They are not separate problems. Each challenge shapes the next.
The health workforce is the largest single cost in health care, and the pressure on it is not easing. Populations are ageing, more people are living longer with multiple long-term conditions, expectations of care are rising, and the range of things health services can diagnose and treat continues to expand. At the same time, health systems are struggling with persistent workforce shortages, growing waiting lists, rising costs and increasing pressure on hospitals. Governments have responded with more training places, recruitment campaigns, workforce strategies, new roles, scope-of-practice reforms and repeated attempts to improve productivity. Yet the underlying problem remains remarkably stubborn.
That is not because nobody is planning. Almost every health system is trying to plan its way out of a workforce shortage, and many of the people doing that work are skilled, committed and working with the best tools they have. The difficulty is that those tools operate inside a workforce architecture that determines what can be seen, counted, funded and changed.
When we talk about workforce planning, we are still mostly talking about doctors and nurses, and occasionally pharmacists, physiotherapists and – sometimes – other registered professions. Yet for more than twenty years, health policy in most wealthy countries has been moving care out of hospitals and into primary care, homes, disability support and aged care. The care moved. The way we see, count and fund the workforce largely did not.
The nine challenges below fall into three groups: what the system can see, what gets locked in, and where the cost lands. They are not nine separate problems, and they are not a criticism of workforce planners. They are parts of the same system. Each shapes the next, and together they help explain why adding more of the same workforce has not made the shortage go away.
What we see
Download the PDF summary here: Nine Structural Challenges in Health Workforce Planning
1. We only see the workforce we count
Workforce data is built around registered professions, mostly employed in hospitals and large services. Much of the work that keeps people well happens elsewhere, done by support workers, assistants, peer workers, Aboriginal and Torres Strait Islander health workers, community workers and carers. Some of that workforce is counted somewhere, in aged care or disability data, but it is poorly connected to health workforce planning, and much of it is effectively invisible to it. A workforce the plan cannot see is one it cannot plan for, and one that is easiest to cut when budgets tighten. Read more: We Moved Care out of Hospital but Still Plan Around the Hospital Bed
2. We plan professions, not the work that needs doing
Once the visible workforce is a set of professions, services tend to be organised around them. Oral health is a clear example. Planning has largely meant counting dentists, while prevention, oral health therapists, school and community programs, and support for people who cannot easily care for their own mouths sit at the edges. We plan dentists, not oral health. Professions may be an appropriate unit for determining who is competent and authorised to do particular work. They are a much less reliable unit for planning what a population actually needs, because they carry existing occupational boundaries into the future and leave work that no single profession owns unplanned (see Ahern et al, 2019)
3. We see need through the services we already provide
Workforce planning aims to start from need, but the need it counts has usually already been shaped by services. Prevalence is counted through diagnoses, demand through service use, and the gap is expressed as a shortage of particular professions. Need with no diagnosis, no profession and no funding stream can barely register. When we asked a small rural town about its mental health needs, people talked about families in crisis, transport, confidentiality and who controls the budget. When we asked the services, they mostly described services. Both are real, but usually only one reaches the plan. Read more: The Hospital Is Where the Failure Shows Up.
What gets locked in
4. Funding counts beds and episodes, not the care that prevents them
Activity-based funding was designed to pay hospitals efficiently for what they do, and it does that job well. The difficulty is that nothing comparable exists for the work that keeps people out of hospital. Admissions, bed days and episodes are counted and priced; a person who stayed well at home is not. Prevention and reablement have to be translated into bed days avoided before they can be valued, and much of their value is lost in the translation. Under budget pressure, the visible acute work is protected and the less visible preventive work is cut. Occupational therapists, among the professions best evidenced for keeping people out of hospital, are increasingly used to move people out of it. Read more: Why Community Care Keeps Becoming a Hospital Crisis; The Hospital Is Where the Failure Shows Up.
5. Reforming one lever at a time rarely works
Occupational boundaries are held in place by four institutions at once: education that trains people, regulation that authorises them, industrial arrangements that classify and pay them, and funding rules that pay for their work. I call this professional boundary instantiation: the process by which an occupation becomes institutionally real. Because the four reinforce each other, reform that changes only one of them is usually absorbed by the other three. A new scope of practice that no funding rule pays for, or a new qualification that no award recognises, changes much less than it promised. This is not a story of professions behaving badly. It is a description of how the architecture around them works. Read more: Professional Boundary Instantiation: How Health Systems Create Workforce Scarcity; Why Australia’s Dermatology Shortage Is Worse Than It Needs to Be.
6. New roles can remain fragile
The same arrangements make it hard for new roles to take hold. When a new or advanced role does emerge, it is often built by one determined practitioner who secures the training, negotiates the authority and builds the service themselves. A regional Queensland sonographer who now performs ultrasound-guided injections is one example. Roles like this can work very well while that person stays, but if the system cannot recognise them as roles, they may not survive their departure. Other workforces, such as mental health peer workers, have grown substantially without gaining a stable institutional footing. Innovation that depends on individuals stays personal and precarious. Read more: Why Advanced Practice Won’t Scale Without Top-Down Strategy and Advanced Practice Sonography: What Luke Kipping’s Story Tells Us About Scope of Practice Reform
Where the cost lands
7. Care moved to where the workforce is hardest to see
For two decades, policy has moved care out of hospitals and residential institutions and into homes and communities. Hospitals are highly visible settings: staff are counted, credentialled, supervised and covered by clinical governance, with a clear employer accountable for their work. Homes and communities are not. Care has moved to settings where the people doing it are spread across small providers, funding schemes and individual arrangements, where they are less visible to workforce data, and where governance is less consistent. Read more: Why Community Care Keeps Becoming a Hospital Crisis; Workforce Is Governance Architecture.
8. We rely most on some of the workforces we support least
The workforces that absorbed that shift are among the least institutionally supported. Support and care workers in aged care, disability and community health often have no registration, uneven training pathways, fragile funding and limited recognition in industrial classifications. Small allied health providers, many of them women-led businesses, have carried much of the disability market and are now expected to absorb its restructuring. These workforces support some of the most vulnerable people in the system, and are asked to adapt to each new reform, often with the least institutional recognition and support for doing so. In effect, the system has shifted more responsibility onto workforces without shifting the institutional infrastructure that supports them. Read more: When a Smelter Goes Idle; Music Therapy: Same Profession, Different Funders, Different Pricing.
9. Funding is not aligned around prevention
Prevention is funded, but the money and the benefit rarely sit in the same place. The savings from early intervention land in a different budget from the one that paid for it: another level of government, another sector, another year. In Australia, the split between Commonwealth and state funding, and between health, aged care and disability, means an organisation that invests early may never see the return, so investment rarely moves upstream. Health systems have tried many ways to reconnect the two, from fundholding and commissioning in England to capitation and blended payment models, with mixed results. China’s barefoot doctors, perhaps the most deliberate attempt to build a workforce at the base of the pyramid, show the stakes: when the collective funding that held them there was withdrawn, many moved towards selling treatment instead. Read more: The Hospital Is Where the Failure Shows Up.
Nine challenges. One connected system.
Read in order, the nine form a chain. What we count shapes how we organise services, and services shape how we understand need. That understanding decides what gets measured and paid for. The institutions around existing professions then hold those arrangements in place, which keeps new roles fragile. Meanwhile, care moves to settings where the workforce is hardest to see and least supported, and the budgets that would reward acting earlier sit in different places from the benefits.
None of this requires anyone to be doing their job badly. Planners, managers, professions and policymakers are all working inside the same architecture, and it shapes what each of them can see and which solutions seem possible. That helps explain why repeatedly training more of the same workforce has not closed the gap. If we plan only within the existing architecture, we will keep finding shortages at the most expensive end of it.
Over the coming months, Health Work 2.0 will take each of these challenges in turn, starting with real cases and asking what would actually have to change — and where — to produce a different result. If you are working on one of these problems, I’d like to hear what it looks like from where you sit.
References
Ahern et al. (2019), “Needs-based planning for the oral health workforce – development and application of a simulation model”, Human Resources for Health, 17:55. DOI: 10.1186/s12960-019-0394-0.
