Is health workforce planning recognising the dynamic interplay between health literacy at an individual, organisation and system level?

The growing demands on the health system to adapt to constant change have led to investment in health workforce planning agencies and approaches. Health workforce planning agencies (e.g. Health Workforce Australia (HWA), Health Workforce New Zealand (HWNZ), UK Centre for Workforce Intelligence (CfWi)) are tasked with predicting and modelling workforce supply and demand. Reviews of workforce planning approaches conclude that no-one is doing workforce planning well¹ and that alternative planning approaches are required.² HWNZ initiated a Workforce Service Forecasts process³ within topic-specific areas to develop a vision of the relevant health service, workforce for 2020 and models of care. The UK CfWi focuses on integrating workforce planning, education, training and development, and has developed a workforce planning framework incorporating horizon scanning with big picture challenges that will impact on the health and social care system.⁴ Within Australia, workforce planning approaches and reports have been prepared by HWA,⁵ and also critiqued.^6,7 Alternative evidence- and needs-based health workforce approaches have been developed.^2,8 Despite investment in alternative workforce planning approaches, we question whether the health literacy of patients, the workforce, organisations and indeed the system is being recognised.

Health literacy is recognised as key to supporting people to better manage their own health and patient experiences, and has the potential to improve health-related outcomes.⁹ Health literacy is defined as an individual trait, as the knowledge, motivation and competencies of a consumer to access, understand, appraise and apply health information to make effective decisions and take appropriate action for their health and health care.¹⁰ Health literacy is now recognised as a dynamic multilayered system issue, the product of the interaction between individual (patients, workforce)-, organisational- and system-level health literacy.^10–12 Health professionals lack adequate awareness and understanding of health literacy issues¹³ and do not routinely use health literacy practices.¹⁴ Although patients require a level of health literacy that enables them to navigate and make decisions in the health environment, so too the workforce, organisations and indeed the system also needs to be health literate.

The US Institute of Medicine has advocated that system- and organisation-level changes are needed to better align health care demands with an individual’s skills and capabilities, and has published 10 attributes of a health-literate healthcare organisation¹⁵ with Attribute 3 emphasising ‘Preparing the workforce to be health literate and monitoring progress’.¹⁵ Within Australia, national health literacy assessments¹⁶ have occurred and a National Statement on Health Literacy has been released by the Australian Commission on Safety and Quality in Health Care.¹⁷ The Statement separates health literacy into two components, namely individual health literacy and the health literacy environment, and proposes a coordinated approach to health literacy based on embedding health literacy into systems, ensuring effective communication and integrating health literacy into education.¹⁷ Multiple health literacy initiatives exist, including the NSW Health Literacy Chronic Disease Network,¹⁸ Centre for Culture, Ethnicity and Health, Health Literacy Training¹⁹ and the Victorian Ophelia research and service initiative.²⁰ The New Zealand Ministry of Health acknowledged that health literacy is an organisational value that should be considered core business, incorporated into all levels of service planning and even the way health centres and hospitals are laid out.²¹ The New Zealand Health Quality and Safety Commission has initiated health literacy projects.²² Educational efforts targeting health professionals also exist.^23,24

The growing demands on the health system to change has also led to a growing focus on health system resiliency, defined as the capacity of the system to absorb disturbances and reorganise while undergoing change so as to maintain its functions, structures and identity.²⁵ Others suggest that resiliency refers to how individuals, teams and organisations monitor, adapt to and act on failure in high-risk situations.²⁶ The concept of resiliency also implies a degree of intuition, situational awareness and an ability to access and quickly use knowledge, tools and resources to mediate (or sometimes prompt) change. Considered across multiple domains, including individual, workforce, financial, regulatory, organisational and service, it offers a system-based approach allowing us to understand what contributes to or erodes our ability to adapt to change and, importantly, how we promulgate good practice and effective solutions.

The growing importance in health literacy and health system resiliency requires health workforce planners and planning approaches to move beyond identifying, predicting and modelling health workforce supply and demand, and to focus on building health system literacy and resiliency using system-based approaches and focusing on the individual, organisational and system level.

Different health literacy and resiliency perspectives and priorities exist at the individual level (e.g. different patient ability to read and understand health information or to speak or to interact with a health professional; different workforce authorisation (formal, tacit and opportunistic) to apply knowledge, skills, competencies and be able to interact with other professionals to perform their roles within and across sectors, settings, organisations and systems), organisational level (e.g. different authorising environments, governance and operating structures to enable the workforce to perform their roles) and systems level (e.g. different legislative, regulatory and financial systems and policy imperatives).

Health literacy and resiliency are dynamic multilayered system issues; thus, it is not possible to simply build health literacy and resiliency approaches into health workforce planning agency approaches in isolation from how we prepare, support and sustain the health workforce. System-based approaches are required, which assumes a connectedness between individual, organisational and health system health literacy and resiliency. These approaches need to transcend organisational structures in order that they are themselves resilient to the numerous structural changes that are inherent in any health system.

The ideas above raise multiple questions:

• What does a health-literate and resilient system look like?

• Which of the component parts (individual, organisational and system) is most critical?

• What benefits accrue when all interconnected parts connect and which benefits are critical to whom and why?

• What factors influence a health literate system and for how long are the benefits of a health-literate system sustainable?

• How does health literacy contribute to system-level resiliency, efficiency and productivity?

• What strategies (workforce planning and development; patient quality and safety) work best to build health system literacy and resiliency, and how can this be measured?

Underpinning, these questions is the recognition that despite receptivity to health literacy and health system resiliency, there is limited evidence to date about their affect on patients, workforces, organisations and indeed systems. The concepts are not new; however, the discourse among health workforce funders, planners, educators and regulators remains disconnected. Recognising and articulating the many elements of resilient systems that already exist, such as policies and programs aimed at increasing individual, workforce and organisational health literacy, are essential first steps. Transitioning to a more integrated space also requires analysis of the potential roadblocks and systemic issues, as well as the incentives that could liberate thinking and conventions.

Planners and policy makers have a critical role to play in articulating a compelling narrative and tangible actions that assist in building stronger, more productive and adaptable systems. They also have a responsibility to mitigate the counterfactual.

Literacy and resiliency are akin to the chemical links that connect the synapses. They act as both the stimulus and the moderator, keeping the system in balance. If you plan for and nurture the connections with the right stimulus you promote fluidity, interchange of thought, new ideas and action, as well as strength and resilience.

None declared.