How the rules that organise work also distribute authority — and why that matters more now than ever
For most of my career, first as a clinician and then as a workforce researcher, I have been trying to answer a question that should be simple, but is far from it. We have well over fifty different occupational groups providing different aspects of health care to our populations. We spend a large and growing share of GDP on the people who deliver care. So why can we never seem to meet healthcare need?
The usual answer is that workforce planning is a technical problem. How many workers do we need? What should they know? How do we fix the shortages? How do we get more out of the people we already have? These are the questions that fill ministerial briefs, taskforce reports and consulting engagements, and workforce conferences are organised around them.
But the longer I have worked inside health systems (designing career frameworks, classifying roles, sitting on review panels, reading industrial instruments), the clearer it has become that this framing misses what workforce systems actually do.
Workforce systems are not labour market mechanisms.
They are governance architecture.
Once you see that, it is very hard to look at professions, regulation, education, AI or healthcare the same way again.
Every workforce structure implicitly answers a set of hidden governance questions:
- Who is trusted to perform a particular task.
- Under what conditions.
- Using which body of knowledge.
- With what oversight.
- Paid through which mechanism.
- Accountable to whom.
- Excluded from what.
These look like employment questions, but they are not. They are the mechanisms that society uses to organise and distribute authority.
This is what makes professions so interesting, and so politically resilient. A profession is not just an occupational group. It is a distributed governance system. Medicine historically governed access to health knowledge. Law governs access to legal legitimacy. Universities govern access to credentialed expertise. Regulators govern access to sanctioned practice. The workforce is the infrastructure through which power flows into institutions, and through which institutions hold their authority over time.
Most governance discussions, even sophisticated ones, focus on the visible apparatus: governments, boards, laws, regulators. Much less attention is paid to the governance embedded in the workforce structures themselves.
In healthcare, this is unusually clear. A workforce framework determines who can diagnose, prescribe, delegate and supervise, who receives funding, who carries legal liability, and whose knowledge counts as legitimate. These decisions shape patient access, system cost, innovation, equity and public trust long before any board paper is written or any minister makes a decision. By the time governance arrives at the formal level (governments, boards, funders, industrial relations commissions etc), most of the consequential choices have already been built into the workforce.
And that architecture is unevenly built. A profession needs infrastructure to exist as a governed entity: an education pathway, a regulatory home, a place in industrial agreements, and a way of being funded. The oldest and most powerful professions have all four, protected and endorsed by the state, and in some cases they control them. Newer and smaller professions have had to assemble that infrastructure themselves, piece by piece, usually incompletely – and often paid for by the members of that profession. Large parts of the workforce have almost none of it.
The consequences of uneven workforce architecture are visible everywhere when you start looking. Globally and nationally, large parts of the health workforce remain poorly recognised, counted or reported. We say we have workforce shortages, but we lack the data to say who needs which workforce, where, and who is actually available to meet that need. Because the workforce is still largely organised around the economics of the hospital bed, the most expensive workforces are the most visible, and resources flow towards high-cost interventions at the expense of alternatives, many of which are not clinical at all.
This persists even though, for more than two decades, most high-income health systems have deliberately moved care out of institutions and into communities, across aged care, disability and health. The result is an enormous and growing vocationally trained workforce, often working alone in the least regulated setting there is, the home. Many have little or no formal training, no regulation, low pay and little recognition, and a high proportion come from overseas. They work with the most vulnerable people in society. We have placed our least visible, least governed workforce where the risk is greatest, and the architecture does not register that as a governance decision at all.
This is why workforce reform is so emotionally charged. Changing workforce structures is never just about efficiency. It threatens institutional legitimacy, professional identity, income flows, status hierarchies, educational monopolies and historical power arrangements. Scope-of-practice debates are rarely only about clinical risk. They are also disputes over governance authority: who counts as a knower, whose judgement the state trusts, and whose work is allowed to attract a price.
AI intensifies all of this because it destabilises the relationship between knowledge, credentials, authority and labour. When access to specialised knowledge becomes dramatically cheaper and more widely distributed, what happens to institutions built partly around controlling access to that knowledge? What happens to workforce structures designed when expertise was harder to access, slower to change, and more tightly bound to particular professional groups?
This is one of the defining governance questions of our time, and almost everywhere it is being treated as a workforce planning problem.
This does not mean that professions should be dismantled. Professions perform critically important governance functions. They protect safety, stabilise trust, preserve standards, coordinate expertise and manage risk in ways no other institutional form has yet matched. The question is not whether these structures should exist. It is whether the architecture we inherited, largely designed in the nineteenth and early twentieth centuries when knowledge changed slowly and authority was geographically bounded, remains fit for purpose under rapid technological, demographic and fiscal change.
When governance systems become too rigid, they stop protecting the public and begin protecting themselves.
For decades, workforce planning has sat at the margins of policy. It has been treated as a technical concern, sometimes a budgetary one, and rarely a strategic one. That era is ending. In an AI-mediated, demographically pressured, fiscally constrained world, workforce systems increasingly determine how societies adapt, who benefits from transition, who is excluded, and whether institutions remain legitimate at all. The same dynamics are visible well beyond healthcare, in universities, energy, media and public administration, wherever societies use credentialed expertise to organise trust and authority.
Workforce architecture is no longer an administrative concern. It is one of the central governance challenges of this century, and it deserves to be treated that way by governments, regulators, the professions themselves, and everyone who designs the systems in which all of us will eventually be cared for.
This essay is the first in a series about what happens when we stop looking at the workforce as a ‘numbers problem’ and start to look at its organizing architecture.
I have come to see and organise those problems around five interrelated questions. Can we SEE the workforce and the need clearly? Can we USE the capability we already have? Do we VALUE the right work? Can we SUSTAIN the workforce by supporting people to build careers, stay, and grow? And ultimately, who has the power to CHANGE the system?
Under those five questions sit a series of more specific questions that I will work through over the coming year – from why shortages coexist with unused capability, to why equivalent work is valued differently, why people leave, why education fails to keep pace with need, and why apparently sensible workforce reforms get stuck.
My starting proposition is that most of the workforce problems we experience as shortages are not caused simply by lack of people. They are produced by the way we define, organise, regulate, classify and fund work.
