The strategic behaviour of health workforce actors: Implications for health workforce planning and forecasting

Abstract

The effects of less than optimal health workforce numbers, skills or distributions are felt across the entire health system. Thus, the aim of health workforce planning is to meet the health system’s needs with a sustainable and fit-for-purpose workforce. Frequently, though, the conventional approaches used for the difficult task of estimating workforces are limited and become less effective in times of change and in conditions of uncertainty.

In response, this Mixed Methods (MM) study takes a system view, exploring New Zealand’s health workforce planning problem through the lens of actor dynamics and presents a complimentary approach to address uncertainty. Influenced by the La Prospective method of scenario planning, the approach uses a multi-phase design combining three foresight methods: actor analysis, scenario development and policy Delphi. Firstly, actor analysis produces critical issue, positional, relational and influence data. These actor data are used to augment a normative scenario to develop exploratory alternatives. Lastly, these scenario sets are interrogated through an online policy Delphi producing and rating sets of workforce policy statements. Two detailed case studies, Primary Health Care (PHC) and Older Persons Health (OPH), are provided as examples of the approach. From inductive content analysis of 18 workforce documents and deductive data from 35 actor interviews, the actor analyses reveal that each case has a few dominant actors who exert considerable influence over the system and are in conflict over particular critical workforce issues. Other actors are found to be positioned to play a facilitative role to build multi-actor relations. The most frequently identified strategic issues found are model of care and funding arrangements, which are indicated as critical for conceiving future actions. These actor data are combined with each case’s normative scenario, developed from the deductive content analysis of 12 workforce planning documents. The Delphi analysis of the case scenario sets reveals that: (a) the scenarios are a reasonable facsimile of sector-plausible futures with some scenarios rated more desirable, likely or valid than others; and (b) the policy statements that favour networked models of care, clinically-influenced service design and leadership, team-work cultures and an emphasis on interprofessional education, are rated desirable and feasible. Considering the findings from the three foresight methods together this thesis provides guidance to workforce planners and policy makers on the use of a complimentary approach to overcome some of conventional workforce forecasting’s limitations. The combined findings elucidate how critical workforce issues can be identified and responses formulated with regard to actor influence and system intervention effectiveness. The synthesis of the findings reveals: (a) that connections between a workforce system’s strategic issues and the actors’ strategic behaviour clarify likely future situations, and (b) that scenario methods and analysis are useful for reducing uncertainty and for devising and rehearsing policy options, signalling that workforce planners should be utilising system-based foresight. This approach provides a framework for exploring the complexities and ambiguities of a health workforce’s evolution; offers a means to capture the values, beliefs and power of diverse actors; and underlines the importance of people in health systems.