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Issues facing the future health care workforce: the importance of demand modelling

Issues facing the future health care workforce: the importance of demand modelling This article examines issues facing the future health care workforce in Australia in light of factors such as population ageing. It has been argued that population ageing in Australia is affecting the supply of health care professionals as the health workforce ages and at the same time increasing the demand for health care services and the health care workforce. However, the picture is not that simple. The health workforce market in Australia is influenced by a wide range of factors; on the demand side by increasing levels of income and wealth, emergence of new technologies, changing disease profiles, changing public health priorities and a focus on the prevention of chronic disease. While a strong correlation is observed between age and use of health care services (and thus health care workforce), this is mediated through illness, as typified by the consistent finding of higher health care costs in the months preceding death. On the supply side, the health workforce is highly influenced by policy drivers; both national policies (eg funded education and training places) and local policies (eg work place-based retention policies). Population ageing and ageing of the health workforce is not a dominant influence. In recent years, the Australian health care workforce has grown in excess of overall workforce growth, despite an ageing health workforce. We also note that current levels of workforce supply compare favourably with many OECD countries. The future of the health workforce will be shaped by a number of complex interacting factors. Market failure, a key feature of the market for health care services which is also observed in the health care labour market – means that imbalances between demand and supply can develop and persist, and suggests a role for health workforce planning to improve efficiency in the health services sector. Current approaches to health workforce planning, especially on the demand side, tend to be highly simplistic. These include historical allocation methods, such as the personnel-to- population ratios which are essentially circular in their rationale rather than evidence-based. This article highlights the importance of evidence-based demand modelling for those seeking to plan for the future Australian health care workforce. A model based on population health status and best practice protocols for health care is briefly outlined. Page 1 of 8 (page number not for citation purposes) Australia and New Zealand Health Policy 2009, 6:12 http://www.anzhealthpolicy.com/content/6/1/12 Influences on the health workforce supply Background The challenges facing Australia's health workforce have The health care workforce incorporates a range of voca- been the subject of recent intense public interest, with per- tions operating in different industry settings; medical ceptions of widespread and increasing workforce short- practitioners, nurses, allied health professionals (physio- ages that could impact upon patient care [1-4]. This therapists, dieticians, occupational therapists, optome- mirrors concerns about health workforce shortages inter- trists, clinical psychologists, social workers, indigenous nationally, for example as expressed by the World Health health workers etc.) and other occupations, working in Organization – although for WHO critical shortages are hospitals and other institutional settings (eg residential particularly identified with sub-Saharan Africa and Asia care facilities) and community settings including private [5]. practice, community health services and non-health set- tings (such as schools and workplaces). There are over Perceptions of health workforce shortages are driven in 450,000 paid health professionals in Australia, of whom part by concern by policy-makers of the impact of 'popu- over 50% are nurses, 12% medical practitioners and 9% lation ageing' upon the supply of and demand for health allied health professionals [5,15,16]. professionals [6,7]. A major demographic shift towards an older population has been occurring in the Australian As noted the ageing of the population and the associated population over several decades (the product of increas- ageing of the health workforce as illustrated, for example, ing life expectancy, lower birth rates and the ageing post- in Figure 1[17-20] for the Australian nursing workforce is war baby boom generation). As this shift has been occur- postulated to be precipitating a crisis in heath workforce ring, government inquiries have sought to understand supply. how the change in the population age structure might impact on the capacity of the health workforce to deliver Commentators have cited the increasing proportion of needed services. health care workers reaching retirement age, the tradition- ally lower per-person hours worked with increasing age The Productivity Commission in its 2005 report on Aus- combined with feminisation of the medical workforce tralia's health workforce, details shortages in the health also associated with lower average hours per worker – as workforce "in general practice, various medical specialty undermining workforce supply [6]. Exacerbated by areas, dentistry, nursing and some key allied health areas." increasing pressures in the work place, especially in public [6]. It suggested shortfalls of 800 to 1300 GPs in 2002 hospitals, that result in high rates of staff turnover and (~5% of the GP workforce), and an anticipated shortfall of departures from the industry [21,22]. 10–12,000 nurses (~5% of the nursing workforce) in 2006 and 12–13,000 in 2010; citing the 2004 Australian The major focus of the debate has been the ageing of the Health Workforce Advisory Committee (AHWAC) 2003– workforce and what is seen as an inevitable decline in 2004 annual report, [8] (This was in turn based on numbers. However, drawing conclusions from cross-sec- research by Access Economics (2004) [9], Preston [10], tional data ignores the many contrary influences affecting Shah and Burke [11] and Karmel and Li [12].) Other com- health workforce supply. Participation rates at older ages mentators have voiced similar concerns about existing and mean hours of work are increasing, especially and impending health workforce shortages [13]. How- amongst women. This is in part a direct response to pol- ever, the basis for these observations and predictions are icy, such as changes in superannuation rules and other highly simplistic models that fail to adjust for any of the regulatory changes specifically designed to delay retire- complex influences on the demand for and supply of ment[23]. More generally, female participation rates in health workers, as described below. They thus fail to pro- Australia are increasing across all age groups, related to vide a sound basis for health workforce planning, which delayed child rearing, smaller family size, policy changes requires a sophisticated understanding of the main drivers in childcare and changes in community attitudes. This has of demand and supply. A factor recognised in the recent seen female participation rates increase from 42.3% in Jan establishment of a National Health Workforce Taskforce 1979 to 58.4% in March 2008 [23,24]. Projections under- through AHMAC (Australian Health Minister's Advisory taken by Evans & Keeley [25] suggested a dramatic Council) to take on a health workforce planning role [14] increase in participation rates for older married women in recognises the complexity of this task and the inadequacy the next two decades; for married women over 55 with of current approaches to health workforce planning. children post-school age from 59% in 2002 to 89% by 2022. This is highly significant given the largely female In this paper we discuss some of the key drivers of health health professional workforce. Healy [26] also argues that workforce demand and health workforce supply and con- an older workforce may also have greater levels of skills clude with a brief discussion of alternative approaches to and experience and potentially greater efficiency. modelling health workforce demand. Page 2 of 8 (page number not for citation purposes) Australia and New Zealand Health Policy 2009, 6:12 http://www.anzhealthpolicy.com/content/6/1/12 Th Figure 1 e age structure of the Australian nursing workforce 1995, 2001, 2005 Source: AIHW [17-20] The age structure of the Australian nursing workforce 1995, 2001, 2005 Source: AIHW [17-20]. The supply and mix of health professionals through new workforce in the UK has demonstrated the potential effec- entrants, training, changing roles and retention of staff tiveness of policy levers. There is no reason to assume a has shown considerable responsiveness to direct policy similar range of policies would not be effective in Aus- initiatives as well as the indirect drivers of changing tech- tralia, especially given the strong competition for places in nology and service demands. This is seen in a constantly clinical schools [31]. The capacity for Australia's health changing health workforce mix, a process detailed by workforce to expand, despite an ageing workforce is evi- Duckett [4]. Recent innovative changes to traditional dent from a simple analysis of the available data. Census health workforce roles in Australia (such as the expanding figures show a growth in the health workforce in Australia role of the practice nurse and nurse practitioner and the of over 3% per annum, significantly faster than the rate of development of new para-professional roles) will allow population growth of 1.2% to 1.5% per annum 2000– an even greater responsiveness to future health workforce 2008) [32]. The AIHW [33] concurred reporting a 26% supply challenges[27]. The recent focus on chronic dis- increase in the number of people employed in health ease prevention through the Australian Better Health Ini- occupations between 2000 and 2005, compared with an tiative is seeing considerable discussion about new allied 18.04% rise in the workforce overall [24]. health roles, such as 'lifestyle coaches'; and the develop- ment of new courses to train for these community-based Health workplaces in Australia are responding to current illness prevention roles [28,29]. and projected health workforce and other capacity prob- lems with a range of reforms. Several successful initiatives The United Kingdom, for example, has increased the size are described in the Supplement to the MJA, [34]. Papers of the health care workforce in a short time period, with identify productivity gain and reduced workforce turnover an appropriately targeted policy mix; including new fund- through redesign of work processes. An example reported ing for additional consultants, GPs, and nurses within the is Flinders Medical Centre in Adelaide, which employed a NHS, an increase in medical school places and hospital- 'lean thinking' approach to reorganise care. Key principles based reforms to improve the work environment [30]. were involvement of 'shop floor staff', a patient focus and These initiatives have seen in the UK National Health detailed understanding of current work activities. Authors Service a growth in the number of GPs by 20.1%, of qual- report an increase in productivity, eg 40% increase in ED ified nurses by 26.8% and of allied health professionals by throughput, over 70% reduction in serious adverse events 35.7% in the period 1997 to 2005 [30]. The health care Page 3 of 8 (page number not for citation purposes) Australia and New Zealand Health Policy 2009, 6:12 http://www.anzhealthpolicy.com/content/6/1/12 and stabilisation of staffing "within the ED and across background papers to the Australian 2020 summit also nursing services throughout the hospital" [35] presumes a dominant influence of an ageing population on demand for health care (and thus the health care work- Another policy lever has been to use a range of initiatives force) [38]. to supplement the Australian health workforce with over- seas trained doctors and nurses. The Australian Health However the evidence suggests that the role of ageing is Workforce Advisory Committee (AMWAC), estimated highly uncertain, as the observed relationship between overseas trained doctors made up 25% of the Australian age and health care use and thus health workforce require- medical workforce in 2005, up from an estimated 19% in ment is entirely mediated through illness. It simply is not 1995; (Productivity Commission [6]). The AIHW 2005 correct to use cross-sectional data of health care costs by medical labour force survey (covering all states except age, for projecting health care use and health care work- NSW and NT) also reports 78.0% of the health workforce force demand. End-of-life events are consistently found to trained in Australia, but with considerable variation make a major contribution to health care costs, which, across the country, (65.5.% WA). Overseas recruitment correlated with increasing age does not mean ageing is an has been designed primarily to address regional maldistri- independent determinant of health care costs. Calver, Bul- bution and a past failure to increase training places for sara and Boldy [39] in their study of hospital costs relating health professionals. High competition from local stu- to end of life events in Western Australia concluded that dents for training places suggests that a shift towards a "Older decedents were not more likely to be hospitalised higher local share is feasible, if resourced. than younger decedents in the final three years of life. Moreover, once hospitalised, their in-patient costs were The evidence concerning health workforce supply suggests lower." They cited a number of studies that reach a similar a picture of a health workforce growing, despite an ageing conclusion, including Gray [40] who reported that "the population and ageing workforce, and one that is highly relationship between age and health expenditure was responsive to policy levers. The challenge is to ensure the weak and possibly inverse once proximity to death was policy levers are driven by a sound understanding of allowed for." health workforce demand. Establishing the desirable level and mix of the health workforce, which reflects the opti- As noted by Calver and colleagues "Failure to account for mal mix of health services, needs to be a focus of health proximity to death will overemphasise the impact of pop- workforce research. Health workforce supply strategies ulation ageing on health care expenditure, because older can then be devised to meet underlying need. people have a higher probability of dying." International studies to develop risk adjusters for insurance premiums, Health workforce demand also find that ageing as an independent variable accounts Rarely is a clear distinction made between 'expressed' for less than 3% of variation in health care costs [41]. Risk health workforce demand and underlying need. Expressed adjustment models are increasingly incorporating health workforce demand is essentially defined by funded places status as the primary drivers. Breyer and Felder [42] also (essentially current supply plus unfilled positions), while warned against simply undertaking a cross-sectional anal- the concept of underlying need refers to the health work- ysis of hospital admission rates by age and applying this force (size and mix) that will meet societal health sector to future population projections, arguing that time before objectives (including equity) in an efficient manner. In death is a better predictor. (See also Coory (p.581)[43]. the context of market failure as typifies the health sector and the health labour market[36,37], concepts of Annual death data show that in contrast to (or in part expressed demand and underlying need are likely to because of) the ageing of the population (people are stay- depart. In a health workforce planning exercise, it is the ing alive longer) the annual number of deaths in Australia underlying health workforce need, which in turn reflects is increasing at only a modest rate. The number of deaths the need for health care – including health promotion – per year over the 10 years from 1995 to 2005 increased by that should drive supply, not expressed demand. We also a mean of just 0.3% pa (cumulative), with just 5,200 more note that the latter concept being mediated by supply is deaths in 2005 than 1995 [44]. Strategies to promote not exogenous. "healthy aging" [45] may further reduce the risk of chronic diseases and associated disability, although there are also The Productivity Commission (p.18)[6] argued that the contrary influences, including rising rates of obesity. demand for health care services and consequently for the health care workforce will primarily be driven by the ' age- Health workforce models ing of the population' and associated increasing disability Because of market failure in health care and the health rates, together with changing technology, changing bur- workforce [35,46], the market will not arrive at an optimal den of disease, higher incomes and expectations. The health workforce solution meaning a clear role for health Page 4 of 8 (page number not for citation purposes) Australia and New Zealand Health Policy 2009, 6:12 http://www.anzhealthpolicy.com/content/6/1/12 workforce planning. The improving quality and scope of associated increase in workforce numbers in line with data collections in the health sector, and linked data sets aggregate population levels. This hardly fits in with the present the opportunity for more detailed modelling in evidence-based approach increasingly demanded in other this area. Tools, such as hardware and software platforms aspects of health care or health services research. capable of undertaking detailed analysis are increasingly cheap and ubiquitous. The current limitation is in the Classification of approaches available models and frameworks that make use of these There have been a number of attempts, internationally, to tools. classify the approaches to modelling health workforce demand. Segal and Robertson [49] described five distinct The dominant approach to 'health workforce planning' health workforce forecasting methods:- has been highly simplistic personnel-to-population ratios. The logic of such approaches is unclear, especially 1. Historic allocation – commonly the personnel-to-pop- in the face of wide variations in observed ratios over time ulation method as described above. and place. For instance, the nursing workforce across 28 OECD countries varied in 2002 from 1.7 nurses per 1,000 2. Budget driven mechanisms – also described as a prag- population in Turkey to 15.3 nurses per 1,000 in Ireland. matic approach, where service levels and associated work- At 10.4 practising nurses per 1000 population, Australia force levels are determined in the context of defined th had the 6 highest nursing ratio, higher than the UK at expenditure targets. This method has also been referred to 8.9, US at 7.9, Canada at 9.4 and New Zealand at 9.4. as the service-demands method [50]. Practising physicians in 2005 ranged from 1.5 to 4.9 per 1000 population across the OECD, with most countries 3. Waiting lists – whereby waiting lists are used as an indi- between 2 and 4, with Australia at 2.7 per 1000 popula- cator of imbalance between supply and demand, which as tion. (See Figure 2) [47]. noted above is compromised by the impact of supply on observed demand. O'Brien-Pallas & colleagues in their international review of various health workforce models [48] are most critical 4. Professional group planning models – this is similar to of the ratio-based methods of service provision and the a Delphi method of forecasting, where experts in the field Pra Figure 2 ctising physicians per 1000 persons, OECD 2005, Source: OECD (2007) [47] Practising physicians per 1000 persons, OECD 2005, Source: OECD (2007) [47]. Page 5 of 8 (page number not for citation purposes) Australia and New Zealand Health Policy 2009, 6:12 http://www.anzhealthpolicy.com/content/6/1/12 – in this case health professionals – develop the roles and Economists such as Maynard [54] also highlighted some responsibilities and determine the appropriate level of of the forecasting challenges of health workforce planning supply. and especially the possible impact of changes in produc- tivity and associated new workforce roles. Changes in 5. Needs Assessment models – presume that health serv- technology are likely to affect both how services will be ices planning and funding should enable and support delivered but also health status and disease profile. This, patients and citizens to access best practice care (including together with changing community expectations – for preventions services). A needs-based model developed by instance about the role for prevention – will reduce the Segal is described in some detail in a recent publication by demand for certain services and associated health profes- Segal at al [51]. Need is defined in this model by best prac- sionals and increase demand for others. Policy choices, tise care and prevention protocols, applied to the health around matters such as specialisation or multi-skilling in status of the population. This is translated into a health the health workforce will also influence how health serv- workforce allowing various options for mapping skills ice demands are translated into health workforce needs. and competencies onto occupations. A similar method is For instance, the shift in disease profile towards chronic described by Ridoutt et al [52] based on work by O'Con- disease and community-based approaches to prevention nor and Van Konkelneberg (1995) [53]. This type of and management means a greater demand for health pro- approach offers an objective evidence-based approach to fessionals with expertise to support lifestyle change such estimating health workforce need. as community and clinical dieticians, exercise physiolo- gists, educators (public health and clinical), health pro- Zurn et al [1] have also postulated a framework for analy- motion professionals and the possible role for new sis of health workforce demand which adopts a needs specialisations. Such changes tend to be gradual and easy based framework. They identify the broad influences on to identify. They should be capable of being incorporated population health status – socio-demographic, economic, into health workforce models. The 'needs-based' demand geographic and cultural, which when combined with model developed by Segal has been devised precisely to available technology, define the health needs of the pop- incorporate changing circumstances. ulation. Policy and resource allocation decisions will influence how health needs are translated into health care It is also important as noted by the World Health Organi- services and workforce demand (see Figure 3). Health sta- zation [5] that health workforce planning consider the tus is shown as mutable, influenced by life style and other need for managers/health planners/researchers as well as factors. This framework is presented as a general schema, the clinical workforce. rather than a model for estimating health workforce demand. Translation of the schema into a demand model Summary would be highly complex, but also highlights the chal- Market failure in the health care labour market and an lenging nature of this task. apparent mismatch between health workforce supply and demand (defined by need) underline the importance of effective health workforce planning. Socio demographic Policy and o Age distribution resource mix o Education Health Geographic and Health states care Environmental Disability service Cultural factors needs Health o Social Norms o Behaviour and Self- Health workforce efficacy promotion Technology Economic Factors demand o Income & wealth F Figure 3 actors and pathways influencing health workforce demand Factors and pathways influencing health workforce demand. Source: Zurn et al [1]. Page 6 of 8 (page number not for citation purposes) x Australia and New Zealand Health Policy 2009, 6:12 http://www.anzhealthpolicy.com/content/6/1/12 5. World Health Organization (WHO): 'The World Health Report The health workforce market is highly complex and influ- 2006 – Working Together for Health'. [http://www.who.int/ enced by many factors. The changing age distribution of whr/2006/en/]. the population is unlikely to have a dominant or critical 6. 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AIHW: Australia's Health 2004 Canberra: AIHW; 2004. workforce planning. More research into supply-side issues 16. AIHW and ABS: Health and community services labour force, 2001 Can- (worker training, recruitment, retention etc.), will fail to berra: AIHW; 2003. 17. AIHW: Health and community services labour force 1996 Canberra: deliver what is achievable in terms of better health, if it AIHW; 2001. proceeds without a complementary and rigorous analysis 18. Australian Institute of Health and Welfare: Nursing and midwifery work- of demand. Simple population-based ratio methods of force 2005 Canberra: AIHW; 2008. 19. Australian Institute of Health and Welfare: Nursing Labour force 2002 estimating workforce demand are demonstrably inade- Canberra: AIHW; 2003. quate. Even supposing such ratios were correct at some 20. Australian Institute of Health and Welfare: Nursing labour force 1995 Canberra: AIHW; 1998. point in time, there is no mechanism to adjust for chang- 21. 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Department of Population and International Health, Harvard School of Public Health, Massachusetts 1993. 51. Segal L, Dalziel K, T Bolton: 'A work force model to support the adoption of best practice care in Chronic Diseases – A miss- ing piece in clinical guideline implementation'. Implementation Science 2008, 3:35. 52. Ridoutt L, Schoo A, Santos T: 'Workload capacity measures for use in Allied Health Workforce Planning'. Sydney: DHS research report; 2006. 53. O'Conner K, Van Konkelenberg R: 'Estimating requirements for selected categories of health personnel in New South Wales'. Sydney: NSW Health Department; 1995. 54. Maynard A: 'Medical Workforce Planning: Some Forecasting Challenges'. Australian Economic Review 2006, 39:323-329. Publish with Bio Med Central and every scientist can read your work free of charge "BioMed Central will be the most significant development for disseminating the results of biomedical researc h in our lifetime." 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Issues facing the future health care workforce: the importance of demand modelling

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Medicine & Public Health; Public Health; Social Policy
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Abstract

This article examines issues facing the future health care workforce in Australia in light of factors such as population ageing. It has been argued that population ageing in Australia is affecting the supply of health care professionals as the health workforce ages and at the same time increasing the demand for health care services and the health care workforce. However, the picture is not that simple. The health workforce market in Australia is influenced by a wide range of factors; on the demand side by increasing levels of income and wealth, emergence of new technologies, changing disease profiles, changing public health priorities and a focus on the prevention of chronic disease. While a strong correlation is observed between age and use of health care services (and thus health care workforce), this is mediated through illness, as typified by the consistent finding of higher health care costs in the months preceding death. On the supply side, the health workforce is highly influenced by policy drivers; both national policies (eg funded education and training places) and local policies (eg work place-based retention policies). Population ageing and ageing of the health workforce is not a dominant influence. In recent years, the Australian health care workforce has grown in excess of overall workforce growth, despite an ageing health workforce. We also note that current levels of workforce supply compare favourably with many OECD countries. The future of the health workforce will be shaped by a number of complex interacting factors. Market failure, a key feature of the market for health care services which is also observed in the health care labour market – means that imbalances between demand and supply can develop and persist, and suggests a role for health workforce planning to improve efficiency in the health services sector. Current approaches to health workforce planning, especially on the demand side, tend to be highly simplistic. These include historical allocation methods, such as the personnel-to- population ratios which are essentially circular in their rationale rather than evidence-based. This article highlights the importance of evidence-based demand modelling for those seeking to plan for the future Australian health care workforce. A model based on population health status and best practice protocols for health care is briefly outlined. Page 1 of 8 (page number not for citation purposes) Australia and New Zealand Health Policy 2009, 6:12 http://www.anzhealthpolicy.com/content/6/1/12 Influences on the health workforce supply Background The challenges facing Australia's health workforce have The health care workforce incorporates a range of voca- been the subject of recent intense public interest, with per- tions operating in different industry settings; medical ceptions of widespread and increasing workforce short- practitioners, nurses, allied health professionals (physio- ages that could impact upon patient care [1-4]. This therapists, dieticians, occupational therapists, optome- mirrors concerns about health workforce shortages inter- trists, clinical psychologists, social workers, indigenous nationally, for example as expressed by the World Health health workers etc.) and other occupations, working in Organization – although for WHO critical shortages are hospitals and other institutional settings (eg residential particularly identified with sub-Saharan Africa and Asia care facilities) and community settings including private [5]. practice, community health services and non-health set- tings (such as schools and workplaces). There are over Perceptions of health workforce shortages are driven in 450,000 paid health professionals in Australia, of whom part by concern by policy-makers of the impact of 'popu- over 50% are nurses, 12% medical practitioners and 9% lation ageing' upon the supply of and demand for health allied health professionals [5,15,16]. professionals [6,7]. A major demographic shift towards an older population has been occurring in the Australian As noted the ageing of the population and the associated population over several decades (the product of increas- ageing of the health workforce as illustrated, for example, ing life expectancy, lower birth rates and the ageing post- in Figure 1[17-20] for the Australian nursing workforce is war baby boom generation). As this shift has been occur- postulated to be precipitating a crisis in heath workforce ring, government inquiries have sought to understand supply. how the change in the population age structure might impact on the capacity of the health workforce to deliver Commentators have cited the increasing proportion of needed services. health care workers reaching retirement age, the tradition- ally lower per-person hours worked with increasing age The Productivity Commission in its 2005 report on Aus- combined with feminisation of the medical workforce tralia's health workforce, details shortages in the health also associated with lower average hours per worker – as workforce "in general practice, various medical specialty undermining workforce supply [6]. Exacerbated by areas, dentistry, nursing and some key allied health areas." increasing pressures in the work place, especially in public [6]. It suggested shortfalls of 800 to 1300 GPs in 2002 hospitals, that result in high rates of staff turnover and (~5% of the GP workforce), and an anticipated shortfall of departures from the industry [21,22]. 10–12,000 nurses (~5% of the nursing workforce) in 2006 and 12–13,000 in 2010; citing the 2004 Australian The major focus of the debate has been the ageing of the Health Workforce Advisory Committee (AHWAC) 2003– workforce and what is seen as an inevitable decline in 2004 annual report, [8] (This was in turn based on numbers. However, drawing conclusions from cross-sec- research by Access Economics (2004) [9], Preston [10], tional data ignores the many contrary influences affecting Shah and Burke [11] and Karmel and Li [12].) Other com- health workforce supply. Participation rates at older ages mentators have voiced similar concerns about existing and mean hours of work are increasing, especially and impending health workforce shortages [13]. How- amongst women. This is in part a direct response to pol- ever, the basis for these observations and predictions are icy, such as changes in superannuation rules and other highly simplistic models that fail to adjust for any of the regulatory changes specifically designed to delay retire- complex influences on the demand for and supply of ment[23]. More generally, female participation rates in health workers, as described below. They thus fail to pro- Australia are increasing across all age groups, related to vide a sound basis for health workforce planning, which delayed child rearing, smaller family size, policy changes requires a sophisticated understanding of the main drivers in childcare and changes in community attitudes. This has of demand and supply. A factor recognised in the recent seen female participation rates increase from 42.3% in Jan establishment of a National Health Workforce Taskforce 1979 to 58.4% in March 2008 [23,24]. Projections under- through AHMAC (Australian Health Minister's Advisory taken by Evans & Keeley [25] suggested a dramatic Council) to take on a health workforce planning role [14] increase in participation rates for older married women in recognises the complexity of this task and the inadequacy the next two decades; for married women over 55 with of current approaches to health workforce planning. children post-school age from 59% in 2002 to 89% by 2022. This is highly significant given the largely female In this paper we discuss some of the key drivers of health health professional workforce. Healy [26] also argues that workforce demand and health workforce supply and con- an older workforce may also have greater levels of skills clude with a brief discussion of alternative approaches to and experience and potentially greater efficiency. modelling health workforce demand. Page 2 of 8 (page number not for citation purposes) Australia and New Zealand Health Policy 2009, 6:12 http://www.anzhealthpolicy.com/content/6/1/12 Th Figure 1 e age structure of the Australian nursing workforce 1995, 2001, 2005 Source: AIHW [17-20] The age structure of the Australian nursing workforce 1995, 2001, 2005 Source: AIHW [17-20]. The supply and mix of health professionals through new workforce in the UK has demonstrated the potential effec- entrants, training, changing roles and retention of staff tiveness of policy levers. There is no reason to assume a has shown considerable responsiveness to direct policy similar range of policies would not be effective in Aus- initiatives as well as the indirect drivers of changing tech- tralia, especially given the strong competition for places in nology and service demands. This is seen in a constantly clinical schools [31]. The capacity for Australia's health changing health workforce mix, a process detailed by workforce to expand, despite an ageing workforce is evi- Duckett [4]. Recent innovative changes to traditional dent from a simple analysis of the available data. Census health workforce roles in Australia (such as the expanding figures show a growth in the health workforce in Australia role of the practice nurse and nurse practitioner and the of over 3% per annum, significantly faster than the rate of development of new para-professional roles) will allow population growth of 1.2% to 1.5% per annum 2000– an even greater responsiveness to future health workforce 2008) [32]. The AIHW [33] concurred reporting a 26% supply challenges[27]. The recent focus on chronic dis- increase in the number of people employed in health ease prevention through the Australian Better Health Ini- occupations between 2000 and 2005, compared with an tiative is seeing considerable discussion about new allied 18.04% rise in the workforce overall [24]. health roles, such as 'lifestyle coaches'; and the develop- ment of new courses to train for these community-based Health workplaces in Australia are responding to current illness prevention roles [28,29]. and projected health workforce and other capacity prob- lems with a range of reforms. Several successful initiatives The United Kingdom, for example, has increased the size are described in the Supplement to the MJA, [34]. Papers of the health care workforce in a short time period, with identify productivity gain and reduced workforce turnover an appropriately targeted policy mix; including new fund- through redesign of work processes. An example reported ing for additional consultants, GPs, and nurses within the is Flinders Medical Centre in Adelaide, which employed a NHS, an increase in medical school places and hospital- 'lean thinking' approach to reorganise care. Key principles based reforms to improve the work environment [30]. were involvement of 'shop floor staff', a patient focus and These initiatives have seen in the UK National Health detailed understanding of current work activities. Authors Service a growth in the number of GPs by 20.1%, of qual- report an increase in productivity, eg 40% increase in ED ified nurses by 26.8% and of allied health professionals by throughput, over 70% reduction in serious adverse events 35.7% in the period 1997 to 2005 [30]. The health care Page 3 of 8 (page number not for citation purposes) Australia and New Zealand Health Policy 2009, 6:12 http://www.anzhealthpolicy.com/content/6/1/12 and stabilisation of staffing "within the ED and across background papers to the Australian 2020 summit also nursing services throughout the hospital" [35] presumes a dominant influence of an ageing population on demand for health care (and thus the health care work- Another policy lever has been to use a range of initiatives force) [38]. to supplement the Australian health workforce with over- seas trained doctors and nurses. The Australian Health However the evidence suggests that the role of ageing is Workforce Advisory Committee (AMWAC), estimated highly uncertain, as the observed relationship between overseas trained doctors made up 25% of the Australian age and health care use and thus health workforce require- medical workforce in 2005, up from an estimated 19% in ment is entirely mediated through illness. It simply is not 1995; (Productivity Commission [6]). The AIHW 2005 correct to use cross-sectional data of health care costs by medical labour force survey (covering all states except age, for projecting health care use and health care work- NSW and NT) also reports 78.0% of the health workforce force demand. End-of-life events are consistently found to trained in Australia, but with considerable variation make a major contribution to health care costs, which, across the country, (65.5.% WA). Overseas recruitment correlated with increasing age does not mean ageing is an has been designed primarily to address regional maldistri- independent determinant of health care costs. Calver, Bul- bution and a past failure to increase training places for sara and Boldy [39] in their study of hospital costs relating health professionals. High competition from local stu- to end of life events in Western Australia concluded that dents for training places suggests that a shift towards a "Older decedents were not more likely to be hospitalised higher local share is feasible, if resourced. than younger decedents in the final three years of life. Moreover, once hospitalised, their in-patient costs were The evidence concerning health workforce supply suggests lower." They cited a number of studies that reach a similar a picture of a health workforce growing, despite an ageing conclusion, including Gray [40] who reported that "the population and ageing workforce, and one that is highly relationship between age and health expenditure was responsive to policy levers. The challenge is to ensure the weak and possibly inverse once proximity to death was policy levers are driven by a sound understanding of allowed for." health workforce demand. Establishing the desirable level and mix of the health workforce, which reflects the opti- As noted by Calver and colleagues "Failure to account for mal mix of health services, needs to be a focus of health proximity to death will overemphasise the impact of pop- workforce research. Health workforce supply strategies ulation ageing on health care expenditure, because older can then be devised to meet underlying need. people have a higher probability of dying." International studies to develop risk adjusters for insurance premiums, Health workforce demand also find that ageing as an independent variable accounts Rarely is a clear distinction made between 'expressed' for less than 3% of variation in health care costs [41]. Risk health workforce demand and underlying need. Expressed adjustment models are increasingly incorporating health workforce demand is essentially defined by funded places status as the primary drivers. Breyer and Felder [42] also (essentially current supply plus unfilled positions), while warned against simply undertaking a cross-sectional anal- the concept of underlying need refers to the health work- ysis of hospital admission rates by age and applying this force (size and mix) that will meet societal health sector to future population projections, arguing that time before objectives (including equity) in an efficient manner. In death is a better predictor. (See also Coory (p.581)[43]. the context of market failure as typifies the health sector and the health labour market[36,37], concepts of Annual death data show that in contrast to (or in part expressed demand and underlying need are likely to because of) the ageing of the population (people are stay- depart. In a health workforce planning exercise, it is the ing alive longer) the annual number of deaths in Australia underlying health workforce need, which in turn reflects is increasing at only a modest rate. The number of deaths the need for health care – including health promotion – per year over the 10 years from 1995 to 2005 increased by that should drive supply, not expressed demand. We also a mean of just 0.3% pa (cumulative), with just 5,200 more note that the latter concept being mediated by supply is deaths in 2005 than 1995 [44]. Strategies to promote not exogenous. "healthy aging" [45] may further reduce the risk of chronic diseases and associated disability, although there are also The Productivity Commission (p.18)[6] argued that the contrary influences, including rising rates of obesity. demand for health care services and consequently for the health care workforce will primarily be driven by the ' age- Health workforce models ing of the population' and associated increasing disability Because of market failure in health care and the health rates, together with changing technology, changing bur- workforce [35,46], the market will not arrive at an optimal den of disease, higher incomes and expectations. The health workforce solution meaning a clear role for health Page 4 of 8 (page number not for citation purposes) Australia and New Zealand Health Policy 2009, 6:12 http://www.anzhealthpolicy.com/content/6/1/12 workforce planning. The improving quality and scope of associated increase in workforce numbers in line with data collections in the health sector, and linked data sets aggregate population levels. This hardly fits in with the present the opportunity for more detailed modelling in evidence-based approach increasingly demanded in other this area. Tools, such as hardware and software platforms aspects of health care or health services research. capable of undertaking detailed analysis are increasingly cheap and ubiquitous. The current limitation is in the Classification of approaches available models and frameworks that make use of these There have been a number of attempts, internationally, to tools. classify the approaches to modelling health workforce demand. Segal and Robertson [49] described five distinct The dominant approach to 'health workforce planning' health workforce forecasting methods:- has been highly simplistic personnel-to-population ratios. The logic of such approaches is unclear, especially 1. Historic allocation – commonly the personnel-to-pop- in the face of wide variations in observed ratios over time ulation method as described above. and place. For instance, the nursing workforce across 28 OECD countries varied in 2002 from 1.7 nurses per 1,000 2. Budget driven mechanisms – also described as a prag- population in Turkey to 15.3 nurses per 1,000 in Ireland. matic approach, where service levels and associated work- At 10.4 practising nurses per 1000 population, Australia force levels are determined in the context of defined th had the 6 highest nursing ratio, higher than the UK at expenditure targets. This method has also been referred to 8.9, US at 7.9, Canada at 9.4 and New Zealand at 9.4. as the service-demands method [50]. Practising physicians in 2005 ranged from 1.5 to 4.9 per 1000 population across the OECD, with most countries 3. Waiting lists – whereby waiting lists are used as an indi- between 2 and 4, with Australia at 2.7 per 1000 popula- cator of imbalance between supply and demand, which as tion. (See Figure 2) [47]. noted above is compromised by the impact of supply on observed demand. O'Brien-Pallas & colleagues in their international review of various health workforce models [48] are most critical 4. Professional group planning models – this is similar to of the ratio-based methods of service provision and the a Delphi method of forecasting, where experts in the field Pra Figure 2 ctising physicians per 1000 persons, OECD 2005, Source: OECD (2007) [47] Practising physicians per 1000 persons, OECD 2005, Source: OECD (2007) [47]. Page 5 of 8 (page number not for citation purposes) Australia and New Zealand Health Policy 2009, 6:12 http://www.anzhealthpolicy.com/content/6/1/12 – in this case health professionals – develop the roles and Economists such as Maynard [54] also highlighted some responsibilities and determine the appropriate level of of the forecasting challenges of health workforce planning supply. and especially the possible impact of changes in produc- tivity and associated new workforce roles. Changes in 5. Needs Assessment models – presume that health serv- technology are likely to affect both how services will be ices planning and funding should enable and support delivered but also health status and disease profile. This, patients and citizens to access best practice care (including together with changing community expectations – for preventions services). A needs-based model developed by instance about the role for prevention – will reduce the Segal is described in some detail in a recent publication by demand for certain services and associated health profes- Segal at al [51]. Need is defined in this model by best prac- sionals and increase demand for others. Policy choices, tise care and prevention protocols, applied to the health around matters such as specialisation or multi-skilling in status of the population. This is translated into a health the health workforce will also influence how health serv- workforce allowing various options for mapping skills ice demands are translated into health workforce needs. and competencies onto occupations. A similar method is For instance, the shift in disease profile towards chronic described by Ridoutt et al [52] based on work by O'Con- disease and community-based approaches to prevention nor and Van Konkelneberg (1995) [53]. This type of and management means a greater demand for health pro- approach offers an objective evidence-based approach to fessionals with expertise to support lifestyle change such estimating health workforce need. as community and clinical dieticians, exercise physiolo- gists, educators (public health and clinical), health pro- Zurn et al [1] have also postulated a framework for analy- motion professionals and the possible role for new sis of health workforce demand which adopts a needs specialisations. Such changes tend to be gradual and easy based framework. They identify the broad influences on to identify. They should be capable of being incorporated population health status – socio-demographic, economic, into health workforce models. The 'needs-based' demand geographic and cultural, which when combined with model developed by Segal has been devised precisely to available technology, define the health needs of the pop- incorporate changing circumstances. ulation. Policy and resource allocation decisions will influence how health needs are translated into health care It is also important as noted by the World Health Organi- services and workforce demand (see Figure 3). Health sta- zation [5] that health workforce planning consider the tus is shown as mutable, influenced by life style and other need for managers/health planners/researchers as well as factors. This framework is presented as a general schema, the clinical workforce. rather than a model for estimating health workforce demand. Translation of the schema into a demand model Summary would be highly complex, but also highlights the chal- Market failure in the health care labour market and an lenging nature of this task. apparent mismatch between health workforce supply and demand (defined by need) underline the importance of effective health workforce planning. Socio demographic Policy and o Age distribution resource mix o Education Health Geographic and Health states care Environmental Disability service Cultural factors needs Health o Social Norms o Behaviour and Self- Health workforce efficacy promotion Technology Economic Factors demand o Income & wealth F Figure 3 actors and pathways influencing health workforce demand Factors and pathways influencing health workforce demand. Source: Zurn et al [1]. Page 6 of 8 (page number not for citation purposes) x Australia and New Zealand Health Policy 2009, 6:12 http://www.anzhealthpolicy.com/content/6/1/12 5. World Health Organization (WHO): 'The World Health Report The health workforce market is highly complex and influ- 2006 – Working Together for Health'. [http://www.who.int/ enced by many factors. The changing age distribution of whr/2006/en/]. the population is unlikely to have a dominant or critical 6. 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AIHW: Australia's Health 2004 Canberra: AIHW; 2004. workforce planning. More research into supply-side issues 16. AIHW and ABS: Health and community services labour force, 2001 Can- (worker training, recruitment, retention etc.), will fail to berra: AIHW; 2003. 17. AIHW: Health and community services labour force 1996 Canberra: deliver what is achievable in terms of better health, if it AIHW; 2001. proceeds without a complementary and rigorous analysis 18. Australian Institute of Health and Welfare: Nursing and midwifery work- of demand. Simple population-based ratio methods of force 2005 Canberra: AIHW; 2008. 19. Australian Institute of Health and Welfare: Nursing Labour force 2002 estimating workforce demand are demonstrably inade- Canberra: AIHW; 2003. quate. Even supposing such ratios were correct at some 20. Australian Institute of Health and Welfare: Nursing labour force 1995 Canberra: AIHW; 1998. point in time, there is no mechanism to adjust for chang- 21. 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Sir Paul Nurse, Cancer Research UK Your research papers will be: available free of charge to the entire biomedical community peer reviewed and published immediately upon acceptance cited in PubMed and archived on PubMed Central yours — you keep the copyright BioMedcentral Submit your manuscript here: http://www.biomedcentral.com/info/publishing_adv.asp Page 8 of 8 (page number not for citation purposes)

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Australia and New Zealand Health PolicySpringer Journals

Published: May 7, 2009

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