and specialist services should be examined for the inefficiencies that could be removed if the gate-keeping functions and therapeutic partitions were removed.
Public submissions for the Unleashing the potential of our workforce – Scope of Practice Review are open to any members of the public with an interest in primary care, including expanding the scope of practice for allied health professionals. Public submissions close October 16.
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