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Managing stealth rationing

9 Strategies to Manage Stealth Rationing and Bureaucracy Creep in Allied Health Services

Allied health workforce models are often historic, frequently tokenistic, and generally unrealistic for the growing population need for allied health services. As a result, allied health service capacity – that is the number and type of services that can be delivered using existing resources and within a specified time frame – is rarely articulated, but often under-resourced.

As we describe in our article on stealth rationing of allied health services, the absence of explicit allied health workforce planning models means that services and, therefore, allied health practitioners, are increasingly being stretched well beyond the resources available to deliver the services. This leads to staff burnout and further decreases the effectiveness and efficiency of allied health services to meet patient needs.

While workforce shortages are not unique to allied health professions, the allied health workforce tends to lack the externally mandated staffing ratios demanded by nurses, and the public and political leverage of the medical profession to achieve minimum workforce standards.

Over the past decade, I have worked with several interdisciplinary allied health services internationally, and while each service is at a different stage of stealth rationing, the themes are common – regardless of the profession, country or service context. The purpose of this article is to start to develop a set of principles to help allied health teams, managers and clinicians identify and manage stealth rationing when it occurs.

1. Have a clear understanding of your service capacity and value proposition

Allied health services have a habit of attempting to be all things to all people. This is, in part, because of the roles that many of our services span that sit across transitions between hospital and community, or in different sectors where our services are designed to optimise functioning for people within their roles or society.

The lack of a clear value proposition for our service means that setting boundaries for service delivery is challenging. However without a clear value proposition for your service (that is the types of patients you treat to achieve  a specific goal and, ideally, in a specified time frame) it is impossible to set boundaries for your service. Our article on managing service demand talks to this point further.

2. Call rationing what it is

workload demand > workload capacity = staff burnout

Stealth rationing, by definition, tends to be a bit like the boiling frog in which the water slowly warms, but by the time the water has boiled, it’s too late to respond. Incremental cuts to service capacity combined with steadily increasing demands erodes existing workload capacity. Clinicians attempt to adapt and respond to each incremental change without questioning the actual service capacity, until they ultimately reach burn-out stage.

Have a frank and open discussion with your team about your workload capacity and acknowledge as soon as new demands start to eat into it to enable you to respond proactively, before the workload tsunami descends. Recognise when workload rationing is happening and call it out. That isn’t a call to ‘work to rule’ necessarily, but it is a call to be aware of the actual workload capacity of your team with the resources available and to develop strategies to respond to new and emerging demands.

It is important to stop and recognise when the demands of the service exceed the capacity to meet those demands as early as possible and start to implement strategies to address the shortfall.

3. Protect yourself

Put on your oxygen mask before attending to others

In the early 2000’s, I worked with a health service manager with a high profile role in my city who made a very explicit point of leaving the office at 5pm every night.  She was openly challenging the (then) prevailing organisational culture of ‘he who stays in the office latest wins’.  It was important symbolically for a senior leader to articulate a reasonable working boundary and implement it publicly. Critically, it gave permission – indeed created an expectation – of healthy working boundaries for everyone within that regional health ecosystem.

This is the principle of ‘put your own oxygen mask on first’. Whatever your role in your organisation, you have the responsibility for your own self-care. That means knowing and setting your personal boundaries at work, knowing what is reasonable, what is safe, and what is appropriate to expect of yourself and of others. If you’re a leader, you are also setting the culture and norms for your team and staff to follow.

Have a clear understanding of your personal workload capacity (which is generally what you are paid to do, and / or the reasonable number of working hours in a week) and try to ensure that you work within those parameters and support others to do the same.

4. Protect your staff

Protect your staff

Your staff are your most important asset. If you fail to protect your staff and support them with appropriate safety equipment, training, supervision and support you risk compromising the delivery of your whole service. That doesn’t mean sending key staff members to an in-service training while you have a waiting room full of critically ill patients, but it does mean, first, protecting your staff from risk (which you have a statutory obligation to do anyway) and ensuring that they have the resources and capability to safely perform the job you require them to deliver.

Every service will have a safe service capacity, which is the total number of staff available to deliver a service within a safe and supported environment.

Your safe service capacity is determined by the number of staff who are employed to do a role and are supported in the following ways:

  • Adequately supported and supervised
  • Adequately trained
  • Working within safe and reasonable workload parameters
  • Ensuring staff have adequate time per patient
  • Appropriate equipment and resources to do the job
  • Working within a safe working environment
  • Appropriately rewarded for their work
  • Can take annual leave and have their workload covered
  • Can take unplanned leave and reasonably expect to catch up on their workload

Your safe service capacity, or the number of patients you can safely see, will depend on your ability to provide services within the structures outline above.

If you exceed your safe service capacity, you create safety risks for your staff and patients, not to mention risks to retention and recruitment for your organisation.

5. Ringfence resources

Report writing, assessments, documentation, letter writing and referrals can all, easily fall into the rule of time management – that is, they will take up all of the available time  plus 10%. If you are a perfectionist, a new graduate,  or new to a field of practice, add 50%.

First, take note of the time you are spending on roles that support clinical care, but are not direct clinical care – referrals, paperwork, documentation, audit, human resources, preparing clinical resources (to name but a few). Actually record this time.

Try to identify benchmarks to see whether the time you are spending on the range of bureaucratic activities is consistent with your peers.

If you are spending way more time on a particular task – try to identify ways to make that task more efficient. For example, use templates for reports or letters; have other workers perform components of the task instead of you; use automated solutions if they exist; if you are slow at typing, learn to use dictation software that automatically transcribes.

As an academic, I made a rule to never spend more than one hour peer-reviewing an article for a journal (a task that could leak into several days otherwise), and would not take on the task unless I knew I could afford the hour to perform the review. Some articles take slightly longer, some take slightly less – but that was my guiding principle. Once you have a benchmark for a reasonable amount of time to spend on [insert relevant bureaucratic task] try to stick to that time – or better.

Allocate your time to the highest value tasks. The 60-30-10 rule of time management  suggests you allocate your time in a way that 60% of your day is spent performing the highest value tasks, 30% to slightly less critical tasks, and 10% of your time on the least valuable tasks. Consider the audience for your documentation and the level of risk / importance of the output – and allocate your time to that task accordingly.

6. Prioritise highest risk, highest need patients within your service specification

Your safe service capacity – in other words the number of patients you can safely see within a specific time period – will be determined by the number of staff available to deliver certain tasks within the parameters outlined in point 1. If your service demand exceeds your safe service capacity,  you need to increase workforce supply (to increase your safe service capacity), manage service demand – or perhaps consider not delivering that service altogether if the potential risks exceed the benefits of an under-resourced service.

Most allied health services have some type of mechanism for triaging patients, however a recent systematic review of patient prioritisation systems in non-emergency health services found that this is an area in need of much greater standardisation.

Involve your staff in the decision making. If the services are non-acute, then involving patients in service rationing decisions can be effective (for example see this paper on public involvement in community services and this paper on the use of a patient panel to increase service efficiency in a podiatry service). 

During COVID-19, we saw an enormous re-organisation of all health care staff away from low-acuity services, such as elective surgery, towards the management of highest risk, highest acuity patients (for example, see this paper). For many workers, this was a major refocus of their role to respond to a health crisis.

7. Use staff to the top of their scope of practice

If you have limited resources, it makes sense to place the highest skilled staff in the areas of greatest risk and greatest potential benefit to the patients and services. For example, if you are working in a high acuity environment, it makes little sense to have your senior staff spending time on interview and recruitment panels. The most effective use of staff will depend on your particular models of care, but it is valuable to start a process where you consider the best way to use your staff to the greatest benefit. Workload delegation and management frameworks may help this process, such as the Victorian Credentialing, Competency and Capability Framework or the Calderdale Framework.

However a challenge in many contexts is that staff shortages limit the actual scope of practice of allied health professionals, forcing them to focus on specific and narrow areas of work, that are not necessarily the highest value areas of care.

8. Delegate, delegate, delegate – but control your division of labour

Allied health staff are notoriously bad at giving away roles and tasks, but if your staff need to work at the top of their scope of practice, there is a good chance that they will need to let go of some work as well. The frameworks mentioned above will help identify areas in which delegation is appropriate, safe and possible. Workload planning models may be beneficial in helping to determine which roles can most effectively and safely be delegated and which roles to hold onto.

Tasks that do not require your clinical expertise or that can clearly be performed by others should be the first in the firing line. We regularly hear about senior allied health leaders being taken out of clinical work to participate in human resource roles. Administration and bureaucracy are other areas that can potentially be delegated to other staff. Similarly, some tasks can be performed by more than one kind of allied health professional, yet we tend to be fairly precious or inflexible about which roles and tasks we share with other types of workers.

9. Identify where you can make the greatest difference with the resources available

The value proposition for your service should clearly outline the purpose of your service, your target client group, and the goals you are trying to achieve for that group. Unfortunately, in a contractionary resource environment, services tend to be allocated not according to high value care, but according to urgency. For example, occupational therapists and social workers are more likely to be re-allocated to areas such as supporting hospital discharge (low value care), rather than delivering services that would contribute to avoiding admission in the first place (high value care).


All health services are being increasingly stretched and face increasing pressure on limited resources to meet a growing need for services. Allied health workload planning and management has largely been responsive, rather than pro-active. As demands increase, it is important to ensure the strategic allocation of allied health services to where they can make the greatest difference.

This article is the start of a discussion around allied health workload management. Further workforce and workload planning tools are needed to ensure the best use of allied health services to achieve the greatest outcomes for the communities they serve.


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