By Helen Burns, Ben Hamer & Angi Bissell
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Before the COVID-19 crisis our health system faced challenges with maintaining sufficient numbers of experienced health professionals and carers to meet the growing demands from an ageing population and increases in chronic disease.
The system is now dealing with COVID-19 too, and with the upcoming flu season, there are both short and long term pressures the system faces. Immediate pressures relate to the need to fill the workforce gap; and, in the longer-term, a need to build resilience in the workforce, all with a focus on sustaining clinical effectiveness and maintaining a commitment to quality patient outcomes.
This article explores the implications and key considerations for the healthcare workforce, with a focus on the public system given the acute impacts to the frontline.
The onset of COVID-19 has intensified the pressure on the healthcare workforce. There are three key challenges:
The potentially overwhelming burden of COVID-19 added to a health system already at capacity;
The adverse effects on healthcare workers, including the risk of infection, exposure and heightened mental health risks;
The need to rebalance resources almost in “real time” as certain specialties (eg. lower priority elective surgery, particularly in the private sector) decrease, whilst others increase.
In this environment where things change daily, the health system is under more stress than ever before. There are a series of critical workforce considerations that must be addressed to manage the COVID-19 pandemic in the short term, rebuild the system in the long term, and maintain a balance between sometimes competing priorities.
There are six key implications, and subsequent considerations, regarding the healthcare workforce as we manage through this crisis.
The Federal Government, in partnership with the State authorities, is implementing policies to flatten the curve. These policies seek to mitigate any immediate spike beyond system capacity. Measures include suspending or cancelling non-critical healthcare and suspending elective surgeries, or having the private sector take the load of non-COVID-19 related acute and elective surgery off the public system.
One key initiative has been educating the community on appropriate practices regarding disease containment. Collectively, these measures should help reduce the demand for COVID-19 critical care services in hospitals if they are properly adopted and enforced. This will allow clinicians to focus their efforts where they are most needed now. However, it has the potential to create future issues post-peak on addressing the backlog of elective surgery and preventive health.
Some lower priority services and activities will be put on hold whilst attention is devoted to the management and treatment of coronavirus disease. Clinical staff will need to work to the top of their license, and innovative solutions found. These impacts will be felt not only inside health services, but in different parts of the community as planned treatment is delayed.
Increasing the supply of a suitably qualified workforce is critical to being able to meet demand. There are opportunities to inflate the supply of talent by redeploying clinicians from the private to the public health system to support COVID-19 efforts, as there is already a decline in demand in the private health care system due to the reduction in non-essential procedures.
Similarly, the Australian Health Practitioner Regulation Agency (AHPRA) has signalled a willingness to fast-track the re-registration of clinicians after 500 retired doctors in Queensland volunteered for service. This is similar to the UK, which has had over 5,000 nurses and 500 doctors come out of retirement. Work must also be undertaken with the education sector including universities, TAFEs, academies and online skills platforms to support reskilling efforts.
It should be acknowledged that there are unique skills, quality and safeguarding issues that govern the available healthcare workforce. Notwithstanding, we are already seeing an alternate workforce being considered, such as engaging students from healthcare disciplines or final year medical students to undertake appropriate tasks to relieve capacity. There is also potential to provide casual opportunities for non-clinically trained labour to redeploy displaced individuals from adjacent sectors. This could include tasks such as food preparation and delivery, making preventive sanitation supplies, or the provision of cleaning services.
The healthcare system has traditionally been criticised for not enabling clinicians to operate at their top-of-license. For example, one study suggested that doctors were overqualified for 70% of their everyday tasks. Now is the time to ensure the appropriate distribution of work, such as empowering nurses to operate to the top of their license to free up the capacity of doctors. This includes appropriately leveraging the allied health workforce, such as Assistants in Nursing and operational staff.
There has been a significant uptake in telehealth since the COVID-19 outbreak. The list of telehealth services has continued to expand since 13 March and are available to GPs, medical practitioners, nurse practitioners, participating midwives and allied health providers. Further efforts should be undertaken to use virtual care models to protect clinicians and patients from further exposure to COVID-19; ensure the provision of clinical advice and information for rural and regional areas; and, reprioritise high demand specialities (ie. infectious disease, respiratory, and interventionist) to be accessed by those that need them most.
Similarly, supplementing exhausted health workforces with a virtual workforce will provide the essential recovery time and/or specialist advice and decision support required. There is also the potential to leverage overseas clinicians from countries such as China that are past the peak of the COVID-19 pandemic.
While many members of the community are encouraged to socially distance themselves or self-quarantine, frontline healthcare workers are continually putting themselves at risk of exposure. Appropriate practices and practical measures need to be enforced to minimise the risk of contraction, including the provision of protective clothing.
Similarly, additional efforts must consider the mental health implications, including the mitigation of post-traumatic stress disorder from vicarious trauma with factors such as scared and/or aggressive patients, heightened anxiety, and concerns regarding a lack of equipment (ie. personal protective equipment (PPE) such as face masks).
As the COVID-19 pandemic unfolds, we will see a proportion of the frontline health workforce requiring self-quarantine due to possible exposure. Some of this quarantined workforce will be asymptomatic or have very mild symptoms and will still be able to work virtually, for example, by providing virtual triaging or monitoring of at-home COVID-19 patients. Interoperability and security considerations will need to be given to enable this workforce to work remotely and provide healthcare to others. Another key activity could include providing pre and post shift briefings to manage emotional wellbeing and fatigue.
A National COVID-19 Coordination Commission (NCCC) has been established to coordinate advice to the Australian Government on actions to anticipate and mitigate the economic and social effects of the pandemic. We recommend the Commission provide system-wide guidance to health systems regarding the mobilisation of the health workforce to meet demand, including helping facilitate public-private collaboration. These recommendations should guide state health departments to work with respective bodies to ensure that resources can be deployed to where they are needed most, with the states to take responsibility for operationalising directives.
The heightened challenges in the current environment will eventually subside. However, the decisions we make now may have lasting implications. As such, these decisions must have an acute focus on today, with an eye on tomorrow to ensure system sustainability. There are several key workforce considerations following the COVID-19 outbreak that our healthcare system should consider.
The supply of our future healthcare workers has been disrupted. The provision of education is being suspended, including existing practitioners studying for their specialty exams, which will significantly impact the future supply of talent. The system will need to apply some new thinking to cope with this situation. Whilst rebuilding, it will be important to consider diversity and widening the talent pools from which the industry is drawing clinicians and carers.
There are several options open to tertiary education providers who have a critical role in upskilling newly qualified clinicians to help them be ‘job ready’. In addition, healthcare providers should look at models utilised in the United Kingdom. To meet a forecasted decline in frontline clinical positions, the NHS and local authorities developed peripatetic allied health and nursing programs which effectively delivered a co-delivered education and placement pathway. This on-the-job training assisted the shortfall in critical roles. It also found that workers were better prepared for the demands of their roles. In nursing these models were not dissimilar to the traditional hospital nursing traineeships that existed until the mid 90’s in some jurisdictions.
The COVID-19 environment will no doubt result in reforms to models of care into the future. While most clinicians are called to the caregiving and nobility associated with medicine and human services, the current strain on the health system and subsequent employee experience may weigh on the minds of some considering healthcare as a vocation. In addition, workforce segments (such as nursing) have an ageing workforce, and the COVID-19 response may impact choices people make about transition to retirement, particularly as some wish to leave the sector after an extremely challenging time.
The mental health implications for clinicians will extend far beyond the current situation. The system must make a sustained investment in the provision of mental health support services. Similarly, the economic shocks are resulting in forecasted unemployment increases, which will see increased demand for mental health professionals servicing the community.
Any non-essential learning and development is largely being cancelled. As such, there will be a lag in catching up with the important but non-mandatory training requirements.
Staff who are working on the frontline are likely to accrue high leave balances that will add to the financial challenges for the system, particularly as these liabilities and obligations are met as people take the necessary time to rest and recharge.
Initial insights into COVID-19 highlight that, as a society, we are constantly at risk of a disease outbreak. However, health systems tend to be built to manage near-term responses above longer-term sustainability. It is critical that the health system at large understands and evaluates the lessons learned, including from the perspective of the workforce, to build longer-term workforce agility, adaptability, and resilience. This could be through activities such as scenario planning.
Our health workforce had significant challenges prior to COVID-19, with decreasing numbers of junior doctors entering some specialities; a lack of appropriately trained and qualified workers in regional and rural communities; instances of unproductive cultures; and, an ageing workforce.
The impact of COVID-19 on the healthcare workforce is not yet fully understood. Nonetheless, it has increased the pressure on, and expectations of, the highly valued healthcare workforce. Lessons learnt from countries such as Taiwan and Singapore following the SARS crisis highlighted the importance of having robust people systems and plans before the outbreak of a pandemic.
To best prepare our healthcare system for the future, we should consider the current challenges as opportunities for future permanent actions. Alternative delivery models deployed and efficiencies driven by this crisis will hopefully open up capacity within our health system post-pandemic. The demand, and supply, of care across the public and private health systems will forever be revolutionised, with the opportunity for greater integration and shared resources. And the lived experience of the majority of the healthcare workforce should lead to clinician safety being paramount - alongside patient experience - in future models of care.
Partner, PwC Australia
Tel: 617 3257 8359
Dr Ben Hamer
Director, PwC Australia
Tel: +61 437 159 517
NSW Government and Australia Health Leader, PwC Australia
Tel: +61 2 8266 5091