6.7 RESOURCE FLEXIBILITY AND EFFICIENCY INFLUENCED
hospital services, the proposal to complex hospitals in KZN has been drafted. However, the patient:
doctor ratio, the work roster stress, clinical errors and changing work patterns with the resultant systemic effect on clinical experience, workforce deficit and staff morale, remain in disequilibrium.
The objective to rationalize the number of hospital beds was to improve performance efficiencies.
Yet, delays to finalize this rationalization hospital services plan have been due to the lack of strategic policy. Other examples of non-aligned policy are the lack of NDOH specialists staffing norms, the management discriminatory stakeholder participation in HR Planning, staff been marginalized when advocating adherence to governance principles, and lack of implementation, monitoring or
accountability of external consultant’s deliverables as per these consultant’s contracts.
Furthermore, inadequate preparation or organizational barriers to access the medical profession, seems to cause a shortage of health professionals. These non-aligned policy initiatives management mental models and poor planning or corporate barriers result in risks of high staff attrition and negative feedback in the health ecosystem (Focus Group, 2018). Policy change and transformed mental models can correct the number of specialists required to regenerate a stable equilibrium of specialists. This stability is an essential result of policy reform and management transformation, as it will necessitate hospitals to employ more junior doctors to achieve the equivalent medical cover as registrars are trained and employed as qualified specialists. The flow rates of doctors in the supply of specialists are determined by dynamic complexity such as the number of medical students recruited annually from secondary schools or as mature students. Also, this undergraduate recruitment of medical students is decided by the Universities Medical Schools Health Science Faculties. The in- flow of medical students into the health system is an exogenous variable, beyond the control of DOH or individual hospitals and independent of the NDOH policy imperatives. Growth in the number of specialists is attained through expansion of medical student recruitment and the number of
successfully qualifying junior doctors.
In SA, it takes five years for a medical student to qualify as a junior doctor, and a further one-year Internship and one year of Community Service. The outflow of junior doctors is controlled by delays in the length of time in medical school training. The rate of junior doctors training is the ratio of medical students to the duration of training which is based on a depletion formula. The flow of qualified students collects in a pool of junior doctors. From this pool, a substantial number will select to remain as general practitioners or to specialize.
The DOH collaborates with the Universities for the number of registrars to be recruited onto the specialist training programmes. The time it takes for registrars to qualify as specialists is three to four years. This postgraduate registrar training is self-directed education while at work, with official clinical on-the-job learning in DOH facilities and seminars which are supervised by senior specialists.
The out-flow of number of qualifying specialists is affected by the attrition. Attrition of registrars is due to changes in the working environment, the registrars’ morale and changes in the academic policy for completion of Masters in Medicine dissertations before applying for specialist registration. The HPCSA policy to recruit specialists from the increased number of SA junior doctors who qualified overseas is under review. The delay in ratifying this HPCSA policy further reduces the inflow of registrars onto the specialist training programme.
Another variable in the dynamic complexity of specialist recruitment are the non-SA resident doctors.
There is a growing number of workforce recruitment among African Union member states to make up the deficit in specialists. As medical immigration increases, overseas doctors also take sabbatical times of clinical practice and develop in specialities in an attempt to achieving permanent residency in SA. The specific workforce deficit in KZN DOH is unavailable. To calculate the specialist staff shortage data on the difference between the target number of specialists and current total specialists comprises SA qualified junior doctors and non-SA doctors. Since there are no NDOH specialist norms to calculate the target, the target number of specialists is a guess-timate. As more hospitals become compliant with the National Quality Core Standards for Hospital Performance, the target workforce will grow.
Other demographic, education and labour marketvariables to consider when recruiting specialist are the time it takes to recruit, the length of the contracts, the category of hospital, for example, whether regional or tertiary and urban or rural and the compensation scales. It takes approximately six months commencing with advertising the post, the shortlisting, and interview, to successfully completing the qualification admittance exams to commence working a SA hospital. Delays in this recruitment process add to the negative systemic feedback. As the dynamic health ecosystem is in disequilibrium regulating the number of specialists in relation to the clinical demand of specific specialists consists of making realistic policy decisions at specific times about the number of registrars in the intake for training. Recruitment and retention policy for specialists should be governed by a balanced skill mix, geographical distribution, conducive working conditions and compensation schedules (Morecroft, 2015).
Regulating the admission policy of junior doctor intake onto the registrar programme in a context of disproportions between the professions, for example, a low ratio of specialized nurses to specialists or imbalance among various clinical specialists, and an inequitable rural urban allocation of specialists needs to be considered to reform HR specialist recruitment policies. The shortage of specialists also causes negative feedback in the supply of specialists. Another variable causing this deficit is the number of female registrars who are eligible for maternity leave, which necessitates delays in the total training time and reduction in the number of qualifying specialists. An additional variable which
causes negative feedback in the supply of specialists is the number of experienced senior specialists who are confronted with mandatory retirement. With the retirement of senior specialists, the experience and supervisory skill are depleted, which has a negative feedback on the number of specialists in the health ecosystem. The demand for specialists is affected by demographic trends towards an older population and change in epidemiologic profiles, which increase the demand for specialists like geriatricians, neurologists, arthropods, urologists, cardiologists, oncologists and family health practitioners (Barber, 2010).
6. 9. CONCLUSION
Health human resources planning is a high priority in many countries and in SA, the NDOH strategic goal is to strengthen human resources for health.Planning methods can be based on HR need, demand or benchmarking. The evolution of supply and demand of specialists projecting for three to five years in each of the forty-six medical specialties authorizes the adjustment of inputs aligned to NDOH policy decision, regulation, technology and demography.
By using the SD approach in this study, simulation of complex organizational behaviour over time was facilitated as was the intention of improving understanding of these complex systems, the imbalances in the medical labour market and this methodology enabled analysis of workforce supply and demand. Other learnings derived from this study is that complex feedback systems can be analysed by using CLD and stock flows in which resources be it financial, HR or material resources, demonstrate accumulation and depletion in the stocks over time and the interdependencies of these variables. Complex data-sets can also be integrated by using the SD tools and the graphical
illustration of the system enables stakeholders to actively participate in the validation process. This improved stakeholder understanding of strategic issues empowers viable strategic action that will advance the system behaviour (CFWI, 2004).
Figure 44: Medical Workforce Dynamics and Patient Care Framework (Adapted from Morecroft, 2015)
The framework of medical workforce dynamics in Figure 44 symbolizes workplace stressors underlying doctor’s morale, attrition, as well as the feedback loops connecting work–life balance, doctors’ remuneration and factors influencing quality of patient care, as iterative systemic relations.
In this chapter, the development of a system dynamics-based workforce framework as illustrated in Figure 44, is inclusive of FGD reflection on current KZN DOH recruitment practices, information flows, actors’ mental models, and best practices, and from my practical experience of understanding the dynamic complexity of the health ecosystem. These variables can therefore be used as leverage in the system to influence equilibrium in the supply and demand of specialists and nurture potential to retain specialists.
This analysis of the policy decision-making and power relations between KZN DOH and NDOH, as illustrated in Figure 40, provided insight to the mental models or mindset of actors, which shapes the health ecosystem’s goals, power structure, rules and the organizational culture. The distribution of power among actors participating in supply and demand of specialists over the rules of the system results in leverage for change in HR policy. Other leverage variables are the need to transform HR recruitment rules of the health system in the form of incentives, penalties or limitations (Meadows, 2017). This effect of policy options in several future scenarios analysis by workforce intelligence can examine future uncertainties and minimise risk to achieve the NDOH goal of strengthening human resources for health(CFWI, 2004).
MEDICAL WORKFORCE
PLANNING
Supply Chain of:
Medical Students
Junior Doctors
Registrars
Specialists
Senior Specialists
Duration of training
Attrition
Junior Doctors
Registrars
Specialists
Recruitment Policy
Workforce deficit
QUALITY OF PATIENT CARE MANAGEMENT
Patient : Doctor Ratio
Work Schedule Pressures
Clinical Errors
Clinical Governance
Changing Work Patterns
Patient Satisfaction surveys
Complaint Compliment and Patient Experience of Care System Work – life
Balance &
Resource Flexibility
Doctors Remuneration
Factors Influencing Morale
Globally, progressively more complex health systems necessitate a culture which consistently develops new leaders and inspires existing leaders. Organizational complexities and dynamic health service platforms require understanding the leadership styles, practices, relationships, decision- making processes and governance structures.
In the next chapter I explore leadership and governance and the notion of self in an attempt to improve my understanding of authentic integral leadership.