The healthcare workforce absorbs 40–90% of the health budget. Instead of viewing this as an investment, governments and administrators regard it as a cost that must be contained – in a system with finite resources, finding ways to make the health dollar go further is seen as essential. While some measures taken in this regard can achieve short-term cost savings, these gains may be negated by the effect that such measures can have on staff morale.

In their 2006 World Health Report, the WHO acknowledged that health services around the globe engaged in poor human resource practices that focus on cost cutting and lead to low staff morale, heavy workloads, lack of professional autonomy, poor supervision and support, long working hours, unsafe workplaces and unfair remuneration.

Given the emphasis on cost saving in healthcare, it is curious that many highly effective management approaches, which consistently improve efficiency in a range of industries, are not utilised in healthcare. These practices place employees and their needs at the centre of business operation, and they work because they build the organisation’s ‘psychological capital’. The notion is not revolutionary, but run it by any doctor working in a public hospital and they will dismiss it as a utopian ideal.

Creating a health system that values doctors is not impossible, but it requires a shift in the priorities of governments, administrators and clinical leaders.

How can it be achieved?

1. Make workplace safety a priority
   • In the 1980s, Paul O’Neill, as CEO of Alcoa aluminium manufacturing, wanted to demonstrate to employees that there ‘would be a code of inviolable values including basic human respect for workers at all levels’. On his first day, he launched a workplace safety campaign that made workers’ health a genuine priority.
   • In the healthcare setting, the hazards may not be as obvious, but they are no less real, and no less preventable. And in health, of course, there are implications not only for workers but also for patients. There is plenty of evidence to show that fatigue, stress and low morale significantly increase the likelihood of needlestick injuries and car accidents for doctors, and serious and costly adverse events for patients.
   • Safety in this context is not about hardhats and earmuffs; it’s about fatigue-minimising rosters, adequate staffing levels, sufficient backup when staff are sick, and appropriate supervision and support. It is also about ensuring the availability of dedicated spaces for doctors to sleep, rest, prepare meals and debrief amongst colleagues.
2. Focus on education and training
   • A recent New Zealand government report on junior doctor welfare, ‘Treating People Well’, clearly articulates many problems in the public hospital system that result in low morale and potentially affect the quality of patient care. It calls for a shift in the model of hospital management to one that regards junior doctors as being employed for training, not simply as service providers. It may be an obvious need, but it’s one that has been obscured in the push for short-term cost savings.
   • The WHO acknowledges that access to training, supervision and mentoring, and a considered and supportive approach to lifelong learning and personal development, are amongst the most significant incentives for healthcare workers. Interestingly, such factors have also been recognised as integral to managing financially successful organisations.
   • Training is an essential investment in the future of the healthcare system. Some practical steps to making it a priority include providing greater financial rewards and administrative support for senior staff who become educators, building education into hospital KPIs so that it becomes a proportion of the budget for each patient’s care, providing dedicated work spaces and training facilities, and investing in programs like Queensland’s MoLIE (More Learning for Interns in Emergency), which ensures that structured clinical training is rostered and paid.
3. Engage health workers in management
   • A major factor contributing to low morale in the healthcare workforce is a lack of autonomy. Employees, particularly trainee doctors, are given few opportunities to engage with management or contribute to organisational decisions, and yet it has been shown that a decentralised organisational structure and systematic communication between management and staff help to build a positive and more efficient working environment.
   • The health system must engage clinicians in management, because the business of health systems is to deliver clinical services. We need more clinically trained professionals in management positions, as well as mechanisms for healthcare workers to contribute to organisational decisions. As well, more information about organisational matters should be shared with health workers, to create an environment of trust and mutual responsibility.

A guarded prognosis

These strategies are only a starting point for improving healthcare workers’ wellbeing and morale. The health system is entirely dependent on its workforce, and as such it needs to be recognised as a valuable asset rather than an unwanted cost. A healthy, motivated workforce and a cost-efficient health system are not mutually exclusive: they are intimately linked. So a real shift in focus is essential if we are serious not only about maintaining workers’ health but also creating an efficient, high-quality, and sustainable workforce. This raises the question – are there other management concepts and frameworks we could apply to the world of medicine?

Dr Sarah Mansfield is a robust advocate for junior doctors through her roles as President of the Australian Medical Association (AMA) Victoria Doctors in Training and Deputy Chair of the Federal AMA Council of Doctors in Training.

Where do you stand?

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