Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

At a glance: The STEP trials

A round-up of the STEP phase 3 clinical trials evaluating semaglutide for weight loss in people with overweight or obesity.
ADVANCED SEARCH
Log in
Top
Human Resources for Health
Published in: Human Resources for Health 1/2015

Open Access 01-12-2015 | Commentary

Six principles to enhance health workforce flexibility

Author: Susan A Nancarrow

Published in: Human Resources for Health | Issue 1/2015

Login to get access

Abstract

Abstract

This paper proposes approaches to break down the boundaries that reduce the ability of the health workforce to respond to population needs, or workforce flexibility.
Accessible health services require sufficient numbers and types of skilled workers to meet population needs. However, there are several reasons that the health workforce cannot or does not meet population needs. These primarily stem from workforce shortages. However, the health workforce can also be prevented from responding appropriately and efficiently because of restrictions imposed by professional boundaries, funding models or therapeutic partitions. These boundaries limit the ability of practitioners to effectively diagnose and treat patients by restricting access to specific skills, technologies and services. In some cases, these boundaries not only reduce workforce flexibility, but they introduce inefficiencies in the form of additional clinical transactions and costs, further detracting from workforce responsiveness.
Several new models of care are being developed to enhance workforce flexibility by enabling existing staff to work to their full scope of practice, extend their roles or by introducing new workers. Expanding on these concepts, this theoretical paper proposes six principles that have the potential to enhance health workforce flexibility, specifically:
1. Measure health system performance from the perspective of the patient.
2. Minimise training times.
3. Regulate tasks (competencies), not professions.
4. Match rewards and indemnity to the levels of skill and risk required to perform a particular task, not professional title.
5. Ensure that practitioners have all the skills they need to perform the tasks required to work in the environment in which they work
6. Enable practitioners to work to their full scope of practice delegate tasks where required
These proposed principles will challenge some of the existing social norms around health-care delivery; however, many of these principles are already being applied, albeit on a small scale. This paper discusses the implications of these reforms.

Proposed discussion points

1. Is person-centred care at odds with professional monopolies?
2. Should the state regulate professions and, by doing so, protect professional monopolies or, instead, regulate tasks or competencies?
3. Can health-care efficiency be enhanced by reducing the number of clinical transactions required to meet patient needs?
Literature
1.
Maier T, Afentakis A: Forecasting supply and demand in nursing professions: impacts of occupational flexibility and employment structure in Germany. Hum Resour Health 2013, 11: 24. 10.1186/1478-4491-11-24PubMedPubMedCentral
2.
Joint Commission on Accreditation of Healthcare Organisations: Health care at the crossroads: strategies foraddressing the evolving nursing crisis. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organisations; 2002:47.
3.
Dubois C-A, Singh D: From staff-mix to skill-mix and beyond: towards a systemic approach to health workforce management. Hum Resour Health 2009, 7: 1–19. 10.1186/1478-4491-7-1
4.
Buchan J, O’May F: The changing hospital workforce in Europe. In Hospitals in a changing Europe. European Observatory on Health Care Systems Series. Edited by: McKee M, Healy J. Buckingham, UK: Open University Press; 2002:226–39.
5.
Collins M: Problems of flexible working research and theory in the new economy. “Ebusiness and Ework” The Key Action II Annual Conference; Madrid 2003.
6.
Rogers A, Flowers J, Pencheon D: Improving access needs a whole systems approach. BMJ 1999, 319: 866–7. 10.1136/bmj.319.7214.866PubMedPubMedCentral
7.
Nancarrow SA, Borthwick AM: Dynamic professional boundaries in the healthcare workforce. Sociol Health Illn 2005, 27: 897–919. 10.1111/j.1467-9566.2005.00463.xPubMed
8.
Fulton BD, Scheffler RM, Sparkes SP, Auh EY, Vujicic M, Soucat A: Health workforce skill mix and task shifting in low income countries: a review of recent evidence. Hum Resour Health 2011, 9: 1. 10.1186/1478-4491-9-1PubMedPubMedCentral
9.
Commission P: Australia’s health workforce: research report. Canberra, ACT: Productivity Commission; 2005.
10.
Murray RB, Wronski I: When the tide goes out: health workforce in rural, remote and indigenous communities. Med J Aust 2006, 185: 37.PubMed
11.
Buchan J: Further flexing? Issues of employment contract flexibility in the UK nursing workforce. Health Serv Manag Res 1998, 11: 148–62.
12.
Department of Health: The NHS plan. A plan for investment. A plan for reform. London: Department of Health; 2000.
13.
Department of Health: A health service of all the talents: developing the NHS workforce. Consultation document on the review of workforce planning. London: Department of Health; 2000.
14.
Nancarrow SA, Roots A, Grace S, Moran AM, Vanniekerk-Lyons K: Implementing large-scale workforce change: learning from 55 pilot sites of allied health workforce redesign in Queensland. Australia Hum Resour Health 2013, 11: 66. 10.1186/1478-4491-11-66PubMed
15.
Bagwell CE: “Respectful image”: revenge of the barber surgeon. Ann Surg 2005, 241: 872. 10.1097/01.sla.0000165185.88634.d0PubMedPubMedCentral
16.
Klairmont-Lingo A: Women healers and the medical marketplace of 16th-century Lyon. DYNAMIS-GRANADA 1999, 19: 79–94.
17.
Ivey SL, Scheffler R, Zazzali JL: Supply dynamics of the mental health workforce: implications for health policy. Milbank Q 1998, 76: 25–58. 10.1111/1468-0009.00078PubMedPubMedCentral
18.
Dolton PJ, Kidd MP, Fooken J: Get a life? The impact of the European working time directive: the case of UK senior doctors. Health Economics. 2014. doi:10.1002/hec.3082
19.
Cameron A, Masterton A: Reconfiguring the clinical workforce. In The future health workforce. Edited by: Davies C, Owen JW. Basingstoke: Palgrave Macmillan; 2003.
20.
Department of Health: Agenda for change. London: DoH; 2001.
21.
Bohmer RM, Imison C: Lessons from England’s health care workforce redesign: no quick fixes. Health Affairs 2013,32(11):2025–2031. 10.1377/hlthaff.2013.0553PubMed
22.
Kamesh L, Clapman M, Foggensteiner L: Developing a higher specialist training programme in renal medicine in the era of competence-based training. Clinical Medicine 2012,12(4):338–341. 10.7861/clinmedicine.12-4-338PubMed
23.
NHS Modernisation Agency: Changing Workforce Programme: developing support worker roles in rehabilitation and intermediate care services. London: NHS Modernisation Agency; 2003.
24.
Borthwick AM: Challenging medicine: the case of podiatric surgery. Work Employ Soc 2000, 14: 369–83. 10.1177/09500170022118455
25.
Martin GP, Currie G, Finn R: Reconfiguring or reproducing intra-professional boundaries? Specialist expertise, generalist knowledge and the ‘modernization’ of the medical workforce. Soc Sci Med 2009, 68: 1191–8. 10.1016/j.socscimed.2009.01.006PubMed
26.
Bolsin S: Quality and safety in healthcare – a challenge accepted. Anaesthesia 2014, 69: 1051–2. 10.1111/anae.12819PubMed
27.
Kennedy I, Britain G: Learning from Bristol: the report of the public inquiry into children’s heart surgery at the Bristol Royal Infirmary 1984–1995: presented to Parliament by the Secretary of State for Health by Command of Her Majesty, July 2001. London, UK: Stationery Office; 2001.
28.
Sharma S, Ward E, Burns C, Theodoros D, Russell T: Training the allied health assistant for the telerehabilitation assessment of dysphagia. J Telemed Telecare 2012, 18: 287–91. 10.1258/jtt.2012.111202PubMed
29.
Larkin GV: Occupational monopoly and modern medicine. London: Tavistock; 1983.
30.
Allsop J, Saks M: Introduction: the regulation of the health professions. In The regulation of the health professions. Edited by: Allsop J, Saks M. London: Sage; 2002.
31.
Hugman R: Power in the caring professions. Basingstoke: Macmillan; 1991.
32.
Parkin F: Marxism and class theory: a bourgeois critique. London: Tavistock; 1979.
33.
Saks M: Professions and the public interest: medical power, altruism and alternative medicine. London: Routledge; 1995.
34.
Friedson E: Professionalism reborn: theory, prophecy and policy. Oxford: Polity Press; 1994.
35.
Horrocks S, Anderson E, Salisbury C: Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. BMJ 2002, 324: 819–23. 10.1136/bmj.324.7341.819PubMedPubMedCentral
36.
Health Workforce Australia: Queensland Health practitioners’ models of care project: evaluation, learning and upscaling of results for a national audience. Adelaide: Health Workforce Australia; 2014:140.
37.
Smith R, Duffy J: Developing a competent and flexible workforce using the Calderdale Framework. Int J Ther Rehabil 2010, 17: 254–62. 10.12968/ijtr.2010.17.5.47844
38.
Nancarrow S, Moran A, Wiseman L, Pighills AC, Murphy K: Assessing the implementation process and outcomes of newly introduced assistant roles: a qualitative study to examine the utility of the Calderdale Framework as an appraisal tool. J Multidiscip Healthc 2012, 5: 307.PubMedPubMedCentral
39.
Nielson I: Rural and remote generalist: allied health project. Greater Northern Australia Regional Training Network. 2014.
40.
Zetka JR Jr: Establishing specialty jurisdictions in medicine: the case of American obstetrics and gynaecology. Sociol Health Illn 2011, 33: 837–52. 10.1111/j.1467-9566.2011.01341.xPubMed
41.
Light D: Countervailing powers: a framework for professions in transition. In Health Professions and the State in Europe. Edited by: Johnson T, Larkin GV, Saks M. London: Routledge; 1995.
42.
Borthwick A: Occupational imperialism at work: the case of podiatric surgery. British Journal of Podiatry 2001,4(3):70–9.
43.
Health Q: Ministerial Taskforce on health practitioner expanded scope of practice: final report. Brisbane: Allied Health Professions’ Office of Queensland; 2014.
44.
Team DT: Cost-effectiveness of magnetic resonance imaging of the knee for patients presenting in primary care. Br J Gen Pract 2008, 58: e10–6.
45.
Pearce C, Phillips C, Hall S, Sibbald B, Porritt J, Yates R, et al.: Following the funding trail: financing, nurses and teamwork in Australian general practice. BMC Health Serv Res 2011, 11: 38. 10.1186/1472-6963-11-38PubMedPubMedCentral
46.
Team DT: Effectiveness of GP access to magnetic resonance imaging of the knee: a randomised trial. Br J Gen Pract 2008, 58: e1–9.
47.
Haug MR: A re-examination of the hypothesis of physician deprofessionalization. Milbank Q 1988, 66: 48–56.PubMed
48.
Courtenay M, Nancarrow S, Dawson D: Interprofessional teamwork in the trauma setting: a scoping review. Hum Resour Health 2013, 11: 1–10. 10.1186/1478-4491-11-1
49.
Nancarrow SA, Booth A, Ariss S, Smith T, Enderby P, Roots A: Ten principles of good interdisciplinary team work. Hum Resour Health 2013, 11: 19. 10.1186/1478-4491-11-19PubMedPubMedCentral
50.
Atkinson J: Flexibility, uncertainty and manpower management. vol. IMS Report No. 89. Brighton: Institute of Manpower Studies; 1984.
51.
Banbury A, Roots A, Nancarrow SA: Rapid review of applications of e-health and remote monitoring for rural residents. Aust J Rural Health 2014,22(5):211–22. 10.1111/ajr.12127PubMed
52.
Purcell K, Hogarth T, Simm C: Whose flexibility?: the costs and benefits of ‘non-standard’ working arrangements and contractual relations. 1999.
53.
Emanuel LL: A professional response to demands for accountability: practical recommendations regarding ethical aspects of patient care. Ann Intern Med 1996, 124: 240–9. 10.7326/0003-4819-124-2-199601150-00008PubMed
54.
Kalleberg AL: Organizing flexibility: the flexible firm in a new century. Br J Ind Relat 2001, 39: 479–504. 10.1111/1467-8543.00211
55.
Pollert A: The ‘flexible firm’: fixation or fact? Work Employ Soc 1988, 2: 281–316. 10.1177/0950017088002003002
56.
Allan C: Stabilising the non-standard workforce: managing labour utilisation in private hospitals. Labour Ind 1998, 8: 61–76. 10.1080/10301763.1998.10669178
57.
Department of Education Employment and Workplace Relations: Australian jobs. Canberra: Australian Government; 2012.
58.
Gilbert R, Franks G, Watkin S: The proportion of general practitioner referrals to a hospital respiratory medicine clinic suitable to be seen in a GPwSI respiratory clinic. Prim Care Respir J 2005, 14: 314–9. 10.1016/j.pcrj.2005.04.006PubMed
59.
Homeming LJ, Kuipers P, Nihal A: Orthopaedic podiatry triage: process outcomes of a skill mix initiative. Australian Health Rev. 2012.
60.
Bowen CJ, Dewbury K, Sampson M, Sawyer S, Burridge J, Edwards CJ, et al.: Musculoskeletal ultrasound imaging of the plantar forefoot in patients with rheumatoid arthritis: inter-observer agreement between a podiatrist and a radiologist. J Foot Ankle Res 2008, 1: 5. 10.1186/1757-1146-1-5PubMedPubMedCentral
61.
Tonna A, Stewart D, West B, McCaig D: Pharmacist prescribing in the UK – a literature review of current practice and research. J Clin Pharm Ther 2007, 32: 545–56. 10.1111/j.1365-2710.2007.00867.xPubMed
62.
Armfield N, Edirippulige S, Bradford N, Smith A: Telemedicine — is the cart being put before the horse? Med J Aust 2014, 200: 530. 10.5694/mja13.11101PubMed
63.
Siciliani L, Hurst J: Tackling excessive waiting times for elective surgery: a comparative analysis of policies in 12 OECD countries. Health Pol 2005, 72: 201–15. 10.1016/j.healthpol.2004.07.003
64.
Guttmann A, Schull MJ, Vermeulen MJ, Stukel TA: Association between waiting times and short term mortality and hospital admission after departure from emergency department: population based cohort study from Ontario, Canada. BMJ 2011., 342:
65.
Freeman JV, Croft S, Cross S, Yap C, Mason S: The impact of the 4 h target on patient care and outcomes in the Emergency Department: an analysis of hospital incidence data. Emerg Med J 2010, 27: 921–7. 10.1136/emj.2009.085431PubMed
66.
Campbell SM, Reeves D, Kontopantelis E, Sibbald B, Roland M: Effects of pay for performance on the quality of primary care in England. N Engl J Med 2009, 361: 368–78. 10.1056/NEJMsa0807651PubMed
67.
Emanuel EJ, Fuchs VR: Shortening medical training by 30%. JAMA 2012, 307: 1143–4. 10.1001/jama.2012.292PubMed
68.
Nancarrow S, Clark J: Accountability and accreditation in the Australian allied health context. Pract Dev Health Care 2003, 2: 33–47. 10.1002/pdh.82
69.
Farnworth L, Rodger S, Curtin M, Brown T, Hunt SG: Occupational therapy entry‒level education in Australia: which path (s) to take? Aust Occup Ther J 2010, 57: 233–8. 10.1111/j.1440-1630.2010.00862.xPubMed
70.
Bollag B: Credential creep. Chron High Educ 2007., 53:
71.
McKenna L, Vanderheide R: Graduate entry to practice in nursing: exploring demographic characteristics of commencing students. J Adv Nurs 2012,29(3):49–55.
72.
Wray N, McCall L: Money matters: students’ perceptions of the costs associated with placements. Med Educ 2007, 41: 975–81. 10.1111/j.1365-2923.2007.02840.xPubMed
73.
74.
Hudson JN, Weston KM, Farmer EA: Medical students on long-term regional and rural placements: what is the financial cost to supervisors? Rural Remote Health 2012,12(2):1–9.
75.
Gruppen L, Mangrulkar R, Kolars J: The promise of competency-based education in the health professions for improving global health. Hum Resour Health 2012, 10: 43. 10.1186/1478-4491-10-43PubMedPubMedCentral
76.
Pugh CM, Watson A, Bell RH Jr, Brasel KJ, Jackson GP, Weber SM, et al.: Surgical education in the internet era. J Surg Res 2009, 156: 177–82. 10.1016/j.jss.2009.03.021PubMed
77.
Nancarrow SA, Moran AM, Graham I: Preparing a 21st century workforce: is it time to consider clinically based, competency-based training of health practitioners? Australian Health Rev. 2013.
78.
Nancarrow SA: Dynamic role boundaries in intermediate care. J Interprof Care 2004, 18: 141–51. 10.1080/13561820410001686909PubMed
79.
Kot FC, Hendel DD: Emergence and growth of professional doctorates in the United States, United Kingdom, Canada and Australia: a comparative analysis. Stud High Educ 2012, 37: 345–64. 10.1080/03075079.2010.516356
80.
Gibbons M, Limoges C, Nowotny H, Schwartzman S, Scott P, Trow M: The new production of knowledge: the dynamics of science and research in contemporary societies. Sage. 1994.
81.
Gross SJ: The myth of professional licensing. Am Psychol 1978, 33: 1009.
82.
Saks M: Regulating the English healthcare professions: zoos, circuses or safari parks? Journal of Professions and Organization. 2013. jot001 jot001
83.
Evetts J: New directions in state and international professional occupations: discretionary decision-making and acquired regulation. Work Employ Soc 2002, 16: 341–53. 10.1177/095001702400426875
84.
Weick KE, Sutcliffe KM: Hospitals as cultures of entrapment: a re-analysis of the Bristol Royal Infirmary. Calif Manag Rev 2003., 45:
85.
Ernst E: Complementary and alternative medicine: what the NHS should be funding? Br J Gen Pract 2008, 58: 208–9. 10.3399/bjgp08X279562PubMedPubMedCentral
86.
87.
Ben-Arye E, Frenkel M, Klein A, Scharf M: Attitudes toward integration of complementary and alternative medicine in primary care: perspectives of patients, physicians and complementary practitioners. Patient Educ Couns 2008, 70: 395–402. 10.1016/j.pec.2007.11.019PubMed
88.
Nancarrow SA, Moran AM, Boyce R: Evaluation of a system of monitoring allied health service provision, quality and outcomes. Global Sci Technol Forum Journal of BioSciences 2012,2(1):55–9.
89.
Ariss SM: Asymmetrical knowledge claims in general practice consultations with frequently attending patients: limitations and opportunities for patient participation. Soc Sci Med 2009, 69: 908–19. 10.1016/j.socscimed.2009.06.045PubMed
90.
Mackey H, Nancarrow S, Nancarrow SA: Enabling independence: a guide for rehabilitation workers. Oxford: Wiley-Blackwell; 2006.
91.
McClimens A, Nancarrow S, Moran A, Enderby P, Mitchell C: ‘Riding the bumpy seas’: or the impact of the knowledge skills framework component of the agenda for change initiative on staff in intermediate care settings. J Interprof Care 2010, 24: 70–9. 10.3109/13561820903078124PubMed
92.
Jewell D: Getting the best out of general practice — an open letter to the Minister of Health. Br J Gen Pract 2001, 51: 523–4.
93.
Charles‒Jones H, Latimer J, May C: Transforming general practice: the redistribution of medical work in primary care. Sociol Health Illn 2003, 25: 71–92. 10.1111/1467-9566.t01-1-00325
94.
Goldfield N: The evolution of diagnosis‒related groups (DRGs): from its beginnings in case‒mix and resource use theory, to its implementation for payment and now for its current utilization for quality within and outside the hospital. Qual Manag Health Care 2010, 19: 3–16.PubMed
95.
96.
Stitzenberg KB, Sheldon GF: Progressive specialization within general surgery: adding to the complexity of workforce planning. J Am Coll Surg 2005, 201: 925–32. 10.1016/j.jamcollsurg.2005.06.253PubMed
97.
New South Wales Ministry of Health: Rural surgery futures. North Sydney: New South Wales Ministry of Health; 2012:41.
98.
Burns CL, Ward EC, Hill AJ, Malcolm K, Bassett L, Kenny LM, et al.: A pilot trial of a speech pathology telehealth service for head and neck cancer patients. J Telemed Telecare 2012, 18: 443–6. 10.1258/jtt.2012.GTH104PubMed
99.
Moran A, Nancarrow SA: Mechanisms to enhance the effectiveness of allied health and social care assistants in community-based rehabilitation services: a qualitative study. Health Soc Care Commun. doi:10.1111/hsc.12158.
100.
Health Q: Blueprint for better healthcare in Queensland. Queensland Health: Brisbane; 2013.
101.
Oelke ND, White D, Besner J, Doran D, Hall L, Giovannetti P: Nursing workforce utilization: an examination of facilitators and barriers on scope of practice. Nurs Leadersh 2008, 21: 58. 10.12927/cjnl.2008.19691
102.
Young G, Hulcombe J, Hurwood A, Nancarrow SA: The Queensland Health Ministerial Taskforce on health practitioner expanded scope of practice: consultation findings. Australian Health Rev. 2014.
103.
Elwood TW: Patchwork of scope-of-practice regulations prevent allied health professionals from fully participating in patient care. Health Aff 2013, 32: 1985–9. 10.1377/hlthaff.2013.0530
104.
Health Q: Ministerial Taskforce on health practitioner expanded scope of practice - consultation paper. Brisbane: Allied Health Professions Office Queensland; 2013.
105.
Moran AM, Nancarrow SA, Wiseman L, Maher K, Boyce RA, Borthwick AM, et al.: Assisting role redesign: a qualitative evaluation of the implementation of a podiatry assistant role to a community health setting utilising a traineeship approach. J Foot Ankle Res 2012., 5:
106.
Abbott A: The system of professions: an essay on the division of expert labour. Chicago: Chicago University Press; 1988.
Metadata
Title
Six principles to enhance health workforce flexibility
Author
Susan A Nancarrow
Publication date
01-12-2015
Publisher
BioMed Central
Published in
Human Resources for Health / Issue 1/2015
Electronic ISSN: 1478-4491
DOI
https://doi.org/10.1186/1478-4491-13-9

Other articles of this Issue 1/2015

Human Resources for Health 1/2015 Go to the issue

Research

Projections of specialist physicians in Mexico: a key element in planning human resources for health

Research

Factors influencing the career choice and retention of community mental health workers in Ghana

Research

Making the transition to workload-based staffing: using the Workload Indicators of Staffing Need method in Uganda

Research

Global health leadership training in resource-limited settings: a collaborative approach by academic institutions and local health care programs in Uganda

Research

Exploring the influence of trust relationships on motivation in the health sector: a systematic review

Review

Costs and cost-effectiveness of community health workers: evidence from a literature review