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The Australian preventive health agenda: what will this mean for workforce development?

The Australian preventive health agenda: what will this mean for workforce development? The formation of the National Health and Hospitals Reform Commission (NHHRC) and the National Preventative Task Force in 2008, demonstrate a renewed Australian Government commitment to health reform. The re-focus on prevention, bringing it to the centre of health care has significant implications for health service delivery in the primary health care setting, supportive organisational structures and continuing professional development for the existing clinical and public health workforce. It is an opportune time, therefore, to consider new approaches to workforce development aligned to health policy reform. Regardless of the actual recommendations from the NHHRC in June 2009, there will be an emphasis on performance improvements which are accountable and aligned to new preventive health policy, organisational priorites and anticipated improved health outcomes. To achieve this objective there will be a need for the existing population health workforce, primary health care and non-government sectors to increase their knowledge and understanding of prevention, promotion and protection theory and practice within new organisational frameworks and linked to the community. This shift needs to be part of a national health services research agenda, infrastructure and funding which is supportive of quality continuing professional development. This paper discusses policy and practice issues related to workforce development as part of an integrated response to the preventive agenda. Background Health Services Commission Act gazetted by the Whitlam The 2008 National Health and Hospitals Reform Com- Government in 1974[2]. mission (NHHRC) reflects a shift in public policy and Australian Government commitment to health system The areas of performance improvement identified in the reform [1]. The eight areas of performance improvement Terms of Reference are [3]: identified in the Commission's Terms of Reference dem- onstrate a renewed national commitment to a prevention 1. reduce inefficiencies generated by cost-shifting, agenda perhaps mirroring the former Hospitals and blame-shifting and buck-passing; Page 1 of 6 (page number not for citation purposes) Australia and New Zealand Health Policy 2009, 6:14 http://www.anzhealthpolicy.com/content/6/1/14 2. better integrate and coordinate care across all lenges associated with the shift in policy. The National aspects of the health sector, particularly between pri- Health Workforce Taskforce was established in 2007 [10] mary care and hospital services around key measura- and has recently called for submissions for a National ble outputs for health; Health Workforce Collaboration [11]; a three-year work- force collaboration research project. While these initia- 3. bring a greater focus on prevention to the health sys- tives are positive for workforce development they do not tem; yet reflect the level of sustainability required for integrated long-term workforce solutions. 4. better integrate acute services and aged care services, and improve the transition between hospital and aged To achieve performance improvements in prevention, care; there will be an urgent requirement for the existing popu- lation health workforce, primary health care and non-gov- 5. improve frontline care to better promote healthy ernment sectors to increase their knowledge and lifestyles and prevent and intervene early in chronic understanding of prevention, promotion and protection illness; theory and practice, within new organisational develop- ment frameworks. New multi-disciplinary models of care, 6. improve the provision of health services in rural community engagement and organisational accountabil- areas; ity will require new workplace competencies, some of which maybe generic and others specific to particular 7. improve Indigenous health outcomes; and organisations. Adequate funding for human resource development and new models of continuing professional 8. provide a well qualified and sustainable health development will be required to enable collaboration and workforce into the future. working to a shared agenda. The NHHRC will report on its long-term plan to achieve This paper discusses policy and practice issues related to sustainable improvements in the Australian health system human resources for health in context with organisational by June 2009. and workforce development. It argues that to achieve health reform aligned to the preventive agenda; policy ini- The interpretation of the NHHRC terms of reference will tiatives must be aligned to organisational and workforce probably be viewed quite differently across health sectors. development through collaboration, leadership, infra- Public health practitioners and academics could argue structure, an aligned research agenda and sustainable that they have the conceptual capacity and methodologies resourcing. to contribute to a number of these performance areas. If this is true, it would be opportune for the sector to ensure Human resources for health that the terms are considered in a broad context. This con- Many authors have recognised the contribution of appro- text should include new partnerships and models for pri- priate and skilled human resources to the success of mary health care beyond the existing limits of chronic health system performance [12-15] and [16]. These disease management [4,5] which is commonly seen as the authors also identify a number of issues acting as barriers public health sphere of activity. Alternative models for to a more coordinated approach to workforce develop- primary health care have been proposed but have not ment linked to health policy and organisational goals. been expanded to identify human resource development Buchan [12] notes that while the evidence base for finance plans necessary to support the new policy implications and stewardship issues related to health reform have been [6,7]. Such models respond to Starfield's [8] arguments investigated, there is limited evidence related to human that Australia's primary health care sector falls behind resources for health. Clinical outcomes are intensely scru- other countries in prevention. tinised, but the contribution of human resource manage- ment linked to health system performance and outcomes While the Australian health system is undergoing this is limited. He argues that the right fit for human resource reform process, it is timely to consider potential opportu- policy and management is integral to health system per- nities for more integrated approaches for human resource formance and that any interventions targeted at organisa- development aligned to health policy reform. The first tional performance should be in context with the comprehensive Australian health workforce policy docu- organisational priorities. The historical absence of health ment was released in 2004 [9]. While the National Health services research in comparison to biomedical research Workforce Strategic Framework was comprehensive, its was noted recently by Van Der Weyden [17]. While a con- implementation plan is not aligned to the prevention siderable boost in funding occurred in 2008 with the agenda or the emerging workforce and education chal- NHMRC package supporting a program for capacity- Page 2 of 6 (page number not for citation purposes) Australia and New Zealand Health Policy 2009, 6:14 http://www.anzhealthpolicy.com/content/6/1/14 building grants for health services research, he notes that workforce supply and integration of care across organisa- this funding has been made available in the absence of a tional boundaries. The recognition and value of a social comprehensive research agenda which is aligned to the and behavioural science model in the primary health care health reform process. sector [20] provides a tool to monitor improved organisa- tional performance but the report does not expand on the Connelly et al [13] identify a lack of connection between inclusion of broader public health interventions across health policy initiatives and existing strategies in place to the continuum of care, or how inter-disciplinary work- achieve such initiatives. An emphasis on inter-sectoral force development would be included. action, inter-professional learning and working to a shared agenda is not supported by the human resource A workforce development framework for the public planning necessary to achieve these outcomes. Nor are the health nutrition workforce has been proposed by Hughes links to education and training clear. These authors rec- [21]. This framework involves an analysis of workforce ommend a 'joined up' human resources plan. However development categories which include building human any attempt to align policy initiatives and implementa- resource infrastructure (quantity), organisational systems tion at the organisational level should acknowledge the and policy (quality), intelligence support (performance), growing 'peoples voice' [18]. There is increasing support learning systems (quality) and workforce preparation. for the 'people principle' through citizen juries and 'wrap However, he notes that this framework will require service around services' which refers to a more individualised and reorientation and a level of unprecedented collaboration community approach to service delivery [19]. Mooney's between academic, industry and community sectors. If evidence suggests that citizens are more supportive of effective strategies are to be adopted to address prevention public health and preventive medicine; an essential ele- across the continuum of care such issues would be ment for the proposed health reform processes. expected to arise, with increased engagement between the public health and industry partners, particularly at the pri- Conway et al [14] note that while the term 'workforce mary health care interface. development' is increasingly popular in the health care field there is little evidence to support a systems approach. The New Zealand Ministry of Health, Public Health Work- These authors note an absence of systems and processes force Development Plan 2007–2016, outlines a number which would facilitate overall integration between organ- of actions to address wider public health workforce devel- isational goals, human resource management policies and opment [22]. The plan adopts a systems approach that education and training, within an evaluated framework. A acknowledges a broad view of public health workforce conceptual framework should distinguish the dynamic development. It recognises the strategic importance of interaction of people, systems and processes working in a education and training for the broader health workforce contextual situation and acknowledging the synergistic including the primary health care sector, public clinical impacts of input, processes and outcomes. training programs and those working in community- based organisations. Investments will be made to provide A systems approach to public health workforce develop- support and input to professional training and compe- ment has been previously associated with significant tency development for public health/health promotion major organisational development and redesign in the skills for the wider workforce. Work is being undertaken public health sector [15]. Kennedy and Moore argue that to integrate primary health care and public health training developing organisations capable of knowledge creation qualification frameworks and strengthen alignment may be the greatest determinant of how public health across sectors. st agencies perform in the 21 century. Even greater chal- lenges will arise with an increasing focus on prevention Another example of workforce development aligned to within the Australian health care system and the antici- key priorities is demonstrated in the NHS London Board, pated reorientating of services. 'Workforce for London A Strategic Framework' released in September 2008 [23]. Goals in this framework support a A report from the Australian Primary Health Care major shift of medical and nursing staff from the acute to Research Institute [4] argues that organisational develop- the community settings. Other goals include aligning ment has the potential to improve the effectiveness of the workforce planning with service needs and a significant primary health care workforce in the future. The report increase in investment to support continuing professional recognises the components of leadership, culture and development for the existing workforce which is aligned inter-professional collaboration as being essential to to service needs. The strategy is underpinned by targets for delivering better performance within an organisational London education providers to improve quality ratings. development framework. It identifies organisational development as having the potential to contribute The World Health Organization has recognised the impor- answers to issues related to chronic disease management, tance of broad multi-sectoral approaches in various settings Page 3 of 6 (page number not for citation purposes) Australia and New Zealand Health Policy 2009, 6:14 http://www.anzhealthpolicy.com/content/6/1/14 and the importance of public health and clinical collabora- Public health is a small component of the health system, tion in the prevention of some of the most serious global both in terms of budgetary allocation at either state or health challenges. For example, the Global School Health national level and in terms of the number of practitioners. Initiative [24] has fostered approaches to prevent Helminth It incorporates a myriad of activities; legislation and regu- infection in 1996 and HIV/STI infection in 1997, in China. lation for health protection, preventive services directed at Such initiatives while predicated upon partnership and col- specific diseases and populations, and health promotion laboration have not, however, led to any global programs programs geared towards particular risk factors and vulner- to join up policy and health workforce development. able groups in the community. As such, it looks like a dis- parate collection of programs and investments. In 2008 the Scottish Government released a report exam- ining the evidence related to a shift in the balance of care The multi-disciplinary nature of public health may also in health and community care with the aim of identifying have contributed to its relative isolation from interaction the contribution of service delivery changes intended to with the broader health system. Public health has few improve health outcomes. The three areas examined were models for health service delivery, with accompanying the shifting focus of care, shifting location of care and funding models, in the acute or primary health care sector. changing roles and responsibilities of patients and profes- However, even without such models, public health has sionals [25]. While there were high levels of evidence ana- the conceptual capacity required to address viable and lysing the shift in focus of care for the elderly, chronic sustainable approaches to the prevention agenda in an st disease and rehabilitation; significant research gaps were efficient and effective manner in the 21 century. found in relation to shifting the focus of care for preven- tive and assessment-based interventions. There is limited While the public health lobby has secured a place in the evidence to support a shift to more extended primary and spotlight for prevention and population approaches to community care team approach supporting the potential chronic disease management in the current health reform for a range of roles to be developed or substituted, includ- agenda, it is still unclear whether system-wide change will ing those of nurses, allied health and lay workers in pri- occur; or merely 'tinkering' at the margins of existing serv- mary care. There was a small body of high level evidence ice delivery, education and funding structures. to support the shift of responsibility to patients through greater use of technology and self management education. In summary, until recent developments, public health has failed to achieve significant political or broader recogni- In the Australian context, there has been little research to tion in terms of the financial and human returns on investigate a systematic partnership model between investment for the multiple prevention interventions in health policy makers, human resource professionals and Australia. While it is not within the scope of this paper to the academic sector, to construct and support a compre- resolve leadership, infrastructure and advocacy issues, or hensive workforce development strategy, itself aligned to to propose new public health service delivery, workforce a more focused prevention agenda. There has been gen- or funding solutions, clearly public health must act deci- eral agreement in the area of professional education and sively to build on recent success in shaping reform and in the tertiary education sector that there are benefits from demonstrate actions and solutions which engage with the a multi-disciplinary approach. Thus, for example, many current preventive health agenda and engage more nursing education programs include aspects of health pro- actively in workforce reform dialogue. motion in their coursework; also epidemiological and population-based coursework is often included in medi- The NHHRC has briefed the National Preventative Health cal education programs; aspects of health service manage- Task Force to provide advice to health providers and the ment and economic analysis models may be included in government on evidence-based preventive programs to health professional programs. However, at a system wide address the burden of chronic disease [10]. While level, new partnerships for public health and clinical prac- acknowledging the complexity of this task, it is antici- tice in primary health care and community settings have pated by many that a large proportion of this strategy will not been identified, investigated and supported – and this be directed towards the primary health care interface needs to change. where to date, the workforce is comprised of clinically trained personnel. Despite good evidence about returns on investment [26], public health has faced an enormous challenge in terms of The Taskforce discussion paper titled 'Australia: the its image. The nature and extent of 'Public Health' is healthiest country by 2020' [28] proposes a number of poorly understood by the general public and is typically options for tackling the burden of chronic disease in Aus- linked to the public hospital system. One explanation tralia related to alcohol, tobacco and obesity. The paper may be, as Lin and Robinson [27] argue, that: acknowledges the importance of national leadership and Page 4 of 6 (page number not for citation purposes) Australia and New Zealand Health Policy 2009, 6:14 http://www.anzhealthpolicy.com/content/6/1/14 coordination and proposes the establishment of a vehicle for new forms of collaborative workforce develop- National Prevention Agency (NPA). Such an agency ment through 'joined up plans', new systems and proc- would support esses for workforce development aligned to preventive health policy and organisational development, and an "The coordination of partnerships and interventions, ensur- integrated plan for continuing professional development ing the relevance and quality of workforce training activi- for primary health care should transpire. ties, social marketing, public education and the monitoring and evaluation of interventions" A national coordinated response to the preventive agenda for the health workforce which is supported financially The taskforce acknowledges that any successful attempt to would contribute to the consistency, sustainability and address prevention must include the integration of new quality of evidence-based continuing professional devel- strategies into the national infrastructure and not just opment. Resources to support effective partnerships and short term projects, despite such being the history of pub- collaborative planning between education providers and lic health funding in Australia. However, there continues relevant health care organisations would ensure continu- to be an apparent absence of strategic policy alignment for ing professional development is consistent and linked to workforce development or consideration for health serv- research, quality and evidence. Quality frameworks for ices in research agendas. public health education currently exist in the tertiary and vocational sectors which could provide the foundation for The successful implementation of the Taskforce recom- the development of appropriate training courses for a mendations will include many challenges, including those broader health workforce in the primary health care set- for workforce development. Such challenges, though not ting [30,31]. Further evaluation of these competencies new, will gain added significance as the clinical workforce will need to occur in line with policy reforms and the pro- intersects with a population health paradigm and seeks to posed core health workforce competency framework cur- extend prevention beyond previous boundaries. Appropri- rently being investigated by the National Health ate models to address these challenges have yet to be tested. Workforce Taskforce [10]. Many authors have identified the link between an ade- quately skilled workforce and health system performance Universities offer formal awards for public health from [12-15] and [16]. Therefore, during the current climate of undergraduate to postgraduate levels, along with various reform, the identification of appropriate systems and proc- forms of continuing professional education in the form of esses for health workforce development between these two short courses, workshops and seminars. This contribution sectors, both aligned to the national preventive agenda, to workforce capacity building can be considered at three becomes more significant. levels of skill: generic skills, specialised skills and high profile specific specialist skills in areas of specific strategic Allengrante et al [29] identify critical competencies for the need. The Population Health Training Package through public health education workforce in line with a changing the TAFE sector provides education from a Certificate II to health agenda which include coalition building, strategic Diploma level in Population Health which covers voca- planning, community health development, advocacy, tionally orientated population health training. The appro- business management, leadership and cultural compe- priate design and delivery of future public health tence. Allengrante's study identifies particular commonal- education for the broader workforce should be closely ities for workforce development relevant between aligned to these quality frameworks with identified com- academic and industry sectors and notes that any success- petencies; aligned to overarching policy initiatives, ful integration of public health competencies into contin- resourcing and rigorous evaluation of workforce develop- uing education will require cooperation from a broad ment outcomes. range of groups including professional associations, uni- versities and government and non-government sectors. Conclusion Similarly, we argue that the intersection of the clinical and This paper considers the potential implications for health public health paradigms will demand comparable coop- workforce development as a result of the NHHRC preven- eration and shared agendas across sectors. tive agenda; particularly in reference to primary health care and public health. The rationale for effective partner- The move to a preventive agenda highlights the impor- ships, aligned agendas and supportive resources for work- tance of collaborative workforce partnerships between the force development are discussed. Issues related to human primary health care, public health and education sectors resource development within an organisational context to facilitate the planning and implementation of more are raised and the need to consider a nationally consistent broadly based and evaluated inter-sectoral and multi-dis- approach to workforce development and quality continu- ciplinary education. By adopting Connelly et al's [13] ing professional development is discussed. Page 5 of 6 (page number not for citation purposes) Australia and New Zealand Health Policy 2009, 6:14 http://www.anzhealthpolicy.com/content/6/1/14 11. National Health Workforce Collaboration: [http://www.nhwt.gov.au/ As noted, public health has a minor budgetary allocation colab.asp]. with limited numbers of identified workforce within the 12. Buchan J: What difference does ("good") HRM make? Human Australian health system. In the absence of any predicted Resources for Health 2004, 2:6. 13. Connelly J, Knight T, Cunningham C, Duggan M, McClenahan J: revolutionary changes, larger sections of the health work- Rethinking public health: new training for new times. J Manag force will be required to adopt population health models Med 1999, 13:4210-7. 14. Conway J, McMillan , Becker J: Implementing workforce devel- and values to transform preventive health care beyond opment in health: A conceptual framework to guide and existing perspectives and models. Through effective and evaluate health service reform. Human Resource Development resourced partnerships new models of primary care and International 2006, 9:1129-139. 15. Kennedy V, Moore F: A systems approach to public health brief public health interventions, supported by evidence, workforce development. J Public Health Manag Pract 2001, will change the structure and delivery of primary health 7(4):17-22. care and impact positively on decreasing the burden of 16. Beaglehole R, Dal Poz M: Public health workforce: challenges and policy issues. Human Resources for Health 2003, 1:4. preventable disease in the Australian population. 17. Weyden M Van der: Health policy and reform: gathering the evidence. Medical Journal of Australia 2008, 189(3):169-170. 18. Mooney G: The people principle in Australian health care. This paper argues that in order to achieve an effective Med J Aust. 2008, 189(3):171-172. response to the preventive agenda, human resources for 19. Copp HL, Bordnick PS, Traylor AC, Thyer BA: Evaluating wrapa- health require improved recognition and alignment to round services for seriously emotionally disturbed youth: pilot study outcomes in Georgia. Adolescence. 2007, policy initiatives. New clinical and public health models, 42(168):723-732. education, infrastructure, an aligned research agenda and 20. Rothwell WJ, Sullivan R: Practicing Organisation Development: A guide for consultants 2005:18-20 [http://media.wiley.com/product_data/ sustainable resourcing will all be essential elements of the excerpt/84/07879623/0787962384.pdf]. John Wiley and Sons integrated response. 21. Hughes R: A conceptual framework for intelligence-based public health nutrition workforce development. Public Health Nutrition 2003, 6(6):599-605. Competing interests 22. 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Abelson P, ed: Returns on Investment in Public Health 2003 [http:// Hospitals Reform Commission [http://www.health.gov.au/internet/ www.health.gov.au/internet/main/publishing.nsf/Content/health- main/publishing.nsf/Content/nhrc-1]. pubhlth-publicat-document-roi_eea-cnt.htm]. Commonwealth 2. Australian Commonwealth Government: Hospitals and Health Services Department of Health and Ageing, Canberra Commission Act [http://www.austlii.edu.au/au/legis/cth/num_act/ 27. Lin V, Robinson P: Australian public health policy in 2003 – hahsca1973406/]. 2004. Aust New Zealand Health Policy. 2(1):7. 3. Commonwealth Department of Health and Ageing: National Health & 28. National Health Task Force Discussion Paper: Australia the healthiest Hospitals Reform Commission Terms of Reference [http:// country by 2020 2007 [http://www.preventativehealth.org.au/internet/ www.health.gov.au/internet/main/publishing.nsf/Content/ preventativehealth/publishing.nsf/Content/home-1/]. 619A18D684E8AFFDCA2573FE0005089D/$File/ 29. Allegrante J, Moon R, Auld E, Gebbie K: Continuing education Terms%20of%20Reference.pdf]. needs of the currently employed public health workforce. 4. Dunbar J, Reddy P, McAvoy B, Carter R, Schoo A, Colgan S, Weller American Journal of Public Health 2001, 91(8):1230-1235. D, Torneus I: The contribution of approaches to organisational change in 30. National Public Health Partnership: Public health functions and compe- optimising the primary health care workforce 2007 [http:// tencies 2004 [http://www.phlr.anaphi.unsw.edu.au/comp/comp.htm]. www.anu.edu.au/aphcri/Domain/Workforce/index.php]. Australian 31. Industry Skills Council: Population health training package [http:// Primary Health Care Institute, Canberra www.public.health.wa.gov.au/cproot/1462/2/ 5. Doust J: Chronic Disease and Primary Care Research 2008 [http:// PopHealth_Qualifications_Framework_Oct05.pdf]. www.uq.edu.au/phcredqld/phcred_news_events.shtml]. Primary Health Care Research Evaluation Development Research (PHCRED) Showcase, Brisbane 6. Gross P: Mind the gaps: increasing personal health security via prevention Publish with Bio Med Central and every and economic incentives 2006 [http://www.ahpi.health.usyd.edu.au/ scientist can read your work free of charge events/gross130706.pdf]. Menzies Centre Winter Lecture Series, University of Sydney "BioMed Central will be the most significant development for 7. Doggett J: A new approach to primary health care. Centre for disseminating the results of biomedical researc h in our lifetime." Policy Development, Occasional Paper No.1 [http://cpd.org.au/sites/cpd/ Sir Paul Nurse, Cancer Research UK files/u51504/a_new_approach_to_Primary_Care_- _CPD_June_07.pdf]. Your research papers will be: 8. Starfield B: Public health and primary care: challenges and available free of charge to the entire biomedical community opportunities for partnerships. Ethn Dis 2003, 13(3 Suppl 3):S3-12-3. peer reviewed and published immediately upon acceptance 9. National Health Workforce Strategic Framework: 2004 [http:// cited in PubMed and archived on PubMed Central www.nhwt.gov.au/theframework.asp]. 10. National Health Workforce Taskforce: [http://www.nhwt.gov.au/ yours — you keep the copyright nhwt.asp]. BioMedcentral Submit your manuscript here: http://www.biomedcentral.com/info/publishing_adv.asp Page 6 of 6 (page number not for citation purposes) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Australia and New Zealand Health Policy Springer Journals

The Australian preventive health agenda: what will this mean for workforce development?

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Copyright © 2009 by Lilley and Stewart; licensee BioMed Central Ltd.
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Medicine & Public Health; Public Health; Social Policy
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Abstract

The formation of the National Health and Hospitals Reform Commission (NHHRC) and the National Preventative Task Force in 2008, demonstrate a renewed Australian Government commitment to health reform. The re-focus on prevention, bringing it to the centre of health care has significant implications for health service delivery in the primary health care setting, supportive organisational structures and continuing professional development for the existing clinical and public health workforce. It is an opportune time, therefore, to consider new approaches to workforce development aligned to health policy reform. Regardless of the actual recommendations from the NHHRC in June 2009, there will be an emphasis on performance improvements which are accountable and aligned to new preventive health policy, organisational priorites and anticipated improved health outcomes. To achieve this objective there will be a need for the existing population health workforce, primary health care and non-government sectors to increase their knowledge and understanding of prevention, promotion and protection theory and practice within new organisational frameworks and linked to the community. This shift needs to be part of a national health services research agenda, infrastructure and funding which is supportive of quality continuing professional development. This paper discusses policy and practice issues related to workforce development as part of an integrated response to the preventive agenda. Background Health Services Commission Act gazetted by the Whitlam The 2008 National Health and Hospitals Reform Com- Government in 1974[2]. mission (NHHRC) reflects a shift in public policy and Australian Government commitment to health system The areas of performance improvement identified in the reform [1]. The eight areas of performance improvement Terms of Reference are [3]: identified in the Commission's Terms of Reference dem- onstrate a renewed national commitment to a prevention 1. reduce inefficiencies generated by cost-shifting, agenda perhaps mirroring the former Hospitals and blame-shifting and buck-passing; Page 1 of 6 (page number not for citation purposes) Australia and New Zealand Health Policy 2009, 6:14 http://www.anzhealthpolicy.com/content/6/1/14 2. better integrate and coordinate care across all lenges associated with the shift in policy. The National aspects of the health sector, particularly between pri- Health Workforce Taskforce was established in 2007 [10] mary care and hospital services around key measura- and has recently called for submissions for a National ble outputs for health; Health Workforce Collaboration [11]; a three-year work- force collaboration research project. While these initia- 3. bring a greater focus on prevention to the health sys- tives are positive for workforce development they do not tem; yet reflect the level of sustainability required for integrated long-term workforce solutions. 4. better integrate acute services and aged care services, and improve the transition between hospital and aged To achieve performance improvements in prevention, care; there will be an urgent requirement for the existing popu- lation health workforce, primary health care and non-gov- 5. improve frontline care to better promote healthy ernment sectors to increase their knowledge and lifestyles and prevent and intervene early in chronic understanding of prevention, promotion and protection illness; theory and practice, within new organisational develop- ment frameworks. New multi-disciplinary models of care, 6. improve the provision of health services in rural community engagement and organisational accountabil- areas; ity will require new workplace competencies, some of which maybe generic and others specific to particular 7. improve Indigenous health outcomes; and organisations. Adequate funding for human resource development and new models of continuing professional 8. provide a well qualified and sustainable health development will be required to enable collaboration and workforce into the future. working to a shared agenda. The NHHRC will report on its long-term plan to achieve This paper discusses policy and practice issues related to sustainable improvements in the Australian health system human resources for health in context with organisational by June 2009. and workforce development. It argues that to achieve health reform aligned to the preventive agenda; policy ini- The interpretation of the NHHRC terms of reference will tiatives must be aligned to organisational and workforce probably be viewed quite differently across health sectors. development through collaboration, leadership, infra- Public health practitioners and academics could argue structure, an aligned research agenda and sustainable that they have the conceptual capacity and methodologies resourcing. to contribute to a number of these performance areas. If this is true, it would be opportune for the sector to ensure Human resources for health that the terms are considered in a broad context. This con- Many authors have recognised the contribution of appro- text should include new partnerships and models for pri- priate and skilled human resources to the success of mary health care beyond the existing limits of chronic health system performance [12-15] and [16]. These disease management [4,5] which is commonly seen as the authors also identify a number of issues acting as barriers public health sphere of activity. Alternative models for to a more coordinated approach to workforce develop- primary health care have been proposed but have not ment linked to health policy and organisational goals. been expanded to identify human resource development Buchan [12] notes that while the evidence base for finance plans necessary to support the new policy implications and stewardship issues related to health reform have been [6,7]. Such models respond to Starfield's [8] arguments investigated, there is limited evidence related to human that Australia's primary health care sector falls behind resources for health. Clinical outcomes are intensely scru- other countries in prevention. tinised, but the contribution of human resource manage- ment linked to health system performance and outcomes While the Australian health system is undergoing this is limited. He argues that the right fit for human resource reform process, it is timely to consider potential opportu- policy and management is integral to health system per- nities for more integrated approaches for human resource formance and that any interventions targeted at organisa- development aligned to health policy reform. The first tional performance should be in context with the comprehensive Australian health workforce policy docu- organisational priorities. The historical absence of health ment was released in 2004 [9]. While the National Health services research in comparison to biomedical research Workforce Strategic Framework was comprehensive, its was noted recently by Van Der Weyden [17]. While a con- implementation plan is not aligned to the prevention siderable boost in funding occurred in 2008 with the agenda or the emerging workforce and education chal- NHMRC package supporting a program for capacity- Page 2 of 6 (page number not for citation purposes) Australia and New Zealand Health Policy 2009, 6:14 http://www.anzhealthpolicy.com/content/6/1/14 building grants for health services research, he notes that workforce supply and integration of care across organisa- this funding has been made available in the absence of a tional boundaries. The recognition and value of a social comprehensive research agenda which is aligned to the and behavioural science model in the primary health care health reform process. sector [20] provides a tool to monitor improved organisa- tional performance but the report does not expand on the Connelly et al [13] identify a lack of connection between inclusion of broader public health interventions across health policy initiatives and existing strategies in place to the continuum of care, or how inter-disciplinary work- achieve such initiatives. An emphasis on inter-sectoral force development would be included. action, inter-professional learning and working to a shared agenda is not supported by the human resource A workforce development framework for the public planning necessary to achieve these outcomes. Nor are the health nutrition workforce has been proposed by Hughes links to education and training clear. These authors rec- [21]. This framework involves an analysis of workforce ommend a 'joined up' human resources plan. However development categories which include building human any attempt to align policy initiatives and implementa- resource infrastructure (quantity), organisational systems tion at the organisational level should acknowledge the and policy (quality), intelligence support (performance), growing 'peoples voice' [18]. There is increasing support learning systems (quality) and workforce preparation. for the 'people principle' through citizen juries and 'wrap However, he notes that this framework will require service around services' which refers to a more individualised and reorientation and a level of unprecedented collaboration community approach to service delivery [19]. Mooney's between academic, industry and community sectors. If evidence suggests that citizens are more supportive of effective strategies are to be adopted to address prevention public health and preventive medicine; an essential ele- across the continuum of care such issues would be ment for the proposed health reform processes. expected to arise, with increased engagement between the public health and industry partners, particularly at the pri- Conway et al [14] note that while the term 'workforce mary health care interface. development' is increasingly popular in the health care field there is little evidence to support a systems approach. The New Zealand Ministry of Health, Public Health Work- These authors note an absence of systems and processes force Development Plan 2007–2016, outlines a number which would facilitate overall integration between organ- of actions to address wider public health workforce devel- isational goals, human resource management policies and opment [22]. The plan adopts a systems approach that education and training, within an evaluated framework. A acknowledges a broad view of public health workforce conceptual framework should distinguish the dynamic development. It recognises the strategic importance of interaction of people, systems and processes working in a education and training for the broader health workforce contextual situation and acknowledging the synergistic including the primary health care sector, public clinical impacts of input, processes and outcomes. training programs and those working in community- based organisations. Investments will be made to provide A systems approach to public health workforce develop- support and input to professional training and compe- ment has been previously associated with significant tency development for public health/health promotion major organisational development and redesign in the skills for the wider workforce. Work is being undertaken public health sector [15]. Kennedy and Moore argue that to integrate primary health care and public health training developing organisations capable of knowledge creation qualification frameworks and strengthen alignment may be the greatest determinant of how public health across sectors. st agencies perform in the 21 century. Even greater chal- lenges will arise with an increasing focus on prevention Another example of workforce development aligned to within the Australian health care system and the antici- key priorities is demonstrated in the NHS London Board, pated reorientating of services. 'Workforce for London A Strategic Framework' released in September 2008 [23]. Goals in this framework support a A report from the Australian Primary Health Care major shift of medical and nursing staff from the acute to Research Institute [4] argues that organisational develop- the community settings. Other goals include aligning ment has the potential to improve the effectiveness of the workforce planning with service needs and a significant primary health care workforce in the future. The report increase in investment to support continuing professional recognises the components of leadership, culture and development for the existing workforce which is aligned inter-professional collaboration as being essential to to service needs. The strategy is underpinned by targets for delivering better performance within an organisational London education providers to improve quality ratings. development framework. It identifies organisational development as having the potential to contribute The World Health Organization has recognised the impor- answers to issues related to chronic disease management, tance of broad multi-sectoral approaches in various settings Page 3 of 6 (page number not for citation purposes) Australia and New Zealand Health Policy 2009, 6:14 http://www.anzhealthpolicy.com/content/6/1/14 and the importance of public health and clinical collabora- Public health is a small component of the health system, tion in the prevention of some of the most serious global both in terms of budgetary allocation at either state or health challenges. For example, the Global School Health national level and in terms of the number of practitioners. Initiative [24] has fostered approaches to prevent Helminth It incorporates a myriad of activities; legislation and regu- infection in 1996 and HIV/STI infection in 1997, in China. lation for health protection, preventive services directed at Such initiatives while predicated upon partnership and col- specific diseases and populations, and health promotion laboration have not, however, led to any global programs programs geared towards particular risk factors and vulner- to join up policy and health workforce development. able groups in the community. As such, it looks like a dis- parate collection of programs and investments. In 2008 the Scottish Government released a report exam- ining the evidence related to a shift in the balance of care The multi-disciplinary nature of public health may also in health and community care with the aim of identifying have contributed to its relative isolation from interaction the contribution of service delivery changes intended to with the broader health system. Public health has few improve health outcomes. The three areas examined were models for health service delivery, with accompanying the shifting focus of care, shifting location of care and funding models, in the acute or primary health care sector. changing roles and responsibilities of patients and profes- However, even without such models, public health has sionals [25]. While there were high levels of evidence ana- the conceptual capacity required to address viable and lysing the shift in focus of care for the elderly, chronic sustainable approaches to the prevention agenda in an st disease and rehabilitation; significant research gaps were efficient and effective manner in the 21 century. found in relation to shifting the focus of care for preven- tive and assessment-based interventions. There is limited While the public health lobby has secured a place in the evidence to support a shift to more extended primary and spotlight for prevention and population approaches to community care team approach supporting the potential chronic disease management in the current health reform for a range of roles to be developed or substituted, includ- agenda, it is still unclear whether system-wide change will ing those of nurses, allied health and lay workers in pri- occur; or merely 'tinkering' at the margins of existing serv- mary care. There was a small body of high level evidence ice delivery, education and funding structures. to support the shift of responsibility to patients through greater use of technology and self management education. In summary, until recent developments, public health has failed to achieve significant political or broader recogni- In the Australian context, there has been little research to tion in terms of the financial and human returns on investigate a systematic partnership model between investment for the multiple prevention interventions in health policy makers, human resource professionals and Australia. While it is not within the scope of this paper to the academic sector, to construct and support a compre- resolve leadership, infrastructure and advocacy issues, or hensive workforce development strategy, itself aligned to to propose new public health service delivery, workforce a more focused prevention agenda. There has been gen- or funding solutions, clearly public health must act deci- eral agreement in the area of professional education and sively to build on recent success in shaping reform and in the tertiary education sector that there are benefits from demonstrate actions and solutions which engage with the a multi-disciplinary approach. Thus, for example, many current preventive health agenda and engage more nursing education programs include aspects of health pro- actively in workforce reform dialogue. motion in their coursework; also epidemiological and population-based coursework is often included in medi- The NHHRC has briefed the National Preventative Health cal education programs; aspects of health service manage- Task Force to provide advice to health providers and the ment and economic analysis models may be included in government on evidence-based preventive programs to health professional programs. However, at a system wide address the burden of chronic disease [10]. While level, new partnerships for public health and clinical prac- acknowledging the complexity of this task, it is antici- tice in primary health care and community settings have pated by many that a large proportion of this strategy will not been identified, investigated and supported – and this be directed towards the primary health care interface needs to change. where to date, the workforce is comprised of clinically trained personnel. Despite good evidence about returns on investment [26], public health has faced an enormous challenge in terms of The Taskforce discussion paper titled 'Australia: the its image. The nature and extent of 'Public Health' is healthiest country by 2020' [28] proposes a number of poorly understood by the general public and is typically options for tackling the burden of chronic disease in Aus- linked to the public hospital system. One explanation tralia related to alcohol, tobacco and obesity. The paper may be, as Lin and Robinson [27] argue, that: acknowledges the importance of national leadership and Page 4 of 6 (page number not for citation purposes) Australia and New Zealand Health Policy 2009, 6:14 http://www.anzhealthpolicy.com/content/6/1/14 coordination and proposes the establishment of a vehicle for new forms of collaborative workforce develop- National Prevention Agency (NPA). Such an agency ment through 'joined up plans', new systems and proc- would support esses for workforce development aligned to preventive health policy and organisational development, and an "The coordination of partnerships and interventions, ensur- integrated plan for continuing professional development ing the relevance and quality of workforce training activi- for primary health care should transpire. ties, social marketing, public education and the monitoring and evaluation of interventions" A national coordinated response to the preventive agenda for the health workforce which is supported financially The taskforce acknowledges that any successful attempt to would contribute to the consistency, sustainability and address prevention must include the integration of new quality of evidence-based continuing professional devel- strategies into the national infrastructure and not just opment. Resources to support effective partnerships and short term projects, despite such being the history of pub- collaborative planning between education providers and lic health funding in Australia. However, there continues relevant health care organisations would ensure continu- to be an apparent absence of strategic policy alignment for ing professional development is consistent and linked to workforce development or consideration for health serv- research, quality and evidence. Quality frameworks for ices in research agendas. public health education currently exist in the tertiary and vocational sectors which could provide the foundation for The successful implementation of the Taskforce recom- the development of appropriate training courses for a mendations will include many challenges, including those broader health workforce in the primary health care set- for workforce development. Such challenges, though not ting [30,31]. Further evaluation of these competencies new, will gain added significance as the clinical workforce will need to occur in line with policy reforms and the pro- intersects with a population health paradigm and seeks to posed core health workforce competency framework cur- extend prevention beyond previous boundaries. Appropri- rently being investigated by the National Health ate models to address these challenges have yet to be tested. Workforce Taskforce [10]. Many authors have identified the link between an ade- quately skilled workforce and health system performance Universities offer formal awards for public health from [12-15] and [16]. Therefore, during the current climate of undergraduate to postgraduate levels, along with various reform, the identification of appropriate systems and proc- forms of continuing professional education in the form of esses for health workforce development between these two short courses, workshops and seminars. This contribution sectors, both aligned to the national preventive agenda, to workforce capacity building can be considered at three becomes more significant. levels of skill: generic skills, specialised skills and high profile specific specialist skills in areas of specific strategic Allengrante et al [29] identify critical competencies for the need. The Population Health Training Package through public health education workforce in line with a changing the TAFE sector provides education from a Certificate II to health agenda which include coalition building, strategic Diploma level in Population Health which covers voca- planning, community health development, advocacy, tionally orientated population health training. The appro- business management, leadership and cultural compe- priate design and delivery of future public health tence. Allengrante's study identifies particular commonal- education for the broader workforce should be closely ities for workforce development relevant between aligned to these quality frameworks with identified com- academic and industry sectors and notes that any success- petencies; aligned to overarching policy initiatives, ful integration of public health competencies into contin- resourcing and rigorous evaluation of workforce develop- uing education will require cooperation from a broad ment outcomes. range of groups including professional associations, uni- versities and government and non-government sectors. Conclusion Similarly, we argue that the intersection of the clinical and This paper considers the potential implications for health public health paradigms will demand comparable coop- workforce development as a result of the NHHRC preven- eration and shared agendas across sectors. tive agenda; particularly in reference to primary health care and public health. The rationale for effective partner- The move to a preventive agenda highlights the impor- ships, aligned agendas and supportive resources for work- tance of collaborative workforce partnerships between the force development are discussed. Issues related to human primary health care, public health and education sectors resource development within an organisational context to facilitate the planning and implementation of more are raised and the need to consider a nationally consistent broadly based and evaluated inter-sectoral and multi-dis- approach to workforce development and quality continu- ciplinary education. By adopting Connelly et al's [13] ing professional development is discussed. Page 5 of 6 (page number not for citation purposes) Australia and New Zealand Health Policy 2009, 6:14 http://www.anzhealthpolicy.com/content/6/1/14 11. National Health Workforce Collaboration: [http://www.nhwt.gov.au/ As noted, public health has a minor budgetary allocation colab.asp]. with limited numbers of identified workforce within the 12. Buchan J: What difference does ("good") HRM make? Human Australian health system. In the absence of any predicted Resources for Health 2004, 2:6. 13. Connelly J, Knight T, Cunningham C, Duggan M, McClenahan J: revolutionary changes, larger sections of the health work- Rethinking public health: new training for new times. J Manag force will be required to adopt population health models Med 1999, 13:4210-7. 14. Conway J, McMillan , Becker J: Implementing workforce devel- and values to transform preventive health care beyond opment in health: A conceptual framework to guide and existing perspectives and models. Through effective and evaluate health service reform. Human Resource Development resourced partnerships new models of primary care and International 2006, 9:1129-139. 15. 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Copp HL, Bordnick PS, Traylor AC, Thyer BA: Evaluating wrapa- health require improved recognition and alignment to round services for seriously emotionally disturbed youth: pilot study outcomes in Georgia. Adolescence. 2007, policy initiatives. New clinical and public health models, 42(168):723-732. education, infrastructure, an aligned research agenda and 20. Rothwell WJ, Sullivan R: Practicing Organisation Development: A guide for consultants 2005:18-20 [http://media.wiley.com/product_data/ sustainable resourcing will all be essential elements of the excerpt/84/07879623/0787962384.pdf]. John Wiley and Sons integrated response. 21. Hughes R: A conceptual framework for intelligence-based public health nutrition workforce development. Public Health Nutrition 2003, 6(6):599-605. Competing interests 22. 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Journal

Australia and New Zealand Health PolicySpringer Journals

Published: May 22, 2009

References