Do you find that you are continually trying to do more with fewer resources, but are not quite sure why? You may be experiencing stealth rationing.

Allied health professionals are generally not trained managers, yet we are often placed in the challenging position of having to stretch finite staff resources to meet an infinite demand for services. Our primary value tends to be altruism – which means we prioritise the needs of our patients even in the face of declining resources. This leads to staff burn out which further decreases service efficiency and equity.

In our discussions with allied health professionals nationally and internationally, we hear the same stories repeated – reports of increasing and unrealistic expectations on the allied health workforce combined with contracting resources. However allied health resources are rarely managed well or systematically, instead they suffer from rationing by ‘stealth’, which is the gradual erosion of service capacity and conditions that is often invisible to clinicians and managers.

There are world-wide health workforce shortages right now which (amongst other challenges) are creating long waiting lists for primary care, increasing pressures on emergency departments, blowing out elective surgery waiting times, and in the UK at least, emergency department delays alone are causing excess deaths. It is a challenging time to be a health care provider and you will probably be experiencing additional demands on your time and work.

The purpose of this article is to help you identify allied health service rationing to help guide decision-making, to protect yourself and your team, while optimising the use of limited resources to meet patient needs. Some give and take is required to ensure ongoing service delivery, but there is also a need to recognise when to stop delivering services because it is unsafe or unviable to do so.

What is stealth rationing of allied health?

When finances are short (and elections are pending), there is little appetite to explicitly cut health service funding or reduce service output. Instead, health services often undergo ‘stealth’ rationing – that is the growth of new tasks and business that is not formally acknowledged as workload, but is expected to be provided with the same, or fewer resources. Alternatively, there may be an explicit reduction in resources to deliver the same workload.

Some common examples of stealth rationing of allied health services include:

• Lack of leave backfill for existing staff, including maternity leave  – in many cases staff are required to find cover for their own leave
• Increasing patient complexity or dependency that requires a greater level of intervention, without a concomitant increase in resources (including training or providing more expert staff)
• Growing patient demand resulting in increased workload (volume) without increasing resources (staff)
• Recruitment delays, leaving roles unfilled for long periods without cover or backfill
• Regularly expecting staff to work overtime without appropriate remuneration
• Reducing the amount of time available to deliver individual services (i.e., increasing service volume within existing resources)
• Failure to fully resource a service when it is established
• Bureaucracy creep (see below)
• Expecting staff to work in a more senior role without re-grading the staff member or the role
• Increasing the proportion of time spent in service delivery while reducing the time spent on training, business development or quality improvement activities

Most employees will have worked under at least some of the conditions outlined above, and ‘mopped up’ the excess service capacity to meet patient need. However, every single activity outlined above reduces your effective service capacity – most of which are easily quantifiable.  This is a form of service rationing. In other words, this is reducing your ability to deliver quality health care services.

The last two points are activities that are less quantifiable, but have an important impact on service quality  – that is, expecting staff to work beyond their grade and / or skill level, without appropriate rewards or recognition; and reducing the proportion of time spent on service and clinical improvement activities. The latter points are often those areas where  if an appropriate investment is made, services can increase their quality or efficiency – or both. Conversely, without appropriate support, services start to spiral into inefficiency.

Failing to acknowledge and act on service rationing creates risks. It creates risks for patient safety, it creates risks for service quality, it increases the pressure on staff and ultimately results in burnout – which further exacerbates health workforce shortages.

All services will have peaks and troughs in throughput and / or staffing shortages at some stage, which means that some of these activities are a normal part of service delivery – occasionally. However, services are increasingly reporting that they routinely experience these forms of service rationing, and with serious workforce shortages in many allied health professions right now, there is little respite in sight.

Bureaucracy creep

Not to be confused with the office jerk, bureaucracy creep is a form of stealth rationing where the non-clinical parts of your role expand without appropriate acknowledgement of the additional workload. Extra documentation, reporting, accreditation, auditing or compliance requirements, all create a growing burden on workload and health service delivery.

Patient held funding systems, such as My Aged Care and the National Disability Insurance Scheme in Australia shift much of the bureaucratic burden away from the health care funders and onto the clinician and the service user, resulting in a substantial additional workload for clinicians which is often unaccounted for and underfunded. Even insurance-based funding systems (public and private) such as Medicare tend to place a larger burden of reporting and administration onto allied health professionals without concomitant financial recognition.

Bureaucracy creep is often invisible, with many clinicians ‘absorbing’ the additional workload in their lunch hour, or even after hours.  In reality, bureaucracy is a part of your job and should be formally recognised as part of your clinical workload.

 Contexts that further reduce service effectiveness and efficiency

Stealth rationing reduces your actual workload capacity, but in the current challenging environment, stealth rationing generally arises in contexts that further increase inefficiencies. Examples include:

• High staff turnover which disrupts service delivery, reduces corporate memory, and takes additional time from service delivery to onboard new staff members.
• High ratios of junior staff to senior staff, diluting supervision capacity, and limiting the amount of senior or more experienced workforce capacity in the service.
• Employing a high proportion of temporary staff (eg agency / locum staff) who do not understand the organisational culture or lack key relationships that would normally increase their efficiency and effectiveness in an organisation.
• Filling strategic or key leadership roles with temporary staff who lack the agency to drive strategic changes and fully lead a team – or not filling key strategic roles at all.
• Having staff on short-term contracts, which means they are always on the lookout for a new, permanent position and could leave at any time.
• Separating critical and interdependent components of the services, creating administrative and service inefficiencies – for instance moving critical equipment providers or technology support out of the service so they are less accessible, or introducing new referral pathways to access a service.
• Not having access to essential equipment needed to perform your role, such as rehabilitation equipment, sterilisation, wheelchairs, and access to home modification services.
• Poor performance management of staff which allows inefficiencies to creep into service delivery.
• Lack of internal career development structures so clinicians look externally for promotion, rather than being supported to grow internally, resulting in increased staff turnover, high recruitment costs, and loss of organisational expertise and capacity.
• Requiring existing staff to go through administrative hurdles to remain employed (e.g. if casual staff want to become full-time in the same organisation).

All of these factors reduce the effective functioning of allied health services – some more directly than others – and further detract from the ability of a team to effectively perform their role. A disrupted work environment will generally require more staff to deliver an equivalent service to a highly functioning and stable team.

Are allied health services more at risk of stealth rationing than medical and nursing services?

There is very little data available on allied health workforce planning to determine definitively that allied health services suffer disproportionately from service rationing. However, in comparison, nurses have far more homogenous roles than allied health practitioners. Nurses tend to work under large award structures, be highly unionised, highly politicised, and have accepted workforce staffing ratios. While it is not always possible to achieve desirable nursing ratios with current workforce shortages, anecdotal evidence suggests that services prioritise the achievement of nursing workforce ratios because of their systemic leverage.

Have you ever heard a politician go into an election campaign promising more physiotherapists, occupational therapists, podiatrists, speech pathologists (etc)?

Similarly, the World Health Organisation publishes global doctor to patient ratios which allows countries to benchmark their medical workforces. Most hospitals and health services will have specific medical workforce planning and appointment committees for strong oversite of the medical workforce needs.

We suggest that the lack of established workforce models for allied health services and their lack of visibility in service planning and strategy makes it easier to hide or ignore workforce shortages. We discuss the challenges inherent in allied health workforce planning in this article.

Why is health service rationing important?

Health service rationing is a way of allocating scarce resources to those who most need them. All health services experience some form of rationing, whether it is implicit or explicit. To ensure that health services are allocated fairly, to those people who most need it, and where the return on investment is greatest (in other words, high value healthcare), the World Health Organisation says that health service rationing is a prerequisite to universal health coverage.

In a critical literature review, Keliddar and colleagues define rationing as “restricting the access of some people to useful or potentially useful health services due to budgetary limitation”.

Health service rationing occurs at several different levels. Government policy makers, health insurers, health care organisations, managers and clinicians all engage in behaviour that determines the priorities for health care accessibility. Keliddar argues that patients also make decisions about their use of health care, that are, in effect, self-rationing.

At its most basic level, rationing involves balancing health service supply (workers, facilities, funding, equipment etc) with demand (the size and attributes of the population potentially eligible to seek those services). A well developed service will make rational decisions about the balance between the supply of health services and demand, which also includes prioritisation. Triage, waiting lists, tiered reimbursement structures, and the need for referrals to access services are all examples of service rationing that we are familiar with. We wrote an article to help allied health services to manage their demand.

However, allied health practitioners are often excluded from the decision making processes that drive service rationing. High value interventions in which allied health can contribute to improving outcomes and reducing the burden of care on the rest of the health service are often overlooked (see our article 10 ways that allied health can keep people out of hospital). Instead, allied health services are generally planned and allocated in a piecemeal way with little understanding of the actual workload required to achieve the potential outcomes.

Stealth rationing, in contrast, is a hidden form of service contraction that is not formally acknowledged, is not systematic, and results in inequities in service allocation.

Conclusion

Stealth rationing is not new, nor is it unique to any particular country, allied health profession or service type. However, unlike ‘rational’ service rationing which aims to achieve equity in health service delivery, stealth rationing affects services disproportionately and often without a rational or evidence base.

We have identified nine strategies to help overcome stealth rationing and bureaucracy creep in your service, details available here.

Stealth rationing, as the definition suggests,  creeps up on you and your team until you realise the work you are trying to deliver is untenable within the resources available. Stealth rationing results in overworking, an inability to meet service demands and deadlines. Staff resist taking planned or unplanned leave in fear of the work building up during their absence. Feelings of helplessness arise because you can’t meet the never-ending needs of service users and the community, and this ultimately leads to burn-out.

Stealth rationing also increases service inefficiency. Services move into a responsive and reactive mode, rather than being able to pro-actively organise work, and lack the capacity to introduce new innovations that will increase efficiency and effectiveness. Stealth rationing also, frequently shifts the focus of services away from ‘high value care’ such as prevention or avoidance of hospitalisation, to having to respond to crises or support more acute care.

We would value hearing your experiences and insights about stealth rationing in your workplace. Please leave a comment below, or join our discussion forum on allied health workforce planning. Allied health professionals need to start a discussion about resource allocation so we can develop appropriate resources to support our value proposition and ensure that services are adequately staffed to best meet patient needs.

 

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