Professional
Volume 47, Issue 8, August 2018

Workforce planning: How we think about the impact of organisations on outcomes

Jagdeesh Singh Dhaliwal   
doi: 10.31128/AJGP-02-18-4486   |    Download article
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Background
Healthcare workforce availability and planning is of fundamental importance to patients, clinicians, operational managers and strategic leaders alike. Despite much attention and development of plans and policy, a definitive answer remains elusive.
Objective
The aim of this article is to encourage colleagues to make explicit their underlying assumed models when undertaking workforce planning.
Discussion
It is posited that, akin to making a holistic diagnosis in medicine, understanding workforce issues by uncovering the prisms of presupposition and assumption that we hold about organisations is critical to generating fruitful new insights. Morgan’s organisational metaphors are described as one example of a management conceptual model that might help us to illuminate these prisms. Examples are given of how each metaphor alters the way in which we might address our workforce needs and priorities. 
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At every tier of the health system – coalface GP, practice manager, business owner, senior healthcare manager, medical educator or health service strategist – getting workforce planning ‘right’ is essential to patient care, professional wellbeing, team morale and, for some, political kudos or survival. To crack the conundrum of workforce planning, meetings are held, numbers are crunched, toolkits are employed and projections are made. Yet we seem to continue to struggle to match our workforce to our need as a country.1–3 What, then, is the answer? Perhaps a better toolkit or better data-gathering and forecasting might provide a once-and-for-all solution. So we try again, and still the solution slips between our fingers.4

A thought starts to build: might the very pressure and urgency to solve the issue of workforce planning lie at the root of our collective struggle to vanquish it? In seeking to act purposefully, do we unwittingly walk past doors that we had not noticed or considered? Such considerations might seem rather ivory tower and divorced from that urgent pressure to take action now and find a reliable source of locums. But the fact that workforce is a perennial issue – as is the garden weed that just will not die – suggests that we have not dug deep enough to understand and tackle its roots. This echoes the clinical risk situation familiar to all doctors: time pressure leading to a rush to act without taking a few minutes to develop a full diagnosis. Action without reflection can superficially feel time-efficient and generate lots of energy, but it is doomed to fail the patient in providing effective and sustained help.

Training and experience teach the GP that adequate reflection on broader medical, social and psychological issues is needed to generate a holistic diagnosis.5 This richer diagnosis in turn unlocks the pathway to effective management for the patient. An explicit process of identifying, acknowledging and reflecting on underlying assumptions is therefore important in healthcare.6 Equally, an explicit process of identifying, acknowledging and reflecting on assumptions7,8 is critical to considering human resource management, the territory and discipline from which we draw our understanding of workforce planning.

Which assumptions, then, might we be making around workforce planning that we need to expose and illuminate in a process of forming a ‘rich diagnosis’ of our healthcare workforce ailments? Much as consultation models help us to step back from the specifics of the consultation and offer, instead, an overview of the dynamics of the consultation, management theory considers models of interaction between organisations and the people who connect with them. Just as there is no one ‘correct’ way of viewing a doctor–patient consultation, there is no ‘correct’ model of considering organisational structure and culture. Rather, the value of these models lies in freeing up thinking, and revealing the melange of conceptual stances one might choose between when thinking about how to interact with a patient or how to plan and interact with an organisation. Morgan’s bestselling management treatise Images of organization9 offers one such fascinating approach to ‘thinking about how we think’. Morgan proposes that many of our ideas about how to run organisations are based on a distinct number of taken-for-granted beliefs or assumptions. He proposes eight ‘organisational metaphors’ that illustrate his ideas.

Machine organisations

This view rests on the presupposition that organisations are machines. The workforce ‘needs to be made ever efficient and productive’, with each person being helped to fit, cog-like, into the machine. It assumes that precise scientific calculations can be made about the numbers of staff needed and that forecasts are possible.

Organisations and organisms

From this perspective, organisations are seen as ‘organic’. One might talk about ‘growing talent’, bringing in ‘new blood’ to extend the ‘life cycle’ of the organisation or providing a ‘fertile environment for new leadership to emerge’. Notice how this perspective differs starkly from the machine metaphor.

Organisations as brains: Learning organisations

The intrinsic focus here is on integrating feedback loops into everyday work to promote organisational learning. The job of management is to ensure that the workforce is ‘engaged in continuous learning’ and steps are taken to breaking down barriers to new learning caused by hierarchies or functional silos.

Organisations as cultures

Emphasis is given to induction into the culture and values of the organisation. Branding, logos and distinctive ‘tribal’ rituals are prevalent so that employees are made to ‘feel part of the team’. Recruitment processes are geared towards selecting people whose values ‘fit’ the dominant organisational culture.

Organisations as political systems

To get anything done, the assumption is that you need to understand the political layout of the organisation and build alliances of power to secure action. You cannot avoid politics – you are ‘in’ politics the moment you join as an employee or contractor. Workforce planning is just one part of the ongoing political struggle between vying power factions.

Organisations as psychic prisons

The organisation is seen as becoming trapped by groupthink:10 The dominant majority of team members see the world and the organisation through a lens that may be broad but is still inherently restricted. Radically different views that might offer promising new avenues are viewed as suspicious and dangerous because they jar and destabilise the dominant worldview and hence the psychological safety of the majority. Workforce planning is held hostage to the dominant worldview and novel solutions are overlooked or actively discredited because of the discomfort they produce rather than any inherent error or fallacy.

Organisations as flux and transformation

This view assumes that change cannot be managed. Rather, the key role of managers is to facilitate conversations and an unshackling from rules and regulations that allow order to emerge. This view would regard ‘workforce planning’ as an oxymoron: it is pointless trying to make firm predictions for the numbers of doctors needed. Rather, transformative ‘disruptive’ ways of meeting the needs of patients and families – the ‘jobs’ that patients and families hire health services to do for them11,12 – need to be encouraged.

Organisations as instruments of domination

Through this prism, organisations are viewed as mechanisms through which powerful elites subdue and control the workforce through a combination of rules and perhaps even threatened or actual force. For example, disempowered international medical graduates might be exploited through ‘golden handcuff’ deals that compel them to work shifts that are unfavourable.

Reflecting on meetings on the subject of workforce planning and reading policy documents13,14 tend to trigger an intuition that our thinking around workforce planning is dominated by just one metaphor: the machine metaphor. We talk about a workforce ‘pipeline’, and an emphasis is placed on predicting numbers into the future. Should we, instead, start a debate around healthcare workforce that views the issue through the prism of ‘growing an ecology’ of healthcare provision that fosters new types of healthcare roles whose adaptability would better match emergent healthcare innovations and technologies?

There is nothing ‘wrong’ at all with adopting any particular organisational worldview. Each metaphor allows a way of seeing the world and is advantageous in helping our thinking. The risk, however, is that of becoming trapped in our own health service psychic prison where we miss other metaphors and ways of conceptualising organisations that in turn offer novel approaches to addressing workforce needs. Perhaps, to help us to shift between metaphorical mental gears, rather than simply ‘getting on’ with the task of planning and managing workforce, a circumscribed agenda item at the start of any such discussion or report would make explicit the otherwise implicit presuppositions that are being made about the nature of the organisation whose workforce needs we are analysing. This is familiar territory for GPs who are used to working with patients with complex needs in testing assumptions and formulating rich, multifaceted diagnoses.

Competing interests: None.
Provenance and peer review: Commissioned, externally peer reviewed.
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