Health workforce planning is conducted across many countries using different methodologies. Many workforce planning models focus on using demographic trends to assess future supply and demand; others try to link health expenditure projections with health workforce projections; some take into account role extension and substitution; while others are trying to move beyond health service utilisation to needs-based models, as well as some examining multi-professional groups rather than professional groups in isolation[6, 7].
A review of existing workforce planning methodologies, in concert with the project brief to HWA (to undertake a workforce planning exercise for doctors, nurses and midwives to present and measure possible future health workforce outcomes under a range of workforce planning scenarios), and an examination of data availability, identified the methodology outlined below as the best fit-for-purpose for the HW 2025 project.
Estimating workforce supply
HW 2025 used a dynamic stock and flow model to estimate future workforce supply at a national level in Australia. The four key inputs in the HW 2025 dynamic stock and flow model were: 1) workforce stock (in 5-year age and gender cohorts); 2) domestic new entrants; 3) migration (permanent and temporary); and 4) net exits, which included all permanent and temporary flows out of the workforce.
In the stock and flow method, the number and characteristics of the current workforce (stock) are identified, along with the sources and number of workforce inflows and outflows. Trends or influences impacting on the stock and flows are also identified.
To project future supply, the initial workforce stock is moved forward based on expected inflows and outflows, allowing for the impact of identified trends and influences on the stock.
In the dynamic stock and flow model, the effect of people ageing is also accounted for. The workforce stock is broken down into age and gender cohorts, and each cohort receives inflows not just from graduates and migration (external flows), but also from people moving from one age cohort into the next. Similarly, each age and gender cohort has exits applied - from people leaving the workforce altogether, as well as exits as a person moves into the next age cohort. This is an iterative calculation for each year over the projection period, and provides for a more realistic representation of labour market dynamics.
The stock and flow process is represented in Figure 1, where people entering and exiting the workforce (the flows) periodically adjust the initial number in the workforce stock to project future supply.
Estimating workforce demand
HWA employed the utilisation method to develop workforce demand projections. This approach measures expressed demand, and is based on service utilisation patterns as they currently exist. It makes no assumptions about potential demand, or unmet demand.
Service utilisation data were matched against age and gender cohorts and, once mapped, were projected against future demographic structures. Mapping service utilisation to age and gender cohorts captures changes in service utilisation associated with changes in population composition. For example, if a particular set of services is associated with 35- to 39-year-old females and their share of the overall population increases, then demand for the workforces associated with the provision of those services will grow greater than the rate of the overall population.
In HW 2025, unique expressed demand growth rates were calculated for each medical specialty, nursing area of practice, and midwifery.
Key data sets used to generate the HW 2025 workforce supply and demand projections are presented in Table 1.
Scenario analysis was used to demonstrate the impact of potential policy options on future workforce supply and demand. The method used was to present a comparison scenario, where current trends in supply and expressed demand were assumed to continue into the future, and use this to compare with a range of alternative scenarios. Varying input parameters in the workforce projection model generated the alternative scenarios. The flow through effect to the future workforce was then measured through the impact relative to the comparison scenario. The alternative planning scenarios were categorised according to the policy options they fit within, and included the following. (Not all scenarios that were modelled are listed in this article. Full details of all scenarios are contained in the HW 2025 suite of publications.)
Innovation and reform scenarios
The demand for the workforce was reduced at a notional rate of 5% over the projection period, to illustrate productivity improvements through reforms including changed skill mix, changing models of care, technological change or other reforms.
Low demand scenario
The demand for the workforce was reduced by a notional value of two percentage points.
Workforce retention scenario (nurses only)
The supply of the nursing workforce was increased through improvements in the nursing retention rate.
Medium and high self-sufficiency scenarios
Immigration was progressively reduced to 50% and 95% of starting levels, respectively, to show the relative reliance of the workforce on international health professionals.
Other impact scenarios
High demand scenario
The demand for the workforce was increased by a notional value of two percentage points.
Capped working hours scenario (doctors only)
Capped the total number of hours worked by the total medical workforce at a notional value of 50 hours per week, to demonstrate the effect of a reduction of working hours for all doctors.
The scenarios were not used as predictions of the future, but were used to provide an estimate of a likely outcome given the set of conditions and assumptions upon which the scenario was based.
Principles underlying the methodology
In developing the HW 2025 project, HWA followed a number of key principles to ensure the workforce projections generated were robust and realistic, and able to be used as a framework for nationwide discussions on future workforce policy and reform directions.
Methodological robustness and coherency
The selection of the workforce projection methodologies used involved consideration of a broad range of literature relating to health workforce planning and modelling[9–13]. The methodology chosen (described above) was determined to be the most fit-for-purpose, and was applied across the medical, nursing and midwifery workforces. This consistency and coherency in application allowed for meaningful comparisons and policy considerations at a national level.
Use of national data
All input data was sourced from nationally comparable data sets (Table 1). This meant the characteristics of the existing workforces and derived items such as exit rates were all developed on the same basis across Australia. The use of national data reinforced the coherence and consistency of applying the same methodology across workforces to allow for meaningful national comparisons.
Workforce projections provide likely outcomes given the assumptions on which they are based. The assumptions underpinning HW 2025 were exposed for critical review through an extensive consultation process to ensure they were realistic and defensible. The underpinning assumptions were also published with the workforce projections to ensure the results could be interpreted accurately.
Consultation and review processes
The methodology, data and underpinning assumptions that created the HW 2025 workforce projections were consulted on extensively through the course of the project. In particular:
A Technical Reference Group, composed of representatives from academia, government and the health sector, provided advice and expertise on issues including the appropriateness of the underpinning assumptions and best practice approaches to quantifying education and training capacity and modelling workload measures.
The methodology paper was available for public comment.
Structured workshops were conducted with workforce participants and organisations to expose the overall method and the assumptions underlying the baseline projections to critical review.
Clinical leads (health professionals representing each of the fields of medicine, nursing and midwifery) provided clinical expertise and context to the workforce projections and the development of alternative scenarios.
Workforce projections become less accurate as the period of time over which they apply increases. The World Health Organization noted “It is therefore critical that plans include mechanisms for adjustment according to changing ongoing circumstances. Making projections is a policy-making necessity, but is also one that must be accompanied by regular re-evaluation and adjustment”. HW 2025 projections will be updated as new data become available, and the methodology and assumptions will be periodically reviewed with the assistance of clinical experts to ensure the projections remain realistic and relevant.
Value of the Health Workforce 2025 methodology and principles
As outlined earlier, health workforce planning can be conducted using different methodologies. Many institutions in Australia, including state and territory governments, employers, professions and other planners, also conduct health workforce planning. Such workforce planning is often conducted for different purposes and has different scopes, data sources and assumptions. A national picture from such workforce planning cannot be obtained.
While previous national health workforce planning has also been conducted, this was in a siloed approach - examining individual specialty workforces (for example, anaesthesia specialists, radiology specialists, critical care nurses) in isolation and at different points in time.
Historically, there has also been no connection between the health and higher education sectors when conducting workforce planning, which is important given the vital role the education sector plays in generating the future health workforce.
HW 2025 addresses the above limitations. Using the methodology and principles outlined, HWA has developed a set of nationally authoritative, consistent and coherent health workforce projections to be used for health workforce planning. The national nature of the workforce projections is vital. National challenges are facing the health workforce, and the national planning conducted allows, for the first time, a single consistent approach to workforce management.
HW 2025 provides the evidence base from which student and training intakes can be aligned with projected health workforce requirements. As part of this, HWA has a responsibility to develop and implement programmes to increase the capacity and effectiveness of clinical training for health professions - providing a clear practical link between the health and education sectors.
Additionally, engagement with stakeholders through the extensive consultation and review processes ensured the workforce projections developed were relevant, trusted and supported across the sector. This has meant HW 2025 results have been accepted as an evidence base upon which policy decisions are made.
Finally, the iterative nature of HW 2025 provides a means for the impact of incremental adjustments to the health workforce to be measured, taking into account significant changes in the health system or the underlying social and economic environment. This, along with the alignment of student and training intakes to projected health workforce requirements, is vital in avoiding previous boom and bust cycles of supply of the health workforce.