COVID-19 exposed and magnified the chinks in the human resource armour of our healthcare systems.
It laid bare how stretched the workforce is, leading to stress and burnout, and exaggerated its gender inequalities. It also highlighted the challenge of ‘surge’ capacity in its human resource – the healthcare system was left unable to deal with anything other than the pandemic, causing routine services to back-up and non-COVID health needs unmet.
The ability to recover from this crisis to create resilient health systems aligned with the population's health needs and able to cope with future national emergencies relies on addressing a cluster of key human resource challenges.
The basis of these were identified by our research examining the health resources in Canada during the pandemic. They have global resonance, with lessons that can be applied to healthcare systems in the UK and other high-income countries.
1 Tackle working conditions
Recruitment and retention cut to the heart of this. Neither of these can be fixed instantaneously due to the length of training (five years plus in the case of doctors). However, COVID-19 has driven health services to breaking point, with waiting lists and waiting times for routine care ballooning in the UK.
Indeed, the UK's National Health Service (NHS) has now been ousted from its ranking as the number one healthcare system out of 11 high-income countries, falling to fourth behind Norway, the Netherlands and Australia.
To keep workers in healthcare roles and to avert chronic staff shortages, there needs to be greater attention paid to working conditions, particularly with regard to health and well-being.
The healthcare workforce has exhibited considerable resilience in the face of COVID, but this has come at a cost to their health. Data from the World Health Organization shows health workers account for eight per cent of COVID-19 cases globally. Meanwhile, mental health costs may be hidden as clinicians, nurses and other key workers have been working 16 hours a day, up to six days a week, for the past 18 months causing burnout for many.
Within this we should note that the impact of COVID has exaggerated racial and gender inequalities in the healthcare workforce, as pressures are acutely felt at the low paid and more precarious end of the labour force, such as those staff delivering frontline long-term social care.
It was clear at the start of the pandemic in the UK that such staff faced shortages of personal protective equipment (PPE) and were exposed to elderly patients being unsafely discharged from hospitals. Unsurprisingly, sheer exhaustion and poor morale have sparked an exodus of health service staff in the UK, an issue that had already been simmering pre-COVID as critical personnel were being drawn to countries like Australia and New Zealand where working conditions are considerably more attractive.
2 Level up staffing in all areas and root out inequalities
The fall-out of COVID-19 has exacerbated pressures on so-called ‘Cinderella’ services, including child and adolescent mental health services (CAMHS), social care and public health.
Strategies focused on getting the right mix and number of frontline workers in all parts of the health system are vital. This will help rebuild those specialist services weakened by years of under-resourcing, and prevent overall care being disjointed or fragmented.
Our research showed that the pandemic exposed the vulnerability of healthcare systems where there’s historically been an imbalance in the way services are developed. Years of concentrating on hospital care while neglecting long-term care for the elderly proved to have dire consequences when COVID-19 hit. Senior citizens (one of the population groups most likely to fall seriously ill or die by catching the virus) were left in the hands of a sector crippled by staff shortages and therefore incapable of providing high-quality care.
COVID-19 has intensified inequalities in access to healthcare for other groups too. Those most adversely affected by the disease, such as those living in deprived areas, are also the ones most poorly resourced in terms of the healthcare workforce. It underlines the case for redressing the skew in how labour is allocated.
Health leaders need to plan ahead to redesign the healthcare workforce so it is fit for purpose both in more benign times and when facing large scale public health crises.
Policymakers and those delivering on partnerships for clinical education need to consider new skill mixes; new professional competencies; and how to encourage more effective multi-professional collaboration and teamwork, particularly for services for vulnerable groups, such as CAMHS, social care and public health.
Regarding the latter, in the UK the public health workforce and valuable data it holds have been poorly used to tackle COVID-19. Their knowledge could have played a much bigger role in ensuring local interventions, noticeably regional lockdowns or tracing cases or hot spots.
Yet, public health has historically been, and continues to be, poorly funded in the UK, with teams now sitting within local authorities, divorced from mainstream healthcare provision. COVID-19 has shown that a more integrated approach between the two is necessary.
3 Accelerate new ways of working
Working in professional and organisational silos would have been an inadequate response in the face of an emergency the size of COVID-19.
However, the silver lining of COVID has been stronger collaboration between different health professionals in delivering care. For example, when setting up testing sites or administering the vaccine to the masses.
We have also seen local organisations develop their surge capacity by re-purposing and redeploying their existing workforce, moving clinicians from their existing duties and roles to provide care for COVID-19 patients. In the UK, this included trainee doctors, such as from Warwick Medical School being pressed into delivering clinical care sooner than they might imagine.
Innovation has accelerated, particularly at the frontline. Specifically, a raft of innovative digital solutions have been rapidly developed and launched to ensure people could access care, advice and order medication online, relieving pressure on staff at the coalface.
My own elderly parents, with multiple health conditions between them, have praised virtual clinical appointments with their GP and hospital specialists. This progress must be further exploited post-COVID to build fit-for-purpose healthcare systems within which human resources and robust technologies act in a complementary way to enhance care for those most vulnerable to disease.
4 Develop leadership capabilities for extreme contexts
Health authorities need to consider how future leadership capacity is developed, focusing on cultivating talent that can deal with both an immediate crisis and then its aftermath by switching to recovery mode.
When facing deep uncertainty and unusual circumstances, as we did with COVID-19, public leaders are under immense pressure. In such extreme contexts, leadership cannot be limited to governing by decrees and formal authority of a limited and visible number of individual leaders. A more collective approach to leadership is needed to co-ordinate activity, characterised as enabling or facilitative leadership.
Leaders have to steer at a distance and focus on generating optimal conditions to ‘mobilise’ co-operation between leaders at local, regional and national jurisdictions. Because of the complexity of extreme contexts, how knowledge capabilities are driven through more collective forms of leadership is crucial. The knowledge located within various communities – be they scientific, policy, delivery or local – is a critical resource, but bringing it together is a considerable challenge.
To date, leadership development in healthcare has tended to focus on developing the individual, usually in a competence-based way. We now require leadership development that recognises leadership as a dynamic process encompassing multiple stakeholders and that is flexible as events shift. Leaders need to be able to take charge of crises, drive innovation, manage recovery and be able to lead in more benign, routine times.
5 Invest in the system at all levels and take a global perspective
Compelling workforce strategies and decisions around hiring, retention, and labour utilisation, as well as integration of health and social care, should be driven by national policies but enacted at a local level.
Human resource functions within healthcare providers need to behave strategically, carefully targeting investment to get the best from the labour force.
There’s also an international dimension to take into account. Countries like the UK shouldn’t be continually hiring from abroad to plug staffing gaps. The increasing dependency of wealthier nations upon an overseas health workforce, commonly from low-medium income countries, is shocking.
The Organisation for Economic Co-operation and Development (OECD), a body of mainly developed nations, show that 27 per cent of doctors and 16 per cent of nurses in wealthier countries are non-nationals. Currently, there are more Malawian doctors in Manchester than in Malawi. Ethically, it’s akin to hoarding the COVID-19 vaccine and leaving other countries vulnerable in a global crisis.
Robbing Peter to pay Paul is an unsustainable trend that will only serve to worsen healthcare provision faced by poorer populations, further intensifying inequality. Policymakers must better invest in recruiting and training a domestic healthcare workforce.
Healthcare executives need to learn from the response to COVID-19, specifically around the development and management of human resources as the recovery progresses across the globe. I have offered a ‘call to arms’ for policymakers and healthcare executives focused on how the UK moves forward
In particular, I have argued the human face of the healthcare staff needs better attending to, so inequalities in the workforce and the population at large can be evened out. Resources to support development will undoubtedly be squeezed, but new ways of working that are more effectively targeted at priority areas and populations will prove value-adding in the medium to longer term.
Denis, J., Cote, N., Fleury, C., Currie, G. and Spyridonidis, D. (2021) "Global health and innovation: a panoramic view on health human resources in the COVID-19 pandemic context", International Journal of Health Planning and Management.
Graeme Currie is a Professor of Public Management and is leading the EXploring Innovation in Transition (EXIT) Study to improve the life chances of young people leaving care. He also teaches on the Leading Strategic Innovation in Healthcare Executive Education course.
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