Charles Guest, Honorary Professor, School of Population and Global Health, University of Melbourne
“The government has had 18 months to prepare for a large surge, yet we find ourselves in a situation where hundreds of staff are being furloughed, staff are working overtime and becoming burnt out, and there are real concerns our health system is not ready.” Victorian Opposition health spokeswoman, Georgie Crozier, reported in The Age, 9 September 2021.
An exaggeration, perhaps, but a reminder of some of the variables that influence the public health workforce. PHAA’s CEO, Terry Slevin, invited me to write a piece on workforce, when I approached him, in my late-career way, looking for – yes – work.
In this post, I will note some worldwide workforce problems, and some national professional constraints. Keep in mind that “the” workforce in public health is not one thing; our workforce actually consists of a wide range of networks, making it hard to evaluate.
Through InTouch Public Health, Terry has presented valuable summaries of where debates and policy shifts concerning the public health workforce are up to. For example, will new public health workers have jobs? Alternatively, where are all the public health workers now, as the pandemic continues? Such questions address the supply side of labour.
A question on the demand side is: Do we need another review to establish what the requirements for workers are? I doubt it, given the following example of the public health sector’s weak leverage in government policy. Just about any of us could see themselves reflected, somewhere, in the National Action Plan for Health Security. Recommendation 38, for example, mentions a need for “sustainable mechanisms” to develop public health professionals, under the auspices of the Australian Health Protection Principal Committee. However, this was accorded “low priority”.
Workforce debate usually depends more on finding jobs for people, rather than finding people for jobs. Getting people to do the right work, in the right way, partly depends – eventually – on how the community sets priorities, with choices at the ballot box. What should we work on? The health of Aboriginal and Torres Strait Islander people? Mitigating the adverse impacts of climate change? The obesity pandemic? Additional, of course, to COVID-19.
These projects will need at least some workers with skills not yet envisaged. The evaluation of changing work tasks and other innovation, often to be led by consumers, will be highly complex in today’s world of knowledge excess. While it may be ideal for the educated consumer to drive the public health workforce debate with evidence-based, rational approaches to changing practice, health economics does not follow the rules of supply and demand seen in other, less complex marketplaces.
Meanwhile, worldwide, maldistribution of workforce is, arguably, the principal problem. Redistribution may involve active international recruitment. Arguing for ‘more of the same’, either in the type of worker, or in the work they do, will not be adequate, either in Australia, or elsewhere.
Has PHAA identified costs in proposed workforce reforms? Reducing the rate of growth of costs must become a driver, alongside consideration of maldistribution and productivity. In making better use of the existing workforce, we need an increasing focus on prevention; ensuring the funding for community and regional initiatives, with tighter control of costs, tele-work, and other work practice innovations.
“Stretch” of the medical workforce could be achieved with an additional workforce of physician assistants. A similar practice might apply to public health positions in high demand, enabling more of us to focus on what we do best – the complex, cognitive tasks of public health.
The “Stretch” produces an ‘Assistant Workforce’, ready to go, in many cases. Applicants for this category could find human interaction to be the most attractive aspect of working in public health, sometimes in contrast with academic or technical public health professionals. The development of this ‘Assistant Workforce’ should be possible without undermining the existing workforce, or current standards of public health practice.
Such workforce experiments require research and evaluation. For example, will a fully extended workforce, with assistants, improve the quality of public health practice? Will greater emphasis on working to protocols lead to better outcomes than working without protocols?
In Australia at present, we are still at early stages which include:
Defining the role and function of public health workers in the current system;
Extrapolating needs, recognising uncertainty; and
Encouraging or discouraging entry to specialties where shortages or excesses appear likely.
Do we know what the drivers and incentives that lead to career choices in public health are?
Have current workforce programs been evaluated rigorously? These and many other questions need answers before the likely roles, functions and need for public health practitioners can be predicted.
Preparing for the future, some craft groups are on the offensive, some on the defensive. As an offensive, how can we increase the demand for practitioners? On the defensive, how can we keep our numbers up? We should focus workforce discussion on problems we know really exist, rather than worry about the maintenance of professional groups.
Finally, there are internal pointers that anyone lucky enough to have a job could consider, to improve their workplace. This category, with selection and recruitment, pay and performance policy, regulation and internal culture, takes us to Human Resources. Save that for another day: my word limit is up.
The public health workforce will contribute to Australia’s greener, more equitable, more resilient, more digital future: its healthier future. I have posed questions; your answers should accelerate the journey.
Prof Charles Guest is a past president of the ACT Branch of the PHAA, and convened the 2000 Australian Public Health Conference