Building a health workforce to meet future population needs

The World Health Organization has declared that “health systems can only function with health workers.”1 In Australia, health practitioners (a subset of health workers) make up 5% of the national workforce, and about half are nurses.2 The health workforce is spread across public and private facilities, across primary, secondary and tertiary care, and across states and territories, and overlaps other health‐related areas, including disability and aged care.3 This workforce is under pressure from rising service demand, environmental, geopolitical, and economic pressures, continual policy reforms, and disparities in pay and conditions,4,5 leading to workforce shortages, some related to maldistribution or deficits in some health care types, and inequity of access.2,3,5 The size of the health practitioner workforce increased 37% during 2013–2022; growth was greatest for allied health professionals (67%), medical practitioners (41%), dental practitioners (29%), nurses and midwives (26%), and general practitioners (24%).2 Relative to population size (fulltime equivalent positions per 100 000 population), the workforce increased by 22% for the same period, the change again varying by profession (general practitioners, 2.7%; nurses and midwives, 13.2%; allied health professionals, 53.1%) and region, but demand continued to outstrip growth, with shortages reported for 82% of occupations in 2023.2 Around the world, the health workforce was significantly affected by attrition caused by the COVID‐19 pandemic,2,6 the erosion of goodwill (eg, willingness to work unpaid overtime),7 and fatigue related to change.8,9 Workforce instability has an impact on the continuity and quality of services, and can vary geographically because of differences in the availability of staff and competition between employers. Recent royal commissions have highlighted the need for a larger, better trained and better paid care workforce, particularly in rural and regional areas.10,11

The increasing pressure on the health system and its workforce, fiscal constraints, complex professional governance, and interactions with other systems mean that a consolidated workforce policy is needed to align efforts to support and strengthen the health system. In their review of federal health workforce policy in Australia, published in this issue of the MJA, Topp and colleagues3 identified a range of policies largely concerned with specific professions, culturally specific workforces, geographic location, career development, specific areas of health care, and the general supply, distribution, and performance of the health care workforce. The authors conclude that such fragmentation undermines coordinated workforce planning and equity, and that a strategy that includes the breadth of the health workforce is needed for supporting the long term resilience of the Australian health care system. They recognise that, while consolidating national health policies is important, most of the workforce is employed by state and territory governments with different policies.3

The review by Topp and colleagues provides a glimpse of the complex health workforce policy landscape and the need for consolidation and coordination within and across jurisdictions. They highlight the fragmented governance of health, leading to proliferation of policy. However, the authors do not discuss the process and dynamics of policy development, which is not described in policy documents, but is potentially more important than the policy itself, particularly in complex and contested environments. Engaging all organisations and individuals affected by health policy in its development is particularly important, given the distribution of health care across different levels of governments, for‐profit and non‐profit providers, and numerous professions.

The study by Topp and colleagues is subject to several limitations. The authors did not include “primary health care” or “general practice” in their search terms for identifying federal health workforce policies,3 although primary health care and general practice, each of which fall within the remit of the federal government, are the gateways to other health services. Perhaps the most important limitation of the review was that it focused on federal policy, but health care is also and arguably largely delivered by states and territories and private businesses.

As Topp and colleagues note,3 the patchwork of health workforce policies are largely responses to specific problems, but whether they were fully understood or resolved by the policies is unclear. Rather than consolidate policies, it would perhaps be preferable to work with the relevant organisations and the broader community to better determine how to sustain the health care workforce; specifically, to understand the challenges and their causes, the interventions required, who needs to act, and to set priorities.12 For example, changes to education curricula could encourage interest in health care among school students, while more accessible professional and vocational training could encourage people to enter and stay in the health workforce.13 Taking a more strategic approach could also help reduce reliance in Australia on recruiting health professionals from overseas, which also affects the sustainability of workforces elsewhere.3,14 Further, any new health workforce strategy should be mindful of how it relates to the broader care sector.15

The health workforce is a vital component of sustainable health systems and warrants a policy framework that focuses attention on overcoming major barriers to ensuring the availability of workers where they are required.2,3 The health workforce operates in an environment of increasing costs, complex governance mechanisms, competing health care reform agendas, and changes in the way the public sector does business; for example, organising services in policy siloes organised by place (placed‐based services) or teams (multidisciplinary teams). Any new policy needs to consider the complex systems within health care, as well as the other systems with which it interacts, and be realistic about what it can therefore achieve.16 This will require resources, collaboration, and political will.