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Stretched and burnt out: an urgent need to invest in the public health workforce

Introduction by Croakey: Around the world, news of the Omicron variant of concern – which the World Health Organization says is now reported in 57 countries – has created concern and questions about the implications for an already stretched and burdened health workforce.

“Watching the United States prepare for the new Omicron variant simultaneously sparks traumatic memories of the past and dread for the future,” writes Dr Eric Kutscher, a physician in New York City, in a powerful article just published by the BMJ.

It is not only the clinical workforce that is feeling the pressure. An important symposium this week heard of an urgent need to invest in expanding and developing the public health workforce, reports Cate Carrigan.


Cate Carrigan writes:

Australia’s public health leaders have called on National Cabinet to honour commitments to invest in the sector, warning the workforce is facing burnout as COVID-19 underscores its critical and ongoing importance.

The emotional and physical toll of the pandemic, inadequacies of public health training, uncertainty around career paths and job security, a long-term under-investment in the public health workforce – these were some key issues raised at a forum this week on the future of the public health workforce.

The virtual symposium, hosted by the Public Health Association of Australia (PHAA), Australasian Faculty of Public Health Medicine (AFPHM) and National Aboriginal Community Controlled Health Organisation (NACCHO), heard of public health worker burnout, the traumas of dealing with the pandemic, of the value and shortage of epidemiologists, and of a lack of adequate data on the workforce.

It was held amid uncertainty and growing concerns about the Omicron variant and news from Victoria of the deaths of two Aboriginal community members who had COVID-19, with a total of 1,385 COVID deaths now reported in Victoria since the pandemic began.

PHAA CEO Adjunct Professor Terry Slevin reminded more than 500 symposium participants of National Cabinet’s 2020 commitments to investing in the public health workforce, and said the organisation was now making workforce enhancement one of its key priorities for the upcoming federal election.

More challenges ahead

Victorian and New South Wales Chief Health Officers, Professor Brett Sutton and Dr Kerry Chant, highlighted the need for socio-political skills to advocate for the public health workforce, with Sutton saying, “We’ve got to keep on reminding Cabinet about the commitments they made”.

Sutton told the forum:

COVID might be the poster child for challenges but there are other existential issues that require a public health workforce in its full capability – whether that be climate change, threats to biodiversity or other threats to human health and wellbeing.”

Chant said the emergence of Omicron was more evidence “we are going to be battling COVID for years to come and that it will give us many curved balls”.

“We really have to look at broad-based training and skills and think about partnerships with universities to provide a diverse workforce that call on to respond to different issues,” said Chant.

She envisaged a future where people with public health knowledge were dispersed across government and agencies.

“I would see success as secretaries for the departments of education, or community and justice coming from a population health background,” she said.

Terry Slevin said the PHAA would keep “thumping the table” with government and decision-makers on the need for investment in public health and was working on a proposal to go to National Cabinet for a nationally-funded Public Health Officer training program based on the NSW model (as outlined by Chant, below).

Under the model, Slevin said 70 percent of recruits would come from non-medical backgrounds and 20 percent would be Aboriginal and Torres Strait Islander people.

In addition to a national training program, the PHAA wanted more medical specialists training in public health, and a thorough review of workforce status and accreditation, and future workforce requirements – not just for the pandemic but for chronic disease and preventive health.

“National Cabinet has twice committed to advance investment in the public health workforce, but so far nothing has happened. Action is now urgently needed. We need to get cracking,” said Slevin.

Responding to a question from Croakey, Slevin said he was “absolutely concerned” governments would forget the lessons of COVID and the importance of public health as they turned to “opening up” economies.

Adding to concerns over the public health workforce is the current lack of any accurate data on workforce numbers across the country or a breakdown across states and territories, and disciplines, such as medicine, nursing or other qualifications.

Terry Slevin addresses the symposium

Emotional and physical exhaustion

Dr Danielle Esler, from the Northern Territory Ministry for Health, spoke of the pandemic’s toll on the wellbeing of the public health workforce, something that has impacted the entire health workforce.

“What has been demanded of the workforce during the pandemic is more than most of us signed up for,” said Esler.

To an enthusiastic response on the forum’s chatline, Esler argued that any discussion of workforce sustainability had to put “the wellbeing of our workforce front and centre”.

Esler said the sector needed to address workforce tensions such as home schooling while working from home, and the need for flexibility – from training positions right up to senior leadership – to take into account roles people may have outside of the workforce.

Public health physician trainees across the country had performed roles well above what would normally be expected, with Esler concerned this could impact their ability to study for and pass exams.

Comments were made in the Forum’s Chat section: Yes such good points Danielle.. so much exhaustion and looming burn-out.. we need to ensure we don’t lose our amazing current and emerging public health leaders.

The pressures of the pandemic response have been felt by Aboriginal health workers across the country, with the head of the National Association of Aboriginal and Torres Strait Islander Health Workers and Practitioners (NAATSIHWP), Karl Briscoe, telling Croakey that social and emotional wellbeing had been a significant issue.

“In communities that were locked down, health workers had feelings of isolation they had never felt before. A lot of them couldn’t just drive out to their homelands to recharge,” he said.

“We’ve had Indigenous psychologists sharing support tools and mechanisms when workers are having this overwhelming sense of emotions they haven’t experienced before.”

Briscoe said Aboriginal health workers, who usually live in their communities, can’t switch off at 5pm, they are on-call to the community and risk being ostracised or isolated if they don’t respond to a request for help.

“Even prior to COVID, we were seeing burn out in a lot of our workforce … and with COVID coming on top of this, and workers having to pivot and be more agile around technology and other new tasks and duties, we’ve been hearing stories of a lot of our members needing to take time out,” said Briscoe.

Training Aboriginal Health Workers

The medical director of the National Aboriginal Community Controlled Health Organisation (NACCHO), Dr Megan Campbell, stressed the need for training and leadership opportunities for First Nations peoples and recognition of the role of Aboriginal Community Controlled Health Organisations (ACCHOs) in keeping communities safe.

Campbell said the public health workforce had been “absolutely essential” in supporting Aboriginal and Torres Strait Islander communities to stay safe during the pandemic and improving the cultural safety and quality of government and mainstream organisation responses as well.

“I think it’s the flexible, community-driven approach of the ACCHO sector that makes us more resilient and adaptable for effective public health responses and ensured very rapid responses from our sector early in the pandemic to minimise risk,” she said.

A key to that model of care – not just in response to COVID but for health promotion and prevention work – were Aboriginal Health Workers, who Campbell said might have little or no formal public health training but had on-the-jobs skills.

“We absolutely need to increase the Aboriginal and Torres Strait Islander public health workforce and that’s going to require substantial commitments. The ACCHOs can and need to have leadership in this space,” she said.

NACCHO recognised the value of national and jurisdictional training programs but wanted to ensure the curriculum is appropriate, includes competencies around Indigenous public health practice – not just knowledge – and its development must be led by Aboriginal and Torres Strait Islander people.

Campbell stressed the need to avoid “a box-ticking” exercise and highlighted the importance of ACCHO experience for trainees to achieve competencies.

In NSW, Public Health Officer (PHO) and Specialist Training Program (STP) trainees had found the ACCHO sector experience invaluable and formative for their careers, she said.

“Such placements are essential for building a sustainable public health workforce within the ACCHO sector but also for building a culturally safe workforce in mainstream institutions,” she said.

Campbell warned against only having city-based traineeships, saying the recent COVID-19 outbreak in Wilcannia had highlighted the importance of local responses and knowledge in responding the crisis.

Many speakers backed the need to increase the number of Aboriginal and Torres Strait Islander public health workers, with NSW CHO Kerry Chant saying the pandemic had demonstrated the need to grow the workforce and increase diversity, and have a strong focus on Aboriginal training programs.

Challenges of training

The issue of training and job security, also raised by public health researchers this week in a Croakey article, was a repeated theme throughout the forum, with calls for more training programs, improved links with universities and placements across jurisdictions and disciplines.

Professor Robyn Lucas, President of the Australasian Faculty of Public Health Medicine (AFPHM), spoke of an under-supply of public health physicians, inadequate data on workforce numbers and proposed a change in training programs to link funding to trainees rather than positions.

Lucas said such a change would allow trainees to move between and outside jurisdictional health systems – to universities, ACCHOs, Commonwealth bodies and other services, making their expertise transferable across the country.

And she called for a nationally-funded training program – potentially as part of a national Public Health Officer (PHO) training scheme – saying the present system was patchy, and that New Zealand, which had a national program, had a much better coverage of public health physicians.

Echoing the concerns, Dr Stephanie Davis, the Deputy Chief Medical Officer, Commonwealth Department of Health, said that even prior to COVID, the public health workforce was facing problems with a shortage of medical and non-medical trainees, an ageing workforce and lack of career pathways.

COVID had highlighted those problems, with high demands on senior leaders, a lack of mid-level staff able to take on senior leadership and a lack of surge capacity.

Davis said these and other issues raised by the pandemic had been considered as part of the long-awaited National Preventive Health Strategy – to be launched next week – which aims to build a stronger and more effective system.

Power of politics

Politics, and the need to be part of the conversation, was another key theme during the forum, with Associate Professor Vanessa Johnston, Deputy Chief Health Officer of the ACT, saying COVID highlighted the consequences of “our post-truth world”.

“A diminution of science and a propagation of falsehoods by people, including decision-makers and politicians, [is] complicating the job of public health,” she said.

“I think politics has really come to the fore in this pandemic, and professionals of the future are really going to have to engage in a very sophisticated manner in this space.”

Johnston said the pandemic has also exposed and worsened underlying inequalities in our health and public health systems, and society at large.

“Without explicit attention to the social determinants of health and going back to public health’s core mission, in the aftermath of this immediate crisis, we’re going to get even greater inequities,” she said.

Johnston questioned how the sector harnesses the gains from the spotlight on public health, not just for the pandemic but for the current climate emergency, which she sees as the biggest health threat of all.

NSW CHO Kerry Chant acknowledged the power of politics, saying public health workers will need to focus on the “soft skills” – the socio-political and the complex decision making skills – that have been required during the pandemic.

“We are really going to have to rely on those that stood before us”, and seek insight into how they navigated difficult conversations in difficult socio-political contexts, she said.

Future hopes

Professor Tarun Weeramanthri, President of the PHAA, stressed the need for the sector to work together to find a way forward.

As part of the 2020 Finkel Review, which recommended long-term investment in the public health workforce (endorsed by but not yet acted upon by National Cabinet), Weeramanthri said the inquiry highlighted the importance of medium and long-term investment in public health expertise.

“There is still some denial from decision-makers who say the numbers are there now – what more do you want? But if that’s the attitude, as soon as COVID is over, we’ll go back to baseline,” said Weeramanthri.

“We need to make the point that the surge workforce only comes on top of a baseline.”

After the review, Australia headed into lockdowns but now the country was opening up there would be a bigger demand for a workforce to oversee testing, tracing, quarantine and isolation in all our states and territories, he said.

“We will only be as good as the weakest link…we will need good public health workforces across the country as a priority.”

Commonwealth Deputy Chief Medical Officer Steph Davis said some of the most pressing questions are how to prepare a workforce capable of responding to fluctuating demands – not just from communicable diseases but also for prevention of chronic disease – and whether a national training scheme will really be the answer or whether other models would be better.

We need to think not just of the ‘Rolls Royce’ national training model, but a communal or hybrid model, or other training routes that don’t involve the traditional pathways, she said.

Diversity matters

NSW CHO Kerry Chant stressed the importance of cross-disciplinary skills in areas such as communication, economic and technical skills, saying she couldn’t stress enough the importance of ensuring workforce diversity.

PHAA CEO Terry Slevin told Croakey an underpinning principle of all the organisation’s work is that training and advancement opportunities should be available and in place across a wide diversity of people, disciplines and backgrounds.

Comments were made in the Symposium’s Chat section: I am struck by the emphasis on the need for a broad range of skills (One Health, behavioural science, risk communication, community engagement, environment, epidemiology skills) alongside the focus in this webinar on public health medicine shortages. To Kerry’s point, we need diversity.

For Victoria’s Brett Sutton, a key challenge is to expand the state’s public health training system. He said there is “no such thing as over-investing in public health”.

Sutton said the next phase is to broaden the scope beyond public health medicine to have a curriculum that really supports a Public Health Officer workforce, whether they come from environmental health, health promotion or a Masters of Public Health background.

“We need ongoing advocacy to make the most of what we’ve learnt in this crisis to promote the extraordinary value of public health beyond public health medicine because there will never be a better time,” said Sutton.

“Everyone can see the manifest value in pandemic control but the value is there in everything Australia has achieved in gun control, in work on cessation of smoking and so many other areas.”

• See a Twitter thread by the Australian Health Promotion Association reporting on the symposium, and also this thread from the PHAA, as well as this report.


See Croakey’s extensive archive of stories on health workforce issues.

 

Comments 2

  1. Deborah Dowsett (Mulla) says:

    What about improving the wages for Aboriginal Health workers across all classifications, as this would be an incentive to attract and retain staff. Qld wages are not that great compared to other allied health work force, unsure of other states. I applied to do a Certificate 4 in Aboriginal primary health care and had to find somewhere who is willing to have me, to undertake 500 hours of clinical placement unwaged, this was just to apply to be accepted into the university as a mature student, and for someone who has to work to support the family, I needed to apply for mixed-mode and could only find one university in Qld who do this. Pathways are not easy and the wages are below standard. With the increasing cost of living, our health workers need to be able to afford to pay their rent and support their families, they do a demanding role yet are paid less than their Non-Indigenous counterparts in allied health services. Time for an overhaul in the system.

  2. Dr Robbie Lloyd says:

    Dear Melissa, This is wonderful reporting and vitally urgent news. The sink hole sitting alongside the neglected Public Health tent is the one marked Community. Until we value the Lived Experience of Consumers and Carers alongside Clinicians there will be no real improvement in Public Health.
    Currently the dominant Clinical/Medical Model vacuums up every cent of new funding and Public Health is and Health Promotion are seen as “do gooder” add ons. Until pandemics, and natural disasters and traumatising public events happen.
    We need to invest in models like Global Mental Health where local people become the front line Health and Wellbeing workforce, and local Healers and Traditional Medicines are respected.
    This is the core principle of The Recovery College movement in Adult Community Education, which should be factored into any response to Public Health improvement.

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