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How Will We Best Serve Our Aging Population?

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We know that Canada's population is aging. Among the many statistics that have been reported is how in 2015, the proportion of Canadian seniors surpassed that of youth under 15 for the first time. The gap will continue to widen over the next 20 years.

There has been much discussion about how to prepare for this bulge of aging baby boomers. Indeed, there has been no shortage of media and policy reports on this topic. These include aging strategies, dementia strategies, aging-at-home strategies; home care strategies, integrated care strategies, end-of-life strategies and more. While most of these are well thought out, they frequently overlook one very important implication: what kind of health workforce will be needed to deliver on these strategies?

If we are serious about preparing for an aging population, we need to get the health workforce right and ensure the capacity of caregivers to deliver the care that is needed.

The health workforce is the "elephant in the room" at health policy tables -- a large, pervasive issue that unfortunately often goes unaddressed. The health workforce is a pillar of the health system and so like the foundation of our homes, it can sometimes go unnoticed. But if we plan on reforming services (i.e., renovating our home), we are going to have to attend to whether the health workforce foundation can support the changes. Failing to address foundational health workforce issues can leave otherwise thoughtful policy initiatives without a basis from which to succeed.

A common theme in recent policy initiatives is the promotion of aging at home to reduce the pressure on institutional long-term care. This also responds to a general preference in the aging population to stay at home as long as possible. While this is a laudable goal, shifting the delivery of care from institutions to the home has significant impacts on the health workforce in terms of who will provide this care, how they work and the number of workers needed to provide the care required.

The health workforce for both institutional long-term care and home care includes nurses but largely includes care workers that are known either as personal support workers or health care assistants or other similar titles. Informal or unpaid caregivers - spouses, children and friends - also play a significant role, filling the gaps left by the formal care system. The vast majority of caregivers (both paid and unpaid) for older adults are women, so gender issues are important considerations that need to be taken into account.

Taking care to the home can increase the burden on informal caregivers, exacerbated for those in the "sandwich generation" who are supporting their own children while caring for aging parents. The social and economic implications of overburdened informal caregivers are rarely acknowledged in any tangible way and yet represent a very important element of health workforce planning for our aging population.

What of the formal health workforce? Do we have sufficient numbers and competently trained workers to meet the care needs in the community? The health needs of seniors are getting more complicated because people are living longer, resulting in higher rates of dementia and multiple chronic conditions. We need a workforce that can keep up with this.

Undertaking such thoughtful health workforce planning is complicated by the dearth of information about the health workforce, particularly when it comes to unregulated health workers who provide the bulk of care. Only two provinces - British Columbia and Nova Scotia - have registries for their unregulated health workers to track information on employment and training. Ontario's registry was shut down earlier this year due to concerns about data quality, and Alberta is planning to launch a registry this fall.

And for health professionals such as doctors who are not used to making house calls, it means an important culture change in practice habits as well as revised payment models to encourage these changes.

So, how can we get policymakers to recognize the elephant in the room and take health workforce considerations into account when developing and implementing policy changes?

One solution is a health workforce impact assessment tool that can be applied to all new health policies. Such a tool could be structured around two guiding questions: (1) does the policy mention/address health workers, professionals, caregivers? and (2) are the health workforce implications of the policy highlighted, including recruitment, training, distributing, retaining, motivating and managing?

A useful precedent for such a tool comes from Australia, where a health workforce impact checklist was created to apply to all health policies as they are developed. A call for greater health workforce impact assessments was also a key element of the Global Human Resources for Health Strategy 2030, recently passed in the 69th World Health Assembly this past week.

If we really want to be prepared for the care needs of our aging population, we need to get better at addressing the health workforce foundation of our care system.

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