How I came to see the health workforce differently
Hi, I'm Susan Nancarrow
Early in my first management role, I had an experience that changed the way I thought about the health workforce. One of my staff had been treating patients as a podiatrist for 20 years. She was competent, we had a long waiting list, and more unmet need than we could possibly ever reach. Then mandatory registration was introduced in our jurisdiction. The next day, that same person was no longer eligible to do the work they had done the day before.
She was just as competent. The patients still needed care. But the rules governing whose competence counted had changed.
That experience stayed with me. For the past thirty years, much of my work has been concerned with the same basic question: Why do health systems struggle to translate population need into work that capable people can actually deliver?
Evidence alone doesn't change workforce systems
Health workforce policy is influenced by evidence, but evidence operates within institutions that already have rules about who can do what.
Those rules sit in regulation, professional standards, funding arrangements, employment classifications, education and organisational practice. They have developed over time and do not necessarily change simply because new evidence shows that work could be organised differently.
This is one reason workforce reform is difficult. A change may make sense clinically and economically, but still run into barriers elsewhere in the system.
Workforce systems are governance architecture
The professions are not simply occupational groupings. They are a part of a governance system — a way of allocating skill, authority and risk across a population. Like any governance system, it is shaped by those who already hold position within it. But it is also a system that can be examined, understood and redesigned. That is where equity of access to care is won or lost.
Why workforce structures matter
The health workforce accounts for the large majority of health expenditure, yet we invest very little in understanding it. We model demand, beds, technology and funding flows. We rarely examine the structures that determine who is allowed do which work, at what level of autonomy, and for what pay.
Those structures are largely inherited. Much of the professional architecture of health systems in Australia, the UK and many other countries took its present shape in nineteenth-century Britain, and has changed remarkably little since. Over time, regulation, education, industrial arrangements and funding systems have reinforced them.
It also explains something that otherwise looks like failure of will: why workforce reform so often produces movement without change.
A new model of care may change what people are trained to do without changing what they are funded to do. Regulation may permit a role that employment classifications do not recognise. An organisation may redesign a service while existing funding rules continue to support the old model.
Understanding where those constraints sit is an important part of workforce reform.
Professional boundaries become durable when they are instantiated across four institutional mechanisms.
I use the term professional boundary instantiation to describe the way professional boundaries become embedded across institutions.
CURRICULUM
What people are trained to do.
REGULATION
What people are permitted to do.
CLASSIFICATION
How roles and pay are structured.
FUNDING
What work gets paid for.
A professional boundary becomes difficult to change when the same assumptions are reproduced across several of these mechanisms.
A claim about who should perform particular work may begin within a profession and then become embedded in education, regulation, employment classification and funding. Once that happens, the arrangement can persist even when practice, technology or population need has changed.
Much of my current work examines how these mechanisms interact, where they produce unnecessary constraints, and what might be required to change them.
How I came to this work
I have approached the same question from several perspectives, and each vantage point shows a different part of the structure.
I trained and practised as a podiatrist before moving into health service management. That was where I first encountered the gap between what people were capable of doing and what the system allowed them to do.
I then spent much of my career in academia, researching interdisciplinary teamwork, workforce redesign, the sociology of professions and the organisation of allied health. That work took me across Australia and the UK, and into projects in India and Malaysia, as well as workforce reform programmes in several Australian jurisdictions.
I have also built and run businesses. Doing so gave me greater freedom to explore questions that do not always fit neatly within academic funding structures, and to continue developing ideas beyond the life of an individual commissioned project.
Today I work as an independent adviser, expert witness and researcher with governments, health services, unions, professional bodies and international agencies. I hold adjunct academic appointments at the University of Queensland and Southern Cross University.
What HealthWorX Futures is for
HealthWorX Futures is where I develop and apply the concept of workforce governance: examining how education, regulation, employment, funding, data and institutional authority combine to shape the work people can do and the care communities can access.
I write about workforce structures, professions and institutions; why reform gets stuck; and what we can learn by looking more closely at the rules governing how work is organised, recognised and funded.
The work takes different forms: articles, working papers, frameworks, practical tools, research and advisory projects. The common thread is an interest in workforce problems that cannot be solved simply by training more people or writing another workforce plan.
If you are dealing with a workforce problem that does not fit neatly within existing structures, or would like to approach one differently, I would love to hear from you.
Start a conversation
If you’re wrestling with a workforce problem, a structural constraint, or an idea that doesn’t quite fit the usual categories, I’m always interested in a good conversation.
Get in touch →
Working papers
Longer-form thinking on professional boundaries, governance and how workforce systems are organised.
Read the working papers →
Seven Minute Sociology
Short essays on workforce governance, professions and the institutional architecture shaping health and care.
Read Health Work 2.0 →
