Age and experience or youthful enthusiasm

A bevy of policy analysts and public-sector managers will do much of the heavy lifting of the health system reform process taking place over the next two years. What type of policy workers and managers do we need, now and in future decades?

What sort of attributes and skills are valued in the public sector, and what sort of mix of experience and expertise is needed across the system?

Such questions need to be answered at both an individu­al and system level.

In a curious way, these questions have many parallels to debates about the nature of our clinical workforce. Should there be a greater emphasis on subject matter specialists, or do we need more flexible generalists?

So, should policy analysts and managers experience lots of different settings to learn and ply their trade, or is the system better off with a more stable, less mobile policy workforce? Having taught many students who have ended up in health sector policy and management roles in the past 20 years, I have skin in the game and that question is never far from my mind.

I teach in a Bachelor of Health Science programme, and many of our graduates begin their careers working for DHBs or in central government. It has never been easier than it is now, for our graduates to land these jobs.

As recently as 10 years ago, young graduates with no health-sector experience were much less successful. Local service managers were largely recruited from the ranks of clinicians, often nurses, physiotherapists or occupational therapists who were looking for a career track, rather than medical professionals.

Until the 1990s, many senior policy positions in the public sector were held by career public servants with deep but narrow expertise. This was the last generation of public servants who started their careers after college and stayed there (and perhaps in the same department) for life.

Today, it’s rare that the public-sector manager under 45 (or perhaps older) does not have a degree.

In 2017, under 50 per cent of public servants had postgraduate qualifications.

Nurses of a certain age will recall the debates within the profession about whether being taught in tertiary institutions made for better nurses than training in hospitals.

There are parallels in health management and policy. Our present and future workforce in these areas have plenty of “book learning”, and know how to communicate effectively and how to think critically. They have a good overview of the health system and of factors outside the health sector that drive health outcomes.

Nevertheless, a policy workforce comprised of bright young things has some potential vulnerabilities. While likely to be much better at seeing the health-system forest, they may have less understanding of the trees – what it is like to deliver services on the front line. This might serve to accentuate and widen the cultural gulf between clinicians and managers.

More worryingly, the average time a policy analyst or manager stays in one position is getting shorter: the most recent graduates are hyper-mobile.

According to the State Services Commission, only about 42 per cent of graduates who started policy roles in 2012 remained in the public sector three years later.

By contrast, 60 per cent of the cohort that started in 2006 remained.

With the instability of a round of health restructuring, the risk of what some policy researchers have termed “institutional amnesia” is heightened.

Plenty of old hands are deeply involved in designing the health restructure, but much of the filling out of policy details will be done by those who haven’t been around very long. Is there anyone to tell them what happened last time someone thought of a particular bright idea?

One unambiguously positive trend is that our public sector overall is gradually becoming more representative of the population it serves, in terms of gender and ethnicity – although significant pay gaps remain.

However, only 8 per cent of Ministry of Health employ­ees in 2017 identified as Māori, and just over 4 per cent as Pacific. At this critical juncture in our health system’s history, this is well short of the critical mass needed.

Policy analysis, as a role, emerged in the US in the 1950s and 1960s, and the first generation doing the job were technocrats. They aimed to find the optimal solution to a given problem and to keep the politics out of policy.

By the turn of the millennium, training in policy work and public-sector management began to recognise the central importance of relationship management and softer skills of negotiation and consensus-building, as well as process management between government agencies and with non-government players.

There always were public servants adept at these more practical and political ways of operating, but it is not until recently that this has been valued.

No one is controlling the changes in the health policy and management workforce; they are the product of deeper social processes.

But, in any future conversation about health workforce planning, the nature and shape of our health policy and management workforce will require more conscious consideration.

Tim Tenbensel is associate professor, health policy, in the School of Population Health at the University of Auckland