THERE is a Māori proverb in Aotearoa New Zealand that says, “He aha te mea nui o te ao? He tangata, he tangata he tangata.” It translates as, “What is the most important thing? It is people, it is people, it is people.”
Throughout the COVID-19 pandemic, health care workers across Australia have said, repeatedly, the biggest problem is not the supply of ventilators, or intensive care beds, or personal protective equipment, the problem is people, specifically the supply of skilled workforce.
We said: “We don’t have enough staff, we don’t have enough staff in the right places, and we don’t have enough staff with expertise in the right areas.”
But this crisis has not been caused by the pandemic. Like so many other social and health problems, COVID-19 didn’t cause the health care workforce crisis, it merely exposed it and worsened it.
There was a story in the media recently about a hospital that was paying locum doctors over $4000 a day to work in an emergency department that was supposed to have 12 doctors but only had two. A colleague of mine asked, “Who in their right mind would want to be the third doctor there? Can you imagine how stressful that shift would be?” Any worker in the world would struggle with just 25% of the staff rostered on – and health care workers often provide life or death care. Imagine working with that pressure.
The staffing crisis is self-perpetuating, creating a vicious cycle. The worse it gets, the more remaining staff are under pressure. There are no appropriate or effective systemic or structural responses to the issue, so health care workers are forced to self-manage the shortfalls.
The first stage of self-management looks like presenteeism. Presenteeism is when staff are showing up to shifts, or signing up for extra shifts, even when they are in poor physical or mental health. So, the health care worker is present in the workplace, but they may not be able to fully perform their duties to the best of their abilities. If working sick, or exhausted, mistakes are more likely to be made, and the potential for burnout will increase (here, here and here).
The next stage of self-management in a staffing crisis can involve health care worker disengagement – leaving health care work entirely, shifting to a role with less stress – or reducing their hours. We are seeing this particularly with senior nursing staff – who form the backbones of hospitals. The loss of highly trained staff is a massive brain-drain that affects the next generation of clinicians too, as they no longer have people with skills and experience from whom to learn.
This then puts more pressure on the remaining staff who, again, first practise presenteeism, and then disengage, leave or reduce their hours.
Then, when staffing gaps get very large and the existing workforce can’t be stretched any further, there are longer waiting times for patients, more complaints, more adverse health outcomes. Stress levels and the risk of burnout are sky-high. This makes workplaces even less desirable and exacerbates the problems.
Then, hospitals must resort to last-ditch, high expense, high risk strategies – such as offering $4000 a day for a vacant shift – simply to manage the enormous deficit in skilled staff. Health services end up competing with each other for precious workforce.
However, none of this would be necessary if the underlying issues were managed before the crisis point was reached.
What are the underlying issues and causes?
First, demand is increasing every year, but resources are not mirroring that. People are presenting for care in growing numbers, and those needing care have increasingly complex social and medical needs requiring multidisciplinary, interprofessional expertise. There are significant boundaries between community and hospital-based care.
Also, the clinical workforce cannot be quickly increased. Much of the medical workforce is highly subspecialised, which requires many years of training: most doctors attain fellowship in their mid- to late 30s. Doctors are often trained in specialty silos and opportunities to develop skills in other specialties or settings are rare.
Our industrial conditions are also a contributing issue: awards and agreements don’t adequately reflect the demands of shift work and are structured to support and drive the provision of health care services during a “business hours” working week, which is increasingly at odds with community expectations of out-of-hours, including overnight, clinical care. We need to remunerate after-hours work better, allocate rest periods, and budget for this.
Rostering practices requires review to improve flexibility and promote better work–life balance, as well as post-shift recovery for health care workers, while providing extended hours access to senior clinical decision making.
The clinical workforce is unevenly distributed. Health professionals, especially doctors, are highly concentrated in major cities. Health outcomes in rural and remote areas lag behind outcomes in metropolitan areas. There is an urgent need to develop workforce models that improve health care access and equity, especially for Indigenous Australians living in remote communities.
The health workforce is also out of balance. While each profession, each specialty area, has its own culture and dynamics, the health system requires that we all work together effectively, and in a way that allows each group to use the full range of their skills. In particular, many clinicians spend too much time on clerical and technical tasks (here and here), that should instead be performed by staff who are trained and employed in clinical support roles.
What are the solutions?
Fixing the health care workforce requires a strategic, long term, whole-of-system, nationwide approach.
First, we need to bring back Health Workforce Australia, or an equivalent federal government agency, to drive coordination and collaboration between all health professions, education and training organisations, and the bodies that represent and regulate health practitioners. The independent agency, which previously had national oversight on health workforce planning, was scrapped by the Tony Abbott federal government in 2014.
We need to monitor and review training pathways to ensure that we are developing the future health workforce to meet community needs. This will require a renewed focus on building generalist skillsets, implementation of flexible, workplace-based learning and assessment, and adequate exposure of trainees to the full variety of health care contexts and settings.
Australia must also train an adequate health workforce to meet its own needs, and the needs of the region, as well as allowing for some international movement of trained clinicians with well designed and responsive re-credentialling processes. In particular, we need urgent and sustained attention to training and supporting Indigenous health professionals.
We need to train and employ staff in adequate numbers to allow for reasonable amounts of planned and unplanned leave. Presenteeism is no longer acceptable for reasons of infection control and patient safety, but also for staff wellbeing.
Employment and training arrangements for all health professionals must be designed to support life-long, sustainable and rewarding careers, and to improve workforce retention and engagement, especially in rural and remote areas, and for other underserved communities and disciplines.
Finally, we must ensure that health workplaces are collaborative, respectful and inclusive. Recruitment and remuneration practices must be updated to be responsive and transparent. We must actively work to build strong interprofessional and interdisciplinary relationships, towards a shared goal of excellent, patient-centred care.
Progress not perfection
As we emerge from COVID-19, we need to ensure that the focus stays on the health system, and we must find solutions for the problems that COVID-19 exposed – this must include deficits in health workforce and impacts of staffing shortages on the delivery of health care.
As we come back to “normal”, we need to remind everyone that what we are experiencing in the health system across Australia is not normal, it isn’t safe, and it can be fixed through careful planning and adequate resourcing.
We need to remember how it feels now and make sure we design a health system that is safe and fair and accessible for all Australians – and the people who work in it.
Workforce planning takes time. We don’t have all the answers, but we know that we urgently need to start a conversation.
At the Australasian College for Emergency Medicine (ACEM), we are reviewing our own training pathways to improve skill development and distribution of the emergency medicine workforce. We are also working with other colleges and groups to share our education and training materials, and to look for solutions that will improve health experiences and outcomes beyond FACEM-run emergency departments.
The Australian Government recently released the National Medical Workforce Strategy, which aligns well with the work of ACEM. It’s a start, but more is needed. Medicine is only one part of a very large and complex system, and integrated, effective patient care requires that we all work together.
Problems with health workforce are deep-seated and complex. Solutions will not be easy, and there are no quick fixes. We need to start by acknowledging that the health workforce, and the health system, was under significant pressure long before COVID-19, and that a nationwide, interdisciplinary, coordinated approach is necessary to build the health workforce that Australia needs now and into the future. Let’s start the conversation and make sure we use this opportunity to build back better.
Because what is the most important thing in the health system? It is the people who work in it. Without skilled health care workers, there is no health system at all.
Dr Clare Skinner is the President of the Australasian College for Emergency Medicine.
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.